aids mania

7/26/2019 Aids Mania

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M ETHOD S

JOU RN A L O F NEUROPSY CH IA TRY

27 7

A ID S M an ia

C onstan tine G . Lyke tso s , M .D ., M .H .S .

Jo seph Schw artz , M .D .

M arc F ishm an , M .D .

G lenn T re ism an , M .D ., Ph .D .

Tw en ty pa tien ts w ith H IV in fec tion a nd m an ia

w ere g roup ed acco rd ing to w he th er th e ir firs t

m an ic ep iso de o ccurred w hen C D 4 coun t w a s


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CL IN IC A L AND RESEARCH REPORT S

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V O LU M E 9 #{149}UM BER 2 #{149}PR IN G 1997

In the ana ly ses , pa rtic ipan ts w ere d iv id ed in to tw o

grou ps: those w ith ea rly -o nse t m an ia , if m an ia o ccu rred

fo r the f irs t tim e in th e ir liv es w h en the ir CD 4 coun t w as

2 00 , and th ose fo r w hom m ania on se t o ccu rred w hen

the ir CD 4 coun t w as < 200 . W e used th is cu to ff because

o f cu rren t CD C recomm end atio ns th a t allow the d iag -

no sis o f A ID S if th e CD 4 coun t is be low 200 . Th e ea rly -

on se t and late -onset ca se s w ere com pared on

soc io dem og raph ic and clin ica l p ro file s by u sing t- tes ts

to com pare co n tinu ou s va riab le s and ch i-squ are te sts to

com pare ca tegorical va riab le s . T he sam ple size w as to o

sm a ll to a llow facto r-an a ly tic stu dy of the c lu ste rin g o f

m an ia sym ptom s.

RESULTS

E ig h t pa tien ts w ere c lass ified as hav ing early -on set m a-

n ia and 11 as hav in g la te -o nse t m an ia. T ab le 1 show s the

com parison o f the ea rly -o nse t an d la te -o nse t p atien ts o n

soc io dem og raph ic and o the r clin ica l v ar iab le s . T he la te-

on se t pa tien ts w ere m ore lik ely to h ave c lin ical AIDS

and w ere in m ore ad vanced stag es o f H IV disease , a s

cou ld be ex pected from the w ay in w h ich ea rly -on se t

and la te-on set ca se s w ere d efined . L ate -onse t in d iv id u -

a ls w ere le ss lik ely to b e A frican Am erican and w ere le ss

like ly to have p erson a l o r fam ily h isto r ies o f m ood d is-

o rde rs . They a lso had h ig he r ra te s o f dem en tia , and

a lm os t a ll had slow in g on th e G rooved P egboa rd , a s

com pared w ith far low er ra te s o f co gn itiv e im pa irm en t

in th e ea rly -o nse t ca se s.

T ab le 2 show s th e com parison of the ea rly -o nse t and

la te-on se t g rou ps on the DSM -III-R m an ic sym ptom

pro files . In gene ral, th e tw o grou ps appea red to h ave

d iffe ren t p ro file s . L ate -onse t pa tien ts h ad m ore sym p -

tom s, w h ich w ere re f lec ted in a sig n ifican tly h ighe r

m ean sym ptom coun t. Th e d iffe ren ces w ere m os t p ro -

no unced fo r irr itab ility , w h ich w as m ore com m on in the

la te-on se t g rou p , and fo r in creased ta lka tiveness, w h ich

w as m ore com m on in the ea rly -on se t g rou p .

D ISCUSS ION

TA BLE 1 . C om pa r ison o f soc iod em og ra ph ic an d h isto r ica l p ro -

file s o f 20 pat ien ts with manic syn drom e o f ear ly or la te

onset in

the co n tex t o f H IV

in fect ion

Late E ar ly

Variable

n

=

n

8 ) P a

A ge (years , m ean

SD ) 35 .5 5 .2 3 4 .7 5 .5

0.75

G ende r (% m ale)

81 .8 50 .0 0 .14

R ace (%

Afr ican

Amer i can )

36 .3 87 .5 0 .02 6

Educa tion (y ea rs , m ean SD ) 12 .5 2 .9 1 0 .6 1 .3 0 .12

Pr imary H IV risk fac to r ( )

Heterosexual co ntact 9.1 12.5 0 .16

Bijhomosexual

con tact

36 .4 0 .0

Intravenous drug use 54 .5 87.5

CDC stage

a t eva lu atio n (% )

I 9.1 62.5 0 .043

III 18.2 12.5

IV

72 .7 25 .0

Fam ily h isto ry of m ood

d iso rde r (firs t deg ree, % )

50 .0 90 .1 0 .04 3

Pe rso nal h isto ry of m ood

diso rd er (l ife tim e, ) 18 .8 10 0 .0 0 .00 04

P re se nc e o f D SM -III-R

dem en tia (% ) 60 .0 0. 0 0 .0073

S low ing on G ro oved

P egboa rd (% )

90 .0 12.5 0 .001

aC om pared by t- te st (age an d educa tion ) o r ch i-sq ua re te st

( a ll o t he r s) .

TA BLE

2.

Com pa r ison o f 20 p a tien ts w ith m an ic sy nd rom e in th e

co n tex t o f H IV

in fect ion

on

ind iv idual

a nd c um u la ti ve

DSM - I I I -R

man i c

sym p tom s b y t ime o f m an ia onse t

M an ic S ym ptom La te ) E ar ly )

SM -III-R ) a

=

11 ) a

= 8)

Pa

Euphor ia

Irritability

Grandiosi ty

D ecreased sleep

Inc reased ta lk

F ligh t o f ideas

Distractability

Increased act iv i ty

P oor judg ment

P sy ch otic s ym pto ms

M ean num ber o f

sym ptom s SE

81 .8 7 7 .8 0 .82

81 .8 3 3 .3 0 .0 2

81 .8 77 .8

0 .82

81 .8 5 5 .5 0 .20

63 .6 100 0 .04

81 .8 6 6 .7 0 .43

72.7

44 .4 0 .19

62 .5 3 7 .5 0 .18

63.6 5 5.6 0.71

36 .4 4 4 .4

0 .71

7 .1 0 .44 5 .8

0 .4 0 0 .04

aComp ed by f-te st (m ean numb e r ) or c hi-s qua re te st (ind iv idu al

symp toms) .

In th is co nsecu tive stu dy o f pa tien ts w ith H IV in fectio n

and m an ia , w e h ave rep licated p rev io us find ing s2 su g-

gestin g th a t pa tien ts w ith ea rly -on se t and th ose w ith

la te-on se t m an ia in H IV in fectio n d iffe r in the ir personal

and p sych ia tr ic h isto rie s . W e have a lso confirm ed th e

assoc ia tion be tw een late -onset m an ia an d dem en tia .

Th e preva len ce o f dem en tia o f 60% in the late -onset

cases w as 4 tim es h ig he r than th e ex pec ted life tim e

prev alence o f H IV d em en tia in A IDS (w hich is abou t

15 % 8) Thus, th e as soc ia tio n be tw een la te -o nse t m an ia

and dem en tia is no t like ly to be due to chance a lo ne .

O ur re su lts also ind ica te tha t la te -o nse t m an ia is a sso -

c iated w ith psych om o to r s low ing , w h ich is no t usu ally

a ssoc ia ted w ith m an ia , in the ab sence of dem en tia . T he

preva len ce o f psychom oto r slow ing is m uch h ig he r

than w ha t has b een rep orted in late -stag e H IV in fectio n

in th e ab sence of m an ia.8 I t is a lso unexp ec ted g iven th at

m an ia is ty p ically tho ugh t o f a s a synd rom e of excessive


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CL IN ICA L AND RE SEARCH REPORTS

JO URNA L OF NEURO PSY CH IA TRY

27 9

ac tiva tion w ith rap id th ou gh ts an d flig h t o f ideas . T he

p reva lence o f m an ic sym ptom s in th is se r ies o f pa tien ts

w as qu ite h igh , p articu la rly w ith reg ard to g rand io sity ,

w h ich m ay ref lect th e fact tha t th is w as a sam p le o f case s

se lec ted o u t o f a te rtia ry c lin ical cen te r. T he find ing tha t

p atien ts w ith late -onse t m an ia had a broade r sym p-

tom pro file , w e re m ore lik ely to b e irritab le , and w ere

le ss like ly to b e hype rta lka tive su ppo rts the h ypo the -

sis tha t la te-on set m an ia is d iffe ren t from ea rly -o nse t

man i a .

W e propo se tha t late -onse t m an ia , w h ich w e term

A ID S m an ia, is a secon da ry m an ia in tim a te ly tied to

the p ath op hysio logy of H IV brain in fectio n . E arly -on se t

mania may represent

b ipo la r m ood d iso rde r in its m an ic

p hase , o r it m ay be a d iffe ren t m an ife sta tion o f A ID S

m an ia in H IV -asym ptom a tic ind iv idu als . T h is h ypo the -

sis is sup ported b y the fact tha t ear ly -onset m an ia w as

asso cia ted w ith a p erso na l o r fam ily h isto ry o f m ood

d iso rd er , in d icatin g a gen etic co nd itio n , w h e reas A ID S

m an ia w as linked to cog n itive im pa irm en t and execu-

tive dy sfu nc tion . G iv en the evo lv ing unde rstand ing of

H IV bra in in fec tion and the re lativ ely p red ic tab le

course o f H IV d isease, p rospectiv e stud y of pa tien ts

w ith H IV in fec tion w ho deve lop m an ia m ay im p rov e

ou r un de rstand ing of som e o f th e b rain reg io ns and

m echan ism s in vo lv ed in the d ev elo pm en t o f m an ic ep i-

so des in gen era l.

Th is w o rk w as su ppo rted by N IH G ran t D RR -O P D -G C RC

00722. An abstra c t o f th is s tu dy w as p resen ted a t th e 19 94

a nnu a l m eetin g o f the Am erican N eu ro p sych ia tr ic A ssoc ia tio n ,

N ew po rt, R I .

References

1 . K ie bu rtz

K , Z e t te lm a ie r

AE , K e ton en L , et a l: M anic sy nd rom e in

A ID S . A m

J

Psy ch iatry 1 991 ;

148 :1068-1070

2 . L yk etsos CG , H anson AL , F ishm an M , et al: M ania early and la te

in th e cou rse o f hum an

immunodef ic iency

v iru s in fec tion . A m J

P sy ch iatry 1993; 15 0:3 26 -32 7

3 . A ylw ard EH , H enderer JD , M cA rthu r JC , et al: R educed b asa l g an -

glia

vo lum e in

FIIV -1 -as soc iated dem entia : resu lts from qu antita-

t ive neuro im aging . N eu ro log y 1993 ; 4 3 :2 09 9-2 104

4 . A m eric an P sych ia tric A ssociatio n : D iag nos tic and S ta tist ica l M an-

u al o f M enta l D isorders,

3 rd ed itio n , rev ised . W ash in g ton , D C ,

A m eric an Psych iatric A ssociatio n , 1 98 7

5 . L yke tso s CG , H anso n AL , F ishm an M , et al: Sc reen in g for psych i-

atric disorder s in an HI V med ica l clin ic : the im por tan ce of a ps y-

c hi at ri c p re se nc e. h it

J

P sych ia try M ed 1994 ; 24 :10 3-1 13

6 . T re ism an G J , F ishm an M , Lyke tsos C G , et a l: E va lua tion and trea t-

m en t o f p sych ia tric d isorders associated w ith H IV infection , in

H W ,

A IDS

an d the B rain , A sso cia tion fo r R esea rch in N ervou s

and M enta l D isease (ARN M D) P roceed ing s, vo l 72 , ed ite d by

P rice RW , P e rry SW . N ew Y ork , R aven , 1993 , p p 2 39 -25 0

7.

C en te rs fo r D isease C on tro l: R ev ision of the CDC surve illance

def in i t ion fo r acq u ired im mune d efic ien cy syn drom e. M M W R

1987 ; 3 6(supp l 1S ):3 S -15S

8 . M cA rth ur JC , S eln es O A , G la ss JD , et a l: H IV dem en tia: in cid ence

and risk fac to rs, in H IV , A IDS an d the B rain , A RN M D Proceed -

in gs, vo l

72 , ed ited by P rice RW , P erry

SW . N ew Y o rk , R aven ,

1993 , pp 251 -2 72

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