aids mania
TRANSCRIPT
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M ETHOD S
JOU RN A L O F NEUROPSY CH IA TRY
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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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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 .
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