AIDS

METHODS

Mania

Twenty

Constantine

G. Lyketsos,

Joseph

Schwartz,

Marc
Glenn

M.D.,

M.H.S.

M.D.

Fishman,
Treisman,

consecutive

were

referred

tient
vice

M.D.
M.D.,

clinic
(APS)

manic

Ph.D.

patients

for

of the Johns
and who
met

episode

with

psychiatric

were

HIV

infection

evaluation

Hopkins
DSM-III-R4

included

who

to the

outpa-

AIDS
Psychiatry
criteria
for

in the

study.

Sercurrent

The

setting

for this research

has been
described
previously.56
tients
were
recruited
after
study
procedures
were
plained
to them
and
written
informed
consent

Twenty

patients

with

HIV

infection

and

mania

obtained.

All

study

were grouped
according
to whether
their first
manic episode occurred
when CD4 count was
<200
(late onset) or
200 (early onset).
The lateonset patients
were less likely to have personal
or
family
histories
of mood disorder
and more likely to
have dementia
or cognitive
slowing.
They also exhibited a different
manic symptom
profile. The dif-

days
of the index
All participants

ferent sociodemographic
and symptom
profiles
associated
with early-onset
and late-onset
mania
may reflect differences
in patho physiology.

cess,

(The

Journal

of Neuropsychiatiy

Neurosciences

1997;

and

sive neuropsychiatric
tionally,
they
Clinical
and

to

syndromes

occur

with

higher

AIDS.12

Manic

of HIV
inversely

disease
are
associated

mood
areas,
the

context

the

lifetime

20 patients,
first lifetime
a clear

Clinical

of HIV

frequencies

syndromes

after

with

onset

associated
with
with a personal

syndromes
infection
quences
mania

are

of mood,
with
an
a distinct

onset
late
condition

onset

in the

dementia
or family

the
caused

of

course

but
history

subcortical
are important

possible
in

tend

that

are
of
brain
to

manic

course
of HIV
by the conse-

and

pathophysiology.
The goal

of this

mographic

and

study

clinical

and late-onset
infection.
We

work
indicating
nia and
dementia
personal

or family

JOURNAL

OF

symptom
would

differences

an

was
profiles

of patients

manic
episodes
also
sought
to
association
and
an
history

NEUROPSYCHIATRY

in the
replicate

the

of mood

disorders.2

by APS.5 Addithe
Structured
diagnoses

or absence

of individual

Family
and personal
histories
also ascertained.
During
this
of mania

was

dated.

For

onset

of mania

several

years

before

of
pro-

13 of the
the
4 had

their

date

of

2 had their
first manic
episodes
and CD4 counts
at the time of the

onset

available

of mania
the

were

onset

of mania

infection

For

to CD4

count

with accuracy,
and
his data
from
the analyses.
A detailed
taken
to stage
each
patients

according

to Centers

(CDC)
criteria.7
In this way,
first lifetime
onset
of mania
Eighteen
participants
also
psychological
testing
battery
and
other
the clinical

records.

in relationship

could
not be determined
were
therefore
excluded
medical
history
was also
HIV

in hospital

for

Disease

Control

it was possible
to date the
in relation
to CD4 count.
underwent
a 1-hour
neurothat included
the Grooved

measures.
examinations,

On

the basis
the presence

of

these
or ab-

or not exhibiting
performance.

significant

slowing

early-

context
previous

between
late-onset
inverse
association

comprehen-

used
with

the index
episode
of mania
represented
onset.
Of the remaining
participants,

fied as exhibiting
in psychomotor

sociode-

with

standard

to confirm

presence

30

sence
of dementia
by DSM-III-R
criteria
was
determined.
On the basis
of performance
on the Grooved
Pegboard
(average
of dominant
and nondominant
performance
based
on 1-scores),
participants
were
classi-

profile.
A demonpoint
to a distinct

to compare

onset

DSM-III-R

within

HIV infection.
Another
within
the past year,

Pegboard
tests and

of HIV brain
infection.
If this is true, late-onset
might
differ
from early-onset
mania
in its associ-

ated sociodemographic
stration
of such

onset
HIV

it appears

the

late

disorder.2
Given
that HIV affects
such as the caudate
nuclei,3
that
regulation

infection

the

symptoms
of mania.
mood
disorders
were

9:277-279)

in the

for

to determine

occurred

examination
examined

were

Interview

patient,
Manic

examinations
manic
episode.
underwent
the

Paexwas

of

Group,
The
correspondence

mawith

Received
February
2, 1996;
From
the AIDS
Psychiatry

Baltimore,
Copyright

Johns
MD

revised
Service

May
and

Hopkins
University,
to Dr. Lyketsos,
Osler

1, 1996; accepted
Neuropsychiatry
Baltimore,
320, The Johns

May
and

Maryland.
Hopkins

13, 1996.
Memory
Address
Hospital,

21287
1997

American

Psychiatric

Press,

Inc.

277

CLINICAL

AND

RESEARCH

In the analyses,
groups:
those
with

REPORTS

participants
early-onset

were
mania,

for the first time

200, and those

in their lives when

for whom
mania

their

was

CD4

count

<200.

We

divided
if mania

their
onset

used

into
two
occurred

this

cutoff

because

that
is below

allow
200.

onset
and
sociodemographic

were
profiles

compared
by using

cases
clinical

and

1.

Comparison
of sociodemographic
and historical
profiles of 20 patients
with manic
syndrome
of early or late
onset
in the context
of HIV infection

CD4 count
was
occurred
when

of current
CDC recommendations
nosis
of AIDS if the CD4 count
late-onset

TABLE

the diagThe earlyon

t-tests

to compare
continuous
variables
and chi-square
tests to
compare
categorical
variables.
The sample
size was too
small
to allow
factor-analytic
study
of the clustering
of
mania
symptoms.

Late
Variable

(n

Age (years, mean SD)

Gender (% male)
Race (% African American)
Education (years, mean SD)
Primary
HIV risk factor
(%)

35.5

Heterosexual
Bijhomosexual
Intravenous

contact
drug

use

at evaluation

CDC stage
I
III
Family

history

disorder
Eight
patients
were
nia and 11 as having
comparison

classified
late-onset

of the

as having
mania.

early-onset

sociodemographic

and

and

other

early-onset
Table
1 shows

late-onset

clinical

could
be expected
from
and late-onset
cases were

the way
defined.

all

had

slowing

on

the

far lower
rates
cases.
the comparison

late-onset

groups

profiles.

In general,

on

the
the

for irritability,

late-onset
was more

group,
common

and were
of mood
dementia,

Grooved

of the

as

impairment

manic

groups

appeared

two

less
disand

early-onset

and

symptom
to have

patients
had more
sympin a significantly
higher
differences
were
most
prowas

for increased
in the early-onset

more

common

in the

talkativeness,
group.

%)

history
of mood
(lifetime,
%)

Presence of
dementia
Slowing on
Pegboard

5.5

0.75

50.0

0.14

36.3

87.5

0.026

2.9

10.6

1.3

0.12

9.1
36.4
54.5

12.5
0.0
87.5

0.16

9.1
18.2
72.7

62.5
12.5
25.0

0.043

50.0

90.1

0.043

DSM-III-R
(%)
Grooved
(%)

18.8

100.0

aCompared

0.0004

60.0

0.0

0.0073

90.0

12.5

0.001

by t-test (age and education)

or chi-square

test

(all others).

Pegboard,

of cognitive

which

and

late-

early-onset
individu-

DSM-III-R

different
profiles.
Late-onset
toms,
which
were
reflected
mean
symptom
count.
The
nounced

on

The

in which
Late-onset

als were
less likely
to be African
American
likely
to have
personal
or family
histories
orders.
They
also
had
higher
rates
of
compared
with
in the early-onset
Table
2 shows

patients

variables.

likely
to have
clinical
AIDS
stages
of HIV disease,
as

onset
patients
were
more
and were
in more
advanced

almost

mathe

34.7

Pa

of mood

(first degree,

Personal
disorder

5.2

8)

(%)

IV

RESULTS

(n

81.8

12.5

contact

Early
11)

which

TABLE

Comparison
of 20 patients
with manic syndrome
in the
context of HIV infection
on individual
and cumulative
DSM-III-R
manic
symptoms
by time of mania onset

2.

Manic Symptom
(DSM-III-R)

Late (%)
(a = 11)

Early (%)
(a = 8)

Pa

Euphoria

81.8

77.8

0.82

Irritability

81.8
81.8
81.8
63.6

33.3

0.02

77.8

0.82

55.5

0.20
0.04

Grandiosity

Decreased
sleep
Increased talk
Flight of ideas
Distractability

Increased
Poor

activity

judgment

Psychotic symptoms
Mean number of
symptoms

SE

aComped

100

81.8

66.7

0.43

72.7

44.4

0.19

62.5

37.5

0.18

63.6

55.6

0.71

36.4

44.4

0.71

7.1 0.44

by f-test (mean

5.8 0.40

or chi-square

number)

0.04

test (individual

symptoms).

DISCUSSION
In this

consecutive

study

and mania,
we have
gesting
that
patients
late-onset
mania
and
psychiatric

of patients

in HIV
histories.

278

4 times
of HIV

HIV

infection

findings2
and
those

sugwith

infection
differ
in their personal
We have
also confirmed
the

association
between
late-onset
The prevalence
of dementia
cases
was
prevalence

with

replicated
previous
with
early-onset

higher
dementia

mania
of 60%
than

in

and
the

the expected
in AIDS
(which

dementia.
late-onset
lifetime
is about

15%

8)

Thus,

the

and dementia
Our results

association

is not likely
also indicate

ciated
with
psychomotor
associated
with
mania,
prevalence

of

than what
has
in the absence
mania

is typically

between

late-onset

to be due to chance
that late-onset
mania

mania
alone.
is asso-

slowing,
which
is not usually
in the absence
of dementia.
The

psychomotor

slowing

is

been
reported
in late-stage
of mania.8
It is also unexpected
thought

VOLUME

of as a syndrome

#{149}
NUMBER

much
HIV

higher
infection
given
that

of excessive

2 #{149}
SPRING

1997

CLINICAL

activation
prevalence

with
rapid
of manic

thoughts
symptoms

and flight
of ideas.
The
in this series
of patients

was quite
high,
particularly
with
regard
to grandiosity,
which
may reflect
the fact that this was a sample
of cases
selected
out of a tertiary
clinical
center.
The finding
that
patients
tom
less
sis

with

profile,
likely
that

late-onset

mania

were
more
likely
to be hypertalkative

late-onset

mania

had

a broader

to be irritable,
supports
the

is different

from

work

was

annual

meeting

Newport,

propose

that

late-onset

phase,

or it may

mania

be

1. Kieburtz
AIDS.

early-onset

by

which

manifestation
individuals.

the

fact

we

term

mania
intimately
tied to
brain
infection.
Early-onset
mood
disorder
in its manic

a different

in HIV-asymptomatic

sis is supported

mania,

that

early-onset

Am

Lyketsos

K, Zettelmaier
J Psychiatry
CG,

mania

our understanding
mechanisms
involved
sodes

JOURNAL

of

some
in the

was

in general.

OF

NEUROPSYCHIATRY

4.

regions
of manic

5.

Hanson

was

DRR-OPD-GCRC

presented

Neuro

at the

psychiatric

in

and
epi-

1994

Association,

psychiatric

in

1993;

results

43:2099-2104
Diagnostic
and

3rd edition,

revised.

late

Am J
basal

from

gan-

quantita-

Statistical

Washington,

Man-

DC,

1987

Fishman

M, et al: Screening
clinic:
the importance

medical

J Psychiatry
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disorders

and

JC, et al: Reduced

dementia:

Association,

early

virus infection.

McArthur

Neurology
Association:

hit

syndrome

M, et al: Mania

FIIV-1-associated

GJ, Fishman

L, et al: Manic

148:1068-1070
Fishman

Lyketsos
CG, Hanson
AL,
atric disorders in an HIV

Med

1994;

for psychiof a psy-

24:103-113

CG, et al: Evaluation

associated

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and treat-

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for Research in Nervous
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tive neuroimaging.
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6. Treisman
ment of

of

study
of patients
mania
may
improve

of the brain
development

Psychiatry
Aylward

glia volume

hypothe-

dysfunction.
Given
the evolving
understanding
brain
infection
and
the
relatively
predictable
prospective
develop

of the American

ual of Mental
Disorders,
American
Psychiatric

associated
with
a personal
or family
history
of mood
disorder,
indicating
a genetic
condition,
whereas
AIDS
mania
was linked
to cognitive
impairment
and execu-

course
of HIV
disease,
with
HIV infection
who

3.

of AIDS
This

Grant

study

RI.

in the course

We

by NIH

of this

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