The relationship between mental illness and violence is controversial. On the one hand, there is considerable unfounded stigma and discrimination toward the mentally ill based on the popular notion that psychiatric patients are dangerous people. On the other hand, there is a legitimate need for psychiatrists to identify and manage what risk of violence does exist in their patients. Research that examines how and why violence occurs in the mentally ill is necessary for psychiatrists to determine as accurately as possible which patients are prone to violence and to manage their care accordingly.
Traumatic experiences in childhood have been linked to the potential for violence in adulthood as well as to vulnerability to psychiatric disorders.1-5 Bipolar disorder has been linked to traumatic childhood experience and to the potential for violence.
In this review, we explain the association between bipolar disorder, trauma, and violence, and we suggest ways of assessing violence potential in bipolar patients.
Childhood trauma in bipolar disorder
DSM-5 defines trauma as exposure to an event that involves “actual or threatened death, serious injury, or sexual violence.” The traumatic event can be experienced firsthand or by learning that the event occurred in a close family member or friend. Moreover, the traumatic event is experienced repeatedly or there is extreme exposure to the details of the event.
A history of childhood traumatic experience has been associated with increased vulnerability to multiple mental disorders, including mood disorders and personality disorders.3-5 Etain and colleagues6 found that a history of 2 or more types of trauma is associated with a 3-fold increase in the risk of bipolar disorder. Prognosis and course of bipolar disorder are worse when there is a history of trauma. Trauma history is associated with earlier onset of bipolar disorder; faster cycling; increased rates of suicide; and more comorbidity, including anxiety disorders, personality disorders, and substance use disorders.7-10
Etain and colleagues6,11 have shown that in patients with bipolar disorder, more than 50% report childhood trauma, with a high incidence of emotional abuse; 63% of the patients had experienced 2 or more forms of trauma as well as more severe forms. Conus and colleagues12 found that about 80% of patients with bipolar disorder had experienced at least 1 stressful life event. Among them, 16% had been physically abused, 15% had been sexually abused, 40% had experienced parental separation, and 20% had problems with a partner.
There are several pathways by which childhood trauma could lead to the development of bipolar disorder. Any one or a combination of these pathways could be operational in the development of bipolar disorder in individuals who have experienced childhood trauma. Thus, either the trauma itself or the factors that lead to trauma—or both—could affect the development and course of bipolar disorder.
• Affective disturbances in relationships between parents and their children directly predispose the children to affective disturbances in adulthood
• Children in whom bipolar disorder later develops are prone to more behavioral disturbances in childhood (a prodrome, or early onset, of bipolar disorder), which could disrupt relationships with parents and lead to dysfunctional parenting
• Children of affectively ill parents could be affected by genetic transmission of affective illness predisposition as well as by parental psychopathology, which increases the likelihood of childhood trauma
The link between trauma and violence in bipolar disorder
Childhood trauma history has been found to correlate with increased aggression in adults with and without affective disorders.1,2,13 In addition, there is an overlap between the neurochemical changes found in adults with histories of traumatic stress and those found in adults with increased impulsive aggression—in particular, increased functioning of both the catecholamine system and the hypothalamic-pituitary-adrenal axis.14
Dr Lee is Assistant Professor of Psychiatry at the Albert Einstein College of Medicine, Bronx, NY. Dr Galynker is Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, Director of The Family Center for Bipolar Disorder, and Associate Chairman in the department of psychiatry and behavioral sciences at Mount Sinai Beth Israel, New York. Ms Kopeykina is Program Manager and Mr Kim and Ms Khatun are Research Assistants at The Family Center for Bipolar Disorder.
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