The prevalence of childhood trauma in persons with bipolar disorder combined with the risks that arise from the symptoms of the disorder itself renders bipolar patients at increased risk for violent behavior. Because childhood trauma has been associated with earlier onset and a greater number of episodes, there is more cumulative time when aggressive behavior is most likely to manifest. In addition, a history of trauma is associated with an increase in rates of substance abuse, which itself is associated with significant violence risk. Aggressiveness is often shown in different clinical settings, including bipolar, borderline, and antisocial personality disorders. Comorbidity with borderline personality disorder is associated with a higher risk of aggression in bipolar disorder during periods of euthymia.
Violence and aggression
Persons with bipolar disorder are at significantly increased risk for violence, with some history of violent behavior ranging from 9.4% to just under 50%, often in the presence of comorbid diagnoses.15-18 Bipolar patients are prone to agitation that can result in impulsive aggression during manic and mixed episodes. However, depressed states can involve intense dysphoria with agitation and irritability, which can also increase the risk of violent behavior. Bipolar patients may have chronic impulsivity during euthymia, predisposing them to aggression. This is especially true with comorbid features of borderline personality disorder. In fact, particularly high levels of impulsivity and aggression in a bipolar patient could be a strong indicator of comorbidity with borderline personality disorder.19
Impulsive aggression (as opposed to premeditated aggression) is most commonly associated with bipolar and other affective disorders. In animal models, premeditated aggression corresponds to predatory behavior, while impulsive aggression is a response to perceived threat (the fight in fight-or-flight). As either a state or trait, increased impulsive aggression is driven by an increase in the strength of aggressive impulses or a decrease in the ability to control these impulses. Neurochemically, impulsive aggression has been associated with low serotonin levels, high catecholamine levels, and a predominance of glutamatergic activity relative to γ-amino-butyric acid (GABA)ergic activity.20
Assessing violence risk
In many ways, the assessment of violence risk in patients with bipolar disorder is similar to risk assessment in any patient. Certain data from the patient’s history and mental status examination are universally important:
• A history of violent acts, especially recent ones and especially if there were any legal consequences.
• The extent of alcohol and drug use, because there is a strong association between substance abuse and risk of violence.19
• Trauma history has a unique relationship with bipolar disorder, and it should be assessed in all patients to determine the risk of violence. Trauma is associated with increased aggression in adults in general, regardless of whether an affective disorder is present.
• Other important historical data include demographic information (young men of low socioeconomic status who have few social supports are the most likely to be violent) and access to weapons.
• In the mental status assessment, it is important to note psychomotor agitation as well as the nature, frequency, and severity of violent ideation.
• Use of an actuarial instrument, such as the Historical, Clinical, and Risk Management-20 (HCR-20) violence assessment scheme, can help integrate systematic inquiry about evidence-based risk factors into assessment of the clinical scenario.21 Although such instruments are often developed for use in forensic populations, they can be integrated into the assessment of other populations; for example, the 10 historical items of the HCR can be used as a structured checklist in conjunction with a clinical assessment (Table).22
In assessing patients with bipolar disorder, pay special attention to violent behavior that may have occurred when the person was manic. Also consider violence during euthymic periods, especially in patients who are substance abusers or who have Axis II comorbidity. If at all possible, obtain collateral information about the history of violence. Patients may minimize previous violent actions or not remember them, especially if they were in the midst of a manic episode.
Bipolar patients are most prone to violence during manic or mixed states—when maximum behavioral dyscontrol is combined with unrealistic beliefs. Patients with dysphoric mania and mixed states may be at especially high risk; the assessment for concurrent depression in a manic patient should therefore be a priority.
Symptoms of bipolar disorder often overlap with those of borderline personality disorder. Comorbid borderline personality disorder, which is often associated with trauma history, has been shown to predict violence potential in bipolar patients, especially during periods of euthymia.19,23 Impulsivity is a prominent feature of bipolar disorder. Information about previous impulsive acts, especially acts of impulsive aggression, can give the clinician an idea of a person’s likelihood to commit violence on impulse. Often, patients with bipolar disorder will use alcohol and other drugs to self-medicate mood episodes or as part of the pleasure-seeking behavior of a manic episode.
Prevention and management of violence in bipolar patients
The bipolar diagnosis introduces some unique aspects to violence prevention and management, although the general principles are similar to those for patients with other disorders. There are 7 areas that are particularly important in the prevention and management of violence in bipolar patients.
A positive treatment alliance. This can be a challenge in bipolar patients who may have low motivation for treatment, especially if they have poor insight or if they enjoy their manic symptoms. In addition, a history of childhood abuse can lead to diminished capacity for trust and collaboration with the clinician.24 To improve the alliance with a reluctant bipolar patient, identify his or her particular barriers to acceptance of treatment and work to diminish them. It may be helpful to normalize the enjoyment of mania and to empathize with the patient’s resistance to treatment as an understandable desire to be healthy and independent.
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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