Tasnia Khatun

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.

 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.

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.

 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.

 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 colleagues

 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.

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.

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.

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.

 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.

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 Î³-amino-butyric acid (GABA)ergic activity.

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.

• 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.

 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 (

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.

 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.

. 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.

 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.

Frame treatment that addresses aggressive behavior in a way that respects the patient’s desire for control; for example, convey that the medication will help the patient control himself rather than saying that the medication will control the patient. A collaborative approach maximizes the patient-physician alliance.

. Because the risk of violent behavior increases during an episode, the sooner mood symptoms can be ameliorated the lower the risk. In addition to the agitation and hyperactivity of mania (or sometimes depression), psychotic symptoms are important targets of violence prevention. Symptoms such as paranoid delusions or command auditory hallucinations can contribute to violent behavior, with a greater number of psychotic-like experiences associated with a higher risk of violence.

 Mixed states may be especially high-risk and may respond better to valproate than to lithium.

. Those close to a person with bipolar disorder can be both potential victims of aggressive behavior and potential sources of help in symptom monitoring, especially for patients with poor insight. Determine with the patient and family what the early warning signs of a mood episode are for that person so that intervention can be instituted early, before behavior becomes unmanageable. Educating friends and family can prevent violence by helping them avoid behavior that could worsen the patient’s aggression; help them understand the need to leave a situation that may become volatile and when urgent intervention is needed (eg, calling 911).

. Bipolar patients may be impulsive even during euthymia, especially if there is comorbid borderline personality disorder. Consider referring the patient for dialectical behavioral therapy if borderline features dominate the clinical picture or if there is a significant history of impulsive risk taking or self-harm during euthymia.

. Substance use disorders are highly comorbid with bipolar disorder and are a major risk factor for violence. Aggressively assess and treat such disorders, and refer the patient to specialized outpatient programs or restrictive residential programs, if needed.

. Use assertiveness training, social skills training, anger management training, and stress management training as needed to help the person express his needs, manage potentially frustrating interactions, avoid stress, and handle any anger that arises.

. If a bipolar patient is an acute danger to others, steps must be taken to incapacitate him. These include involuntary hospitalization and medication. Bipolar patients are most often involuntarily hospitalized during manic episodes. An aggressive pharmacological approach should be taken to address the manic symptoms so as to quickly diminish the risk of aggressive behavior.

Aside from treating the manic episode, other measures may be used if needed to quickly control aggressive behavior. These include sedating medication (eg, benzodiazepines, antipsychotics), seclusion, and restraint. It is important to provide an environment that minimizes overstimulation and includes clear interpersonal communication and limit-setting.

Bipolar disorder is associated with a high prevalence of childhood trauma as well as with the possibility of aggressive and potentially violent behavior. It is important for clinicians to assess a patient’s potential for violence as accurately as possible to minimize risk. Taking clinical and historical information into account, such as mood symptoms and history of violence, substance abuse, childhood trauma, and impulsivity, can help clinicians make an accurate assessment.

Handling emergencies and treating mood episodes pharmacologically are first steps in managing risk; this should be followed up with treating substance abuse and trait impulsivity and with involving significant others and teaching coping skills. Recognizing the impact of early trauma on a patient can help improve the therapeutic alliance and lead to better outcomes.

This article was originally published on November 17, 2010 and has since been updated.

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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