7 Steps to Prevent and Manage Violence in Bipolar Patients

November 6, 2014

Allison M. R. Lee, MD, Igor I. Galynker, MD, PhD

Â Related content:For more on this topic please see “Violence in Bipolar Disorder,” by Allison M. R. Lee, MD and Igor I. Galynker, MD, PhD, on which this slideshow is based.

The bipolar diagnosis introduces some unique aspects to violence prevention and management, although the general principles are similar to those for patients with other psychiatric disorders. This slideshow summarizes 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 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. Mixed states may be especially high-risk; these 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; teaching them when 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 for aggressive behavior.