Article

Predictors of trait aggression in bipolar disorder

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Abstract

Although aggressive behavior has been associated with bipolar disorder (BD), it has also been linked with developmental factors and disorders frequently found to be comorbid with BD, making it unclear whether or not it represents an underlying biological disturbance intrinsic to bipolar illness. We therefore sought to identify predictors of trait aggression in a sample of adults with BD. Subjects were 100 bipolar I (n = 73) or II (n = 27) patients consecutively evaluated in the Bipolar Disorders Research Program of the New York Presbyterian Hospital-Payne Whitney Clinic. Diagnoses were established using the Structured Clinical Interview for the DSM-IV (SCID-I) and Cluster B sections of the SCID-II. Mood severity was rated by the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS). Histories of childhood maltreatment were assessed via the Childhood Trauma Questionnaire (CTQ), while trait aggression was measured by the Brown-Goodwin Aggression Scale (BGA). In univariate analyses, significant relationships were observed between total BGA scores and CTQ total (r = 0.326, p = 0.001), childhood emotional abuse (r = 0.417, p < 0.001), childhood physical abuse (r = 0.231, p = 0.024), childhood emotional neglect (r = 0.293, p = 0.004), post-traumatic stress disorder (t = -2.843, p = 0.005), substance abuse/dependence (t = -2.914, p = 0.004), antisocial personality disorder (t = -2.722, p = 0.008) and borderline personality disorder (t = -5.680, p < 0.001) as well as current HDRS (r = 0.397, p < 0.001) and YMRS scores (r = 0.371, p < 0.001). Stepwise multiple regression revealed that trait aggression was significantly associated with: (i) diagnoses of comorbid borderline personality disorder (p < 0.001); (ii) depressive symptoms (p = 0.001); and (iii) manic symptoms (p < 0.001). Comorbid borderline personality disorder and current manic and depressive symptoms each significantly predicted trait aggression in BD, while controlling for confounding factors. The findings have implications for nosologic distinctions between bipolar and borderline personality disorders, and the developmental pathogenesis of comorbid personality disorders as predisposing to aggression in patients with BD.

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... Previous studies have shown that comorbidity with other disorders, namely substance and alcohol abuse and borderline personality disorder (BPD), increased the risk of aggressiveness in BD patients (12,13). ...
... This emerged from both psychometric and clinical assessment, and included higher rates of psychiatric comorbidities, more affective episodes, higher frequencies of lack of psychiatric treatment, greater impairment in global social/occupational functioning, more frequent psychotic symptoms and higher rates of previous suicide attempts. Similar findings were reported in previous studies (13,23,33), showing that the presence of aggressive behaviors had a significant impact on the clinical outcome of the BD illness, with major implications in terms of management and treatment strategies. ...
... In particular, the comorbidity with BPD and substance abuse were significantly more reported in depressed patients with aggressiveness. Previous studies found that the presence of comorbid BPD could have an independent predictive value in determining trait aggressiveness in patients with BD (13). It has been supposed that the link between BD, BPD, substance abuse and aggressiveness involves the role of impulsivity (13,46), indicating that aggressive behaviors could be more associated with impulsive-related comorbidities than with bipolar illness itself. ...
Article
Objective: To evaluate aggressiveness during a major depressive episode (MDE) and its relationship with bipolar disorder (BD) in a post hoc analysis of the BRIDGE-II-MIX study. Method: A total of 2811 individuals were enrolled in this multicenter cross-sectional study. MDE patients with (MDE-A, n = 399) and without aggressiveness (MDE-N, n = 2412) were compared through chi-square test or Student's t-test. A stepwise backward logistic regression model was performed. Results: MDE-A group was more frequently associated with BD (P < 0.001), while aggressiveness was negatively correlated with unipolar depression (P < 0.001). At the logistic regression, aggressiveness was associated with the age at first depressive episode (P < 0.001); the severity of mania (P = 0.03); the diagnosis of BD (P = 0.001); comorbid borderline personality disorder (BPD) (P < 0.001) but not substance abuse (P = 0.63); no current psychiatric treatment (P < 0.001); psychotic symptoms (P = 0.007); the marked social/occupational impairment (P = 0.002). The variable most significantly associated with aggressiveness was the presence of DSM-5 mixed features (P < 0.001, OR = 3.815). After the exclusion of BPD, the variable of lifetime suicide attempts became significant (P = 0.013, OR = 1.405). Conclusion: Aggressiveness seems to be significantly associated with bipolar spectrum disorders, independently from BPD and substance abuse. Aggressiveness should be considered as a diagnostic criterion for the mixed features specifier and a target of tailored treatment strategy.
... This emerged from both psychometric and clinical assessment, and included higher rates of psychiatric comorbidities, more affective episodes, higher frequencies of lack of psychiatric treatment, greater impairment in global social/occupational functioning, more frequent psychotic symptoms and higher rates of previous suicide attempts. Similar findings were reported in previous studies (13,23,33), showing that the presence of aggressive behaviors had a significant impact on the clinical outcome of the BD illness, with major implications in terms of management and treatment strategies. ...
... Previous studies found that the presence of comorbid BPD could have an independent predictive value in determining trait aggression in patients with BD (13). It has been supposed that the link between BD, BPD, substance abuse and aggression involves the role of impulsivity (13,46), indicating that aggressive behaviors could be more associated with impulsive-related comorbidities than with bipolar illness itself. ...
... Previous studies found that the presence of comorbid BPD could have an independent predictive value in determining trait aggression in patients with BD (13). It has been supposed that the link between BD, BPD, substance abuse and aggression involves the role of impulsivity (13,46), indicating that aggressive behaviors could be more associated with impulsive-related comorbidities than with bipolar illness itself. ...
... However, in studying persons with BD, they did not detect associations of BIS with decreased OFC GMV, but instead with dorsal and rostral anterior cingulate cortex (ACC) GMV (Cauda et al., 2011), particularly associated with the motor subscale (Matsuo et al., 2009b), suggesting the connection between ACC volume and cognitive motor control in BD. Both aggression and impulsiveness measures have shown associations with childhood maltreatment (CM) (Adigüzel et al., 2019;Garno et al., 2008;Richard-Lepouriel et al., 2019;Song et al., 2020;Tunc and Kose, 2019), mood symptoms (Garno et al., 2008;Strakowski et al., 2009;Swann et al., 2008), substance use disorders (SUDs) (Cassidy et al., 2001;Garno et al., 2008;Grunebaum et al., 2006a;Latalova, 2009;Swann et al., 2004) and suicide behavior in BD (Ekinci et al., 2011;Gilbert et al., 2011;Grunebaum et al., 2006b;Jiménez et al., 2012Jiménez et al., , 2016Mahon et al., 2012;Michaelis et al., 2004;Oquendo et al., 2004Oquendo et al., , 2000Reich et al., 2019). Thus, improved understanding of aggression and impulsivity in BD, and the relationship between them with factors, such as CM, SUD, and severe outcomes, could inform prevention strategies. ...
... However, in studying persons with BD, they did not detect associations of BIS with decreased OFC GMV, but instead with dorsal and rostral anterior cingulate cortex (ACC) GMV (Cauda et al., 2011), particularly associated with the motor subscale (Matsuo et al., 2009b), suggesting the connection between ACC volume and cognitive motor control in BD. Both aggression and impulsiveness measures have shown associations with childhood maltreatment (CM) (Adigüzel et al., 2019;Garno et al., 2008;Richard-Lepouriel et al., 2019;Song et al., 2020;Tunc and Kose, 2019), mood symptoms (Garno et al., 2008;Strakowski et al., 2009;Swann et al., 2008), substance use disorders (SUDs) (Cassidy et al., 2001;Garno et al., 2008;Grunebaum et al., 2006a;Latalova, 2009;Swann et al., 2004) and suicide behavior in BD (Ekinci et al., 2011;Gilbert et al., 2011;Grunebaum et al., 2006b;Jiménez et al., 2012Jiménez et al., , 2016Mahon et al., 2012;Michaelis et al., 2004;Oquendo et al., 2004Oquendo et al., , 2000Reich et al., 2019). Thus, improved understanding of aggression and impulsivity in BD, and the relationship between them with factors, such as CM, SUD, and severe outcomes, could inform prevention strategies. ...
... However, in studying persons with BD, they did not detect associations of BIS with decreased OFC GMV, but instead with dorsal and rostral anterior cingulate cortex (ACC) GMV (Cauda et al., 2011), particularly associated with the motor subscale (Matsuo et al., 2009b), suggesting the connection between ACC volume and cognitive motor control in BD. Both aggression and impulsiveness measures have shown associations with childhood maltreatment (CM) (Adigüzel et al., 2019;Garno et al., 2008;Richard-Lepouriel et al., 2019;Song et al., 2020;Tunc and Kose, 2019), mood symptoms (Garno et al., 2008;Strakowski et al., 2009;Swann et al., 2008), substance use disorders (SUDs) (Cassidy et al., 2001;Garno et al., 2008;Grunebaum et al., 2006a;Latalova, 2009;Swann et al., 2004) and suicide behavior in BD (Ekinci et al., 2011;Gilbert et al., 2011;Grunebaum et al., 2006b;Jiménez et al., 2012Jiménez et al., , 2016Mahon et al., 2012;Michaelis et al., 2004;Oquendo et al., 2004Oquendo et al., , 2000Reich et al., 2019). Thus, improved understanding of aggression and impulsivity in BD, and the relationship between them with factors, such as CM, SUD, and severe outcomes, could inform prevention strategies. ...
Article
Background Elevated aggression and impulsivity are implicated in Bipolar Disorder (BD); however, relationships between these behavioral constructs have not been clarified, which can lead to misconceptions with negative consequences including stigma and adverse outcomes including suicide. The study aimed to clarify brain-based distinctions between the two constructs and their associations to risk factors, symptoms and suicide thoughts and behaviors. Methods Self-rated Brown-Goodwin Aggression (BGA) and Barratt Impulsiveness Scale (BIS) scores were compared between adults with BD (N=38, 74% female) and healthy control (HC, n=29, 64% female). Relationships were examined between BGA and BIS with childhood trauma questionnaire (CTQ), mood, comorbidities, and magnetic resonance imaging gray matter volume (GMV) assessments. Results In BD, BGA and BIS total scores were both elevated and associated with childhood maltreatment (CM), particularly emotional CM, depression, substance use disorders (SUDs) and suicide attempts (SAs). BGA scores were increased by items corresponding to dysregulation of emotional and social behavior and associated with elevated mood states and suicide ideation and GMV decreases in bilateral orbitofrontal cortex and left posterior insula brain regions, previously associated with these behaviors and clinical features. BIS motor impulsiveness scores were associated with GMV decreases in anterior cingulate cortex implicated in mood and behavioral dyscontrol. Limitations modest sample size, self-reports Conclusions The findings suggest separable brain-based domains of dysfunction in BD of a motor impulsiveness versus emotionally dysregulated feelings primarily self-directed. Both domains are associated with suicide behavior and modifiable risk factors of CM, depression and SUDs that could be targeted for prevention.
... 12 Moreover, borderline personality disorder, which has been associated with a history of childhood trauma, has been linked to increased impulsive aggression in bipolar patients during periods of euthymia. 5,13 Violence and aggression in bipolar disorder Studies have found that just under 50% of people with bipolar disorder have some history of violent behavior. 14 Bipolar patients are prone to agitation that may result in impulsive aggression during manic and mixed episodes. ...
... In animal models, premeditated aggression corresponds to predatory behavior, while impulsive aggression is a response to perceived threat (the fight in fight-or-flight). 13,17 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, dysphoria with agitation and irritability, may also carry a risk of violent behavior. ...
... 16 Even during euthymia, bipolar patients-especially those with comorbid features of borderline personality disorder-may have chronic impulsivity that predisposes them to aggression. 13 Impulsive aggression (as opposed to premeditated aggression) is most commonly associated with bipolar (Please see Violence, page 34) At Western Psychiatric Institute and Clinic of UPMC, we take on complex disorders that some other centers won't even attempt to treat. ...
Article
Full-text available
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 historical and clinical information into account, such as violence history, substance abuse, childhood trauma, and impulsivity in addition to mood symptoms can help clinicians reach 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 treatment outcomes.
... ASPD prevalence in BD ranged between 4.8% and 63% [47,57] and was higher in BD I [37] than II [17,49,58] and, in particular, in BD patients with substance use disorder (SUD) comorbid [47][48][49] with combined cocaine and alcohol abuse was most frequent [48,49,59]. Patients with BD and ASPD in comorbidity showed early onset [58], a higher number of depressive and manic episodes [47], higher scores of depression [59] and psychosis [47], more aggressive [60], and impulsive [47,61] traits and more suicide attempts [47]. The psychometric tools used to assess the psychopathology were the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS) [49,57], the 12-Item Short Form Survey (SF-12) [49,57], the Barratt Impulsiveness Scale (BIS-11) [47,58], the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto-questionnaire version (TEMPS-A) [62], Hamilton Depression Rating Scale (HDRS) [60,63], Young mania rating scale (YMRS) [60,63], Brown-Goodwin Aggression Scale (BGA) [60], and the Schedule for Affective Disorders and Schizophrenia (SADS-C) [47,63]. ...
... Patients with BD and ASPD in comorbidity showed early onset [58], a higher number of depressive and manic episodes [47], higher scores of depression [59] and psychosis [47], more aggressive [60], and impulsive [47,61] traits and more suicide attempts [47]. The psychometric tools used to assess the psychopathology were the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS) [49,57], the 12-Item Short Form Survey (SF-12) [49,57], the Barratt Impulsiveness Scale (BIS-11) [47,58], the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto-questionnaire version (TEMPS-A) [62], Hamilton Depression Rating Scale (HDRS) [60,63], Young mania rating scale (YMRS) [60,63], Brown-Goodwin Aggression Scale (BGA) [60], and the Schedule for Affective Disorders and Schizophrenia (SADS-C) [47,63]. ASPD symptoms predicted a history of many depressive and manic episodes (but not either type alone) and a early onset. ...
... Patients with BD and ASPD in comorbidity showed early onset [58], a higher number of depressive and manic episodes [47], higher scores of depression [59] and psychosis [47], more aggressive [60], and impulsive [47,61] traits and more suicide attempts [47]. The psychometric tools used to assess the psychopathology were the Alcohol Use Disorder and Associated Disabilities Interview Schedule (AUDADIS) [49,57], the 12-Item Short Form Survey (SF-12) [49,57], the Barratt Impulsiveness Scale (BIS-11) [47,58], the Temperament Evaluation of Memphis, Pisa, Paris and San Diego-auto-questionnaire version (TEMPS-A) [62], Hamilton Depression Rating Scale (HDRS) [60,63], Young mania rating scale (YMRS) [60,63], Brown-Goodwin Aggression Scale (BGA) [60], and the Schedule for Affective Disorders and Schizophrenia (SADS-C) [47,63]. ASPD symptoms predicted a history of many depressive and manic episodes (but not either type alone) and a early onset. ...
Article
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Background and Objectives: Bipolar Disorder (BD) is a severe psychiatric disorder that worsens quality of life and functional impairment. Personality disorders (PDs), in particular Cluster B personality, have a high incidence among BD patients and is considered a poor prognostic factor. The study of this co-morbidity represents an important clinical and diagnostic challenge in psychiatry. Particularly, clinical overlap has been shown between antisocial personality disorder (ASPD) and BD that could worsen the course of both disorders. We aimed to detect the frequency of ASPD in bipolar patients with greater accuracy and the impact of ASPD on the clinical course of BD. Materials and Methods: A systematic literature search was conducted in PubMed, Embase, MEDLINE and the Cochrane Library through December 2020 without language or time restriction, according to PRISMA statement guidelines. Results: Initially, 3203 items were identified. After duplicates or irrelevant paper deletion, 17 studies met the inclusion criteria and were included in this review. ASPD was more frequent among BD patients, especially in BD type I. BD patients with ASPD as a comorbidity seemed to have early onset, higher number and more severe affective episodes, higher levels of aggressive and impulsive behaviors, suicidality and poor clinical outcome. ASPD symptoms in BD seem to be associated with a frequent comorbidity with addictive disorders (cocaine and alcohol) and criminal behaviors, probably due to a shared impulsivity core feature. Conclusions: Considering the shared symptoms such as impulsive and dangerous behaviors, in patients with only one disease, misdiagnosis is a common phenomenon due to the overlapping symptoms of ASPD and BD. It may be useful to recognize the co-occurrence of the disorders and better characterize the patient with ASPD and BD evaluating all dysfunctional aspects and their influence on core symptoms.
... In patients with BD, higher levels of trauma correlated with a higher emotional deregulation such as increased affective lability and affect intensity (Aas et al., 2014a;Etain et al., 2008). Childhood trauma has also been associated with traits of aggression in BD (Garno et al., 2008), suggesting that childhood trauma might influence not only emotional regulation but also components of hostility or impulsivity. In turn, such measures of emotional, behavioral and impulsive dysregulation have been proposed to be associated to the clinical complexity/severity of BD. ...
... In patients with BD, impulsivity has also been associated with alcohol or cannabis misuse comorbidity, rapid cycling and mixed episodes (Etain et al., 2013b), but not with suicidality when using assessments such as the Barrat Impulsivity Scale (Etain et al., 2013b;Olie et al., 2015;Parmentier et al., 2012;Patton et al., 1995). Finally, externalized or internalized hostility and aggression traits were associated with suicide attempts in BD (Galfalvy et al., 2006;Garno et al., 2008;Parmentier et al., 2012). ...
... Not only being bipolar patient but also, being male [13], having current psychotic symptoms [14], co-morbid substance abuse and personality disorders [15,16] show significant association with aggressive behaviour. Trait aggression was significantly associated with diagnoses of childhood emotional abuse and neglect, childhood physical abuse, post-traumatic stress disorder, antisocial personality disorder [17]. ...
... Any current substance usage of (alcohol, smoking, and khat) among bipolar patients had two times more likely aggressive than patients who hadn't use of these substances [AOR = 2.17, 95% CI (1.16, 4.06)]. Studies in Sweden, Nigeria, USA, and Czech Republic agree with this finding in which use of substances increase the impulsivity and emotionality of bipolar patients [10,12,17,27]. The possible justification may be use of these substances had influence on the effect of medication and worsening of active symptoms. ...
Article
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Background Aggressive behavior is a challenging behavior among bipolar patients that causes poor social interaction and hospitalization. But, there is no information regards of the magnitude and contributing factors for aggressive behaviour among bipolar patients in Ethiopia. Therefore, this study was designed to assess the prevalence and associated factors of aggressive behaviour among patients with bipolar disorder. Method An institutional based cross sectional study was conducted at Amanual Mental Specialized Hospital from May 1 to June 1, 2015 among 411 participants who were selected by systematic random sampling technique. Data was collected by interview technique by using Modified Overt Aggression Scale, entered and analyzed by using Epi Data 3.1 and Statistical Package for Social Science version 20, respectively. Adjusted Odd Ratio (AOR) with 95% Confidence Interval (CI) were used to show the odd and P-value <0.05 was considered as statistically significant. Results A total of 411 bipolar patients were included in the study and the prevalence of aggressive behaviour was 29.4%. Significant associated factors for aggression were, having two or more episode [AOR = 2.35 95% CI (1.18, 4.69)], previous history of aggression, [AOR = 3.72, 95% CI (1.54, 8.98)], depressive symptoms [AOR = 3.63, 95% CI (1.89, 6.96)], psychotic symptoms [AOR = 5.41,95% CI (2.88, 10.1)], manic symptoms [AOR = 3.85,95% CI (2.06, 7.19)], poor medication adherence [AOR = 3.73 95% CI (1.71, 8.13)], poor social support [AOR = 2.99 95% CI (1.30, 6.91)] and current use of substance[AOR = 2.17 95% CI (1.16, 4.06)]. Conclusion Prevalence of aggression is high among bipolar patients and associated with many factors. So it needs public health attention to decrease aggression among bipolar patients.
... Previous studies showed that CT is a contributing factor to aggressive behaviors (MOAS) in BD (Garno et al., 2008). Our study showed that this association is more pronounced in male victims with BD than in female victims with BD. ...
... These outcomes could be due to gender-related differences in coping mechanisms to CT among PBD patients (Adams et al., 2013;Chaplin and Aldao, 2013). These maladaptive coping mechanisms and impulsivity are often the signs of emotional dysregulation (Marusak et al., 2015), which are well-established mediators of CT outcomes in adults with BD (Garno et al., 2008;Pompili et al., 2013). ...
Article
Objective Histories of childhood trauma (CT) are risk factors for affect dysregulation and poor clinical outcomes in women with bipolar disorder (BD). While much is known about the link between BD and CT in adult patients, there is limited data on this research topic in pediatric BD (PBD). The present study aims to investigate the impact of CT on irritability, aggressive and suicidal behaviors in PBD patients across gender types. Methods From 2013 to 2015, 59 PBD patients Aged 6–17 (30 female) were administered the Childhood Trauma Questionnaire (CTQ) along with scales assessing irritability (Affective Reactivity Index), aggression (Modified Overt Aggression Scale) and suicidal thoughts and behaviors (Columbia-Suicide Severity Rating Scale). We examined the severity of these behaviors across types of CT and gender using univariate regression analyses. Findings were adjusted for age, number of traumas, and CTQ denial score. Results In PBD patients, analyses showed that the effect of physical abuse depended on gender, whereby females were more likely than males to engage in suicidal thoughts and behaviors (p < 0.05). Male gender and CT were strong determinants of irritability (p < 0.05). Violence against property and people was found to be reduced in females, and increased in males with a history of emotional and sexual abuse, respectively (p < 0.05). Conclusion These preliminary findings highlight the significant impact of CT in PBD and suggest that gender may predict the risk for dysfunctional behaviors in PBD patients with CT. Future large scale, longitudinal, investigations focusing on fear processing and extinction may provide a deeper understanding of these gender differences, and their role in the course of BD.
... In patients with BD, higher levels of trauma correlated with a higher emotional deregulation such as increased affective lability and affect intensity (Aas et al., 2014a;Etain et al., 2008). Childhood trauma has also been associated with traits of aggression in BD (Garno et al., 2008), suggesting that childhood trauma might influence not only emotional regulation but also components of hostility or impulsivity. In turn, such measures of emotional, behavioral and impulsive dysregulation have been proposed to be associated to the clinical complexity/severity of BD. ...
... In patients with BD, impulsivity has also been associated with alcohol or cannabis misuse comorbidity, rapid cycling and mixed episodes (Etain et al., 2013b), but not with suicidality when using assessments such as the Barrat Impulsivity Scale (Etain et al., 2013b;Olie et al., 2015;Parmentier et al., 2012;Patton et al., 1995). Finally, externalized or internalized hostility and aggression traits were associated with suicide attempts in BD (Galfalvy et al., 2006;Garno et al., 2008;Parmentier et al., 2012). ...
Article
Background: This study aims at testing for paths from childhood abuse to clinical indicators of complexity in bipolar disorder (BD), through dimensions of affective dysregulation, impulsivity and hostility. Method: 485 euthymic patients with BD from the FACE-BD cohort were included from 2009 to 2014. We collect clinical indicators of complexity/severity: age and polarity at onset, suicide attempt, rapid cycling and substance misuse. Patients completed questionnaires to assess childhood emotional, sexual and physical abuses, affective lability, affect intensity, impulsivity, motor and attitudinal hostility. Results: The path-analysis demonstrated significant associations between emotional abuse and all the affective/impulsive dimensions (p < 0.001). Sexual abuse was moderately associated with emotion-related dimensions but not with impulsivity nor motor hostility. In turn, affect intensity and attitudinal hostility were associated with high risk for lifetime presence of suicide attempts (p < 0.001), whereas impulsivity was associated with a higher risk of lifetime presence of substance misuse (p < 0.001). No major additional paths were identified when including Emotional and Physical Neglect in the model. Conclusions: This study provides refinement of the links between early adversity, dimensions of psychopathology and the complexity/severity of BD. Mainly, dimensions of affective dysregulation, impulsivity/hostility partially mediate the links between childhood emotional to suicide attempts and substance misuse in BD.
... Disorders associated with risk-taking behavior, such as bipolar disorder (BD), are characterized by elevated and abnormally persistent positive emotions (39), excessive reward pursuit and deficits in reward-related learning [e.g., Ref. (40)], and deficits in positive emotion regulation [e.g., Ref. (41)(42)(43)]. BD is often characterized by elevated risk-taking behaviors and impulsivity (44,45), such as substance use (46), impulsive gambling behavior (47), aggressive behavior (48), and harmful substance use (46). Broadly, deficits in the behavioral approach system (BAS) are thought to characterize BD and elevated behavioral dysregulation (49). ...
... Clinical disorders associated with risk-taking behavior, such as BD, are characterized by elevated and abnormally persistent positive emotions (39), excessive reward pursuits and deficits in reward-related learning [e.g., Ref. (40)], and deficits in positive emotion regulation [e.g., Ref. (3,41,42)]. BD is often characterized by elevated risk-taking behaviors and impulsivity (44,45), such as substance use (46), impulsive gambling behavior (47), aggressive behavior (48), and harmful substance use (46). In addition to excessive positive emotion, this heightened irritability may also potentiate behavioral dysregulation, such as impulsive aggression (55). ...
Article
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Emerging lines of research suggest that both testosterone and maladaptive reward processing can modulate behavioral dysregulation. Yet, to date, no integrative account has been provided that systematically explains neuroendocrine function, dysregulation of reward, and behavioral dysregulation in a unified perspective. This is particularly important given specific neuroendocrine systems are potential mechanisms underlying and giving rise to reward-relevant behaviors. In this review, we propose a forward-thinking approach to study the mechanisms of reward and behavioral dysregulation from a positive affective neuroendocrinology (PANE) perspective. This approach holds that testosterone increases reward processing and motivation, which increase the likelihood of behavioral dysregulation. Additionally, the PANE framework holds that reward processing mediates the effects of testosterone on behavioral dysregulation. We also explore sources of potential sex differences and the roles of age, cortisol, and individual differences within the PANE framework. Finally, we discuss future prospects for research questions and methodology in the emerging field of affective neuroendocrinology.
... Risk factors for aggression were examined in a sample of 100 consecutively evaluated patients with bipolar disorder [153]. The 32-item Brown-Goodwin Aggression scale (BGA) [154] was used to assess lifetime history of aggression. ...
... In the study of 100 bipolar patients reviewed above [153], comorbid substance use disorder, posttraumatic stress Advances in Psychiatry 13 disorder, borderline personality disorder, and antisocial personality disorder were all found to be associated with elevated BGA scores in bivariate analyses. ...
Article
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Most individuals diagnosed with a mental illness are not violent, but some mentally ill patients commit violent acts. PubMed database was searched for articles published between 1980 and November 2013 using the combination of key words “schizophrenia” or “bipolar disorder” with “aggression” or “violence.” In comparison with the general population, there is approximately a twofold increase of risk of violence in schizophrenia without substance abuse comorbidity and ninefold with such comorbidity. The risk in bipolar disorder is at least as high as in schizophrenia. Most of the violence in bipolar disorder occurs during the manic phase. Violence among adults with schizophrenia may follow two distinct pathways: one associated with antisocial conduct and another associated with the acute psychopathology, particularly anger and delusions. Clozapine is the most effective treatment of aggressive behavior in schizophrenia. Emerging evidence suggests that olanzapine may be the second most effective treatment. Treatment nonadherence greatly increases the risk of violent behavior, and poor insight as well as hostility is associated with nonadherence. Nonpharmacological methods of treatment of aggression in schizophrenia and bipolar disorder are increasingly important. Cognitive behavioral approaches appear to be effective in cases where pharmacotherapy alone is not sufficient.
... Aggression and violence appear particularly likely when those with BD are experiencing current manic and depressive symptoms, comorbid substance-related diagnoses (Grunebaum et al., 2006;McNiel et al., 2003), borderline personality disorder (Carpiniello, Lai, Pirarba, Sardu, & Pinna, 2011), and PTSD (Garno, Gunawardane, & Goldberg, 2008). Hence symptom levels and comorbid conditions may be of importance for understanding the heightened rates of aggression, although comorbid conditions do not appear to fully explain the aggression levels observed within bipolar disorder (Johnson & Carver, 2016;Van Dorn, Volavka, & Johnson, 2012). ...
Article
In this era of insistence on evidence-based treatments, cognitive behavioral therapy (CBT) has emerged as a highly preferred choice for a spectrum of psychological disorders. Yet, it is by no means immune to some of the vagaries of client participation. Special concerns arise when clients drop out from treatment. The aim of this study was to answer questions about the rate and timing of dropout from CBT, with specific reference to pretreatment versus during treatment phases. Also explored were several moderators of dropout. A meta-analysis was performed on dropout data from 115 primary empirical studies involving 20,995 participants receiving CBT for a range of mental health disorders. Average weighted dropout rate was 15.9% at pretreatment, and 26.2% during treatment. Dropout was significantly associated with (a) diagnosis, with depression having the highest attrition rate; (b) format of treatment delivery, with e-therapy having the highest rates; (c) treatment setting, with fewer inpatient than outpatient dropouts; and (d) number of sessions, with treatment starters showing significantly reduced dropout as number of sessions increased. Dropout was not significantly associated with client type (adults or adolescents), therapist licensure status, study design (randomized control trial [RCT] vs. non-RCT), or publication recency. Findings are interpreted with reference to other reviews. Possible clinical applications include careful choice and supplementing of treatment setting/delivery according to the diagnosis, and use of preparatory strategies. Suggestions for future research include standardization of operational definitions of dropout, specification of timing of dropout, and exploration of additional moderator variables. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
... Interestingly, childhood trauma is associated with increased amygdala activation (van Harmelen et al. 2013), a brain region important for regulating fear and emotions (Aas et al. 2012;Gallagher and Chiba 1996), thus reinforcing potential links between childhood trauma, changes in emotional or affect regulation and brain imaging abnormalities (limbic system). Childhood trauma is also a contributing factor to traits of aggression in BD (Garno et al. 2008), suggesting that childhood trauma could influence, in addition to emotional regulation, components of hostility or impulsivity that could prove to increase the risk for suicide attempt or substance misuse (Etain et al. 2013b;Parmentier et al. 2012). This could be related to the effects of childhood trauma on the brain inhibitory control network (Elton et al. 2014), and should be further investigated in BD. ...
... Lo strumento tradotto ha mostrato anche un'adeguata capacità di predire il livello di distress personale e la bassa autostima, due outcomes riscontrati nella letteratura relativa alle conseguenze del maltrattamento psicologico. Studi retrospettivi su soggetti adulti hanno evidenziato associazioni significative tra maltrattamento psicologico ed esiti negativi, tra cui disturbi mentali (per esempio, Garno, Gunawardane, & Goldberg, 2008), disturbi del comportamento alimentare (per esempio, Allison, Grilo, Copyright © FrancoAngeli N.B: Copia ad uso personale. È vietata la riproduzione (totale o parziale) dell'opera con qualsiasi mezzo effettuata e la sua messa a disposizione di terzi, sia in forma gratuita sia a pagamento. ...
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This research aims to evaluate the psychometric properties of an Italian version of the Psychological Maltreatment Measure (PMM-I) in a sample of 739 community members. The factor structure of the measure was explored, and internal consistency was tested. Finally, concurrent validity of the PMM-I with a measure of parental care and predictive validity to scores on distress occurrence and low levels of self-esteem were checked. Results, according to our assumptions and to the psychological maltreatment literature, show a two factor structure of the PMM-I, and suggest it is a reliable and valid measure for assessing psychological maltreatment in adult Italian samples.
... These factors can have adaptive benefits or negative impacts as well as anti-social characteristics [2,64,65]. Aggressive behaviours are associated with adjustment problems and several psychopathological symptoms such as Antisocial Personality Disorder (ASPD) [66,67], Borderline Personality Disorder (BPD) [68][69][70], Attention Deficit/Hyperactivity Disorder (ADHD) [71,72], Intermittent Explosive Disorder (IED) [73], Schizophrenia [74,75], and Bipolar Mood Disorder (BMD) [76,77]. Some of these disorders have different incidences for men and women [78][79][80], but gender differences are also observed in non-pathological manifestations of aggressive behaviours [2]. ...
Article
Aggression is a key component for social behaviour and can have an adaptive value or deleterious consequences. Here, we review the role of sex-related differences in aggressive behaviour in both human and nonhuman primates. First, we address aggression in primates, which varies deeply between species, both in intensity and in display, ranging from animals that are very aggressive, such as chimpanzees, to the nonaggressive bonobos. Aggression also influences the hierarchical structure of gorillas and chimpanzees, and is used as the main tool for dealing with other groups. With regard to human aggression, it can be considered a relevant adaptation for survival or can have negative impacts on social interaction for both sexes. Gender plays a critical role in aggressive and competitive behaviours, which are determined by a cascade of physiological changes, including GABAergic and serotonergic systems, and sex neurosteroids. The understanding of the neurobiological bases and behavioural determinants of different types of aggression is fundamental for minimising these negative impacts. Copyright © 2015. Published by Elsevier Inc.
... Interestingly, childhood trauma is associated with increased amygdala activation (van Harmelen et al. 2013), a brain region important for regulating fear and emotions (Aas et al. 2012;Gallagher and Chiba 1996), thus reinforcing potential links between childhood trauma, changes in emotional or affect regulation and brain imaging abnormalities (limbic system). Childhood trauma is also a contributing factor to traits of aggression in BD (Garno et al. 2008), suggesting that childhood trauma could influence, in addition to emotional regulation, components of hostility or impulsivity that could prove to increase the risk for suicide attempt or substance misuse (Etain et al. 2013b;Parmentier et al. 2012). This could be related to the effects of childhood trauma on the brain inhibitory control network (Elton et al. 2014), and should be further investigated in BD. ...
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This review will discuss the role of childhood trauma in bipolar disorders. Relevant studies were identified via Medline (PubMed) and PsycINFO databases published up to and including July 2015. This review contributes to a new understanding of the negative consequences of early life stress, as well as setting childhood trauma in a biological context of susceptibility and discussing novel long-term pathophysiological consequences in bipolar disorders. Childhood traumatic events are risk factors for developing bipolar disorders, in addition to a more severe clinical presentation over time (primarily an earlier age at onset and an increased risk of suicide attempt and substance misuse). Childhood trauma leads to alterations of affect regulation, impulse control, and cognitive functioning that might decrease the ability to cope with later stressors. Childhood trauma interacts with several genes belonging to several different biological pathways [Hypothalamic-pituitary-adrenal (HPA) axis, serotonergic transmission, neuroplasticity, immunity, calcium signaling, and circadian rhythms] to decrease the age at the onset of the disorder or increase the risk of suicide. Epigenetic factors may also be involved in the neurobiological consequences of childhood trauma in bipolar disorder. Biological sequelae such as chronic inflammation, sleep disturbance, or telomere shortening are potential mediators of the negative effects of childhood trauma in bipolar disorders, in particular with regard to physical health. The main clinical implication is to systematically assess childhood trauma in patients with bipolar disorders, or at least in those with a severe or instable course. The challenge for the next years will be to fill the gap between clinical and fundamental research and routine practice, since recommendations for managing this specific population are lacking. In particular, little is known on which psychotherapies should be provided or which targets therapists should focus on, as well as how childhood trauma could explain the resistance to mood stabilizers.
... Aggression and violence appear particularly likely when those with BD are experiencing current manic and depressive symptoms, comorbid substance-related diagnoses (Grunebaum et al., 2006;McNiel et al., 2003), borderline personality disorder (Carpiniello, Lai, Pirarba, Sardu, & Pinna, 2011), and PTSD (Garno, Gunawardane, & Goldberg, 2008). Hence symptom levels and comorbid conditions may be of importance for understanding the heightened rates of aggression, although comorbid conditions do not appear to fully explain the aggression levels observed within bipolar disorder (Johnson & Carver, 2016;Van Dorn, Volavka, & Johnson, 2012). ...
... Of interest, the increased risk for suicidality has been associated high-lethality suicidal behaviors ( Joyce et al., 2010;Neves et al., 2009Neves et al., , 2010). The two studies that evaluated hostility reported greater trait hostility among BD subjects with comorbid BPD in comparison with BD alone ( Garno et al., 2008;Wilson et al., 2007). Global functioning. ...
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Background: The relationship between bipolar disorder (BD) and borderline personality disorder (BPD) has been controversial and widely debated. Specifically, the comorbidity between both disorders has yielded a plethora of research, but there are no comprehensive reviews on this issue. Objective: To determine the empirical evidence regarding the comorbidity between BD and BPD based on prevalence data, explanatory theories for their co-occurrence, and clinical impact of one disorder in the other. Method: A comprehensive search of databases (PubMed and PsycINFO) was performed. Published manuscripts between January 1985 and August 2015 were identified. Overall, 70 studies fulfilled inclusion criteria. Results: Over a fifth of subjects showed comorbidity between BPD and BD. Empirical evidence from common underlying factors was inconclusive, but BPD appears to be a risk factor for BD. Data also indicated that the negative impact of BPD in BD (e.g., suicidality, worse mood course) was greater than vice verse. Conclusions: Given the high prevalence of comorbidity between BD and BPD and the negative effects of BPD in subjects with BD, further studies are needed to clarify the factor associated with the comorbidity between these two disorders. This information is important to develop appropriate treatments for subjects with both disorders, improve their clinical course, and prevent the increased risk of suicidality commonly found in these subjects.
... That 40% of the sample reported PM rates this high is a concern in light of the research that has shown that even at low levels, some of these PM behaviors can be quite harmful to children's development and well-being (see Binggeli et al., 2001;Brassard & Donovan, 2006;Barnett, Manly, & Cicchetti, 1993;Kairys & Johnson, 2002;English & LONGSCAN Investigators, 1997;Portwood, 1999;Trickett et al., 2009;Wright, 2007, for recent reviews), including causing damage to intrapersonal thoughts, feelings and behaviors; social competency; learning; and physical health. Retrospective studies have found associations between PM and a range of negative outcomes including eating disorders (Allison et al., 2007), substance abuse (Eiden, Foote, & Schuetze, 2007), and psychiatric conditions (Garno, Gunawardane, & Goldberg, 2008). ...
Article
112 foster care youth were interviewed as part of mandated mental health screenings about 19 types of psychological maltreatment (PM) by birth and foster parents. 77.7% reported at least one form of PM by a parent and 24.3% by a foster parent. The average number of types endorsed was approximately 4 for parents and approximately 1 for foster parents. Data indicate that PM is fairly common among these children who may be underreporting the extent of their experiences. Data also indicate that what they report having experienced is negatively affecting them. Implications for prevention, intervention, and treatment are discussed.
... Not only is psychological maltreatment widespread, but it is also damaging. Retrospective studies with adults have examined and found associations between psychological maltreatment and negative outcomes such as eating disorders (e.g., Allison et al. 2007), substance abuse (e.g., Eiden et al. 2007), and psychiatric conditions (e.g., Garno et al. 2008). Even at low levels, some forms of psychological maltreatment can be detrimental to children's social and emotional development and wellbeing (e.g., Binggeli et al. 2001;Brassard and Donovan 2006;Kairys et al. 2002;English and LONGSCAN Investigators 1997;Trickett et al. 2009;Wright 2007). ...
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Seven hundred and thirty nine (739) Italian adults completed a survey about (A) the extent to which each parent engaged in parental alienation behaviors (B) the extent to which each parent engaged in psychological maltreatment and (C) a measure of parental bonding for each parent. Associations between these variables were examined for each parent and separately for participants whose parents remained married and those who divorced/separated. Results revealed that across the board, parental alienation was associated with psychological maltreatment over and above the effects of parental bonding. These data are understood in the context of a relationship-specific model of psychological maltreatment in which the child experiences parental acceptance of the self as distinct from parental acceptance of the child’s relationship with the other parent.
... Attempts have been made in approaching the effects of childhood trauma on personality traits in clinical samples. For example, one study found that among individuals diagnosed with cocaine dependence, those reporting past childhood maltreatment evidenced more problematic profiles on the NEO Personality Inventory (Brents, Tripathi, Young, James, & Kilts, 2015;DeYoung, Cicchetti, & Rogosch, 2011;Garno, Gunawardane, & Goldberg, 2008). To our knowledge, however, there has not been a study that incorporated all of the five personality trait dimensions when examining the relationship between childhood maltreatment and pathological personality while investigating their association with different types of childhood maltreatment. ...
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Extant literature indicates that childhood maltreatment is significantly associated with personality disorders. With the recent call for a more dimensional approach to understanding personality and pathological personality traits, the aim of the present study was to examine whether the experience of childhood maltreatment is associated with pathological personality traits as measured by the Personality Psychopathology Five (PSY-5). We analyzed data from 557 adult psychiatric patients with diverse psychiatric diagnoses, including mood disorders, schizophrenia spectrum disorders, and anxiety disorders. Hierarchical multiple regression analyses were conducted to determine the degree to which childhood maltreatment explained the five trait dimensions after controlling for demographic variables, presence of psychotic symptoms, and degree of depressive symptoms. Childhood maltreatment significantly predicted all of the five trait dimensions of the PSY-5. This suggests that childhood maltreatment may negatively affect the development of an adaptive adjustment system, thereby potentially contributing to the emergence of pathological personality traits.
... Total scores on the CTQ are higher for BD than for normal controls, and further analysis reveals that emotional abuse in particular is associated with BD, with a suggestive dose effect (Etain et al. 2010). Childhood trauma is also associated with worse cognitive function (Aas et al. 2012), as well as greater aggression traits in bipolar patients (Garno et al. 2008), suggesting that trauma plays a role in clinical outcomes and disease burden of BD (Daruy-Filho et al. 2011). Similarly, EDs are sometimes associated with childhood trauma or maltreatment; in particular, AN binging/purging-type patients score higher on the CTQ (Jaite et al. 2012), and BED patients report higher rates of emotional abuse and emotional neglect than controls. ...
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Eating disorders (ED) are noted to occur with bipolar disorder (BD), but relationships between additional comorbidities, clinical correlates, and personality factors common to both remain largely unknown. Using data from the Prechter Longitudinal Study of Bipolar Disorder, we measured the prevalence and demographic factors of comorbid ED with BD, presence of additional comorbidity of anxiety and substance use disorders, psychosis, suicide attempts, mixed symptoms, childhood abuse, impact of NEO-Personality Inventory (NEO-PI) personality factors, and mood outcome in 354 patients with BD. We analyzed the prevalence of ED using both broad and narrow criteria. ED was more common in the Prechter BD sample than the general population, with the majority of those with ED being female. Anxiety disorders, alcohol abuse/dependence, and NEO-PI N5 impulsiveness were independently associated with ED in a multivariable linear regression analysis. BD age at onset was earlier in the ED group than that in the non-ED group and was earlier than the average onset of ED. Anxiety occurred before ED and alcohol use disorders after both BD and ED. Childhood trauma was associated with ED. Impulsivity and anxiety associated with BD may fuel ED and put patients at risk for other impulsivity-related disorders such as alcohol use disorders. ED was associated with more severe and variable moods and more frequent depression. Patients with BD should be regularly screened for ED, anxiety disorders, and alcohol use disorders, and comorbidity should be promptly addressed.
... The use of Khat among bipolar patients was almost two times more likely managed with physical restrained than patients who had not used Khat [AOR = 1.83, 95% CI (1.10, 3.04)]. This may be related to use of substances increases the impulsivity, aggressiveness and emotionality of bipolar patients (Webb et al. 2014;Garno et al. 2008). The possible justification may be that use of Khat (since it is a stimulant) had influence on the brain and worsening of active symptoms. ...
Article
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Background Even though United Nation announced that all persons with a mental illness shall be treated with humanity and respect for the inherent dignity of the human being, up to now, the use of coercion (physical restrain) is still considered as unavoidable in managing abnormal behavior of psychiatric patients. But, there is no information regarding the magnitude and contributing factors of physical restrain among bipolar patients in low-income countries like Ethiopia. MethodsA cross-sectional study was conducted at Amanuel Mental Specialized Hospital from May 1 to June 1, 2015 among 400 participants who were selected by systematic random sampling technique. Data were collected by interviewing; adjusted odd ratios (AOR) with 95% confidence intervals (CI) were used and p value <0.05 was considered as statistically significant. ResultsThe prevalence of physical restrain was 65%. Factors like, having two or more episodes [AOR = 1.84 95% CI (1.16, 2.93)], history of aggression [AOR = 2.14, 95% CI (1.26, 3.63)], comorbid illness [AOR = 1.76, 95% CI (1.26, 3.63)], use of antipsychotic [AOR = 1.79, 95% CI (1.08, 2.95)] and current use of Khat [AOR = 1.83, 95% CI (1.10, 3.04)] were associated significantly. Conclusions The prevalence of physical restraint is found high among bipolar patients and it needs public health attention.
... La comorbidité avec la personnalité antisociale est bien décrite dans des observations cliniques [91] ou des populations de patients maniaques en contexte de psychiatrie légale [92]. Dans une étude portant sur 100 patients bipolaires, l'agressivité apparaît fortement liée à l'existence d'une personnalité borderline comorbide ainsi qu'à des antécédents de traumatisme dans l'enfance et à la sévérité des symptômes maniaques ou dépressifs [93]. ...
Article
Several recent publications describe a probable underestimation of criminal potential of depression and suicidal ideation as well as forensic consequences of affective disorders. In murder-suicides, a depressive illness seems the most commune disease, ranging from 36 to 75 % of cases in studies. These crimes are essentially filicides by depressive parents in an extended suicide context, family or spouse homicides. A depressive symptomatology is also relatively often seen in firesetting and sexual aggressions. In manic episodes of bipolar disorders, antisocial acts are more frequent albeit serious crimes seem relatively rare and often linked to substance abuse. Comorbidity is important with addictive behaviors, especially alcohol and substance abuse and antisocial personality disorder. Psychiatric examination of mental state in forensic conditions may unrecognize affectives disorders. Criminal history are frequent for bipolar patients. The absence of treatment or a delayed prescription expose patients to dangerous behaviors and medico-legal acts which may belong to the illness course.
... There is plenty of evidence that indicate possible neurobiological relations between aggression and BD such as serotoninergic hypoactivation or blunted HPA activity (Fico et al., 2020). However, studies also show that trait aggression can be associated with BD if there is a comorbid psychiatric condition such as borderline personality disorder or substance use (Garno et al., 2008). Nevertheless, other studies point out that aggression can also have a stable course in BD (Ballester et al., 2014). ...
Article
This study aimed to investigate the associations of risk-taking, aggression, and impulsivity as well as risk adjustment in bipolar I patients (BD-I). 50 BD-I patients and age- and education-matched healthy controls (HC) were compared by using a modified Balloon Analogue Risk Task (m-BART) , Barratt Impulsiveness Scale-11(BIS-11), and Buss Perry Aggression Questionnaire (BPAQ). BD-I performed worse than HC in terms of risk-taking measures. However, the risk adjustment pattern in the BD-I group was similar to HC. BIS-11 scores were positively correlated with risk-taking after unsuccessful trials. The BPAQ scores were positively correlated with the number of exploded balloons and the maximum number of pumps while negatively correlated with reaction time. This study supported risk-taking as a robust feature of BD-I. These results may reflect that higher risk-taking may be due to impulsivity and also aggression may be associated with undesired outcomes of risk-taking. However, decision-making/adjustment abilities seem to be preserved.
... stressed that clinicians needed to recognize the vulnerability of people with bipolar disorder to comorbid disruptive behavior disorders, such as conduct disorder or intermittent/explosive disorder.Garno, Gunawardane, and Goldberg (2008) found that comorbid borderline personality disorder and current manic and depressive symptoms each significantly predicted aggression in individuals with bipolar disorder. Personality Disorders. Comparatively higher Hostile Affect scores were given to subjects in the Personality Disorder NOS and Combined Personality Disorders (Personali ...
... Considering the life history of schizophrenic patients who were recorded in forensic records due to violent behavior, childhood abuse or neglect, parents' antisocial behavior or stressful life events are quite common [15]. Again, according to police records, people with Bipolar Disorder, who have shown violent behavior, have the diagnosis of Borderline Personality Disorder and childhood traumas as a comorbid [16]. The prevalence of Bipolar I and Bipolar II diagnoses was 25.34% and 13.55% in lifelong aggressive behaviors. ...
Article
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Most criminology theories and criminologists explain questions such as “why do some people deviate from legal and social norms?” or “why do people commit crimes?” at the factual level. Criminology does not only treat crime as a set of actions or inaction defined within the legal parameters. Understanding what lies beneath the cognitive, emotional, and social aspects of the criminal act is highly dependent on the information available about the nature of the illegal act and the criminal. Criminal law also needs a broader perspective because of this need. In that sense, to understand the individual and socio-psychological aspects of crimes, it is vital to understand the details of current crimes and their perpetrators. For the perpetrator to be held accountable for their criminal act or inaction; they must have committed the said crime deliberately, knowing the consequences of their actions, must be aware that they will be punished as a result, and must have the ability to control their impulses. It is the basis of the law approach that individuals cannot be held responsible for their actions and cannot be punished if they cannot control their behavior. The perpetrator’s mental health at the time of the criminal act is evaluated by mental health professionals. While there is no relationship between the majority of people with mental disorders and criminal behavior, it can be said that certain disorders may be a risk factor in some criminal acts. However, even if a relationship can be established between some mental disorders and the criminal acts, it should also be investigated how this relationship was indirectly affected by variables such as low socioeconomic status, previous arrest records, or substance abuse. Therefore, it should be noted that mental disorders that affect perpetrators do not lead them to criminal acts.
... Precisely, one out five patients reported multiple trauma, therefore a considerable proportion of subjects seems to be at risk of a more complex course of the disorder. Indeed, previous studies outlined that traumatic experiences are highly inter-related, as for example physical and sexual abuse that often cooccur, with the result of greater severity of mood symptoms and a worse prognosis of the BD (Garno et al., 2008). Although the proportion of multiple trauma in our sample is considerable, the low number of subjects reporting this condition did not allow us to perform reliable tests, therefore future studies with larger sample size should consider the impact of multiple trauma specifically. ...
Article
Background Psychopathological symptoms during euthymia in Bipolar Disorder (BD) affect quality of life and predispose to the occurrence of new acute episodes, however only few studies investigated potential risk-factors. This study aims to explore the association between childhood trauma (CT), lifetime stressful events (SLEs) and psychopathological symptoms in BD patients during euthymia and controls (HC). Methods A total of 261 participants (93 euthymic patients with BD, 168 HC) were enrolled. Generalized linear models and multiple logistic models were used to assess the association among the Symptom Check List-90-R (SCL-90-R), the Infancy Trauma Interview, the Paykel Life Events Scale. Results The rate of participants reporting CT was higher in BD (n=47; 53%) than HC (n=43; 30%) (p=0.001). The experience of neglect was strongly related to BD (OR 6.5; p=0.003). CT was associated to higher scores on the SCL-90-R subscales (all the subscales except Phobia). No effects of the interaction between CT and diagnosis were found on SCL-90-R. Finally, there was a main effect of CT on lifetime SLEs (p<.001), that was not associated with diagnosis (p=0.833), nor with the interaction between CT and diagnosis (p=0.624). Limitations The cross-sectional design does not allow causal inferences; the exclusion of subjects reporting medical or psychiatric comorbidity limits generalizability. Conclusions CT was associated both to psychopathological symptoms during euthymia and the lifetime SLEs, thus it may represent a vulnerability factor influencing the course of BD. Overall, these data contribute to overcome the limited evidences documenting the influence of environmental factors on euthymic phase in BD.
... (Deltito et al., 2001) suggest that the current classification may fail to differentiate between the two disorders considering the complexity and heterogeneity within these patient groups and that perhaps borderline and bipolar might be the two extremes of the same spectrum (Deltito et al., 2001). Additionally, a longitudinal study showed that comorbid borderline and antisocial personality traits predicted the risk of aggression in BD, while controlling for potential confounding factors (Garno et al., 2008). ...
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Introduction Feelings of anger and irritability are prominent symptoms of bipolar disorder (BD) that may occur during hypomanic, depressive and, especially, during mixed mood states. We aimed to determine whether such constructs are associated with the conversion to BD in subjects with a history of unipolar depression. Methods Data were derived from the depressed participants of Netherlands Study of Depression and Anxiety with 9 years of follow‐up. Hypomania was ascertained using the Composite International Diagnostic Interview at 2, 4, 6, and 9 years follow‐up. Cross‐sectionally, we studied the association between prevalent hypomania and anger related constructs with the “Spielberger Trait Anger subscale,” the “Anger Attacks” questionnaire, the cluster B personality traits part of the “Personality Disorder Questionnaire,” and “aggression reactivity.” Prospectively, we studied whether aggression reactivity predicted incident hypomania using Cox regression analyses. Results Cross‐sectionally, the bipolar conversion group (n = 77) had significantly higher scores of trait anger and aggression reactivity, as well as a higher prevalence on “anger attacks,” “antisocial traits,” and “borderline traits” compared to current (n = 349) as well as remitted (n = 1159) depressive patients. In prospective analyses in 1744 participants, aggression reactivity predicted incident hypomania (n = 28), with a multivariate‐adjusted hazard ratio of 1.4 (95% confidence interval: 1.02–1.93; p = .037). Conclusion Anger is a risk factor for conversion from unipolar depression to BD. In addition, patients who converted to BD showed on average anger, agitation and irritability than people with a history of unipolar depression who had not converted.
... These include sedating medication, seclusion, and restraint. it is important to provide an environment that minimizes overstimulation and includes clear interpersonal communication and limit setting (Garno et al., 2008). This can all be done in managed when a patient is confined in a mental health facility. ...
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Background: Patients taking atypical antipsychotics are in danger of antipsychotic-induced weight gain. Weight increases rapidly in the initial period after starting antipsychotics. Cardiovascular and cerebrovascular morbidity and mortality and reduced quality of. Both nonpharmacologic prevention and intervention strategies have shown modest effects on weight. Changes in physical appearance can lead to body image issues and problems with self-esteem, which in turn could lead to poor compliance with medication. Purpose: This study aimed to evaluate the effectiveness of an exercise program that can benefit patients who are gaining weight related to atypical antipsychotic agent intake.Methods: A quasi-experimental research design was undertaken. The research setting was held in a general tertiary medical teaching/training medical facility owned by the Philippine government. There are 31 respondents for this study 12 were males and 19 were females who were chosen from the list of the in-patients utilizing the universal sampling technique. Data were gathered using a self-formulated tool to collect mostly demographic data which is adopted from the National Alliance for Mental Health.Results: Patients’ diagnosis tends to have a positive relationship with weight loss. Respondents diagnosed with bipolar with psychotic features showed to have loss weight more than the diagnosed with schizophrenia. The results of this study showed that patient’s adhering to the exercise program had lost weight after the course. Conclusion: Activity and exercise are especially important for people living with mental illness. Furthermore, physical activity does not only help patients manage their weight but to serve as diversional activity that adds vitality for patients in the facility
... To date, only a few studies have investigated the potential contribution of cluster B disorders to impulsivity/aggressiveness in mood disorders (including BDs) converging on higher levels of impulsivity/aggressiveness in comorbid patients compared with those with only a mood disorder diagnosis (Henry et al., 2001;Wilson et al., 2007;Garno et al., 2008). ...
Article
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Borderline personality disorder (BPD) often co-occurres with bipolar disorder (BD). Impulsivity and aggressiveness represent core shared features and their pharmacological management is mainly based on mood stabilizers and antipsychotics, although scarce evidence is available for this context of comorbidity. The aim of the present study was to evaluate the role of Asenapine as an adjunctive drug for reducing aggressiveness and impulsivity in a sample of Italian BD type I outpatients with or without a comorbid BPD. This was an observational 12-week open-label uncontrolled clinical study carried out from April to October 2014 in two psychiatric clinics in Sicily. Each patient was treated with asenapine at two dose options, 5 mg (twice daily) or 10 mg (twice daily), and concomitant ongoing medications were not discontinued. We measured impulsivity using the Barratt Impulsiveness Scale (BIS) and aggressiveness using the Aggressive Questionnaire (AQ). For the analysis of our outcomes, patients were divided into two groups: with or without comorbid BPD. Adjunctive therapy was associated with a significant decrease of BIS and AQ overall scores in the entire bipolar sample. Yet, there was no significant difference in BIS and AQ reductions between subgroups. Using a regression model, we observed that concomitant BPD played a negative role on the Hostility subscale and overall AQ score variations; otherwise, borderline co-diagnosis was related positively to the reduction of physical aggression. According to our post-hoc analysis, global aggressiveness scores are less prone to decrease in patients with a dual diagnosis, whereas physical aggressiveness appears to be more responsive to the add-on therapy in patients with comorbidity.
... Notably, the prevalence of AB in patients with BD might increase up to 12 % when there is a comorbid substance or alcohol abuse (Garno et al., 2008;Grant et al., 2005;Salloum et al., 2002). Additionally, AB in BD shows a direct prognostic value, being linked to suicide attempts and more frequent hospitalizations, severity of mania, presence of mixed symptoms, and comorbid borderline personality disorder (Michaelis et al., 2004;Murru et al., 2019;Popovic et al., 2015;Verdolini et al., 2017;Webb et al., 2014). ...
Article
Aggressive behavior (AB) represents a public health concern often associated with severe psychiatric disorders. Although most psychiatric patients are not aggressive, untreated psychiatric illness, including bipolar disorder (BD), may associate with an increased risk of AB. Accurate predictive models of AB are still lacking and it is crucial to delineate AB biomarkers state of the art in BD. We performed a systematic review according to PRISMA guidelines to identify biological correlates of AB in BD. Final results included 20 studies: 10 involving genetic and 10 other biological AB biomarkers (total sample size N = 5,181). Our results pointed to a serotoninergic hypoactivation in violent suicidal BD patients. Similarly, BD violent suicide attempters had a blunted hypothalamic-pituitary-adrenal (HPA) activity. Violent behavior in BD was associated with a chronic inflammatory state. While the role of lipids as biomarkers for AB remains equivocal, uric acid appears as a potential biomarker for hetero-AB in BD. Available data can be useful in the fulfill of specific biomarkers of AB in BD, ultimately leading to the development of accurate predictive models.
... These include sedating medication, seclusion, and restraint. it is important to provide an environment that minimizes overstimulation and includes clear interpersonal communication and limit setting (Garno et al., 2008). This can all be done in managed when a patient is confined in a mental health facility. ...
... Additionally, it is reported that being exposed to childhood abuse has been associated with unfavorable course and outcomes among patients with bipolar disorder, including earlier age of onset of bipolar disorder (8,9), more frequent relapses (10), increased risk of suicide attempts, frequency of comorbid illnesses (11,12), and substance abuse (13). ...
... [1][2][3][4] In patients with bipolar disorder, aggressive behavior has been linked to comorbid personality disorder, history of childhood trauma, and the severity of current manic or depressive symptoms. 5 Because patients with bipolar disorder are at high risk of becoming violent during acute manic episodes, 6,7 treatment of at-risk patients before their symptoms progress to violence is critical. Behaviors such as hostility and agitation can be used to identify patients who are at risk of aggressive behavior. ...
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Background Bipolar disorder is associated with an increased risk of aggression. However, effective management of hostility and/or agitation symptoms may prevent patients from becoming violent. This analysis investigated the efficacy of the antipsychotic asenapine on hostility and agitation in patients with bipolar I disorder. Methods Data were pooled from three randomized, double-blind, placebo-controlled, Phase III trials of asenapine in adults with manic or mixed episodes of bipolar I disorder (NCT00159744, NCT00159796, and NCT00764478). Post hoc analyses assessed the changes from baseline to day 21 on the Young Mania Rating Scale (YMRS) and the Positive and Negative Syndrome Scale (PANSS) hostility-related item scores in asenapine- or placebo-treated patients with at least minimal or mild symptom severity and on the PANSS-excited component (PANSS-EC) total score in agitated patients. Changes were adjusted for improvements in overall mania symptoms to investigate direct effects on hostility. Results Significantly greater changes in favor of asenapine versus placebo were observed in YMRS hostility-related item scores (irritability: least squares mean difference [95% confidence interval] =−0.5 [−0.87, −0.22], P=0.001; disruptive–aggressive behavior: −0.7 [−0.99, −0.37], P<0.0001), PANSS hostility item score (−0.2 [−0.44, −0.04]; P=0.0181), and PANSS-EC total score (−1.4 [−2.4, −0.4]; P=0.0055). Changes in the YMRS disruptive–aggressive behavior score and the sum of the hostility-related items remained significant after adjusting for improvements in other YMRS item scores. Conclusion Asenapine significantly reduced hostility and agitation in patients with bipolar I disorder; improvement was at least partially independent of overall improvement on mania symptoms.
... Although aggression is more likely during manic episodes, longitudinal studies that followed those with BD to remission document high rates of aggression compared to healthy controls ( (Ballester, Goldstein, Goldstein, Obreja, Axelson, Monk, & Birmahe, 2012;Garno, Gunawardane, & Goldberg, 2008;. This suggests the need to target aggression above and beyond addressing mood episodes. ...
Article
Although aggression is related to manic symptoms among those with bipolar disorder, new work suggests that some continue to experience elevations of aggression after remission. This aggression post-remission appears related to a more general tendency to respond impulsively to states of emotion, labelled emotion-related impulsivity. We recently developed the first intervention designed to address aggression in the context of emotion-related impulsivity. Here, we describe feasibility, acceptability, and pilot data on outcomes for 21 persons who received treatment for bipolar disorder and endorsed high levels of aggression and emotion-related impulsivity. As with other interventions for aggression or bipolar disorder, attrition levels were high. Those who completed the intervention showed large changes in aggression using the interview-based Modified Overt Aggression Scale that were sustained through three months and not observed during wait list control. Although they also showed declines in the self-rated Buss-Perry Aggression Questionnaire and in self-rated emotion-related impulsivity as assessed with the Feelings Trigger Action Scale, these self-ratings also declined during the waitlist control. Despite the limitations, the findings provide the first evidence that a brief, easily disseminated intervention could have promise for reducing aggression among those with bipolar disorder.
... Childhood trauma has been found to contribute to the early onset and severity of bipolar disorder, resulting in poorer clinical outcomes, higher prevalence of a faster cycling pattern and suicide attempts [27,28]. The prevalence of childhood abuse was 49% in bipolar patients [29]. ...
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... Although it is reported that the sexual abuse is a factor associated with the development of several mental disorders, especially BPD and BD [38,39,60,61], this association is controversial and not supported by other studies [40][41][42]62]. Similarly, there are disagreements about the role of physical abuse in the development of these disorders [43,63,64]. Therefore, it is important to emphasize the necessity of considering fully all types of ELS in mental health evaluations and developing a perhaps less stereotypical view of childhood trauma, such as viewing violence in just a sexual and/or physical form. ...
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Alkol ve madde kullanım bozukluklarında hem intihar davranışı riski hem de şiddet davranışı riski artmaktadır. Ayrıca, alkol ve madde kullanım bozukluklarının dünya genelinde artan intihar ve şiddet yaygınlığına önemli ölçüde katkıda bulunduğu ileri sürülmektedir. Bu nedenlerle intihar, şiddet ve bağımlılık kavramlarından oluşan sorunlar sarmalının küresel ölçekte çözüm beklediği düşünülmektedir. Bu problemlerle başa çıkmak için altta yatan nörobiyolojik mekanizmaların keşfi gereklidir. İntihar, şiddet ve bağımlılık davranışlarını anlamada nörobiyolojik mekanizmaların önemi daha önceki araştırmalarda ortaya konulmuştur. Özellikle son zamanlarda yapılan çalışmalar, bu üç durumun birbiriyle ilişkili genetik, epigenetik ve nörobiyolojik temellere sahip olabileceğine dair bazı kanıtlar göstermiştir. Bu nedenle bu derlemede alkol ve madde kullanım bozuklukları ile ilgili güncel nörobiyolojik araştırmaların yanı sıra intihar ve şiddet davranışları ile ilgili bilimsel yazın bir arada sunulacaktır. Anahtar sözcükler: Madde kullanımına bağlı bozukluklar, alkolizm, şiddet, intihar, psikiyatri Both the risk of suicidal and violent behaviours increases in alcohol and substance use disorders. Besides, it's proposed that alcohol and substance use disorders significantly contribute to the increasing prevalence of suicide and violence worldwide. For these reasons, it is thought that the spiral of problems consisting of the concepts of suicide, violence, and addiction awaits a solution on a global scale. The discovery of the underlying neurobiological mechanisms is required to deal with these problems. Previous research has revealed the importance of neurobiological mechanisms in understanding suicidal, violent, and addictive behaviours. Especially recent studies have shown some evidence that these three conditions have some related genetic, epigenetic, and neurobiological bases. Therefore, besides the current neurobiological research on alcohol and substance use disorders, scientific literature related to suicidal and violent behaviours will be presented in this review altogether.
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The existence of mixed affective states challenges the idea of specific biological abnormalities in depression and mania. We compared biogenic amines and hypothalamic-pituitary-adrenocortical (HPA) function in mixed manic (n = 8), pure manic (n = 11), agitated bipolar depressed (n = 20), and nonagitated bipolar depressed (n = 27) inpatients (Research Diagnostic Criteria). Mixed manics met Research Diagnostic Criteria for primary manic episodes and also met criteria for major depressive episodes except for duration. The norepinephrine metabolite methoxyhydroxy phenthylene glycol (MHPG) was higher in cerebrospinal fluid from mixed manic than from agitated depressed patients, consistent with differences previously reported between the overall samples of depressed and manic patients. Similarly, patients in a mixed state had higher urinary excretion of norepinephrine (NE) and elevated output of NE relative to its metabolites. HPA activity was similar in mixed manic and agitated depressed patients. These data suggest that mixed manics combine certain biological abnormalities considered to be characteristic of mania and of depression.
Depending on the population studied, anywhere from half to two-thirds of DSM-III borderline disorders seem to represent subaffective expressions, principally on the border of bipolar disorder. "Borderland" may actually be a better characterization of this large temperamentally unstable terrain with a population prevalence of 4-6% (as compared with 1% for classical bipolar disorder). The temperaments include the dysthymic, irritable, and cyclothymic types which, respectively, coexist with "double depressive", mixed bipolar, and bipolar II disorders; others conform to an anxious-sensitive temperament in continuum with hysteroid dysphoric and atypical depressive disorders. Borderline "stable instability" in these patients appears secondary to affective temperamental dysregulation, which has exacerbated into a protracted emotional storm during a difficult maturational phase in the biography of a given patient.
Article
This report presents initial findings on the reliability and validity of a new retrospective measure of child abuse and neglect, the Childhood Trauma Questionnaire. Two hundred eighty-six drug- or alcohol-dependent patients were given the Childhood Trauma Questionnaire as part of a larger test battery, and 40 of these patients were given the questionnaire again after an interval of 2 to 6 months. Sixty-eight of the patients were also given a structured interview for child abuse and neglect, the Childhood Trauma Interview, that was developed by the authors. Principal-components analysis of responses on the Childhood Trauma Questionnaire yielded four rotated orthogonal factors: physical and emotional abuse, emotional neglect, sexual abuse, and physical neglect. Cronbach's alpha for the factors ranged from 0.79 to 0.94, indicating high internal consistency. The Childhood Trauma Questionnaire also demonstrated good test-retest reliability over a 2- to 6-month interval (intraclass correlation = 0.88), as well as convergence with the Childhood Trauma Interview, indicating that patients' reports of child abuse and neglect based on the Childhood Trauma Questionnaire were highly stable, both over time and across type of instruments. These findings provide strong initial support for the reliability and validity of the Childhood Trauma Questionnaire.
Article
This paper examines the multi-dimensional nature of resiliency to risk in mental health, and tests regression models of differential resiliency, based on two hospital-based clinical research projects. The first project involves adult children of problem drinkers, individuals who are at greater risk to alcohol abuse given their parents' pathology. The second involves schizophrenics diagnosed with varying dispositions to depression. The analyses reveal that for both adult children of problem drinkers and for schizophrenics, individuals have varying degrees of susceptibility to adversity and that these variations are based, to a large degree, on psychosocial concerns. Furthermore, the results show quite clearly that men and women suffer to varying degrees when exposed to the same kinds of adversity, and that the causal origins of resiliency are different for men and women.
Article
Prolactin (PRL) responses to acute challenge with the serotonin (5-HT) releaser/uptake inhibitor, d-fenfluramine (PRL[d-FEN]), were correlated with three different measures of aggression in 14 male personality-disordered subjects. Consistent with previous work, PRL[d-FEN] responses were inversely correlated with scores on the Buss-Durkee Hostility Inventory-Assault scale (BDHI-Assault) and with the Brown-Goodwin Aggression-Revised (BGA-R) Aggression scale. In addition, PRL[d-FEN] responses were inversely correlated with a direct laboratory measure of aggressive behavior (Point-Subtraction Aggression Paradigm: PSAP). Although all measures of aggression correlated with PRL[d-FEN] response, differences among the intercorrelations of these measures were found. Specifically, BGA-R Aggression scores correlated with both BDHI-Assault and PSAP scores, but no relation was found between BDHI-Assault and PSAP scores. The results suggest that central 5-HT function may be associated with both self-report and behavioral measures of aggressive behavior, which may represent somewhat separate aspects of aggressive behavior.
Article
This investigation examined the relationship between trauma, psychiatric symptoms and urinary free cortisol (UFC) and catecholamine (epinephrine [EPI], norepinephrine [NE], dopamine [DA]) excretion in prepubertal children with posttraumatic stress disorder (PTSD) secondary to past child maltreatment experiences (n = 18), compared to non-traumatized children with overanxious disorder (OAD) (n = 10) and healthy controls (n = 24). Subjects underwent comprehensive psychiatric and clinical assessments and 24 hour urine collection for measurements of UFC and urinary catecholamine excretion. Biological and clinical measures were compared using analyses of variance. Maltreated subjects with PTSD excreted significantly greater concentrations of urinary DA and NE over 24 hours than OAD and control subjects and greater concentrations of 24 hour UFC than control subjects. Post hoc analysis revealed that maltreated subjects with PTSD excreted significantly greater concentrations of urinary EPI than OAD subjects. Childhood PTSD was associated with greater co-morbid psychopathology including depressive and dissociative symptoms, lower global assessment of functioning, and increased incidents of lifetime suicidal ideation and attempts. Urinary catecholamine and UFC concentrations showed positive correlations with duration of the PTSD trauma and severity of PTSD symptoms. These data suggest that maltreatment experiences are associated with alterations of biological stress systems in maltreated children with PTSD. An improved psychobiological understanding of trauma in childhood may eventually lead to better treatments of childhood PTSD.
Article
Bipolar disorder is generally viewed as a disturbance of mood. However, prominent aspects of behavior that occur during depressive and manic states of bipolar disorder, including psychosis, aggression, and anxiety, are not specific to mood syndromes and occur across many psychiatric states. Severe hyperarousal--beyond that usually associated with classic manic or depressive episodes--could result in a variety of behavioral or symptomatic disturbances including aggression, impulsivity, and anxiety. Since aggression is a well-recognized aspect of mood syndromes, the management of aggression is likely to be an important component of managing bipolar disorder.
Article
Abnormalities of 5-HT and noradrenergic functioning have been implicated in aggressive impulsivity, SIB, and suicidal behavior. The role of DA and GABA in human studies of these behaviors requires further investigation. Most studies suggest that impulsive aggression is related to lower levels of CNS 5-HT. Some studies demonstrate that increasing NE correlates to impulsive aggression, whereas other studies demonstrate an opposite relationship. The role of NE in impulsive aggressive behavior is still unclear. Self-injurious behavior is similar to impulsive aggression in that it seems to be mediated by the neurotransmitter systems previously mentioned. For example, the presence of lower levels of 5-HT and abnormalities in the DA system are related to SIB in patients with BPD and depression. SIB severity also seems to be influenced by neglect (e.g., severe isolation during rearing). As animal studies suggest, increasing the amount of isolation and an earlier onset of isolation increase the severity of SIB. Suicidal behaviors and the lethality of suicide attempts may also be linked to the abnormalities in neurotransmitter systems similar to those found in patients with impulsive aggression and SIB, namely, lowered 5-HT transmission and enhanced DA and NE functioning. Understanding the biological triggers of impulsive aggression or SIB may allow for the evaluation of suicidal attempts and completion from a different perspective and, in conjunction with genetic predictors, may eventually help with the early prediction and prevention of suicidal behaviors. Additional studies of live subjects and postmortem brains will assist in clarifying the neurobiology of suicidal behaviors that are common to many disorders and are clinically relevant to BPD.
Article
Borderline personality disorder is characterized by affective instability, impulsivity, and aggression and is associated with considerable morbidity and mortality. Since anticonvulsant agents may be helpful in such symptomatology, we compared divalproex sodium with placebo in patients with borderline personality disorder. A 10-week, parallel, double-blind design was conducted. Sixteen outpatients meeting Structured Clinical Interview for DSM-IV Axis II Personality Disorders criteria for borderline personality disorder were randomly assigned to receive placebo (N = 4) or divalproex sodium (N = 12). Change was assessed in global symptom severity (Clinical Global Impressions-Improvement Scale [CGI-I]) and functioning (Global Assessment Scale [GAS]) as well as in specific core symptoms (depression, aggression, irritability, and suicidality). There was significant improvement from baseline in both global measures (CGI-I and GAS) following divalproex sodium treatment. A high dropout rate precluded finding significant differences between the treatment groups in the intent-to-treat analyses, although all results were in the predicted direction. Treatment with divalproex sodium may be more effective than placebo for global symptomatology, level of functioning, aggression, and depression. Controlled trials with larger sample sizes are warranted to confirm these preliminary results.
Article
This report examines clinical indicators for bipolarity in a cohort of patients suffering from Borderline Personality Disorder (BPD). The study was conducted in the Cornell-Westchester Hospital, famed for its expertise in BPD. To avoid biasing our sample, we excluded all BPD patients who were active patients in our anxiety and mood disorders program. Through the use of both open clinical interviews and standardized diagnostic interviews (SCID), borderline patients were examined for evidence of bipolarity by five indicators: history of spontaneous mania, history of spontaneous hypomania, bipolar temperaments, pharmacologic response typical of bipolar disorder, and a positive bipolar family history. Depending on the level of bipolar disorder from the most rigorous (mania) to the most 'soft' (bipolar family history), between 13 and 81% of borderline patients showed signs of bipolarity. Based on what the emerging literature supports as rigorously defined bipolar spectrum (bipolar I and II), we submit that at least 44% of BPD belong to this spectrum; adding hypomanic switches during antidepressant pharmacotherapy, the rate of bipolarity in BPD reaches 69%. As expected from this formulation, most responded negatively to antidepressants (e.g. hostility and agitation) and positively to mood stabilizers. Small sample size and retrospective gathering of data on treatment response. Patients with BPD more often than not exhibit clinically ascertainable evidence for bipolarity and may benefit from known treatments for Bipolar Spectrum Disorders. Large scale, systematic treatment studies with mood stabilizers are indicated.
Article
There is growing awareness of the association between physical and sexual abuse and subsequent development of psychopathology, but little is known, however, about their relationship to the longitudinal course of bipolar disorder. We evaluated 631 outpatients with bipolar I or II disorder for general demographics, a history of physical or sexual abuse as a child or adolescent, course of illness variables, and prior suicide attempts, as well as SCID-derived Axis I and patient endorsed Axis II comorbidity. Those who endorsed a history of child or adolescent physical or sexual abuse, compared with those who did not, had a history of an earlier onset of bipolar illness, an increased number of Axis I, II, and III comorbid disorders, including drug and alcohol abuse, faster cycling frequencies, a higher rate of suicide attempts, and more psychosocial stressors occurring before the first and most recent affective episode. The retrospectively reported associations of early abuse with a more severe course of illness were validated prospectively. Greater appreciation of the association of early traumatic experiences and an adverse course of bipolar illness should lead to preventive and early intervention approaches that may lessen the associated risk of a poor outcome.
Article
Few studies have addressed whether symptom profiles remain consistent between episodes of mania. Those that have done so focused on mood only and adopted the strictly categorical approach. We evaluated 77 subjects during two discrete manic episodes (mean interval, 2 years, 2 weeks). Episodes were characterized on five established symptom factors of mania and on overall severity of classic manic symptoms (i.e., excluding dysphoric symptoms). Pearson correlation coefficients were computed to compare symptom profiles across episodes. Four symptom factors (dysphoria, hedonic activation, psychosis, and irritable aggression) were significantly correlated across episodes, as was manic severity. Psychomotor symptoms were not significantly correlated. Manic symptomatology remains generally similar in bipolar subjects during different episodes. The characterization of manic episodes by the empirical dimensions of symptom factors, as suggested by Kraepelin nearly a century ago, may provide additional information for biological and treatment response studies of manic states that is not captured by categorical subtype diagnosis focused solely on mood symptoms (i.e., mixed v pure manic episodes).
Article
In Part I of this three-part article, consideration of the core features of BPD psychopathology, of comorbidity with Axis I disorders, and of underlying personality trait structure suggested that the borderline diagnosis might be productively studied from the perspective of dimensions of trait expression, in addition to that of the category itself. In Part II, we review the biology, genetics, and clinical course of borderline personality disorder (BPD), continuing to attend to the utility of a focus on fundamental dimensions of psychopathology. Biological approaches to the study of personality can identify individual differences with both genetic and environmental influences. The aspects of personality disorder that are likely to have biologic correlates are those involving regulation of affects, impulse/action patterns, cognitive organization and anxiety/inhibition. For BPD, key psychobiological domains include impulsive aggression, associated with reduced serotonergic activity in the brain, and affective instability, associated with increased responsivity of cholinergic systems. There may be a strong genetic component for the development of BPD, but it seems clear, at least, that there are strong genetic influences on traits that underlie it, such as neuroticism, impulsivity, anxiousness, affective lability, and insecure attachment. The course of BPD suggests a heterogeneous disorder. Predictors of poor prognosis include history of childhood sexual abuse, early age at first psychiatric contact, chronicity of symptoms, affective instability, aggression, substance abuse, and increased comorbidity. For research purposes, at least, biological, genetic, and prognostic studies all continue to suggest the need to supplement categorical diagnoses of BPD with assessments of key underlying personality trait dimensions and with historical and clinical observations apart from those needed to make the borderline diagnosis itself.