Aggressiveness in bipolar illness: from stigma to reality

Raffaella Zanardi 1,2, Francesco Attanasio 2, Elena Manfredi 2, Cristina Colombo 1,2

1 IRCCS San Raffaele Scientific Institute, Department of Clinical Neurosciences, Mood Disorder Unit, Milan, Italy; 2 University Vita-Salute San Raffaele, Department of Clinical Neurosciences, Milan, Italy

Objectives 

Many studies over the years have searched for an association between violence and psychiatric diagnoses, though not providing a unanimous and confirmative result. We have sought to extend and deepen the evidence on this topic, focusing on a specific diagnosis and its particular phases of illness and looking for correlation between psychiatric co-diagnoses and outpatients’ visits adherence. Considering the clinical importance of violent acts and the social stigma related to them, we analysed different aspects of aggressivity: those undoubtedly violent acts and aspects like irritability or agitation that are frequently alarming and contribute to maintaining the social stigma towards psychiatric patients.

Methods 

Over a 12-month period we recruited 151 consecutively admitted bipolar type I inpatients. We studied their presenting complaint, past medical and family history; we collected information about lifetime hetero- or self-aggressive behaviours, irritability, agitation, suicide attempts, alcohol, or substance abuse. Every patient was evaluated for personality disorders through SCID-5 for Personality Disorders (SCID-5-PD).

Results 

The overall aggressivity in our sample resulted in 11.92% of cases, while the number of aggressive episodes during euthymia decreased to 2.64%, a level that is nearly close to that of the population without a lifetime psychiatric disorder. Personality disorders and alcohol abuse appeared to be the main risk factors for irritability; substance abuse, above all cannabis and cocaine, for both irritability and hetero-aggressive behaviour. We observed how subjects who displayed more compliance to psychiatric and psychological visits exhibited a significant lower aggressive behaviour than less adherent subjects. Our data disconfirms the common conception that links psychotic features to violence and shows how the great majority of patients displaying symptoms like irritability or agitation (often alarming as aggressiveness) do not display any violent action.

Conclusions

Studying aggressive behaviours in a population with a diagnosis of bipolar disorder we observed how the rare episodes of aggressiveness were mainly condensed in the active phases of the illness and mainly related to alcohol or substance abuse, while violent acts during long periods of wellbeing appear in line with those of the general population. We are confident our data might be helpful in deconstructing stigma that a psychiatric diagnosis equals violence, and that violence could somehow be justified by a disease.

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