Self and Hetero-Aggression: Clinical Implications in Bipolar Disorder and Mixed States

Abstract

The poorest outcomes in bipolar disorder are represented by self-aggressive (i.e. deliberate self-harm, attempted or completed suicide) and hetero-aggressive violent behaviors. A better understanding of the clinical factors associated with both the risk of criminal behavior and the risk of self-injurious behaviors among individuals suffering from bipolar disorder may improve the course of illness and the risk management. The main objective of this doctoral thesis was to evaluate the psychiatric correlates of self- or hetero-aggression in the context of bipolar disorder, particularly in those patients presenting mixed features. The five published articles included in this thesis had different study designs: Study I. A meta-analysis including studies on the association between bipolar disorder and violent criminal behaviors; Study II. A cross-sectional study assessing clinical correlates of deliberate self-harm and suicide attempts in prisoners, particularly mood disorders and bipolar disorder; Study III. A post-hoc analysis of the Bipolar Disorders: Improving Diagnosis, Guidance and Education (BRIDGE)-II-MIX multicentric study aimed at evaluating hetero-aggression as a mixed feature during a major depressive episode and its relationship with other clinical variables, such as the lifetime history of suicide attempts. Study IV. Another post-hoc analysis of the BRIDGE-II-Mix study focused on the clinical relevance of the intertwined association between affective lability and mood reactivity and their correlation with other mixed symptoms, particularly verbal or physical hetero-aggression and suicide attempts. Study V. A critical systematic review of guidelines on the treatment of mixed states with a methodological quantitative quality assessment of included articles and a specific focus on challenging aspects such as hetero- and self-aggression. One every fourteen patients suffering from bipolar disorder reported violent criminal behavior. Even though the association with violent criminality was not significant when patients suffering from bipolar disorder were compared with patients suffering from any other psychiatric disorder, the chance of committing violent criminal behavior was smaller in patients with bipolar disorder than in those suffering from psychotic disorders but higher in comparison with patients with depressive disorders. In meta-regression analyses, no significant moderators emerged. The associations for violent criminal behaviors in bipolar disorder in comparison with patients suffering from anxiety, alcohol and drug abuse/dependence and personality disorders were not significant. Mood disorders as well as psychoses, borderline personality disorder and poly-drug use were the most relevant clinical predictors of deliberate self-harm in prison. In the sample of affective patients evaluated during a major depressive episode, the presence of aggressive behaviors was mainly related with bipolarity and the most relevant clinical variable associated with aggression was the presence of mixed features. A significant increase of the risk for aggressive behaviors associated with the presence of lifetime suicide attempts has been observed. As for the association between affective lability with other mixed symptoms, irritable mood and impulsivity were directly significantly associated with affective lability. These two clinical features are two of the most important mediators of self-aggressive behaviors. Despite this, affective lability was not correlated with a higher rate of suicide attempts.

The identification of self- and hetero-aggressive behaviors represented the target of a tailored treatment strategy in the subgroup of bipolar disorder patients characterized by a shared psychopathological “aggressive” dimension and mixed characteristics. in conclusion, the self- and hetero-aggressive components of bipolar disorder have been investigated in this doctoral thesis, leading to a better and broader knowledge on the topic, with important implications for the every-day clinical practice and in terms of treatment strategies, both in psychiatric and in correctional settings.

El objetivo principal de esta tesis doctoral fue evaluar los correlatos clínicos de auto o hetero-agresiones, en el contexto del trastorno bipolar, con especial foco en aquellos pacientes que presentan características clínicas mixtas. Los cinco artículos incluidos tenían diseños de estudio diferentes: I. Meta-análisis de estudios sobre la asociación entre trastorno bipolar y conductas criminales violentas; II. Estudio transversal que evalúa los correlatos clínicos de autolesiones e intentos de suicidio en presos, en particular trastornos afectivos y trastorno bipolar; III. Análisis post-hoc del estudio BRIDGE-II-MIX, con el objetivo de evaluar la hetero-agresión considerada como característica mixta durante un episodio depresivo, y su relación con otras variables clínicas, como la historia de intentos de suicidio; IV. Análisis post-hoc del estudio de BRIDGE-II-MIX, enfocado en la importancia clínica de la asociación entrelazada entre la labilidad afectiva y la reactividad de humor y su correlación con otros síntomas mixtos, en particular la hetero-agresión verbal o física; V. Revisión crítica sistemática de guías clínicas sobre el tratamiento de estados mixtos con una evaluación cuantitativa de la calidad metodológica de los artículos incluidos. Uno cada catorce pacientes que padecen de trastorno bipolar presentó una conducta criminal violenta. La posibilidad de cometer una conducta criminal violenta era menor en pacientes con trastorno bipolar que en aquellos que padecen de trastornos psicóticos, pero mayor en comparación con pacientes con trastornos depresivos. Los análisis de meta-regresión no detectaron moderadores significativos. Los trastornos afectivos así como las psicosis, el trastorno límite de personalidad y el consumo de diferentes tóxicos eran los factores clínicos de riesgo más relevantes de autolesiones en la cárcel. En la muestra de pacientes afectivos evaluados durante un episodio depresivo, la presencia de comportamientos agresivos principalmente fue relacionada con la bipolaridad y la variable más relevante clínica asociada con agresión, fue la presencia de características mixtas. Se observó además un aumento significativo del riesgo para comportamientos agresivos asociados con la presencia de intentos suicidas previos. La identificación de comportamientos auto y hetero-agresivos representa el objetivo de una estrategia de tratamiento adaptada en el subgrupo de pacientes con trastorno bipolar, caracterizado por una dimensión psicopatológica "agresiva" compartida.