Expert: Ivan Goldberg, M.D. - 9/15/2010

Question
I have read, on a few websites, that there is NOT a higher rate of violence in people who have BPD compared to the general public. (I understand this to mean that most people with BPD are NOT violent.) I have read that if there is violence there is often a link to substance abuse. If the person with BPD is violent and is not abusing a substance then this person has additional problems. Are these statement correct?

Does this mean that if a person with BPD who also has violent tendencies that they should get an additional diagnosis for the violent tendencies? Would they then have two labels?

When I say violent tendencies I am referring to; threatening others with knives, attempting to stab a person with a knife while they sleep in bed, hands around the throat, and repeatedly hitting adults and or children.

Answer
Hi . . .

Below is an abstract of the study which demonstrated the relationship between bipolar disorder, substance abuse, and violence.

Arch Gen Psychiatry. 2010 Sep;67(9):931-8.

Bipolar disorder and violent crime: new evidence from population-based longitudinal studies and systematic review.
Fazel S, Lichtenstein P, Grann M, Goodwin GM, Långström N.

Department of Psychiatry, University of Oxford, Warneford Hospital, England. seena.fazel@psych.ox.ac.uk

Abstract
CONTEXT: Although bipolar disorder is associated with various adverse health outcomes, the relationship with violent crime is uncertain.

OBJECTIVES: To determine the risk of violent crime in bipolar disorder and to contextualize the findings with a systematic review.

DESIGN: Longitudinal investigations using general population and unaffected sibling control individuals.

SETTING: Population-based registers of hospital discharge diagnoses, sociodemographic information, and violent crime in Sweden from January 1, 1973, through December 31, 2004.

PARTICIPANTS: Individuals with 2 or more discharge diagnoses of bipolar disorder (n = 3743), general population controls (n = 37 429), and unaffected full siblings of individuals with bipolar disorder (n = 4059).

MAIN OUTCOME MEASURE: Violent crime (actions resulting in convictions for homicide, assault, robbery, arson, any sexual offense, illegal threats, or intimidation).

RESULTS: During follow-up, 314 individuals with bipolar disorder (8.4%) committed violent crime compared with 1312 general population controls (3.5%) (adjusted odds ratio, 2.3; 95% confidence interval, 2.0-2.6). The risk was mostly confined to patients with substance abuse comorbidity (adjusted odds ratio, 6.4; 95% confidence interval, 5.1-8.1). The risk increase was minimal in patients without substance abuse comorbidity (adjusted odds ratio, 1.3; 95% confidence interval, 1.0-1.5), which was further attenuated when unaffected full siblings of individuals with bipolar disorder were used as controls (1.1; 0.7-1.6). We found no differences in rates of violent crime by clinical subgroups (manic vs depressive or psychotic vs nonpsychotic). The systematic review identified 8 previous studies (n = 6383), with high heterogeneity between studies. Odds ratio for violence risk ranged from 2 to 9.

CONCLUSION: Although current guidelines for the management of individuals with bipolar disorder do not recommend routine risk assessment for violence, this assertion may need review in patients with comorbid substance abuse.

PMID: 20819987 [PubMed - in process]


There is no need for a separate diagnosis of someone demonstrates violence. BUT, many people with bipolar disorder who are violent do exhibit behaviors associated with substance abuse and/or one or more of the personality disorders.

Best regards . . .

Ivan
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