Violence and Mental Illness: The Stigma and the Truth

This is a huge topic, so I will only touch on one “mental illness”, as there is a trial all about BPD in the press and the jury is deliberating whether to send the woman to be executed or not. So I am not going to write about BPD, as it is extremely complicated and I’d rather wait and see what happens with the jury’s decision and then post on BPD and violence. Just one thing to say, without any statistics, it is my experience that people suffering from BPD do a lot of self harming rather than violence towards others. Everything from extreme binging and purging, self-mutilation, repeated suicide attempts, drug and alcohol abuse, etc. plagues people who suffer from BPD.

As I was posting about the movie “Silver Linings Playbook” and felt that it gave a bad impression that people who are going through mania and manic psychosis are violent, I wanted to write about that and shed some light on it. A colleague shared with me that unlike my experiences, she had seem many males who became violent while manic and in the midst of a manic psychosis, so I wondered, is this movie off the mark or not?

Ok.
I looked around the internet and found a study done in England around Sept. 20101. You can read the whole summary here:

http://www.ncbi.nlm.nih.gov/pubmed/20819987

Here’s the important finding, which is that the comorbidity of substance abuse and bipolar disorder is what increases the incidence of violence in people diagnosed with Bipolar Disorder. In regular English, this means that the subgroup of people who have BIpolar Disorder and are abusing drugs and alcohol on a regular basis, usually knows as “MICA” (Mentally Ill and Chemically Addicted), and requiring treatment of both problems, that those people are more likely to be violent than the general population. However, it seems the risk of violence in individuals suffering from BIpolar Disorder alone is minimally different from the rest of the population. This makes sense as there is probably a lot of evidence that especially polysubstance abuse but also alcoholism and any drug addiction that becomes severe and episodic can result in violent behavior. Which is not to say that every alcoholic or person suffering from drug addiction is dangerous, however, I am sure there are some statistics out there supporting a higher evidence of violence occuring among this population…

“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.”

So, to get back to the movie, they did not show the protagonist drinking or doing drugs at all in the movie as far as I remember. Even at the football game, I don’t think he was drunk, but I could be remembering wrong. It seemed like the only hints of drinking under stress were evidenced by the character Tiffany who did not suffer from bipolar disorder, and she was not portrayed as abusing alcohol. So I think this movie could mislead the public into associating manic and other forms of Bipolar Disorder with episodes of violence, when the evidence does not support it…

Here’s another article about the topic, talking about men vs. women but also focusing on the co-occurence of substance abuse and bipolar episodes. The memoir by Marya Hornbacher: Madness: A Bipolar LIfe, is a real roller coaster ride, and great portrayal of someone with a huge drinking problem and bipolar disorder and the self destruction and pain she undergoes after recovering from a very severe eating disorder.

Here are her words about her drinking:

I started drinking when I was ten. There’s a scene in the book where I talk about discovering the booze in the cupboard underneath the stove… It, too, functioned very briefly as a mood stabilizer… It elevated my mood, and just made me feel like I was flying. Instead of feeling like I was going up and down and up and down, there were no more crashes. For a few hours at a time, I wasn’t terrified, I wasn’t anxious — I was just high as a kite. Of course, like any other alcoholic, the reasons you do it at first become irrelevant, because then, you’re just drinking because you’re an alcoholic. When you try to stop drinking, as I did many, many times many years later, you realize it’s not about anything. It’s a function of a kind of desperation and addiction.

So, of course, this topic is extremely complicated, but it is interesting how adding addiction to any other issues magnifies the risks of impulsive behavior, self-harming and suicidal behavior, and sometimes violent behavior towards others… But it makes sense that I have worked with and known of so many cases of people suffering from various forms of Bipolar Disorder who never had any episodes of any violent behavior towards others…

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