Criminal conviction, impulsivity, and course of illness in bipolar disorder

Psychiatric disorders and reoffending risk in individuals with community sentences in Sweden: a national cohort study

BACKGROUND

Community sentences are widely used in many countries, often comprising the majority of criminal justice sanctions. Psychiatric disorders are highly prevalent in community-sentenced populations and are thus potential targets for treatment interventions designed to reduce reoffending. We examined the association between psychiatric disorders and reoffending in a national cohort of individuals given community sentences in Sweden, with use of a sibling control design to account for unmeasured familial confounding.

METHODS

We did a longitudinal cohort study of 82 415 individuals given community sentences between Nov 1, 1991, and Dec 31, 2013, in Sweden using data from population-based registers. We calculated hazard ratios (HRs) for any reoffending and violent reoffending with Cox regression models. We compared community-sentenced siblings with and without psychiatric disorders to control for potential familial confounding. Additionally, we calculated population attributable fractions to assess the contribution of psychiatric disorders to reoffending behaviours. The primary outcomes of the study were any (general) reoffending and violent reoffending.

FINDINGS

Between Nov 1, 1991, and Dec 31, 2013, those given community sentences who were diagnosed with any psychiatric disorder had an increased reoffending risk in men (adjusted HR 1·59, 95% CI 1·56-1·63 for any reoffending; 1·60, 1·54-1·66 for violent reoffending) and women (1·71, 1·61-1·82 for any reoffending; 2·19, 1·88-2·54 for violent reoffending). Risk estimates remained elevated after adjustment for familial confounding. Schizophrenia spectrum disorders, personality disorders, and substance use disorders had stronger associations with violent reoffending than did other psychiatric disorders. Assuming causality, the adjusted population attributable risk of psychiatric disorders on violent reoffending was 8·3% (95% CI 6·6-10·0) in the first 2 years of community follow-up in men and 30·9% (22·7-39·0) in women.

INTERPRETATION

Psychiatric disorders were associated with an increased risk of any reoffending and violent reoffending in the community-sentenced population. The magnitude of the association between psychiatric disorders and reoffending varied by individual diagnosis. Substance use disorders had the highest absolute and relative risks. Most of the increased risk for any reoffending in individuals with psychiatric disorders could be attributed to comorbid substance misuse. Given their high prevalence, substance use disorders should be the focus of treatment programmes in community-sentenced populations.

FUNDING

Wellcome Trust.

Impaired risk avoidance in bipolar disorder and substance use disorders

Comorbid substance use disorders are highly prevalent in bipolar disorder, and research suggests that individuals with the comorbid presentation typically have worse outcomes than individuals with bipolar disorder without this comorbidity. However, psychosocial treatments for the comorbid presentation have not demonstrated effectiveness for both mood and substance use symptom domains, suggesting novel treatments are needed. An alternative path to treatment development is to identify mechanisms that underlie comorbid bipolar disorder and substance use disorders that can subsequently be targeted in treatment. We evaluated neurocognitive markers for impairments in risk avoidance (the tendency to engage in a persistent pattern of problematic behaviors despite negative outcomes resulting from such behaviors) as potential mechanistic variables underlying negative illness outcomes in the comorbid population. Participants with bipolar disorder (n = 45) or comorbid bipolar disorder and substance use disorders (n = 31) in a relatively euthymic mood state completed clinical risk behavior assessments, task-based risk avoidance assessments, and neurocognitive assessments. Results indicated a lack of notable between-group differences in the clinical risk composite score, task-based risk avoidance assessments, and neurocognitive assessments, with the exception of self-reported executive dysfunction which was elevated among the comorbid sample. Collapsing across group, we found that increased discounting of delayed rewards, older age, and an earlier age of (hypo)mania onset predicted an increased clinical risk composite score. These findings underscore the potential importance of delay discounting as a novel mechanistic target for reducing clinical risk behaviors among individuals with bipolar disorder both with and without comorbid substance use disorders.

Suicidal Ideation in Bipolar Disorder: The Relation with Clinical and Sociodemographic Variables

INTRODUCTION

Bipolar disorder (BD) has the highest risk of suicide among all mental disorders. Thus, identifying factors related to suicidal ideation is essential for a better assessment of the risk of suicide in BD.

OBJECTIVE

To analyze the relationship between suicidal ideation and clinical and sociodemographic characteristics in BD patients.

METHOD

This is a cross-sectional study that included eighty individuals with BD. Information regarding sociodemographic data and history of attempted suicide were collected, and the Hamilton Depression Scale, Young Mania Rating Scale, Positive And Negative Syndrome Scale/positive symptom subscale, Clinical Global Impressions Scale for use in bipolar illness, Insight Scale for Affective Disorders, and Barratt Impulsiveness Scale were administered. The presence and severity of suicidal ideation were assessed using the Beck Scale for Suicidal Ideation.

RESULTS

All regression models significantly predicted suicidal ideation. In the model that had the lowest AIC score and the highest cross-validity, the severity of depressive and of manic symptoms (standardized β = 0.49, p < 0.001; standardized β = 0.42, p = 0.007), the insight level (standardized β = - 0.38, p = 0.012) and previous suicide attempt (standardized β = 0.20, p = 0.036) acted as predictors of suicidal ideation, while degree of impulsivity (β standardized = 0.13, p = 0.229) and educational level (standardized β = - 0.16, p = 0.108) did not give a significant contribution.

CONCLUSION

According to our results, more severe depression and mania symptoms, higher level of insight and a history of suicide attempt indicate the occurrence of suicidal ideation in BD.

Inpatient early intervention for serious mental illnesses and post-discharge criminal involvement in a high-volume psychiatric hospital setting

Individuals with serious mental illness (SMI) are at increased risk for arrest and incarceration relative to the same-community population without SMI. Publicly-funded inpatient psychiatric hospitals usually feature short lengths of stay and limited opportunities for extended services that might impact criminal justice involvement after discharge. This study examined the influence of an early intervention program for SMI at a high-volume public psychiatric hospital on involvement in the criminal justice system post-discharge. The Early Onset Treatment Program (EOTP) is an extended service intervention program for uninsured patients who are within 5 years of SMI onset. Criminal justice records (number of arrests with conviction, days of incarceration) were obtained for EOTP participants (n = 164) and comparison patients (n = 164) matched on demographics, diagnosis, and discharge date via propensity score matching. Data were zero-inflated and analyzed using hurdle models, controlling for prior arrests. The EOTP group was less likely to be convicted of at least one crime post-discharge (0 arrests vs. > 0, p < .001), and spent fewer days incarcerated (if incarcerated ≥1 day, p < .03). Participation in the EOTP service was linked to reduced likelihood of post-discharge arrest and days incarcerated. Several alternative variables may contribute to this preliminary observation, including length of stay, medication adherence, longer environmental stability, and individual patient characteristics.

Clinical Impact of Psychopathy on Bipolar Disorder

Background and Objectives. Bipolar disorder (BD) is associated with a significant burden due to affective symptoms and behavioral manifestations, but also cognitive and functional impairment. Comorbidity with other psychiatric conditions, including personality disorders, is frequent. The comorbidity with psychopathy deserves special consideration given that both disorders share some clinical characteristics, such as grandiosity, risky behavior or poor insight, among others, that can worsen the outcome of BD. Therefore, this study aimed to evaluate the prevalence of psychopathy in a sample of clinically stabilized patients with BD and its impact on the severity of BD. Materials and Methods. A sample of 111 patients with BD (38 type I and 73 type II) was studied. The Hamilton Depression Rating Scale (HAM-D) and the Young Mania Rating Scale (YMRS) served to assess the severity of BD. Psychopathy was measured by means of the Psychopathic Personality Inventory-Revised (PPI-R). Patients were divided into three groups according to the severity of psychopathy (Group 1: no psychopathy; Group 2: “psychopathic” trait; Group 3: clinical psychopathy). Other measures regarded impulsiveness (Barratt Impulsiveness Scale-11, BIS-11) and empathy (Empathy Quotient, EQ). Comparisons of mania, depression, impulsivity and empathy scores were run with MANOVA considering psychopathy and diagnosis as independent variables. Results. The prevalence of psychopathy was 5.4%. A significant association between the level of psychopathy and YMRS, attentional/cognitive impulsivity and motor impulsivity scores emerged. No interaction between psychopathy and BD diagnosis was found. Post hoc analysis demonstrated significantly higher YMRS scores in Group 3 than in Group 1; that is, patients with psychopathy have more manic symptoms. Conclusion. Psychopathy seems quite frequent among patients with BD. The association of psychopathy with BD results in higher impulsivity and manic symptoms. In light of this, psychopathy should be investigated when assessing patients with BD, regardless of the comorbidity of BD with other personality disorders.

Insanity defence in bipolar patients at the time of committing murder according to Iranian law: Case studies

Bipolar disorder is a chronic, relapsing illness characterised by recurrent episodes of manic or depressive symptoms, with intervening periods that are relatively (but not fully) symptom-free. Studies have found higher rates of psychiatric disorders in homicide offenders than in the general population. The insanity defence is a legal construct that, under some circumstances, excuses defendants with mental illness from legal responsibility for criminal behaviour. Here we report two cases of family murder by the mother of the family caused by bipolar disease. The role of the forensic psychiatrist in diagnosing insanity during the commission of a crime is very important as these patients should be diagnosed, treated as soon as possible, and monitored. Public education through social media should be considered to reduce crimes in societies. Diagnosing insanity during the commission of a crime is very important and requires high precision forensic psychiatry. Public education through social media should be considered to reduce crimes in societies.

Allelic variation in dopamine D2 receptor gene is associated with attentional impulsiveness on the Barratt Impulsiveness Scale (BIS-11)

OBJECTIVES

Previous studies have postulated that noradrenergic and/or dopaminergic gene variations are likely to underlie individual differences in impulsiveness, however, few have shown this. The current study examined the relationship between catecholamine gene variants and self-reported impulsivity, as measured by the Barratt Impulsiveness Scale (Version 11; BIS-11) Methods: Six hundred and seventy-seven non-clinical adults completed the Barratt Impulsiveness Scale (BIS-11). DNA was analysed for a set of 142 single-nucleotide polymorphisms (SNPs) across 20 autosomal catecholamine genes. Association was tested using an additive regression model with permutation testing used to control for the influence of multiple comparison.

RESULTS

Analysis revealed an influence of rs4245146 of the dopamine D2 receptor (DRD2) gene on the BIS-11 attention first-order factor, such that self-reported attentional impulsiveness increased in an additive fashion with each copy of the T allele.

CONCLUSIONS

These findings provide preliminary evidence that allelic variation in DRD2 may influence impulsiveness by increasing the propensity for attentional lapses.

Psychiatric Disorders and Crime in the US Population: Results From the National Epidemiologic Survey on Alcohol and Related Conditions Wave III

OBJECTIVE

Current knowledge regarding the intersection of psychiatric disorders and crime in the United States is limited to psychiatric, forensic, and youth samples. This study presents nationally representative data on the relationship of DSM-5 psychiatric disorders, comorbid substance and mental health disorders, and multimorbidity (number of disorders) with criminal behavior and justice involvement among non-institutionalized US adults.

METHODS

Data were drawn from the National Epidemiologic Survey on Alcohol and Related Conditions Wave III (NESARC-III; 2012-2013; N = 36,309). Logistic regressions were used to examine the association of specific disorders (eg, mood, anxiety, eating, posttraumatic stress, substance use), comorbid substance use and mental health disorders, and multimorbidity with lifetime criminal behavior, incarceration experience, and past-12-month general, alcohol-related, and drug-related legal problems.

RESULTS

Overall, 28.5% of participants reported a history of criminal behavior, 11.4% reported a history of incarceration, 1.8% reported current general legal problems, 0.8% reported current alcohol-related legal problems, and 2.7% reported current drug-related legal problems. The presence of any disorder was associated with a 4 to 5 times increased risk of crime outcomes. Drug use disorders were associated with the highest risk of lifetime crime (adjusted odds ratio [AOR] = 6.8; 95% CI, 6.1-7.6) and incarceration (AOR = 4.7; 95% CI, 4.1-5.3) and current legal problems (AOR = 3.3; 95% CI, 2.6-4.2). Multimorbidity and comorbid substance use and mental health disorders were associated with additional risk. Controlling for antisocial personality disorder did not change the findings.

CONCLUSIONS

Community adults with substance use disorders, comorbid substance use and mental health disorders, and increasing multimorbidity are most at risk of crime and justice involvement, highlighting the importance of community-based addiction treatment.

Risk of criminal justice system involvement among people with co-occurring severe mental illness and substance use disorder

While there are documented risk factors for criminal justice system involvement (CJSI) among persons with severe mental illness, little is known about risk for CJSI among people with co-occurring severe mental illness and substance use disorders. Using logistic regression, we identified sociodemographic and clinical risk factors that most increase risk of CJSI among people with co-occurring disorders (N = 10,855: National Survey of Drug use and Health, 2006-2014), and examined whether co-occurring disorders increase CJSI risk and risk of violent offenses in relation to severe mental illness alone versus substance use disorder alone. Seventeen percent of people with co-occurring disorders in our study were arrested and booked for breaking the law in the past year. At heightened risk were males, Blacks (relative to Whites), younger people, people with less education, divorced or separated individuals (relative to married), the unemployed, persons in the largest households (6 or more people, relative to one person), people in substance abuse treatment, and persons with certain drug use disorders (e.g., both alcohol and marijuana, relative to alcohol only). At reduced risk were Asians (relative to Whites), people with the highest incomes, and people with marijuana use disorders (relative to alcohol). In relation to people without severe mental illness or substance use disorder, those with co-occurring disorders were 7.47 times as likely (CI = 6.56-8.51, p < .001) to be arrested and booked for breaking the law in the last 12 months, while those with severe mental illness (only) were 1.84 times as likely (CI = 1.64-2.08, p < .001) and those with substance use disorder (only) were 5.32 times as likely (CI = 4.86-5.83, p < .001). After using our findings to identify people who are at greatest risk for CJSI, preventative interventions could be offered.

Method of homicide and severe mental illness: A systematic review

There is limited research that has examined offense characteristics in homicides committed by individuals with mental illness and with differing psychiatric diagnoses. The aim of this systematic review is to synthesize previous findings of studies analyzing homicide behavior by mentally ill individuals, and reporting any associations between mental illness and method of homicide. We searched four databases (MedLine, PsychINFO, Web of Science and Embase), and identified 52 relevant articles for analysis. Of these 52 articles, nine reported specific information on mental illness and method of homicide. Five out of nine articles revealed an association between schizophrenia/delusional disorder and the use of sharp instruments as a method of homicide. Four out of nine studies revealed an association between mood disorders (bipolar disorder/major depression) and strangulation/asphyxiation/suffocation/drowning. Our review confirms consistency across studies reporting a significant association between close contact methods and schizophrenia/mood disorders. Also identified as possible influential factors concerning weapon choice are illness duration, victim characteristics and planning/lack of planning of the homicide. Additionally, studies revealed up to 96% of severely mentally ill offenders experienced psychiatric symptoms at the time of the homicide. Future research may examine the presence of specific psychiatric symptoms when a mentally ill offender commits a homicide and whether these may be more influential in the method of homicide used than the psychiatric diagnosis of the offender.

Do High-risk Prisoners Entering Treatment Have Clinically Impaired Cognitive Impulse Control?

Moffitt's (1993) developmental theory suggests that offenders on the life-course persistent (LCP) trajectory inherit or acquire neuropsychological deficits that compromise impulse control, and ultimately contribute to criminality. Empirical tests of this notion with adult LCP offenders are rare; the expected degree of impairment and which mechanisms are unclear. This research adopted a neurocognitive framework that proposes three cognitive mechanisms of impulse control: decision-making, perceptual control, and motor impulse control. Participants were 77 adult males, predominantly LCP prisoners completed five assessment tasks during pre-treatment assessment. Overall, proportions of impairment were unexpectedly low within and across cognitive impulse control domains. The highest proportions of impairment were observed on tasks requiring cognitive flexibility and sustained attention, and only cognitive flexibility uniquely predicted estimated pre-treatment violence risk. Results suggest the need to disaggregate cognitive from personality and behavioural variants of impulsivity and to further investigate how impaired cognitive flexibility affects progress during and following treatment.

Genetic and environmental determinants of violence risk in psychotic disorders: a multivariate quantitative genetic study of 1.8 million Swedish twins and siblings

Patients diagnosed with psychotic disorders (for example, schizophrenia and bipolar disorder) have elevated risks of committing violent acts, particularly if they are comorbid with substance misuse. Despite recent insights from quantitative and molecular genetic studies demonstrating considerable pleiotropy in the genetic architecture of these phenotypes, there is currently a lack of large-scale studies that have specifically examined the aetiological links between psychotic disorders and violence. Using a sample of all Swedish individuals born between 1958 and 1989 (n=3 332 101), we identified a total of 923 259 twin-sibling pairs. Patients were identified using the National Patient Register using validated algorithms based on International Classification of Diseases (ICD) 8-10. Univariate quantitative genetic models revealed that all phenotypes (schizophrenia, bipolar disorder, substance misuse, and violent crime) were highly heritable (h(2)=53-71%). Multivariate models further revealed that schizophrenia was a stronger predictor of violence (r=0.32; 95% confidence interval: 0.30-0.33) than bipolar disorder (r=0.23; 0.21-0.25), and large proportions (51-67%) of these phenotypic correlations were explained by genetic factors shared between each disorder, substance misuse, and violence. Importantly, we found that genetic influences that were unrelated to substance misuse explained approximately a fifth (21%; 20-22%) of the correlation with violent criminality in bipolar disorder but none of the same correlation in schizophrenia (Pbipolar disorder<0.001; Pschizophrenia=0.55). These findings highlight the problems of not disentangling common and unique sources of covariance across genetically similar phenotypes as the latter sources may include aetiologically important clues. Clinically, these findings underline the importance of assessing risk of different phenotypes together and integrating interventions for psychiatric disorders, substance misuse, and violence.

Trait impulsivity and increased pre-attentional sensitivity to intense stimuli in bipolar disorder and controls

Impulsivity and sensation seeking are stimulus-oriented traits. Because they differ in degree of intention and planning, they may have distinct neurophysiological mechanisms. Impulsivity is prominent in bipolar disorder, and may be related to pre-attentional information filtering and stimulus-orientation. We investigated specificity of relationships between impulsivity and sensitivity to stimulus intensity in bipolar disorder and controls, using intensity-sensitivity of auditory evoked potentials. Seventy-six subjects (37 healthy controls, 39 with bipolar disorder) were administered an intensity-sensitivity paradigm. Additional measures included Barratt Impulsiveness Scale (BIS-11) and Eysenck Impulsivity and Venturesomeness scores. State-dependent rapid-response impulsivity was measured using the Immediate Memory Task. Intensity-sensitivities of the auditory evoked P1N1, N1P2, P1, N1, and P2 potentials were assessed as the slope of amplitude relative to loudness. Analyses used general linear models (GLM) with impulsivity-related measures as dependent variables and age, gender, education, and diagnosis as dependent variables. BIS-11 total, motor, and attentional impulsivity scores correlated positively with pre-attentional N1 and P1N1 intensity-sensitivity slopes in bipolar disorder, but not in controls. BIS-11 nonplanning and Eysenck Venturesomeness scores did not correlate with intensity-sensitivity. Intensity-sensitivity slopes did not correlate with rapid-response impulsivity. Correlations between N1 or P1N1 slopes and BIS-11 scores in bipolar disorder were not affected by age, education, WAIS, treatment, symptoms, or gender. Trait impulsivity in bipolar disorder may be related to poorly modulated stimulus-driven late pre-attentional responses to stimuli, potentially resulting in exaggerated responses to intense stimuli even before conscious awareness. Components of trait impulsivity are physiologically heterogenous relative to intensity-sensitivity.

Bipolar disorder and criminal offending: a data linkage study

PURPOSE

The current study explored criminal offending among people diagnosed with bipolar disorder with and without comorbid substance use and compared this with a community sample with no history of bipolar disorder.

METHODS

A case-linkage design was used to compare patterns of officially recorded criminal offending between 1,076 people with bipolar disorder drawn from a state-wide psychiatric case register with a community comparison group.

RESULTS

Those with bipolar disorder were significantly more likely than community members to be charged with, convicted of, and be found guilty of, violent, non-violent and intermediate level criminal offences. Those with a comorbid substance use disorder were two times more likely than those without a substance use disorder to offend; both groups had a significantly higher chance of offending than the community sample. Females with bipolar disorder were significantly more likely to have been convicted of violent offences, irrespective of substance use. Significant interactions were found between bipolar disorder and substance use for males and females with respect to violent offending and for males with respect to non-violent offending.

CONCLUSIONS

There is a statistically significant association between bipolar disorder and the likelihood of having a criminal history. Co-occurring substance use differentially impacts on the likelihood of criminal offending for males and females.

Shared clinical associations between obesity and impulsivity in rapid cycling bipolar disorder: a systematic review

BACKGROUND

Obesity seems to show a two-way relationship with bipolar disorder (BD), representing not only a possible vulnerability factor but also a consequence of chronic mood dysregulation associated with an overall poor prognosis. Increased impulsivity has been described across all stages and phases of BD as being also associated with a worse prognosis. Although obesity and impulsivity are common features among rapid cycling bipolar disorder (RC-BD) patients, there is a lack of understanding about the clinical implications of these conditions combined in BD.

METHODS

To explore and integrate available evidence on shared clinical associations between obesity and impulsivity in RC-BD a systematic search of the literature in the electronic database of the National Library of Medicine (PubMed) has been conducted.

RESULTS

One hundred and fourteen articles were included in our systematic review. Among RC-BD patients, substance abuse disorders (SUDs), anxiety disorders (ADs), predominantly depressive polarity, chronic exposure to antidepressants, psychotic symptoms, suicidality, and comorbid medical conditions are strongly associated with both obesity and impulsivity.

LIMITATIONS

Heterogeneity of published data, inconsistent measurements of both obesity and impulsivity in RC-BD and an absence of control for RC-BD in epidemiological surveys. Consequently, their combined impact on the severity of RC-BD is yet to be recognized and remains to be poorly understood.

CONCLUSION

In RC-BD patients the co-occurrence of obesity and impulsivity is associated with an unfavorable course of illness, specific shared clinical correlates, negative psychosocial impact, and overall worse prognosis. There is a need to examine obesity and impulsivity as modulating factors and markers of severity in RC-BD.

Personality, coping, risky behavior, and mental disorders in the offspring of parents with bipolar disorder: a comprehensive psychosocial assessment

OBJECTIVES

It has been proposed that the offspring of parents with bipolar disorder (OBD), through genetic mechanisms and early family interactions, develop a heightened sensitivity to stress, maladaptive coping, and dysregulated behavior, which ultimately increases the risk for affective disorders. The current study tested certain predictions of this model by assessing different psychosocial and health-related outcomes in the OBD, including personality, coping style, smoking, suicidality, high-risk sexual behaviors, criminality, and mental health.

METHOD

The sample was composed of 74 OBD and 75 control offspring, who were between 14 and 27 years of age (mean: 19.38±3.56). Participants underwent a diagnostic interview and a structured interview to assess high-risk behavior and other maladaptive outcomes, and they completed the Revised NEO Personality Inventory and Coping in Stressful Situations questionnaire.

RESULTS

The rates of affective (31.1%) and non-affective (56.8%) disorders were elevated in the OBD compared to controls (9.5% and 32.4%). Relative to controls, OBD endorsed fewer task-oriented and more distraction coping strategies [Wilk׳s λ=.83, F(1, 136) =6.92, p<.01], and were more likely to report engaging in high-risk sexual behavior (OR=2.37; Wald=4.13, 1 df, p<05). Importantly, OBD reported elevated high-risk sexual behavior relative to controls, irrespective of affective disorder diagnosis.

CONCLUSION

The results highlight a potential risk profile for the OBD, consisting of ineffective coping strategies and risky sexual behavior and are discussed in the context of current knowledge of stress and coping in this population.

LIMITATIONS

The present findings were based on cross-sectional data and relied on offspring self-report. It would be useful to corroborate these findings with biobehavioural and longitudinal measures.

Suicide, hospital-presenting suicide attempts, and criminality in bipolar disorder: examination of risk for multiple adverse outcomes

OBJECTIVE

To compare risks for suicidality and criminality in a national cohort of people diagnosed with bipolar disorder, and to assess how risk factor profiles differ between these outcomes.

METHOD

We conducted 2 case-cohort studies using interlinked Swedish national registers. Primarily, using International Classification of Diseases (ICD) coding, we identified 15,337 people diagnosed with bipolar disorder, 1973-2009, matched by age and gender to 20 individuals per case sampled randomly from the general population. We estimated risks of suicide and hospital-presenting attempted suicide, and violent and nonviolent criminal offending. We separately assessed these risks among 14,677 unaffected siblings matched to a second general population sample.

RESULTS

22.2% of bipolar disorder cohort members engaged in suicidal or criminal acts after diagnosis. They were at greatly elevated risk for completed suicide (risk ratio = 18.8; 95% CI, 16.0-22.2), attempted suicide (risk ratio = 14.3; 95% CI, 13.5-15.2), violent crime (risk ratio = 5.0; 95% CI, 4.6-5.4), and nonviolent crime (risk ratio = 2.9; 95% CI, 2.8-3.1) compared with the general population. Elevations in risk were far less marked among the unaffected siblings than in the bipolar disorder cohort. Three factors independently predicted raised risk of all 4 adverse outcomes: if the first 2 patient episodes for bipolar disorder required admission, a history of attempted suicide, and a history of diagnosed alcohol/drug disorder. Criminal offending before bipolar diagnosis was an especially strong independent predictor of criminality after diagnosis.

CONCLUSIONS

The combined risk of suicidality or criminality is substantially elevated in both relative and absolute terms. Clinical prediction rules focusing on multiple vulnerabilities following onset of bipolar disorder, especially when there is history of attempted suicide, substance misuse disorders, or criminal offending, may improve risk management.

Anxiety, depression, impulsivity and substance misuse in violent and non-violent adolescent boys in detention in China

The present investigation aims to identify the factors which differentiate violent from non-violent juvenile offenders, with a particular emphasis on the association between internalizing psychiatric morbidity (i.e. anxiety and depression), impulsivity, substance misuse, and violence. A total of 323 incarcerated male juvenile offenders from one of three Youth Detention Centers (YDCs) in China were recruited between August 2007 and November 2008. Interviews were conducted by trained psychiatrists using the Barratt Impulsivity Scale (BIS-11), the Screen for Child Anxiety Related Emotional Disorders (SCARED), and the Birleson Depression Self-Rating Scale (DSRS) to assess impulsivity, anxiety and depression, respectively. The Schedule for Affective Disorder and Schizophrenia for School-Age Children Present and Lifetime (K-SADS-PL) was also used to assess psychiatric diagnoses. Violent offenders had significantly higher BIS-11 total scores, and attention and nonplanning subscale scores (p<0.05). In the multiple logistic regression model, substance use disorders (SUD) and BIS-11 total scores independently predicted violence. Prison-based treatment services designed to reduce impulsivity and substance misuse in juvenile detention facilities should be prioritized.

Psychopathy and facial emotion recognition ability in patients with bipolar affective disorder with or without delinquent behaviors

BACKGROUND

It is well known that patients with bipolar disorder are more prone to violence and have more criminal behaviors than general population. A strong relationship between criminal behavior and inability to empathize and imperceptions to other person's feelings and facial expressions increases the risk of delinquent behaviors. In this study, we aimed to investigate the deficits of facial emotion recognition ability in euthymic bipolar patients who committed an offense and compare with non-delinquent euthymic patients with bipolar disorder.

METHOD

Fifty-five euthymic patients with delinquent behaviors and 54 non-delinquent euthymic bipolar patients as a control group were included in the study. Ekman's Facial Emotion Recognition Test, sociodemographic data, Hare Psychopathy Checklist, Hamilton Depression Rating Scale and Young Mania Rating Scale were applied to both groups.

RESULTS

There were no significant differences between case and control groups in the meaning of average age, gender, level of education, mean age onset of disease and suicide attempt (p>0.05). The three types of most committed delinquent behaviors in patients with euthymic bipolar disorder were as follows: injury (30.8%), threat or insult (20%) and homicide (12.7%). The best accurate percentage of identified facial emotion was "happy" (>99%, for both) while the worst misidentified facial emotion was "fear" in both groups (<50%, for both). The total accuracy rate of recognition toward facial emotions was significantly impaired in patients with delinquent behaviors than non-delinquent ones (p<0.05). The accuracy rate of recognizing the fear expressions was significantly worse in the case group than in the control group (p<0.05). In addition, it tended to be worse toward angry facial expressions in criminal euthymic bipolar patients. The response times toward happy, fear, disgusted and angry expressions had been significantly longer in the case group than in the control group (p<0.05).

CONCLUSION

This study is the first, searching the ability of facial emotion recognition in euthymic patients with bipolar disorder who had delinquent behaviors. We have shown that patients with bipolar disorder who had delinquent behaviors may have some social interaction problems i.e., misrecognizing fearful and modestly anger facial emotions and need some more time to response facial emotions even in remission.

Pre-attentive information processing and impulsivity in bipolar disorder

Early responses to stimuli can be measured by sensory evoked potentials (EP) using repeated identical stimuli, S1 and S2. Response to S1 may represent efficient stimulus detection, while suppression of response to S2 may represent inhibition. Early responses to stimuli may be related to impulsivity. We compared EP reflecting stimulus detection and inhibition in bipolar disorder and healthy controls, and investigated relationships to impulsivity. Subjects were 48 healthy controls without family histories of mood disorder and 48 with bipolar disorder. EP were measured as latencies and amplitudes for auditory P50 (pre-attentional), N100 (initial direction of attention) and P200 (initial conscious awareness), using a paired-click paradigm, with identical stimuli 0.5 s apart. Impulsivity was measured by questionnaire and by laboratory tests for inability to suppress responses to stimuli or to delay response for a reward. Analyses used general linear models. S1 amplitudes for P50, N100, and P200, and gating of N100 and P200, were lower in bipolar disorder than in controls. P50 S1 amplitude correlated with accurate laboratory-task responding, and S2 amplitude correlated with impulsive task performance and fast reaction times, in bipolar disorder. N100 and P200 EP did not correlate with impulsivity. These findings were independent of symptoms, treatment, or substance-use history. EPs were not related to questionnaire-measured or reward-based impulsivity. Bipolar I disorder is characterized by reduced pre-attentional and early attentional stimulus registration relative to controls. Within bipolar disorder, rapid-response impulsivity correlates with impaired pre-attentional response suppression. These results imply specific relationships between ERP-measured response inhibition and rapid-response impulsivity.

Inhibitory deficits in euthymic bipolar disorder patients assessed in the human behavioral pattern monitor

BACKGROUND

Bipolar disorder (BD) is associated with inhibitory deficits characterized by a reduced ability to control inappropriate actions or thoughts. While aspects of inhibition such as exaggerated novelty-seeking and perseveration are quantified in rodent exploration of novel environments, similar models are rarely applied in humans. The human Behavioral Pattern Monitor (hBPM), a cross-species exploratory paradigm, has identified a pattern of impaired inhibitory function in manic BD participants, but this phenotype has not been examined across different BD phases. The objective of this study was to determine if euthymic BD individuals demonstrate inhibitory deficits in the hBPM, supporting disinhibition as an endophenotype for the disorder.

METHODS

25 euthymic BD outpatients and 51 healthy comparison subjects were assessed in the hBPM, where activity was recorded by a concealed videocamera and an ambulatory monitoring sensor.

RESULTS

Euthymic BD individuals, similar to manic subjects, demonstrated increased motor activity, greater interaction with novel objects, and more frequent perseverative behavior relative to comparison participants. The quantity of locomotion was also reduced in BD individuals treated with mood stabilizers compared to other patients.

LIMITATIONS

Low sample size for treatment subgroups limits the evaluation of specific medication regimens.

CONCLUSIONS

Our results suggest that BD is distinguished by both trait- and state-dependent inhibitory deficits optimally assessed with sophisticated multivariate measures. These data support the use of the hBPM as a tool to elucidate the effects of BD across various illness states, facilitate the development of BD animal models, and advance our understanding of the neurobiology underlying the disorder.

Norepinephrine and impulsivity: effects of acute yohimbine

RATIONALE

Rapid-response impulsivity, characterized by inability to withhold response to a stimulus until it is adequately appraised, is associated with risky behavior and may be increased in a state-dependent manner by norepinephrine.

OBJECTIVE

We assessed effects of yohimbine, which increases norepinephrine release by blocking alpha-2 noradrenergic receptors, on plasma catecholamine metabolites, blood pressure, subjective symptoms, and laboratory-measured rapid-response impulsivity.

METHODS

Subjects were 23 healthy controls recruited from the community, with normal physical examination and ECG, and negative history for hypertension, cardiovascular illness, and axis I or II disorder. Blood pressure, pulse, and behavioral measures were obtained before and periodically after 0.4 mg/kg oral yohimbine or placebo in a randomized, counterbalanced design. Metabolites of norepinephrine [3-methoxy-4-hydroxyphenylglycol (MHPG) and vanillylmandelic acid (VMA)] and dopamine [homovanillic acid (HVA)] were measured by high-pressure liquid chromatography with electrochemical detection. Rapid-response impulsivity was measured by commission errors and reaction times on the immediate memory task (IMT), a continuous performance test designed to measure impulsivity and attention.

RESULTS

Yohimbine increased plasma MHPG and VMA but not HVA. Yohimbine increased systolic and diastolic blood pressure and pulse rate. On the IMT, yohimbine increased impulsive errors and impulsive response bias and accelerated reaction times. Yohimbine-associated increase in plasma MHPG correlated with increased impulsive response rates. Time courses varied; effects on blood pressure generally preceded those on metabolites and test performance.

CONCLUSIONS

These effects are consistent with increased rapid-response impulsivity after pharmacological noradrenergic stimulation in healthy controls. Labile noradrenergic responses, or increased sensitivity to norepinephrine, may increase risk for impulsive behavior.

Is there an empirical link between impulsivity and suicidality in bipolar disorders? A review of the current literature and the potential psychological implications of the relationship

OBJECTIVES

Suicide is highly prevalent among individuals with bipolar disorder and understanding the factors that increase risk for suicide may help to develop targeted interventions to prevent attempts. Impulsivity is thought to be an influential factor associated with suicidality and is also discussed as a key construct of bipolar disorder. The aim of this paper was to systematically review the current evidence to examine the association between impulsivity and suicidality in bipolar disorder.

METHODS

PsycInfo, Medline, and Web of Knowledge databases were searched for articles published up until March 2012. Papers were included if they assessed an adult sample of individuals with bipolar disorders, focused on suicidality (ideation with intent to die, suicide attempts, or completion), and used a validated measure to determine impulsivity.

RESULT

Sixteen papers were identified. Contrary to widespread belief, we found (i) a very inconsistent picture of results including positive, negative, and insignificant associations between impulsivity and suicidality; and (ii) some studies do not take into account important aspects such as state-trait or measurement issues.

CONCLUSIONS

The link between suicidality and impulsivity is less straightforward than often assumed. Drawing clear conclusions about the association is hampered by factors such as inconsistencies in defining suicidality, measuring impulsivity, and differentiating between impulsivity as a personality trait and impulsivity as a state (e.g., a consequence of substance use or premeditation of the attempt). We suggest that the association is less direct and that psychological models (e.g., Joiner's theory of suicidality) can help foster a more in-depth understanding regarding the relationship.

Predictors of criminal justice involvement in severe mania

BACKGROUND

Criminal justice problems among those with bipolar disorder lead to disruption in social functioning, treatment, and recovery. Understanding factors that contribute to arrest during episodes of illness can help inform approaches to risk management and improve clinical care.

METHODS

Data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a longitudinal, nationally representative survey conducted in two waves were used to identify factors that predicted inter-wave criminal justice involvement during bipolar I manic episodes.

RESULTS

Over 10% of respondents experienced legal involvement during their most severe manic episode. Risk was found in a range of historical, clinical, and contextual factors. Multivariate analyses suggest risk is particularly high for those who are unemployed, non-white, have past juvenile detention, have a prior arrest (while using substances or when manic), used an illicit drug in the past year, and whose mania is characterized by both social and occupational impairment. Legal problems were particularly elevated among those who lacked health insurance while experiencing both social and occupational impairment.

LIMITATIONS

Respondents did not include prisoners and hospital inpatients; criminal justice problems were only assessed with regard to the most severe manic episode.

CONCLUSIONS

The particular array of factors that elevate the risk of legal involvement during manic episodes offers guidance when identifying prevention strategies and evaluating patients in clinical and forensic settings. Reducing such involvement will require that these issues be dealt with in the broader context of mental health and other services, which in turn necessitates providing adequate access to healthcare.

Antisocial personality disorder and borderline symptoms are differentially related to impulsivity and course of illness in bipolar disorder

BACKGROUND

Interactions between characteristics of bipolar and Axis II cluster B disorders are clinically and diagnostically challenging. Characteristics associated with personality disorders may be dimensional aspects of bipolar disorder. We investigated relationships among antisocial personality disorder (ASPD) or borderline personality disorder symptoms, impulsivity, and course of illness in bipolar disorder.

METHODS

Subjects with bipolar disorder were recruited from the community. Diagnosis was by structured clinical interview for DSM-IV (SCID-I and -II), psychiatric symptom assessment by the change version of the schedule for affective disorders and schizophrenia (SADS-C), severity of Axis II symptoms by ASPD and borderline personality disorder SCID-II symptoms, and impulsivity by the Barratt impulsiveness scale (BIS-11).

RESULTS

ASPD and borderline symptoms were not related to clinical state or affective symptoms. Borderline symptoms correlated with BIS-11 impulsivity scores, and predicted history of suicide attempts independently of the relationship to impulsivity. ASPD symptoms were more strongly related to course of illness, including early onset, frequent episodes, and substance-related disorders. These effects persisted after allowance for gender and substance-use disorder history.

CONCLUSIONS

Personality disorder symptoms appear to be dimensional, trait-like characteristics of bipolar disorder. ASPD and Borderline symptoms are differentially related to impulsivity and course of illness.

Trait impulsivity as an endophenotype for bipolar I disorder

OBJECTIVE

Impulsivity, conceptualized as impairment in planning and poor attentional and inhibitory control, is a key feature of bipolar disorder. Familial risk for bipolar disorder is known to affect inhibitory control but its impact on the attentional and planning dimensions of impulsivity is still unclear.

METHODS

We administered the Barratt Impulsiveness Scale, version 11 (BIS-11) to 54 euthymic individuals with DSM-IV bipolar I disorder, 57 of their clinically unaffected siblings, and 49 healthy comparison subjects. Groups were compared on the attentional (rapid shifts in attention/impatience with complexity), motor (acting impetuously), and non-planning (absence of weighing upon long-term consequences of actions) subscales of the BIS-11, and on total BIS-11 score. To investigate functional implications of trait impulsivity, total BIS-11 score was examined in relation to current psychosocial functioning and criminal history.

RESULTS

Individuals with bipolar I disorder had elevated scores compared to healthy comparison subjects on BIS-11 total score and all three subscales (p < 0.0001). Unaffected siblings had elevated BIS-11 total score (p = 0.0037), motor (p = 0.0027), and non-planning (p = 0.0379) subscales in comparison to unrelated healthy controls. Total BIS-11 score was negatively associated with global assessment of functioning (GAF) score (β = -0.32, p < 0.0001).

CONCLUSIONS

 Our results suggest that impulsivity is sensitive to familial liability for the illness, making it a potential endophenotype for bipolar disorder.

Antisocial Personality Disorder in People with Co-Occurring Severe Mental Illness and Substance Use Disorders: Clinical, Functional, and Family Relationship Correlates

Antisocial personality disorder (ASPD) is an important correlate of substance abuse severity in the addiction population and in people with co-occurring serious mental illness and addiction. Because family members often provide vital supports to relatives with co-occurring disorders, this study explored the correlates of ASPD in 103 people with co-occurring disorders (79% schizophrenia-schizoaffective, 21% bipolar disorder) in high contact with relatives participating in a family intervention study. Clients with ASPD were more likely to have bipolar disorder and to have been married, but less likely to have graduated from high school. ASPD was associated with more severe drug abuse and depression, worse functioning, and less planning-based social problem solving. The relatives of clients with ASPD also reported less planning-based problem solving, worse attitudes towards the client, and worse mental health functioning. Client ASPD was associated with less long-term exposure to family intervention. The findings suggest that clients with ASPD in addition to co-occurring disorders are a particularly disadvantaged group with greater illness severity, more impaired functioning, and more strained family relationships. These difficulties may pose special challenges to delivering family intervention for this group.

Antisocial personality and bipolar disorder: interactions in impulsivity and course of illness

Antisocial personality disorder (ASPD) and bipolar disorder are both characterized by impulsive behavior, increased incarceration or arrest, addictive disorders and suicidal behavior. These characteristics appear more severe in the combined disorders. Individuals with ASPD who also have bipolar disorder have higher rates of addictive disorders and suicidal behavior and are more impulsive, as measured by questionnaires or behavioral laboratory tests. Those with bipolar disorder who have ASPD have higher rates of addictive, criminal and suicidal behavior, earlier onset of bipolar disorder with a more recurrent and predominately manic course and increased laboratory-measured, but not questionnaire-rated, impulsivity. These characteristics may result in part from differential impulsivity mechanisms in the two disorders, with bipolar disorder driven more by excessive catecholamine sensitivity and ASPD by deficient serotonergic function.