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Does Dual Diagnosis Affect Violence and Moderate/Superficial Self-harm in Heroin Addiction at Treatment Entry?

Maremmani, Angelo Giovanni Icro MD; Rugani, Fabio MD; Bacciardi, Silvia MD; Rovai, Luca MD; Pacini, Matteo MD; Dell'Osso, Liliana MD; Maremmani, Icro MD

doi: 10.1097/ADM.0000000000000019
Original Research

Objectives: The presence of aggressive and self-harm behaviors is common in heroin-addicted patients, but these frequent co-occurrences have been poorly investigated. Given the fact that self-harm may be seen as both a clear addictive behavior, with its opiate theory, and as part of psychiatric illness, such as psychosis and bipolar spectrum disorders, in this study, we intend to investigate which of the 2 models is more consistent.

Methods: We compared dual diagnosis with the clinical features of 30 moderate/superficial self-harmed and 162 violent heroin-addicted patients who reported aggressive behavior in the month preceding their request to be treated. As control group, we selected 808 lifetime nonviolent heroin-addicted patients.

Results: The presence of a bipolar spectrum diagnosis proved to be the highest risk factor (B = 4.33; exp(B) = 76.52; 95% confidence interval for exp(B) = 35.69-164.04; P < 0.001) for the presence of aggressive behavior (χ2= 433.05; df = 5; P < 0.001). The highest risk factor for the presence of moderate/superficial self-harm2 = 24.83; df = 2; P < 0.001) was a dual diagnosis for chronic psychosis (β = 1.46; exp(B) = 4.34); 95% confidence interval for exp(B) = 1.11-16.98; P < 0.001). The relationships between aggressive and/or self-harm behaviors and the natural history of addiction in heroin-addicted patients seemed to be less consistent.

Conclusions: Our data show a frequent co-occurrence of aggression and bipolar spectrum disorder in heroin-addicted patients, which is manifested as aggression directed toward others (violence). On the contrary, self-injurious behavior seems to be strongly correlated with psychotic disorders. Thus, aggressive behavior seems to be correlated, in heroin-addicted patients before entering treatment, with dual diagnosis rather than with a natural history of heroin addiction.

From the Vincent P. Dole Dual Diagnosis Unit (AGIM, FR, SB, LR, MP, IM), Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Italy, EU; Association for the Application of Neuroscientific Knowledge to Social Aims (AU-CNS) (AGIM, IM), Pietrasanta, Lucca, Italy, EU; G. De Lisio Institute of Behavioural Sciences (MP, IM), Pisa, Italy, EU; and Department of Clinical and Experimental Medicine (LD), University of Pisa, Italy, EU.

Send correspondence and reprint requests to Icro Maremmani, MD, Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Via Roma, 67 56100 Pisa, Italy, EU. E-mail:

The authors declare no conflicts of interest.

Received April 12, 2013

Accepted December 14, 2013

© 2014 American Society of Addiction Medicine