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This study aimed to investigate the associations between testosterone levels, aggressive behavior, and manic symptoms using a network analysis among bipolar disorder (BD) patients in psychiatric emergency departments (PED). Data from January 2021 and March 2022 BD patients in PED were analyzed. Manic symptoms were assessed using the Young Mania Rating Scale (YMRS). Aggression was assessed with subscale of the PANSS scale (PANSS-AG). The undirected network structures of testosterone levels, aggressive behavior, and manic symptoms were estimated, and centrality and bridge centrality indices were examined. Network stability was examined using the case-dropping procedure. The Network Comparison Test (NCT) was conducted to evaluate whether network characteristics differed by gender. We recruited a total of 898 BD patients, with the mean YMRS score as 13.30\u2009\u00b1\u20099.58. The prevalence of level II aggression was 35.6% (95%CI\u2009=\u200932.5%\u201338.7%), level III aggression was 29.5% (95%CI\u2009=\u200926.3%\u201332.6%), and level VI aggression was 7.0% (95%CI\u2009=\u20095.4%\u20138.8%). The male participants had a mean testosterone level of 391.71 (Standard Deviation (SD):223.39) compared to 36.90 (SD:30.50) for female participants in the whole sample. Through network analysis, \u201cIncreased motor activity-energy\u201d emerged as the central symptom, with the highest centrality expected influence, followed by \u201cEmotional Instability\u201d and \u201cDisruptive\/aggression behavior\u201d. Notably, \u201cEmotional Instability\u201d appeared to be the bridge symptom linking manic symptoms to aggressive behavior. Within the flow network model, \u201cSpeech rate and amount\u201d exhibited the strongest positive correlation with testosterone levels, followed closely by \u201cDisruptive\/aggression behavior\u201d. The constructed network model demonstrated robust stability, with gender showing no significant impact on the structure. In this study, \u201cIncreased motor activity-energy\u201d stood out as the most influential symptom, and \u201cSpeech rate and amount\u201d acted as the main bridge symptom linking testosterone levels, aggressive behavior, and manic symptoms. Targeting the central and bridge symptoms may improve the outcomes of aggression interventions implemented among BD patients in psychiatric emergency care.<\/jats:p>","DOI":"10.1038\/s41398-024-02957-1","type":"journal-article","created":{"date-parts":[[2024,5,29]],"date-time":"2024-05-29T18:02:02Z","timestamp":1717005722000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":13,"title":["Network analysis of comorbid aggressive behavior and testosterone among bipolar disorder patients: a cross-sectional study"],"prefix":"10.1038","volume":"14","author":[{"given":"Yi","family":"Liu","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7915-1092","authenticated-orcid":false,"given":"Hong","family":"Cai","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tian","family":"Han","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yi-Fan","family":"Wang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Juan","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6759-9685","authenticated-orcid":false,"given":"Xiao-meng","family":"Xie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-9248-0719","authenticated-orcid":false,"given":"Xiao","family":"Ji","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2024,5,29]]},"reference":[{"key":"2957_CR1","doi-asserted-by":"publisher","first-page":"19","DOI":"10.1111\/bdi.12358","volume":"18","author":"AR Van Meter","year":"2016","unstructured":"Van Meter AR, Burke C, Kowatch RA, Findling RL, Youngstrom EA. 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