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The association of adverse childhood experiences and appetitive aggression with suicide attempts and violent crimes in male forensic psychiatry inpatients
Psychiatry Research 240 (2016) 352–357
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Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
The association of adverse childhood experiences and appetitive aggression with suicide attempts and violent crimes in male forensic psychiatry inpatients Manuela Dudeck a, Zrinka Sosic-Vasic b, Stefanie Otte a, Katharina Rasche a, Katharina Leichauer a, Susanne Tippelt a, Riad Shenar a, Solveig Klingner a, Nenad Vasic a,1, Judith Streb a,n,1 a b
Department of Forensic Psychiatry and Psychotherapy, University of Ulm, Germany Department of Psychiatry and Psychotherapy III, University of Ulm, Germany
art ic l e i nf o
a b s t r a c t
Article history: Received 9 July 2015 Received in revised form 23 February 2016 Accepted 21 April 2016 Available online 22 April 2016
Although previous studies in inmates, forensic and psychiatric samples suggest the relation between childhood trauma and suicide behavior as well as between childhood trauma and violent delinquency, the understanding of possible underlying mechanisms is still fragmentary. In a naturalistic study design, we tested if suicidal attempts and violent crimes are differently associated with adverse childhood experiences and levels of appetitive aggression in male forensic psychiatry inpatients. Adverse childhood experiences and appetitive aggression styles were collected by means of self-report measures, suicide attempts were taken from the medical history and violent crimes were appraised by official court records. The data were analyzed by the means of generalized linear models. Results revealed that appetitive aggression and adverse childhood experiences were significant predictors of suicide attempts, whereas violent crimes were associated solely with appetitive aggression. Suicide attempts and violent delinquency in forensic patients seem to be both positively associated with high levels of appetitive aggression, whereas their etiological pathways might differ with regard to adverse childhood experiences. Considering these interrelations to a greater extent might improve both diagnostics and treatment of forensic patients. & 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Aggressive behavior Violence Maltreatment Child abuse Forensic inpatients
1. Introduction The relation between violence and suicide risk has been extensively studied (see Camilleri et al., 1999 for an overview; Korn and van Praag, 1991; Hillbrand, 1995; Stalenheim, 2001), disclosing that violent criminals are overrepresented in the suicide statistics, with rates of suicides in criminals four to five times greater than those found in the general population (Fazel et al., 2011; Kopp et al., 2011). However, the factors contributing to the overlap between self-directed and interpersonal aggression are still largely unclear. It has been argued that interpersonal violence might arise from the same type of cognitive distortion as suicidal behavior (Beck, 1999). Initially, anxiety and fear would lead to distress. If externally directed aggression is non-executable, the focus might switch to one's own person and self-directed aggression becomes n
Corresponding author. E-mail address: [email protected] (J. Streb). 1 These authors contributed equally to this work.
http://dx.doi.org/10.1016/j.psychres.2016.04.073 0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved.
more likely. Thus, aggressive behavior toward others and self-injurious or suicidal behavior may be the result of the same increased or disinhibited aggressive potential. Human aggressive behavior is multifaceted. Psychologically and biologically two forms of aggressive behavior can be distinguished: reactive and proactive aggression. Reactive aggression can be described as an impulsive, hostile response to a perceived threat or provocation (Blair, 2010). On the other hand, proactive aggression is instrumental and premeditated. It can be directed toward possessing objects or dominating people (Kempes et al., 2005; Conner et al., 2009). There are findings indicating discriminative validity for reactive and proactive aggression. One study on reactive and proactive aggression and suicide attempts in several hundreds of patients with substance addiction showed that proactive aggression was associated with suicide attempts, whereas reactive aggression was not (Conner et al., 2009). Furthermore, proactive but not reactive aggression seems to be associated with delinquency (Pulkkinen, 1996; Vitaro et al., 1998), antisocial behavior and psychopathic traits (Kempes et al., 2005; Fite et al., 2009).
M. Dudeck et al. / Psychiatry Research 240 (2016) 352–357
However, recent studies on former child soldiers and war veterans show that the traditional classification of aggression has to be questioned and another third motive has to be considered, namely pleasure and joy (Weierstall and Elbert, 2011). The perpetration of violence for the purpose of experiencing violencerelated enjoyment is called appetitive aggression. According to Elbert et al. (2010) appetitive aggression developed from hunting behavior in the course of evolutionary adaptation. Being rewarded with food and social approval, hunting behavior turned out to be appetitive, going along with the release of testosterone, serotonine and endorphins, supporting feelings of euphoria and alleviating pain. While investigating former child soldiers from northern Uganda the authors found out that boys might be able to commit murders if they were massively exposed to violence themselves during the age from 8 to 17 years. During this time window executive functions mature (Gogtay et al., 2004), probably allowing to better control aggressive or impulsive behavior against others. If this form of inhibition is not learnt, aggressive behavior towards humans might remain fascinating and emotionally arousing, quite similar to the lust for hunting animals (Elbert et al., 2010). Also within this context, a large body of literature has documented that both the perpetration of violence (e.g., MalinoskyRummell and Hansen, 1993; Lansford et al., 2007; Wilson et al., 2009) as well as an increased risk of suicidal behavior (e.g., Dube et al., 2001; Afifi et al., 2008; Chapman and Ford, 2008; Swogger et al., 2011; Turner et al., 2012) are associated with adverse childhood experiences (Fazel et al., 2008; Sakelliadis et al., 2010; Dudeck et al., 2011; Mandelli et al., 2011; Roy et al., 2014; Lipschitz et al., 1999; Lang et al., 2002; Ystgaard et al., 2004; Banducci et al., 2014). The phenomenon that maltreated children are at risk of becoming perpetrators of violence themselves later in life has been labeled as the “cycle of violence” (Widom, 1989). This hypothesis has been supported by various studies and several models have been put forward (Dudeck et al., 2012; Hoeve et al., 2015; Garland et al., 2011; Cicchetti and Toth, 2005). Otherwise, childhood maltreatment has demonstrated as a consistent correlate of suicidal ideation and behavior, too (Dube et al., 2001; Afifi et al., 2008; Chapman and Ford, 2008; Swogger et al., 2011; Turner et al., 2012; Swogger et al., 2011). Controlling for demographic and clinical characteristics, Turner et al. (2012) showed significant effects of peer victimization, sexual assault, and maltreatment by a parent on suicidal ideation in a representative sample of 1186 American adolescents. Hence, the risk of suicidal ideation was 2.4 times greater among youth who experienced peer victimization in the past year, 3.4 times greater among those who were sexually assaulted, and 4.4 times greater among those exposed to maltreatment, relative to children who were not exposed to these types of victimization. Against this rather complex background, we were interested to explore the moderators promoting violent crimes and suicide attempts in a sample of German forensic inpatients. This issue might be critical in order to better address the needs of this population, thus improve the treatment possibilities and the legal prognosis. There are two specific aims of the present study: First, we wanted to determine the interplay of adverse childhood experiences and appetitive aggression on suicide attempts. Second, we wanted to determine the interplay of adverse childhood experiences and appetitive aggression on violent crimes.
2. Methods 2.1. Subjects 55 male forensic psychiatry inpatients being treated at the Department of Forensic Psychiatry and Psychotherapy at the
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University of Ulm in Germany were studied. All patients were hospitalized under the terms of a hospital treatment order according to §63 or §64 of the German penal code. Patients averaged 35.75 years of age (minimum¼ 22, maximum ¼60, standard deviation ¼10.07) and are treated on average for 6.25 years (minimum ¼0, maximum ¼26, standard deviation ¼8.17) at the Department of Forensic Psychiatry and Psychotherapy. The diagnoses were determined according to the ICD-10 criteria: substance-related disorders (n ¼30; 55%), schizophrenia (n ¼2; 4%), personality disorders (n ¼ 2; 4%), substance-related disorders and schizophrenia (n ¼3; 5%), substance-related disorders and personality disorders (n¼ 16; 29%), and schizophrenia and personality disorders (n ¼ 2; 4%). 14 patients had no educational qualifications, 31 patients completed general secondary school (“Hauptschulabschluss” ), 6 completed intermediate secondary school (“Realschulabschluss” ), and 4 patients acquired high-school qualification (“Abitur” ). 2.2. Procedures All patients were informed on the objectives of the study and written informed consent was obtained. The project was approved by the local ethics committee (Ulm University, Germany). Patients received neither financial remuneration nor some other, non-financial gratification for their participation in accordance to the internal rules of the treatment program and the recommendation of the ethics committee. Patients completed the questionnaires in small groups in a separate room on the ward, while a research assistant was available to offer help. 2.3. Measures 2.3.1. Assessment of adverse childhood experiences Adverse childhood experiences were inquired using the German version of the Maltreatment and Abuse Chronology of Exposure Scale (MACE; Teicher and Parigger, 2011), in German translation called Belastende Kindheitserfahrungen (KERF; Isele et al., 2014). This self-rating questionnaire enables a detailed retrospective assessment of traumatic experiences in the childhood on the basis of following ten subscales: physical abuse (6 items), verbal abuse (4 items), nonverbal emotional abuse (5 items), sexual abuse (12 items), emotional neglect (10 items), physical neglect (6 items), witnessed physical violence toward parents (8 items), witnessed violence toward siblings (7 items), peer emotional violence (4 items), and peer physical violence (4 items). Each item can be answered with yes or no (item example from scale nonverbal emotional abuse: “Have you been locked by your parents in a closet, storage, basement, garage or another, perhaps even very narrow, dark location?”). No- answers were coded with 0, yes-responses with 1. For each scale the values were summed up and transformed by linear interpolation, as suggested by the authors, to obtain comparable scale values. Finally, a total score was calculated by taking the average over all ten scales; creating total scores ranging from 0 to 10. While each of the traumatic events in the KERF exerts negative impact on an individual's health, behavior, and/or psychological development (Anda et al., 2010), exposure to multiple adverse experiences has an exponentially more harmful effect (Felitti et al., 1998). Thus, higher scores indicate more severe maltreatment. To determine the co-occurrence amongst the different types, a summary score was created that ranged from 0 to 10 to signify the total number of adverse experiences based on whether participants met the cutoff values for each subtype. Furthermore, participants had to specify at what age and for how long the adverse experience took place. For this purpose, they marked the period on a scale reaching from 1 to 18 (years). Convergent and divergent validity of the KERF is
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Table 1 Characteristics of patients with/without suicide attempt and with/without violent crime.
Age in years Educational level (%) No educational qualification General secondary school Secondary/High school Adverse childhood experiences Appetitive aggression
Age in years Educational level (%) No educational qualification General secondary school Secondary/High school Adverse childhood experiences Appetitive aggression a b c
Mean (SD)/frequency
Mean (SD)/frequency
Suicide attempt
No suicide attempt
30.3 (10.5)
36.9 (6.4)
41.7 50.0 8.3 3.5 (2.0) 16.1 (10.0)
21.4 57.1 21.4 2.0 (1.7) 9.0 (7.8)
Violent crime
No violent crime
34.2 (9.9)
36.9 (10.3)
26.1 65.2 8.7 2.3 (1.9) 12.4 (8.5)
25.8 48.4 25.8 2.3 (1.9) 7.7 (8.2)
t/χ2/U
p value
2.070a
0.043
b
2.424
0.298
118.0c 118.5c
0.016 0.020
0.972a
0.336
b
0.251
309.5c 195.5c
0.765 0.023
2.761
Student's t. Chi-square χ2. Mann-Whitney-U.
established, since satisfying associations with the childhood trauma questionnaire (Wingenfeld et al., 2010) and psychopathology (Hamilton-Depression-Scale, Hamilton, 1960; Borderline-Symptom-Liste, Bohus et al., 2008; Shutdown-DissociationScale, Schalinski et al., 2014) were found (see Isele et al., 2014). 2.3.2. Assessment of appetitive aggression A person's attraction to appetitive aggression was assessed by the Appetitive Aggression Scale (Weierstall and Elbert, 2011). The Appetitive Aggression Scale constructed as self-assessment questionnaire consists of 15 items measuring appetitive aspects of aggressive acts. An example item is “Is it exciting for you if you make an opponent really suffer? ” All items consist of statements about feelings towards aggression to which the patients respond on a five-point Likert scale (0 ¼never, 1 ¼rarely, 2 ¼sometimes, 3 ¼often, 4 ¼very often), creating total scores ranging from 0 to 60. The questionnaire has been validated in different populations, including former Congolese combatants, German world war II veterans and former Ugandan child soldiers (Hecker et al., 2012; Weierstall et al., 2012a, 2012b). It has good psychometric properties. The reliability is moderate to good (Cronbach’s alpha for the appetitive aggression scale: 0.85; Weierstall and Elbert, 2011). 2.3.3. Assessment of delinquency and suicide attempts We examined the official court records to identify those patients that were convicted because of a violent crime. Among violent crimes we subsumed homicide, robbery and bodily harm. We explicitly distinguished violent crimes from sexual offences, traffic offences, acts of arson, property offences, violations of the narcotics law and other drug-related offences. Information about attempted suicide were taken from the medical history and validated by members of the professional stuff (psychiatrist, psychologist, and psychiatric social worker). 2.4. Data analysis Sample characteristics of the two groups with/without attempted suicide and with/without violent crime were compared using Student t test, Pearson's chi-squared test and Mann-Whitney
U test. Predicting the dependent binary variables “suicide attempt/ no suicide attempt” and “violent crime/no violent crime” we used generalized linear models (GLMs). We included the variables age, adverse childhood experiences and appetitive aggression as independent variables. Because there were significant correlations between the predictors (total childhood abuse and appetitive aggression) to be included in the model, we conducted a multicollinearity test using the analyses of variance inflation factors (VIF) for the independent variables. In both models subsequently reported the predictor variables yielded VIF values lower to 1.23 (values ranging: 1.14–1.23). According to a rule of thumb VIF should be lower than 10. Otherwise severe multi-collinearity is present (O’Brian, 2007). Data were analyzed using IBM SPSS Statistics version 21.0.
3. Results 3.1. Group characteristics Twelve patients committed at least one suicide attempt in lifetime. 33 patients were convicted because of a violent crime, thereof 8 of homicide, 2 of robbery, 18 of grievous bodily harm and 5 of other violent crimes. The remaining 22 patients were convicted because of non-violent offences. The suicide attempters were almost entirely also individuals who committed violent crimes, thus making this cohort a very specialized subgroup of the larger population of suicide attempters. Patients with and without suicide attempt, as well as patients with and without violent crimes, were compared according to age, educational level, childhood abuse scores and appetitive aggression scores, the results are summarized in Table 1. 34% of patients reported no adverse childhood experience, 22% reported experiencing one type of abuse, 26% reported experiencing 2–4 types of abuse, 13% reported experiencing 5–7 types of abuse and 4% reported experiencing 8–9 types of abuse (see Finkelhor et al., 2009a, 2009b for comparable rates). Further analyses show, that experiences of peer physical violence were positively associated with high appetitive aggression scores (r ¼ 0291; p o0,05).
M. Dudeck et al. / Psychiatry Research 240 (2016) 352–357
Table 2 Results of the generalized linear models predicting attempted suicide (top) and committing a violent crime (below) by age, adverse childhood experiences and appetitive aggression scores. B
OR
95% CI
0.132 0.801 0.224 0.033
0.876 2.228* 1.251* 0.967
0.741 1.063 1.013 0.806
1.037 4.669 1.546 1.161
0.041 0.125 0.483 0.119
0.960 0.883 1.621* 0.888
0.877 0.572 1.075 0.773
1.050 1.361 2.444 1.021
Suicide attempt Age Adverse childhood experiences Appetitive aggression Adverse childhood experiences x appetitive aggression
Violent crime Age Adverse childhood experiences Appetitive aggression Adverse childhood experiences x appetitive aggression
Note: *p o 0.05; B¼unstandardized regression coefficient; OR ¼odds ratio; CI¼ confidence interval.
3.2. Association of adverse childhood experiences and appetitive aggression with suicidal behavior The results of the generalized linear model determining the probability to attempt suicide can be seen in Table 2 (top). The omnibus test of the model coefficients was significant (Chi2(4)¼ 13.103, p ¼0.011). Adverse childhood experiences were a strong and significant predictor, above and beyond the impact of all other risk factors for suicidal behavior in the model. Specifically, for each additional adverse childhood experience that a patient experienced, the odds of attempting a suicide increased by 123% even when controlling for age and appetitive aggression, this odds ratio resembles a small to intermediate effect size (Lenhard and Lenhard, 2015). Appetitive aggression was also a significant predictor of attempting suicide (each additional total appetitive aggression score raised the risk by 25%; which corresponds to a small effect size according to Lenhard and Lenhard, 2015). 3.3. Association of adverse childhood experiences and appetitive aggression with interpersonal violent behavior The results of the generalized linear model determining the probability of committing a violent crime can be seen in Table 2 (below). The omnibus test of the model coefficients was significant (Chi2(4)¼ 10.003, p ¼0.040). Adverse childhood experiences were no significant predictor. Appetitive aggression was positively associated with committing a violent crime. Thus, patients with high appetitive aggression scores were more likely to commit a violent crime (each additional total appetitive aggression score raised the risk by 62%, which corresponds to a small effect size according to Lenhard and Lenhard, 2015).
4. Discussion The present study focused on a sample of male forensic inpatients and investigated if suicidal behavior and violent delinquency were differently associated with adverse childhood experiences and levels of appetitive aggression. We found that (a) appetitive aggression was a substantial predictor of both suicide attempts and violent delinquency and (b) suicide attempts were further significantly associated with adverse childhood experiences. The statistical prediction of both suicide attempts and violent crimes was affected by a common factor, namely high appetitive
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aggression. To the extent that appetitive aggression is present among forensic patients, they may confer greater risk for suicide attempts and violent delinquencies. Aggressive behavior, particularly a possibly lethal act, engenders fear that one must overcome to carry out the behavior. Appetitive aggressive patients may experience less potentially protective emotional distress prior to suicide attempts or violent delinquencies. On the contrary, they may perceive violence as emotionally arousing and exciting. Also in accordance with the results from Elbert et al. (2010), in our study appetitive aggression was positively correlated with experiences of peer physical violence that occurred at a mean age of 11.18 years (SD ¼4.28), thus during the critical time window while executive functions develop. Further evidence for this association can be found in the study of Kim and colleagues who showed that being bullied in childhood leads to different forms of dysfunctional and psychopathologic behavior, such as social problems, aggression and externalizing behavioral problems (Kim et al., 2006). Particularly, both perpetrators and victim-perpetrators have developed increased aggression over time. Our results indicate that solely peer physical violence might be associated with appetitive aggression. This is in line with the differential effects model proposing that particular types of adverse childhood experiences are associated with specific related outcomes in adulthood (Ford et al., 2010; Senn and Carey, 2010; Banducci et al., 2014). However, peer physical violence is a very specific type of adversity that possibly is more likely to be related to the individual’s own aggression (because it involves peers and not caregivers) than all of the other types of childhood adversity. This is consistent with the overall finding that childhood adversity was not related to violent crimes. Only suicide attempts were associated with adverse childhood experiences. Which is consistent with research showing that childhood adversity (involving caregivers) is related to self-harm but not to externalized aggression (e.g., D’Andrea et al., 2012). A number of limitations have to be considered when interpreting our findings. The cross-sectional design of the study does not allow causal statements to be made about the directions of the relationships between adverse childhood experiences, aggression and suicidal and aggressive behavior. This should also be kept in mind, when reading the term “predictor” , which should solely be interpreted in a statistical way as the independent variable of a linear regression model. In this naturalistic study we investigated almost all patients from our clinic. Consequently, there might be unnoticed confounding variables since our patients were heterogeneous with regard to the diagnosis, offense and the legal background of hospitalization (§63 or §64 of the German penal code). Data concerning suicide attempts was collected as part of the initial diagnosis and not for the explicit purpose of the present research. As such, this information might be seen as indicator for suicidal behavior. In future studies, additional information might be gleaned from the use of frequency of suicide attempts, suicide ideation, etc. as an outcome variable in order to better characterize suicidal behavior and further delineate patients at high risk for suicide attempts. Also, it must be noticed that we investigated a highly specific population of forensic psychiatry patients, so that the relations described here cannot be readily generalized to other psychiatric samples or general population. Finally, the small sample size made detecting effects less likely and so caution should be exercised in interpreting lack of findings.. We hope that studies using larger samples will help to clarify the robustness of our findings and their generalizability to other high-risk populations. Overall, our results suggest that risk of violent delinquency and risk of suicidal behavior are interconnected. Thereby, appetitive aggression might be a common predictor of suicide attempt and
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violent behavior, since associated to both. Appetitive aggression itself seems to be associated with peer physical violence during adolescence. In our view, therapists should be aware of these relations and sensitized for assessment of different aggression forms (appetitive, proactive and reactive, self-directed versus against others) and explicit exploration of childhood experiences. This might help characterizing individual patterns of aggression development and possibly better predicting future aggressive behavior. On this basis, also the development of more specific treatment approaches focusing to prevent and reduce aggressive behavior among forensic patients seems possible and would be of great importance.
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Contents lists available at ScienceDirect
Psychiatry Research journal homepage: www.elsevier.com/locate/psychres
The association of adverse childhood experiences and appetitive aggression with suicide attempts and violent crimes in male forensic psychiatry inpatients Manuela Dudeck a, Zrinka Sosic-Vasic b, Stefanie Otte a, Katharina Rasche a, Katharina Leichauer a, Susanne Tippelt a, Riad Shenar a, Solveig Klingner a, Nenad Vasic a,1, Judith Streb a,n,1 a b
Department of Forensic Psychiatry and Psychotherapy, University of Ulm, Germany Department of Psychiatry and Psychotherapy III, University of Ulm, Germany
art ic l e i nf o
a b s t r a c t
Article history: Received 9 July 2015 Received in revised form 23 February 2016 Accepted 21 April 2016 Available online 22 April 2016
Although previous studies in inmates, forensic and psychiatric samples suggest the relation between childhood trauma and suicide behavior as well as between childhood trauma and violent delinquency, the understanding of possible underlying mechanisms is still fragmentary. In a naturalistic study design, we tested if suicidal attempts and violent crimes are differently associated with adverse childhood experiences and levels of appetitive aggression in male forensic psychiatry inpatients. Adverse childhood experiences and appetitive aggression styles were collected by means of self-report measures, suicide attempts were taken from the medical history and violent crimes were appraised by official court records. The data were analyzed by the means of generalized linear models. Results revealed that appetitive aggression and adverse childhood experiences were significant predictors of suicide attempts, whereas violent crimes were associated solely with appetitive aggression. Suicide attempts and violent delinquency in forensic patients seem to be both positively associated with high levels of appetitive aggression, whereas their etiological pathways might differ with regard to adverse childhood experiences. Considering these interrelations to a greater extent might improve both diagnostics and treatment of forensic patients. & 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Aggressive behavior Violence Maltreatment Child abuse Forensic inpatients
1. Introduction The relation between violence and suicide risk has been extensively studied (see Camilleri et al., 1999 for an overview; Korn and van Praag, 1991; Hillbrand, 1995; Stalenheim, 2001), disclosing that violent criminals are overrepresented in the suicide statistics, with rates of suicides in criminals four to five times greater than those found in the general population (Fazel et al., 2011; Kopp et al., 2011). However, the factors contributing to the overlap between self-directed and interpersonal aggression are still largely unclear. It has been argued that interpersonal violence might arise from the same type of cognitive distortion as suicidal behavior (Beck, 1999). Initially, anxiety and fear would lead to distress. If externally directed aggression is non-executable, the focus might switch to one's own person and self-directed aggression becomes n
Corresponding author. E-mail address: [email protected] (J. Streb). 1 These authors contributed equally to this work.
http://dx.doi.org/10.1016/j.psychres.2016.04.073 0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved.
more likely. Thus, aggressive behavior toward others and self-injurious or suicidal behavior may be the result of the same increased or disinhibited aggressive potential. Human aggressive behavior is multifaceted. Psychologically and biologically two forms of aggressive behavior can be distinguished: reactive and proactive aggression. Reactive aggression can be described as an impulsive, hostile response to a perceived threat or provocation (Blair, 2010). On the other hand, proactive aggression is instrumental and premeditated. It can be directed toward possessing objects or dominating people (Kempes et al., 2005; Conner et al., 2009). There are findings indicating discriminative validity for reactive and proactive aggression. One study on reactive and proactive aggression and suicide attempts in several hundreds of patients with substance addiction showed that proactive aggression was associated with suicide attempts, whereas reactive aggression was not (Conner et al., 2009). Furthermore, proactive but not reactive aggression seems to be associated with delinquency (Pulkkinen, 1996; Vitaro et al., 1998), antisocial behavior and psychopathic traits (Kempes et al., 2005; Fite et al., 2009).
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However, recent studies on former child soldiers and war veterans show that the traditional classification of aggression has to be questioned and another third motive has to be considered, namely pleasure and joy (Weierstall and Elbert, 2011). The perpetration of violence for the purpose of experiencing violencerelated enjoyment is called appetitive aggression. According to Elbert et al. (2010) appetitive aggression developed from hunting behavior in the course of evolutionary adaptation. Being rewarded with food and social approval, hunting behavior turned out to be appetitive, going along with the release of testosterone, serotonine and endorphins, supporting feelings of euphoria and alleviating pain. While investigating former child soldiers from northern Uganda the authors found out that boys might be able to commit murders if they were massively exposed to violence themselves during the age from 8 to 17 years. During this time window executive functions mature (Gogtay et al., 2004), probably allowing to better control aggressive or impulsive behavior against others. If this form of inhibition is not learnt, aggressive behavior towards humans might remain fascinating and emotionally arousing, quite similar to the lust for hunting animals (Elbert et al., 2010). Also within this context, a large body of literature has documented that both the perpetration of violence (e.g., MalinoskyRummell and Hansen, 1993; Lansford et al., 2007; Wilson et al., 2009) as well as an increased risk of suicidal behavior (e.g., Dube et al., 2001; Afifi et al., 2008; Chapman and Ford, 2008; Swogger et al., 2011; Turner et al., 2012) are associated with adverse childhood experiences (Fazel et al., 2008; Sakelliadis et al., 2010; Dudeck et al., 2011; Mandelli et al., 2011; Roy et al., 2014; Lipschitz et al., 1999; Lang et al., 2002; Ystgaard et al., 2004; Banducci et al., 2014). The phenomenon that maltreated children are at risk of becoming perpetrators of violence themselves later in life has been labeled as the “cycle of violence” (Widom, 1989). This hypothesis has been supported by various studies and several models have been put forward (Dudeck et al., 2012; Hoeve et al., 2015; Garland et al., 2011; Cicchetti and Toth, 2005). Otherwise, childhood maltreatment has demonstrated as a consistent correlate of suicidal ideation and behavior, too (Dube et al., 2001; Afifi et al., 2008; Chapman and Ford, 2008; Swogger et al., 2011; Turner et al., 2012; Swogger et al., 2011). Controlling for demographic and clinical characteristics, Turner et al. (2012) showed significant effects of peer victimization, sexual assault, and maltreatment by a parent on suicidal ideation in a representative sample of 1186 American adolescents. Hence, the risk of suicidal ideation was 2.4 times greater among youth who experienced peer victimization in the past year, 3.4 times greater among those who were sexually assaulted, and 4.4 times greater among those exposed to maltreatment, relative to children who were not exposed to these types of victimization. Against this rather complex background, we were interested to explore the moderators promoting violent crimes and suicide attempts in a sample of German forensic inpatients. This issue might be critical in order to better address the needs of this population, thus improve the treatment possibilities and the legal prognosis. There are two specific aims of the present study: First, we wanted to determine the interplay of adverse childhood experiences and appetitive aggression on suicide attempts. Second, we wanted to determine the interplay of adverse childhood experiences and appetitive aggression on violent crimes.
2. Methods 2.1. Subjects 55 male forensic psychiatry inpatients being treated at the Department of Forensic Psychiatry and Psychotherapy at the
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University of Ulm in Germany were studied. All patients were hospitalized under the terms of a hospital treatment order according to §63 or §64 of the German penal code. Patients averaged 35.75 years of age (minimum¼ 22, maximum ¼60, standard deviation ¼10.07) and are treated on average for 6.25 years (minimum ¼0, maximum ¼26, standard deviation ¼8.17) at the Department of Forensic Psychiatry and Psychotherapy. The diagnoses were determined according to the ICD-10 criteria: substance-related disorders (n ¼30; 55%), schizophrenia (n ¼2; 4%), personality disorders (n ¼ 2; 4%), substance-related disorders and schizophrenia (n ¼3; 5%), substance-related disorders and personality disorders (n¼ 16; 29%), and schizophrenia and personality disorders (n ¼ 2; 4%). 14 patients had no educational qualifications, 31 patients completed general secondary school (“Hauptschulabschluss” ), 6 completed intermediate secondary school (“Realschulabschluss” ), and 4 patients acquired high-school qualification (“Abitur” ). 2.2. Procedures All patients were informed on the objectives of the study and written informed consent was obtained. The project was approved by the local ethics committee (Ulm University, Germany). Patients received neither financial remuneration nor some other, non-financial gratification for their participation in accordance to the internal rules of the treatment program and the recommendation of the ethics committee. Patients completed the questionnaires in small groups in a separate room on the ward, while a research assistant was available to offer help. 2.3. Measures 2.3.1. Assessment of adverse childhood experiences Adverse childhood experiences were inquired using the German version of the Maltreatment and Abuse Chronology of Exposure Scale (MACE; Teicher and Parigger, 2011), in German translation called Belastende Kindheitserfahrungen (KERF; Isele et al., 2014). This self-rating questionnaire enables a detailed retrospective assessment of traumatic experiences in the childhood on the basis of following ten subscales: physical abuse (6 items), verbal abuse (4 items), nonverbal emotional abuse (5 items), sexual abuse (12 items), emotional neglect (10 items), physical neglect (6 items), witnessed physical violence toward parents (8 items), witnessed violence toward siblings (7 items), peer emotional violence (4 items), and peer physical violence (4 items). Each item can be answered with yes or no (item example from scale nonverbal emotional abuse: “Have you been locked by your parents in a closet, storage, basement, garage or another, perhaps even very narrow, dark location?”). No- answers were coded with 0, yes-responses with 1. For each scale the values were summed up and transformed by linear interpolation, as suggested by the authors, to obtain comparable scale values. Finally, a total score was calculated by taking the average over all ten scales; creating total scores ranging from 0 to 10. While each of the traumatic events in the KERF exerts negative impact on an individual's health, behavior, and/or psychological development (Anda et al., 2010), exposure to multiple adverse experiences has an exponentially more harmful effect (Felitti et al., 1998). Thus, higher scores indicate more severe maltreatment. To determine the co-occurrence amongst the different types, a summary score was created that ranged from 0 to 10 to signify the total number of adverse experiences based on whether participants met the cutoff values for each subtype. Furthermore, participants had to specify at what age and for how long the adverse experience took place. For this purpose, they marked the period on a scale reaching from 1 to 18 (years). Convergent and divergent validity of the KERF is
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Table 1 Characteristics of patients with/without suicide attempt and with/without violent crime.
Age in years Educational level (%) No educational qualification General secondary school Secondary/High school Adverse childhood experiences Appetitive aggression
Age in years Educational level (%) No educational qualification General secondary school Secondary/High school Adverse childhood experiences Appetitive aggression a b c
Mean (SD)/frequency
Mean (SD)/frequency
Suicide attempt
No suicide attempt
30.3 (10.5)
36.9 (6.4)
41.7 50.0 8.3 3.5 (2.0) 16.1 (10.0)
21.4 57.1 21.4 2.0 (1.7) 9.0 (7.8)
Violent crime
No violent crime
34.2 (9.9)
36.9 (10.3)
26.1 65.2 8.7 2.3 (1.9) 12.4 (8.5)
25.8 48.4 25.8 2.3 (1.9) 7.7 (8.2)
t/χ2/U
p value
2.070a
0.043
b
2.424
0.298
118.0c 118.5c
0.016 0.020
0.972a
0.336
b
0.251
309.5c 195.5c
0.765 0.023
2.761
Student's t. Chi-square χ2. Mann-Whitney-U.
established, since satisfying associations with the childhood trauma questionnaire (Wingenfeld et al., 2010) and psychopathology (Hamilton-Depression-Scale, Hamilton, 1960; Borderline-Symptom-Liste, Bohus et al., 2008; Shutdown-DissociationScale, Schalinski et al., 2014) were found (see Isele et al., 2014). 2.3.2. Assessment of appetitive aggression A person's attraction to appetitive aggression was assessed by the Appetitive Aggression Scale (Weierstall and Elbert, 2011). The Appetitive Aggression Scale constructed as self-assessment questionnaire consists of 15 items measuring appetitive aspects of aggressive acts. An example item is “Is it exciting for you if you make an opponent really suffer? ” All items consist of statements about feelings towards aggression to which the patients respond on a five-point Likert scale (0 ¼never, 1 ¼rarely, 2 ¼sometimes, 3 ¼often, 4 ¼very often), creating total scores ranging from 0 to 60. The questionnaire has been validated in different populations, including former Congolese combatants, German world war II veterans and former Ugandan child soldiers (Hecker et al., 2012; Weierstall et al., 2012a, 2012b). It has good psychometric properties. The reliability is moderate to good (Cronbach’s alpha for the appetitive aggression scale: 0.85; Weierstall and Elbert, 2011). 2.3.3. Assessment of delinquency and suicide attempts We examined the official court records to identify those patients that were convicted because of a violent crime. Among violent crimes we subsumed homicide, robbery and bodily harm. We explicitly distinguished violent crimes from sexual offences, traffic offences, acts of arson, property offences, violations of the narcotics law and other drug-related offences. Information about attempted suicide were taken from the medical history and validated by members of the professional stuff (psychiatrist, psychologist, and psychiatric social worker). 2.4. Data analysis Sample characteristics of the two groups with/without attempted suicide and with/without violent crime were compared using Student t test, Pearson's chi-squared test and Mann-Whitney
U test. Predicting the dependent binary variables “suicide attempt/ no suicide attempt” and “violent crime/no violent crime” we used generalized linear models (GLMs). We included the variables age, adverse childhood experiences and appetitive aggression as independent variables. Because there were significant correlations between the predictors (total childhood abuse and appetitive aggression) to be included in the model, we conducted a multicollinearity test using the analyses of variance inflation factors (VIF) for the independent variables. In both models subsequently reported the predictor variables yielded VIF values lower to 1.23 (values ranging: 1.14–1.23). According to a rule of thumb VIF should be lower than 10. Otherwise severe multi-collinearity is present (O’Brian, 2007). Data were analyzed using IBM SPSS Statistics version 21.0.
3. Results 3.1. Group characteristics Twelve patients committed at least one suicide attempt in lifetime. 33 patients were convicted because of a violent crime, thereof 8 of homicide, 2 of robbery, 18 of grievous bodily harm and 5 of other violent crimes. The remaining 22 patients were convicted because of non-violent offences. The suicide attempters were almost entirely also individuals who committed violent crimes, thus making this cohort a very specialized subgroup of the larger population of suicide attempters. Patients with and without suicide attempt, as well as patients with and without violent crimes, were compared according to age, educational level, childhood abuse scores and appetitive aggression scores, the results are summarized in Table 1. 34% of patients reported no adverse childhood experience, 22% reported experiencing one type of abuse, 26% reported experiencing 2–4 types of abuse, 13% reported experiencing 5–7 types of abuse and 4% reported experiencing 8–9 types of abuse (see Finkelhor et al., 2009a, 2009b for comparable rates). Further analyses show, that experiences of peer physical violence were positively associated with high appetitive aggression scores (r ¼ 0291; p o0,05).
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Table 2 Results of the generalized linear models predicting attempted suicide (top) and committing a violent crime (below) by age, adverse childhood experiences and appetitive aggression scores. B
OR
95% CI
0.132 0.801 0.224 0.033
0.876 2.228* 1.251* 0.967
0.741 1.063 1.013 0.806
1.037 4.669 1.546 1.161
0.041 0.125 0.483 0.119
0.960 0.883 1.621* 0.888
0.877 0.572 1.075 0.773
1.050 1.361 2.444 1.021
Suicide attempt Age Adverse childhood experiences Appetitive aggression Adverse childhood experiences x appetitive aggression
Violent crime Age Adverse childhood experiences Appetitive aggression Adverse childhood experiences x appetitive aggression
Note: *p o 0.05; B¼unstandardized regression coefficient; OR ¼odds ratio; CI¼ confidence interval.
3.2. Association of adverse childhood experiences and appetitive aggression with suicidal behavior The results of the generalized linear model determining the probability to attempt suicide can be seen in Table 2 (top). The omnibus test of the model coefficients was significant (Chi2(4)¼ 13.103, p ¼0.011). Adverse childhood experiences were a strong and significant predictor, above and beyond the impact of all other risk factors for suicidal behavior in the model. Specifically, for each additional adverse childhood experience that a patient experienced, the odds of attempting a suicide increased by 123% even when controlling for age and appetitive aggression, this odds ratio resembles a small to intermediate effect size (Lenhard and Lenhard, 2015). Appetitive aggression was also a significant predictor of attempting suicide (each additional total appetitive aggression score raised the risk by 25%; which corresponds to a small effect size according to Lenhard and Lenhard, 2015). 3.3. Association of adverse childhood experiences and appetitive aggression with interpersonal violent behavior The results of the generalized linear model determining the probability of committing a violent crime can be seen in Table 2 (below). The omnibus test of the model coefficients was significant (Chi2(4)¼ 10.003, p ¼0.040). Adverse childhood experiences were no significant predictor. Appetitive aggression was positively associated with committing a violent crime. Thus, patients with high appetitive aggression scores were more likely to commit a violent crime (each additional total appetitive aggression score raised the risk by 62%, which corresponds to a small effect size according to Lenhard and Lenhard, 2015).
4. Discussion The present study focused on a sample of male forensic inpatients and investigated if suicidal behavior and violent delinquency were differently associated with adverse childhood experiences and levels of appetitive aggression. We found that (a) appetitive aggression was a substantial predictor of both suicide attempts and violent delinquency and (b) suicide attempts were further significantly associated with adverse childhood experiences. The statistical prediction of both suicide attempts and violent crimes was affected by a common factor, namely high appetitive
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aggression. To the extent that appetitive aggression is present among forensic patients, they may confer greater risk for suicide attempts and violent delinquencies. Aggressive behavior, particularly a possibly lethal act, engenders fear that one must overcome to carry out the behavior. Appetitive aggressive patients may experience less potentially protective emotional distress prior to suicide attempts or violent delinquencies. On the contrary, they may perceive violence as emotionally arousing and exciting. Also in accordance with the results from Elbert et al. (2010), in our study appetitive aggression was positively correlated with experiences of peer physical violence that occurred at a mean age of 11.18 years (SD ¼4.28), thus during the critical time window while executive functions develop. Further evidence for this association can be found in the study of Kim and colleagues who showed that being bullied in childhood leads to different forms of dysfunctional and psychopathologic behavior, such as social problems, aggression and externalizing behavioral problems (Kim et al., 2006). Particularly, both perpetrators and victim-perpetrators have developed increased aggression over time. Our results indicate that solely peer physical violence might be associated with appetitive aggression. This is in line with the differential effects model proposing that particular types of adverse childhood experiences are associated with specific related outcomes in adulthood (Ford et al., 2010; Senn and Carey, 2010; Banducci et al., 2014). However, peer physical violence is a very specific type of adversity that possibly is more likely to be related to the individual’s own aggression (because it involves peers and not caregivers) than all of the other types of childhood adversity. This is consistent with the overall finding that childhood adversity was not related to violent crimes. Only suicide attempts were associated with adverse childhood experiences. Which is consistent with research showing that childhood adversity (involving caregivers) is related to self-harm but not to externalized aggression (e.g., D’Andrea et al., 2012). A number of limitations have to be considered when interpreting our findings. The cross-sectional design of the study does not allow causal statements to be made about the directions of the relationships between adverse childhood experiences, aggression and suicidal and aggressive behavior. This should also be kept in mind, when reading the term “predictor” , which should solely be interpreted in a statistical way as the independent variable of a linear regression model. In this naturalistic study we investigated almost all patients from our clinic. Consequently, there might be unnoticed confounding variables since our patients were heterogeneous with regard to the diagnosis, offense and the legal background of hospitalization (§63 or §64 of the German penal code). Data concerning suicide attempts was collected as part of the initial diagnosis and not for the explicit purpose of the present research. As such, this information might be seen as indicator for suicidal behavior. In future studies, additional information might be gleaned from the use of frequency of suicide attempts, suicide ideation, etc. as an outcome variable in order to better characterize suicidal behavior and further delineate patients at high risk for suicide attempts. Also, it must be noticed that we investigated a highly specific population of forensic psychiatry patients, so that the relations described here cannot be readily generalized to other psychiatric samples or general population. Finally, the small sample size made detecting effects less likely and so caution should be exercised in interpreting lack of findings.. We hope that studies using larger samples will help to clarify the robustness of our findings and their generalizability to other high-risk populations. Overall, our results suggest that risk of violent delinquency and risk of suicidal behavior are interconnected. Thereby, appetitive aggression might be a common predictor of suicide attempt and
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violent behavior, since associated to both. Appetitive aggression itself seems to be associated with peer physical violence during adolescence. In our view, therapists should be aware of these relations and sensitized for assessment of different aggression forms (appetitive, proactive and reactive, self-directed versus against others) and explicit exploration of childhood experiences. This might help characterizing individual patterns of aggression development and possibly better predicting future aggressive behavior. On this basis, also the development of more specific treatment approaches focusing to prevent and reduce aggressive behavior among forensic patients seems possible and would be of great importance.
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