Psychiatry Research 240 (2016) 352–357

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
Department of Forensic Psychiatry and Psychotherapy, University of Ulm, Germany
b
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: Although previous studies in inmates, forensic and psychiatric samples suggest the relation between
Received 9 July 2015 childhood trauma and suicide behavior as well as between childhood trauma and violent delinquency,
Received in revised form the understanding of possible underlying mechanisms is still fragmentary. In a naturalistic study design,
23 February 2016
we tested if suicidal attempts and violent crimes are differently associated with adverse childhood ex-
Accepted 21 April 2016
periences and levels of appetitive aggression in male forensic psychiatry inpatients. Adverse childhood
Available online 22 April 2016
experiences and appetitive aggression styles were collected by means of self-report measures, suicide
Keywords: attempts were taken from the medical history and violent crimes were appraised by official court re-
Aggressive behavior cords. The data were analyzed by the means of generalized linear models. Results revealed that appe-
Violence
titive aggression and adverse childhood experiences were significant predictors of suicide attempts,
Maltreatment
whereas violent crimes were associated solely with appetitive aggression. Suicide attempts and violent
Child abuse
Forensic inpatients 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 experi-
ences. Considering these interrelations to a greater extent might improve both diagnostics and treatment
of forensic patients.
& 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
The relation between violence and suicide risk has been ex-
tensively 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 be-
tween 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: judith.streb@bkh-guenzburg.de (J. Streb).
1
These authors contributed equally to this work.
more likely. Thus, aggressive behavior toward others and self-in-
jurious or suicidal behavior may be the result of the same in-
creased or disinhibited aggressive potential.
Human aggressive behavior is multifaceted. Psychologically
and biologically two forms of aggressive behavior can be dis-
tinguished: 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 dis-
criminative 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). Fur-
thermore, proactive but not reactive aggression seems to be as-
sociated with delinquency (Pulkkinen, 1996; Vitaro et al., 1998),
antisocial behavior and psychopathic traits (Kempes et al., 2005;
Fite et al., 2009).

http://dx.doi.org/10.1016/j.psychres.2016.04.073
0165-1781/& 2016 Elsevier Ireland Ltd. All rights reserved.
 M. Dudeck et al. / Psychiatry Research 240 (2016) 352–357
However, recent studies on former child soldiers and war ve-
terans 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 per-
petration of violence for the purpose of experiencing violence-
related 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 ex-
ecutive 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 docu-
mented that both the perpetration of violence (e.g., Malinosky-
Rummell 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 hy-
pothesis 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 ex-
posed 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 at-
tempts 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
353
University of Ulm in Germany were studied. All patients were
hospitalized under the terms of a hospital treatment order ac-
cording 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 diag-
noses were determined according to the ICD-10 criteria: sub-
stance-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 per-
sonality 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 (“Hauptschu-
labschluss” ), 6 completed intermediate secondary school (“Re-
alschulabschluss” ), and 4 patients acquired high-school qualifi-
cation (“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-fi-
nancial 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 Ger-
man version of the Maltreatment and Abuse Chronology of Ex-
posure Scale (MACE; Teicher and Parigger, 2011), in German
translation called Belastende Kindheitserfahrungen (KERF; Isele
et al., 2014). This self-rating questionnaire enables a detailed ret-
rospective 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 emo-
tional 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 au-
thors, 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, beha-
vior, and/or psychological development (Anda et al., 2010), ex-
posure 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 ex-
periences 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
354 M. Dudeck et al. / Psychiatry Research 240 (2016) 352–357

Table 1
Characteristics of patients with/without suicide attempt and with/without violent crime.

Mean (SD)/frequency Mean (SD)/frequency t/χ2/U p value

Suicide attempt No suicide attempt

Age in years 30.3 (10.5) 36.9 (6.4) 2.070a 0.043

Educational level (%)
b
No educational qualification 41.7 21.4 2.424 0.298
General secondary school 50.0 57.1
Secondary/High school 8.3 21.4
Adverse childhood experiences 3.5 (2.0) 2.0 (1.7) 118.0c 0.016
Appetitive aggression 16.1 (10.0) 9.0 (7.8) 118.5c 0.020

Violent crime No violent crime

Age in years 34.2 (9.9) 36.9 (10.3) 0.972a 0.336

Educational level (%)
b
No educational qualification 26.1 25.8 2.761 0.251
General secondary school 65.2 48.4
Secondary/High school 8.7 25.8
Adverse childhood experiences 2.3 (1.9) 2.3 (1.9) 309.5c 0.765
Appetitive aggression 12.4 (8.5) 7.7 (8.2) 195.5c 0.023

a
Student's t.
b
Chi-square χ2.
c
Mann-Whitney-U.

established, since satisfying associations with the childhood
trauma questionnaire (Wingenfeld et al., 2010) and psycho-
pathology (Hamilton-Depression-Scale, Hamilton, 1960; Border-
line-Symptom-Liste, Bohus et al., 2008; Shutdown-Dissociation-
Scale, 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 ques-
tionnaire 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 proper-
ties. 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 pa-
tients 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 vali-
dated by members of the professional stuff (psychiatrist, psy-
chologist, and psychiatric social worker).
2.4. Data analysis
Sample characteristics of the two groups with/without at-
tempted 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 in-
dependent variables. Because there were significant correlations
between the predictors (total childhood abuse and appetitive ag-
gression) to be included in the model, we conducted a multi-
collinearity 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 Sta-
tistics 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 con-
victed 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 re-
sults are summarized in Table 1. 34% of patients reported no ad-
verse childhood experience, 22% reported experiencing one type
of abuse, 26% reported experiencing 2–4 types of abuse, 13% re-
ported experiencing 5–7 types of abuse and 4% reported experi-
encing 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) 352–357 355

Table 2 aggression. To the extent that appetitive aggression is present

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
Suicide attempt
Age  0.132 0.876
Adverse childhood experiences 0.801 2.228*
Appetitive aggression 0.224 1.251*
Adverse childhood experiences x appetitive  0.033 0.967
aggression
Violent crime
Age  0.041 0.960
Adverse childhood experiences  0.125 0.883
Appetitive aggression 0.483 1.621*
Adverse childhood experiences x appetitive  0.119 0.888
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 experi-
enced, 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 Len-
hard, 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 as-
sociated 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 in-
patients and investigated if suicidal behavior and violent de-
linquency were differently associated with adverse childhood ex-
periences and levels of appetitive aggression. We found that
(a) appetitive aggression was a substantial predictor of both sui-
cide 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
among forensic patients, they may confer greater risk for suicide
attempts and violent delinquencies. Aggressive behavior, particu-
larly a possibly lethal act, engenders fear that one must overcome
95% CI to carry out the behavior. Appetitive aggressive patients may ex-
perience less potentially protective emotional distress prior to
suicide attempts or violent delinquencies. On the contrary, they
0.741 1.037
1.063 4.669
may perceive violence as emotionally arousing and exciting. Also
1.013 1.546 in accordance with the results from Elbert et al. (2010), in our
0.806 1.161 study appetitive aggression was positively correlated with ex-
periences 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
0.877 1.050
being bullied in childhood leads to different forms of dysfunctional
0.572 1.361
1.075 2.444 and psychopathologic behavior, such as social problems, aggres-
0.773 1.021 sion and externalizing behavioral problems (Kim et al., 2006).
Particularly, both perpetrators and victim-perpetrators have de-
veloped increased aggression over time.
Our results indicate that solely peer physical violence might be
associated with appetitive aggression. This is in line with the dif-
ferential effects model proposing that particular types of adverse
childhood experiences are associated with specific related out-
comes in adulthood (Ford et al., 2010; Senn and Carey, 2010;
Banducci et al., 2014).
However, peer physical violence is a very specific type of ad-
versity 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 ad-
verse 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 inter-
preting 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 hetero-
geneous with regard to the diagnosis, offense and the legal back-
ground of hospitalization (§63 or §64 of the German penal code).
Data concerning suicide attempts was collected as part of the in-
itial diagnosis and not for the explicit purpose of the present re-
search. 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
356 M. Dudeck et al. / Psychiatry Research 240 (2016) 352–357
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 re-
lations 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 de-
velopment and possibly better predicting future aggressive beha-
vior. On this basis, also the development of more specific treat-
ment approaches focusing to prevent and reduce aggressive be-
havior among forensic patients seems possible and would be of
great importance.
References
Afifi, T.O., Enns, M.W., Cox, B.J., Asmundson, G.J.G., Stein, M.B., Sareen, J., 2008.
Population attributable fractions of psychiatric disorders and suicide ideation
and attempts associated with adverse childhood experiences. Am. J. Public
Health 98 (5), 946–952.
Anda, R.F., Butchart, A., Felitti, V.J., Brown, D.W., 2010. Building a framework for
global surveillance of the public health implications of adverse childhood ex-
periences. Am. J. Prev. Med. 39 (1), 93–98.
Banducci, A.N., Hoffman, E.M., Lejuez, C.W., Koenen, K.C., 2014. The impact of
childhood abuse on inpatient substance users: specific links with risky sex,
aggression, and emotion dysregulation. Child Abuse Negl. 38, 928–938.
Beck, A.T., 1999. Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and
Violence. HarperCollins Publishers,, New York.
Blair, R.J., 2010. Neuroimaging of psychopathy and antisocial behavior: a targeted
review. Curr. Psychiatry Rep. 12 (1), 76–82.
Bohus, M., Kleindienst, N., Limberger, M.F., Stieglitz, R.-D., Domsalla, M., Chapman,
A.L., Wolf, M., 2008. The short version of the borderline symptom list (BSL-23):
development and initial data on psychometric properties. Psychopathology 42,
32–39.
Chapman, J.F., Ford, J.D., 2008. Relationships between suicide risk, traumatic ex-
periences, and substance use among juvenile detainees. Arch. Suicide Res. 12
(1), 50–61.
Cicchetti, D., Toth, S.L., 2005. Child maltreatment. Annu. Rev. Clin. Psychol. 1,
409–438.
Conner, K.R., Swogger, M.T., Houston, R.J., 2009. A test of the reactive aggression-
suicidal behavior hypothesis: is there a case for proactive aggression? J. Ab-
norm. Psychol. 118 (1), 235.
D’Andrea, W., Ford, J.D., Stolbach, B., Spinazzola, J., van der Kolk, B.A., 2012. Un-
derstanding interpersonal trauma in children: why we need a developmentally
appropriate trauma diagnosis. Am. J. Orthopsychiatry 82 (2), 187–200. http:
//dx.doi.org/10.1111/j.1939–0025.2012.01154.x.
Dube, S.R., Anda, R.F., Felitti, V.J., Chapman, D.P., Williamson, D.F., Giles, W.H., 2001.
Childhood abuse, household dysfunction, and the risk of attempted suicide
throughout the life span: findings from the adverse childhood experiences
study. J. Am. Med. Assoc. 286 (24), 3089–3096.
Dudeck, M., Drenkhahn, K., Spitzer, C., Barnow, S., Freyberger, H.J., Grabe, H.J., 2012.
Is there an association between intrafamiliar sexual abuse and sexual offences
in later life? Findings of a European study of long-term prisoners. Psychiatr.
Prax. 39 (5), 217–221.
Dudeck, M., Drenkhahn, K., Spitzer, C., Barnow, S., Kopp, D., Freyberger, H.J., Dünkel,
F., 2011. Traumatisation and mental distress in long-term prisoners in Europe.
Punishm. Soc. 13 (4), 403–423.
Elbert, T., Weierstall, R., Schauer, M., 2010. Fascination violence: on mind and brain
of man hunters. Eur. Arch. Psychiatry Clin. Neurosci. 260 (2), 100–105.
Fazel, S., Cartwright, J., Norman-Nott, A., Hawton, K., 2008. Suicide in prisoners: a
systematic review of risk factors. J. Clin. Psychiatry 69 (11), 1721–1731.
Fazel, S., Grann, M., Kling, B., Hawton, K., 2011. Prison suicide in 12 countries: an
ecological study of 861 suicides during 2003–2007. Soc. Psychiatry Psychiatr.
Epidemiol. 46 (3), 191–195.
Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V.,
Marks, J.S., 1998. Relationship of childhood abuse and household dysfunction to
many of the leading causes of death in adults: the adverse childhood experi-
ences (ACE) study. Am. J. Prev. Med. 14 (4), 245–258.
Finkelhor, D., Ormrod, R.K., Turner, H.A., 2009a. Lifetime assessment of poly-victi-
mization in a national sample of children and youth. Child Abuse Negl. 33,
403–411.
Finkelhor, D., Ormrod, R.K., Turner, H.A., 2009b. The developmental epidemiology
of childhood victimization. J. Interpers. Violence 24 (5), 711–731.
Fite, P.J., Raine, A., Stouthamer-Loeber, M., Loeber, R., Pardini, D.A., 2009. Reactive
and proactive aggression in adolescent males: examining differential outcomes
10 years later in early adulthood. Crim. Justice Behav. 37 (2), 141–157.
Ford, J.D., Fraleigh, L.A., Connor, D.F., 2010. Child abuse and aggression among
seriously emotionally disturbed children. J. Clin. Child Adolesc. Psychol. 39 (1),
25–34.
Garland, E.L., Boettiger, C.A., Howard, M.O., 2011. Targeting cognitive-affective risk
mechanisms in stress-precipitated alcohol dependence: an integrated,
biopsychosocial model of automaticity, allostasis, and addiction. Med. Hy-
potheses 76 (5), 745–754.
Gogtay, N., Giedd, J.N., Lusk, L., Hayashi, K.M., Greenstein, D., Vaituzis, A.C., 2004.
Dynamic mapping of human cortical development during childhood through
early adulthood. Proc. Natl. Acad. Sci. USA 101 (21), 8174–8179.
Hamilton, M., 1960. A rating scale for depression. J. Neurol. Neurosurg. Psychiatry
23 (1), 56.
Hecker, T., Hermenau, K., Maedl, A., Elbert, T., Schauer, M., 2012. Appetitive ag-
gression in former combatants – derived from the ongoing conflict in DR Congo.
Int. J. Law Psychiatry 35 (3), 244–249.
Hillbrand, M., 1995. Aggression against self and aggression against others in violent
psychiatric patients. J. Consult. Clin. Psychol. 63 (4), 668.
Hoeve, M., Colins, O.F., Mulder, E.A., Loeber, R., Stams, G.J., Vermeiren, R.R., 2015.
The association between childhood maltreatment, mental health problems, and
aggression in justice-involved boys. Aggress. Behav. 9999, 1–14.
Schalinski, I., Schauer, M., Elbert, T., 2014. The Shutdown Dissociation Scale (Shut-
D). (Unpublished manuscript).
Isele, D., Teicher, M.H., Ruf-Leuschner, M., Elbert, T., Kolassa, I.-T., Schury, K.,
Schauer, M., 2014. KERF - Ein Instrument zur umfassenden Ermittlung belas-
tender Kindheitserfahrungen. Z. Klin. Psychol. Psychother. 43 (2), 121–130.
Kempes, M., Matthys, W., Vries, H., de, van Engeland, H., 2005. Reactive and
proactive aggression in children: a review of theory, findings and the relevance
for child and adolescent psychiatry. Eur. Child Adolesc. Psychiatry 14 (1), 11–19.
Kim, Y.S., Leventhal, B.L., Koh, Y.-J., Hubbard, A., Boyce, W.T., 2006. School bullying
and youth violence: Causes or consequences of psychopathologic behavior?
Arch. Gen. Psychiatry 63, 1035–1041.
Kopp, D., Drenkhahn, K., Dünkel, F., Freyberger, H.J., Spitzer, C., Dudeck, M., 2011.
Psychiatric symptoms in german short-term and long-term prisoners. Nerve-
narzt. 82, 880–885.
Korn, M., van Praag, H., 1991. Correlates of risk of suicide in violent and nonviolent
psychiatric patients. Am. J. Psychiatry 1 (48), 883.
Lang, S., af Klinteberg, B., Alm, P.-O., 2002. Adult psychopathy and violent behavior
in males with early neglect and abuse. Acta Psychiatr. Scand. 106 (s412),
93–100.
Lansford, J.E., Miller-Johnson, S., Berlin, L.J., Dodge, K.A., Bates, J.E., Pettit, G.S., 2007.
Early physical abuse and later violent delinquency: a prospective longitudinal
study. Child Maltreat. 12 (3), 233–245.
Lenhard, W., Lenhard, A., 2015. Berechnung von Effektstärken. (URL). 〈http://www.
psychometrica.de/effektstaerke.html〉 (Retrieved 10/22/2015).
Lipschitz, D.S., Winegar, R.K., Nicolaou, A.L., Hartnick, E., Wolfson, M., Southwick, S.
M., 1999. Perceived abuse and neglect as risk factors for suicidal behavior in
adolescent inpatients. J. Nerv. Ment. Dis. 187 (1), 32–39.
Malinosky-Rummell, R., Hansen, D.J., 1993. Long-term consequences of childhood
physical abuse. Psychol. Bull. 114 (1), 68.
Mandelli, L., Carli, V., Roy, A., Serretti, A., Sarchiapone, M., 2011. The influence of
childhood trauma on the onset and repetition of suicidal behavior: an in-
vestigation in a high risk sample of male prisoners. J. Psychiatr. Res. 45 (6),
742–747.
O’Brian, R.M., 2007. A caution regarding rules of thumb for variance inflation fac-
tors. Qual. Quant. 41, 673–690.
Camilleri, P.J., McArthur, M., Webb, H., Territory, A.C., 1999. Suicidal Behaviour in
Prisons: A literature Review. School of Social Work, Australian Catholic Uni-
versity, Canberra.
Pulkkinen, L., 1996. Proactive and reactive aggression in early adolescence as pre-
cursors to anti-and prosocial behavior in young adults. Aggress. Behav. 22 (4),
241–257.
Roy, A., Carli, V., Sarchiapone, M., Branchey, M., 2014. Comparisons of prisoners
who make or do not make suicide attempts and further who make one or
multiple attempts. Arch. Suicide Res. 18 (1), 28–38.
Sakelliadis, E.I., Papadodima, S.A., Sergentanis, T.N., Giotakos, O., Spiliopoulou, C.A.,
2010. Self-injurious behavior among Greek male prisoners: prevalence and risk
factors. Eur. Psychiatry 25 (3), 151–158.
Senn, T.E., Carey, M.P., 2010. Child maltreatment and women's adult sexual risk
behavior: childhood sexual abuse as a unique risk factor. Child Maltreat. 15,
324–335.
Stalenheim, E.G., 2001. Relationships between attempted suicide, temperamental
vulnerability, and violent criminality in a Swedish forensic psychiatric popu-
lation. Eur. Psychiatry 16 (7), 386–394.
Swogger, M.T., You, S., Cashman-Brown, S., Conner, K.R., 2011. Childhood physical
abuse, aggression, and suicide attempts among criminal offenders. Psychiatry
Res. 185 (3), 363–367.
Teicher, M.H., Parigger, A., 2011. Modified adverse childhood modified adverse
childhood experience scale, version 0.9; inspired by the ACE scale, Narrative
Exposure Therapy (NET). A Short-Term Intervention for Traumatic Stress Dis-
orders. Hogrefe, Göttingen, pp. 80–90.
Turner, H.A., Finkelhor, D., Shattuck, A., Hamby, S., 2012. Recent victimization ex-
posure and suicidal ideation in adolescents. Arch. Pediatr. Adolesc. Med. 166
(12), 1149–1154.
Vitaro, F., Gendreau, P.L., Tremblay, R.E., Oligny, P., 1998. Reactive and proactive
aggression differentially predict later conduct problems. J. Child Psychol. Psy-
chiatry 39 (3), 377–385.
Weierstall, R., Elbert, T., 2011. The appetitive aggression scale – development of an
instrument for the assessment of human's attraction to violence. Eur. J. Psy-
chotraumatol. 2, 8430.
Weierstall, R., Huth, S., Knecht, J., Nandi, C., Elbert, T., 2012a. Appetitive aggression
as a resilience factor against trauma disorders: appetitive aggression and PTSD
 M. Dudeck et al. / Psychiatry Research 240 (2016) 352–357 357

in German World War II veterans. PloS One 7 (12), e50891.
Weierstall, R., Schalinski, I., Crombach, A., Hecker, T., Elbert, T., 2012b. When combat
prevents PTSD symptoms – results from a survey with former child soldiers in
Northern Uganda. BMC Psychiatry 12 (1), 41.
Widom, C.S., 1989. The cycle of violence. Science 244 (4901), 160–166.
Wilson, H.W., Stover, C.S., Berkowitz, S.J., 2009. The relationship between childhood
violence exposure and juvenile antisocial behavior: a meta-analytic review. J.
Child Psychol. Psychiatry 50 (7), 769–779.
Wingenfeld, K., Spitzer, C., Mensebach, C., Grabe, H.J., Hill, A., Gast, U., Schlosser, N.,
Höpp, H., Beblo, T., Driessen, M., 2010. The German version of the childhood
trauma questionnaire (CTQ): preliminary psychometric properties. Psychother.
Psychosom. Med. Psychol. 60 (11), 442–450.
Ystgaard, M., Hestetun, I., Loeb, M., Mehlum, L., 2004. Is there a specific relationship
between childhood sexual and physical abuse and repeated suicidal behavior?
Child Abuse Negl. 28 (8), 863–875.