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Introduction
Violence is a major public health problem and the elucidation of factors that predict violence is essential to inform risk management and the development of interventions for risk reduction. Although violence is most typically conceptualized as being externally directed, compelling arguments have been made for including self-harming behaviors within the rubric of violence (Gray et al. 2003). Elevated rates of both self-directed violence (SDV) and other-directed violence (ODV) have been identified among psychiatric patients (Torrey et al. 2008), and both forms of violence represent important targets for clinical intervention. However, despite substantial clinical interest in elucidating SDV and ODV among psychiatric patients, relatively few studies have examined the extent to which these distinct forms of violence are associated with common versus distinct risk factors. In the present study we address this by examining how individual differences associated with general violence predict inward- or outward-directed violence.
SDV and ODV
Several investigations have reported a link between SDV and ODV. Angst & Clayton (1986) found higher aggression scores at last observation among psychiatric patients who eventually died by suicide relative to controls. Conner et al. (2001) found that interpersonally violent behavior in the last year of life predicted suicide in a large community sample. In addition to suicide deaths, the association between ODV and SDV extends to suicide attempts (Angst & Clayton, 1986; Conner et al. 2009) and non-lethal, self-injurious behavior (Hillbrand, 1995). Common biological underpinnings of SDV and ODV raise the possibility that tendencies toward the two may arise from the same diathesis. Serotonergic function is crucial for the regulation of ODV (Gietl et al. 2007), and several studies have demonstrated a correlation between low serotonergic activity and SDV (Mann, 2003; Braquehais et al. 2010). Similarly, alterations in cholesterol homeostasis have been implicated in attempted suicide and in suicide among individuals with low serum cholesterol (Gietl et al. 2007), and studies of interpersonally violent individuals have shown decreased levels of serum cholesterol relative to non-violent individuals (Troisi & D'Argenio, 2006). It has been suggested that these largely genetically determined biological mechanisms interact to create a diathesis for generally violent behavior (Gietl et al. 2007). Whereas this genetic and biological-level model of violence highlights features that underlie both SDV...