Personality and Individual Differences 49 (2010) 689–693

Contents lists available at ScienceDirect

Personality and Individual Differences

journal homepage: www.elsevier.com/locate/paid

Comparing psychache, depression, and hopelessness in their associations

with suicidality: A test of Shneidman’s theory of suicide
Talia Troister *, Ronald R. Holden
Department of Psychology, Queen’s University, Kingston, Ontario, Canada K7L 3N6

a r t i c l e i n f o a b s t r a c t

Article history: In a test of Edwin Shneidman’s theory of suicide, this study examined the contribution of psychache,
Received 6 April 2010 depression, and hopelessness to the statistical prediction of various suicide-related criteria, for a sample
Received in revised form 1 June 2010 of 1475 undergraduate students. Regression analyses indicated that, relative to depression and hopeless-
Accepted 5 June 2010
ness, psychache was the psychological variable most strongly associated with suicidality, but that depres-
Available online 1 July 2010
sion and hopelessness did contribute unique variance in the statistical prediction of some suicide criteria.
In finding that psychache was the strongest statistical predictor of suicidality, results offered support for
Keywords:
Shneidman’s theory of psychache as the pre-eminent psychological cause of suicide. Additional theoret-
Suicidality
Psychache
ical and practical implications for the statistical prediction of suicide risk are discussed.
Hopelessness Ó 2010 Elsevier Ltd. All rights reserved.
Depression
Shneidman’s model

1. Introduction sequently die by suicide (Bradvick, Mattisson, Bogren, & Nettel-

bladt, 2008). Although it is evident that depression plays a role
In the United States, suicide is the 11th leading cause of death in suicide, not every depressed person is suicidal and not all suicide
(National Institute of Mental Health (n. d.). Suicide in the U.S.: Sta- attempts occur during a depressive episode (Harkavy-Friedman,
tistics, 2009) representing an average of 85 suicide deaths every Nelson, Venarde, & Mann, 2004).
day (Moscicki, 1999). Worldwide, suicide claims the lives of almost Hopelessness is another psychological factor having a central
one million people per year (World Health Organization, 2002). role in suicide (Beck & Lester, 1973; DeLisle & Holden, 2004; Mink-
With such a large number of people dying by suicide annually, sui- off, Bergman, Beck, & Beck, 1973; Wetzel, Margulies, Davis, & Kar-
cide prevention is an important public health issue. Therefore, it is am, 1980). Numerous studies have found hopelessness to be an
crucial that health researchers and practitioners are better able to indicator of current suicide intent (Lester, Beck, & Mitchell, 1979;
identify who is at risk for suicide and to design effective interven- Nekanda-Trepka, Bishop, & Blackburn, 1983; Weishaar & Beck,
tion programs. 1992), and prospective investigations find that when hopelessness
Identifying psychological variables associated with suicidality is is statistically controlled, depression is no longer a significant pre-
a promising avenue for assessing risk, because psychological fac- dictor of completed suicide (Beck, Brown, & Steer, 1989; Beck, Steer,
tors can be targeted during interventions and may be amenable Kovacs, & Garrison, 1985; Brown, Beck, Steer, & Grisham, 2000).
to treatment. Depression in particular has long been a well-recog- Although both hopelessness and depression are strong predic-
nized risk factor for suicide (Robins, Schmidt, & O’Neil, 1959). A tors of who will attempt, and die by, suicide (Lester et al., 1979;
major depressive episode is the most common axis I disorder diag- Thompson, Mazza, Herting, Randell, & Eggert, 2005), neither one
nosed in individuals who eventually die by suicide, with some esti- of these constructs alone or in combination is able to fully account
mates that 87% of those who die by suicide have had a previous for and/or predict suicidality. Edwin Shneidman proposed that psy-
major depressive episode (Cheng, Chen, Chen, & Jenkins, 2000). chological pain, or psychache, is a necessary condition for suicide
Abundant research has supported the association between depres- to occur, and that all other factors, such as depression and hope-
sion and suicidality (Konick & Gutierrez, 2005; Silver, Bohnert, lessness are secondary, and only relevant for suicide insofar as
Beck, & Marcus, 1971), and depression does predict who will sub- their association with psychache (Shneidman, 1993). Shneidman
defined psychache as the ‘‘hurt, anguish, soreness, aching, psycho-
logical pain in the psyche, the mind” (Shneidman, 1993, p. 145). For
* Corresponding author. Address: Department of Psychology, Queen’s University,
an individual to die by suicide, Shneidman asserts that the percep-
62 Arch Street, Kingston, Ontario, Canada K7L 3N6. Tel.: +1 613 533 2879; fax: +1
613 533 2499. tion of the pain must be unbearable for that person, and that the
E-mail address: 6tt5@queensu.ca (T. Troister). cessation of the pain, or psychache, by stopping consciousness is

0191-8869/$ - see front matter Ó 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.paid.2010.06.006
690 T. Troister, R.R. Holden / Personality and Individual Differences 49 (2010) 689–693

seen as the only solution. He postulated that if the pain can be re- sion for an introductory psychology course subject pool. Partici-
lieved, the individual would be willing to continue to live (Shneid- pants ranged in age from 16 to 45 years (M = 18.36, SD = 2.09)
man, 1984). and 71% were women. All individuals were treated in accordance
Support for psychache as a factor in suicide has been increasing with guidelines of the University Research Ethics Board.
in recent years. Examination of suicide notes reveals that wanting
to escape from unbearable psychological pain is a common theme 2.2. Procedure
(Leenaars, 1991; Valente, 1994). Worst-ever psychache is associ-
ated with both current depression and a history of suicide ideation Participants were asked to provide their age and gender, to indi-
(Lester, 2000). Holden, Mehta, Cunningham, and McLeod (2001) cate whether they had ever attempted suicide and, if so, how long
operationalized psychache, developing the 13-item Psychache ago their most recent attempt was, how they attempted to commit
Scale based on Shneidman’s (1993) definition of psychological suicide, how intent they were on killing themselves during their
pain. In evaluating the scale for samples of university students, re- most recent attempt, and how many times they had attempted sui-
sults demonstrated that psychache and hopelessness were both cide in their lifetime. In addition, individuals were asked to com-
unique contributors to suicide ideation, but that psychache had plete measures of suicide ideation, psychache, depression, and
the largest standardized regression coefficient. Further, in their hopelessness.
sample of female university students, findings were that psychache
was the only variable that contributed significant and unique var-
2.3. Measures
iation to the statistical prediction of suicide ideation and self-in-
jury. Psychache was also correlated with attempter status in an
The Beck Scale for Suicide Ideation (BSS; Beck & Steer, 1991) is a
offender sample (Mills, Green, & Reddon, 2005). In a group of
19-item measure of suicide ideation and intent. Each item com-
mood-disordered outpatients, psychache (as measured by psycho-
prises three statement options scored from 0 to 2 based on increas-
logical quality of life) was shown to have a unique relationship to
ing intensity of suicidality. Alpha reliability coefficients have
suicidality that was not accounted for by the other psychological
ranged from .84 to .93 in psychiatric samples (Beck, Brown, & Steer,
variables (Berlim et al., 2003), consistent with Shneidman’s per-
1997; Beck, Kovacs, & Weissman, 1979; Beck, Steer, & Ranieri,
spective on suicidality.
1988). The BSS has two subscales (Beck et al.): Motivation and
Holden et al. (2001) suggested that the link between hopeless-
Preparation. Motivation refers to individuals’ attitudes about living
ness and self-destructive behaviors may be mediated by psych-
and dying, and measures formal characteristics of ideation such as
ache. This claim aligns with Shneidman’s view that psychache
the frequency and duration of suicidal thoughts. Preparation refers
mediates the relationship between all other psychological predic-
to a more active stage that involves a formulation of the contem-
tors and suicide. Testing this hypothesis, DeLisle and Holden
plated suicide attempt. Research with suicide attempters has found
(2009) found good fit for a model in which psychache mediated
support for this two-subscale model (Holden & DeLisle, 2005), with
the effects of hopelessness and depression, and was the most prox-
alpha reliability coefficients of .85 for Motivation and .73 for Prep-
imal factor associated with suicidality. Psychache has also been
aration subscales.
found to fully mediate the relationship between perfectionism
The Psychache Scale (Holden et al., 2001) is a 13-item self-re-
and suicidality (Flamenbaum & Holden, 2007) and between alexi-
port scale used to assess Shneidman’s (1993) conceptualization
thymia and suicidality (Keefer, Holden, & Gillis, 2009).
of psychache or psychological pain, with responses coded on a 5-
It is evident from current literature that empirical support for
point Likert scale. Alpha reliability coefficients of .92 and .95 have
psychache as a psychological variable relevant for suicidality is
been reported in university and offender populations, respectively
accumulating. Additional research is necessary to bring it forward
(Holden et al.; Mills et al., 2005). The Psychache Scale has also been
as a pre-eminent predictor of suicide risk, and to show that psych-
shown to distinguish between suicide attempters and nonattemp-
ache merits consideration alongside depression and hopelessness
ters (Holden et al.).
as a psychological predictor of suicide. Therefore the purpose of
The Beck Depression Inventory (BDI-II; Beck, Steer, & Brown,
this research was to test Shneidman’s theory of suicide by evaluat-
1996) is a 21-item scale of depression severity in adolescents
ing the contributions of depression, hopelessness, and psychache
and adults. Participants rate each item on a 4-point scale on which
to the statistical prediction of suicidality. This research builds upon
symptoms increase in severity from 0 to 3. Participants are asked
previous investigations by incorporating a psychometrically stron-
to respond to each item according to their experiences over the
ger measure of suicide ideation than previously used (Holden et al.,
past two weeks. Research has shown the BDI-II to have construct
2001), by examining a different range of suicide-related criteria,
validity as it was more highly correlated with scores on the
and by including a relatively large number of participants. Based
Depression subscale of the SCL-90 (revised) than on the Anxiety
on Shneidman’s model of suicide, the following hypotheses were
subscale in a group of psychiatric outpatients (Steer, Ball, Ranieri,
evaluated:
& Beck, 1997). In another group of outpatients, the BDI-II was
shown to have high internal consistency with an alpha of .91 (Beck,
1. Psychache would correlate significantly with measures of
Steer, Ball, & Ranieri, 1996).
suicidality.
The Beck Hopelessness Scale (BHS; Beck, Weissman, Lester, &
2. In the statistical prediction of suicidality, psychache would be
Trexler, 1974) is a 20-item true/false measure that assesses nega-
more important than either depression or hopelessness.
tive expectations for the future. In examining BHS psychometric
3. In the statistical prediction of suicidality, controlling for psych-
properties with patients hospitalized for a suicide attempt, Beck
ache would reduce the unique contributions of depression and
et al. report an alpha reliability coefficient of .93, a correlation of
hopelessness to nonsignificant levels.
the BHS with clinical ratings of hopelessness of .62, and correlations
ranging between .60 and .63 with other measures of hopelessness.
2. Method

2.1. Participants 3. Results

Fourteen hundred and seventy-five undergraduates responded Thirty-eight participants (2.5%) reported having previously at-
to a set of self-report research material as part of a screening ses- tempted suicide, with pills being the most common method
 T. Troister, R.R. Holden / Personality and Individual Differences 49 (2010) 689–693 691

(44.1%), followed by cutting (26.5%). Suicide attempters reported a 4. Discussion

mean of 41.39 months since their most recent suicide attempt
(SD = 34.04, range = 2 to 168), and a moderate to high level of sui- The present study addressed the question of whether psychache
cide intent at the time of that attempt (M = 3.12, SD = 1.22) on a can statistically predict suicidality beyond the effects of depression
five-point rating scale. Their number of lifetime attempts ranged and hopelessness in university undergraduates. The findings par-
from 1–11 (M = 1.66, SD = 1.78). tially supported the original hypotheses. The hypothesis that
Scales of psychache, depression, and hopelessness were used as psychache would be significantly correlated with each of the sui-
psychological, statistical predictors of the suicide-related criteria of cide criteria was supported. In each case, psychache was the factor
suicide ideation, history of a past suicide attempt, and life-time most strongly associated with the suicide-related outcomes.
number of suicide attempts. Descriptive statistics and correlations Regression analyses indicated that psychache was the strongest
among measures are reported in Table 1. Significant, positive cor- statistical predictor of all suicidal criteria, supporting the second
relations were obtained between the psychological variables of hypothesis. In each regression equation, psychache had a larger
depression, hopelessness, and psychache. The correlations among standardized regression coefficient than those of depression and
the predictor variables are comparable to those found in other re- hopelessness. Psychache has also been shown to outperform hope-
search with university students (DeLisle & Holden, 2009). Signifi- lessness and depression in other undergraduate samples (DeLisle &
cant, positive correlations were also found between the three Holden, 2004) and in a forensic sample (Holden & Kroner, 2003).
predictor variables and each of the criterion variables, including Partial support was found for the third hypothesis. For the pre-
suicidal ideation, suicidal motivation, suicidal preparation, atte- diction of attempter status and number of lifetime attempts, statis-
mpter status and number of life-time suicide attempts. In terms tically controlling for psychache did reduce the contributions of
of magnitude, each outcome variable was most strongly correlated depression and hopelessness to nonsignificant levels. This finding
with psychache, as compared to their correlations with depression supports Shneidman’s assertion that depression and hopelessness
and hopelessness. This finding supports the first hypothesis that are only important to suicide insofar as their relation to psychache,
psychache would correlate significantly with each suicide and is consistent with findings from other university (DeLisle &
criterion. Holden, 2009) and community samples (Holden et al., 2001). How-
To assess the relative importance of each predictor, suicide- ever, for the prediction of suicide ideation, suicide motivation, and
related criteria were regressed simultaneously onto the psycho- suicide preparation, depression and hopelessness maintained sig-
logical predictors (Table 2) and statistically significant standard- nificant unique explanatory variance after controlling for psych-
ized regression weights were compared. In undertaking ache. Therefore, Shneidman’s (1993) claim that psychache
regressions, assumptions of independence of errors and lack of mediates the relationship between all risk factors and suicidality,
multicollinearity were met based on consideration of Durbin– was only partially substantiated. A number of other studies have
Watson statistics, tolerances (all greater than .43), and condition- also found that psychache does not completely residualize the
ing indexes (all less than 8.9). Due to violations of distributional associations between other psychological variables and measures
normality, nonparametric bootstrapping with 5000 bootstrap of suicidality (Berlim et al., 2003; DeLisle & Holden, 2004; Flynn
samples was used to undertake these tests of significance. In & Holden, 2007; Holden et al., 2001). Overall, these findings sug-
support of the second hypothesis, for the BSS total, R2 = .36, sui- gest that although psychache is an important factor that should
cide motivation, R2 = .34, and suicide preparation, R2 = .24, psych- be taken into account when determining suicide risk, it is not the
ache contributed the greatest variance, followed by hopelessness, only factor to be considered.
and depression. Also in support of the second hypothesis, for
attempter status, R2 = .07, and number of lifetime attempts,
R2 = .26, only psychache contributed significant, unique explana- 5. Limitations and future research
tory variance. In partial support of the third hypothesis, for both
attempter status and lifetime attempts, depression and hopeless- This research has potential limitations based on the obtained
ness failed to reach statistical significance. These findings suggest sample, the materials used, and the research design. The sample
that psychache is the predictor most strongly associated with was drawn from a population of undergraduate students in which
suicidality. there were very few male participants, and who were a relatively

Table 1
Descriptive statistics and correlations between measures of suicidality (N = 1475).

Scale Possible range Observed range Coefficient a 1 2 3 4 5 6 7 8

Predictors
1 0–63 0–56 .94 –
2 0–20 0–20 .90 .65** –
3 13–65 13–65 .78 .48** .52** –

Criteria
4 0–38 0–30 .76 .55** .50** .44** –
5 0–18 0–14 .70 .51** .49** .46** .86** –
6 0–18 0–15 .61 .46** .38** .35** .90** .64** –
7 0–1 0–1 – .25** .21** .17** .41** .32** .43** –
8 1-1 1–11 – .48** .46** .32** .51** .47** .53** .67** –
M 7.76 3.16 20.55 4.44 .94 2.69 .03 1.66
SD 7.04 2.92 8.22 3.68 1.70 2.15 .16 1.78

Note. 1 = Psychache Scale; 2 = Beck Depression Inventory; 3 = Beck Hopelessness Scale; 4 = Beck Scale for Suicide Ideation; 5 = Beck Scale for Suicide Ideation-Motivation;
6 = Beck Scale for Suicide Ideation-Preparation; 7 = attempter status; 8 = number of previous attempts. Lifetime attempt data are based only on those who reported a previous
attempt.
**
p < .01.
692 T. Troister, R.R. Holden / Personality and Individual Differences 49 (2010) 689–693

Table 2
Regression coefficients for predicting suicidality (N = 1475).

Suicidal ideation Suicidal motivation Suicidal preparation Attempter status Lifetime attempts
2 *** *** *** ***
R .36 .34 .24 .07 .26***
Statistical predictor b b b b b b b b b b
Intercept .24 1.00 .34 .068 .63
* * * *
Psychache .15 .34 .06 .28 .09 .33 .004 .18 .03 .31*
Depression .09 .17* .04 .19* .03 .10* .001 .06 .02 .22
Hopelessness .24 .19* .13 .23* .10 .14* .003 .06 .01 .02
*
p < .05.
***
p < .001, two-tailed.

healthy population. Therefore, notwithstanding consistency in Troister & Holden, 2010). Therefore, the next step is to conduct lon-
depression research between analogue and clinical samples (Vre- gitudinal research with larger samples and a longer study period.
denburg, Flett, & Krames, 1993), the generalizability of current Measuring actual death by suicide is also needed to elucidate fur-
findings to clinical or other populations remains to be confirmed. ther the psychological causes of suicidal outcomes. The present re-
Another consideration is that suicidality was studied in terms of search suggests that the addition of the measurement of psychache
suicide attempts, suicide ideation, suicide motivation and suicide to risk assessment, along with measures of depression and hope-
preparation. Findings of this research may not generalize to actual lessness, may serve to improve the accuracy of suicide risk
death by suicide. Although a history of suicide attempts and suici- prediction.
dality are substantive risk factors for later suicidal behavior (Joiner
et al., 2005), not everyone who dies by suicide has made a previous Acknowledgement
attempt. Despite the potential lack of generalizability to actual
death by suicide, the current focus on suicide ideation is highly rel- This research was supported by the Social Sciences and Human-
evant in that ideation is itself a major mental health issue for indi- ities Research Council of Canada.
viduals, their families, and society.
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