A Note on Shneidman's Psychological Pain

OMEGA, Vol. 50(4) 301-307, 2004-2005

A NOTE ON SHNEIDMAN’S PSYCHOLOGICAL PAIN ASSESSMENT SCALE

ANTOON A. LEENAARS Windsor, Canada DAVID LESTER Richard Stockton College, Pomona, New Jersey

ABSTRACT Shneidman’s Psychological Pain Assessment Scale (PPAS) was explored for its validity and reliability. The test-retest reliability of the measures was quite modest for a 28-day interval. In a sample of undergraduate students, measures of psychache were significantly associated with prior suicidality; yet, the PPAS had only a modest degree of validity. More detailed study is warranted, before final conclusions can be made.

It is perhaps true to say that suicidal individuals are experiencing psychological distress or suffering and that suicide may be, at least in part, an attempt to escape from this suffering (Baumeister, 1990; Murray, 1967). Shneidman (1996) coined the term “psychache” to describe this pain: Psychache is the hurt, anguish, or ache that takes hold in the mind...the pain of excessively felt shame, guilt, fear, anxiety, loneliness, angst, dread of growing old or of dying badly (p. 13). Although, as Menninger (1938) noted, other motives may be present in suicidal behavior (such as anger felt toward others, anger which may be expressed by means of the suicidal act), Shneidman has argued that unendurable psychache is the common stimulus for all suicidal behaviors. Suicide, as Murray (1967) noted, is functional because it abolishes the pain for the individual, an escape from intolerable suffering.

301 Ó 2005, Baywood Publishing Co., Inc. 302 / LEENAARS AND LESTER

Shneidman (1999) proposed a paper-and-pencil test (with pictures), called the Psychological Pain Assessment Scale (PPAS), for assessing the level of psychache experienced by individuals. The PPAS is an attempt to bridge the interpersonal phenomenological gulf (or problem), regarding psychological pain, by means of using picture (visual) stimuli; it is an obvious application of Murray’s TAT principle (Leenaars, 1999). The present study was designed to explore both the reliability and the validity of this scale as a correlate of suicidality.

STUDY 1

Method: The Psychological Pain Assessment Scale The form used for the Psychological Pain Assessment Scale (PPAS) is similar to that in Shneidman (1999). Page 1 requests personal data (age and sex), presents the purpose of the test, and defines psychological pain. Then the respondent is asked to rate their current psychological pain on a scale of 1 (least) to 9 (most). Page 2 presents 10 pictures (five of which are in the shortened version of the scale in Shneidman (1999)), and respondents are requested to rate the psychological pain experienced by the main character in each picture on a scale of 1 to 9. The sum of these ratings was calculated. Page 3 asks the respondent to rate the worst psychological pain they have ever experienced on a scale of 1 to 9, and then to check which of 28 feelings were prominent at that time. Page 4 requests respondents to provide an essay describing this time of worst-ever psychological pain.

Subjects The subjects were 127 undergraduate students at a state college, enrolled in social science courses. There were 37 males and 90 females, with a mean age of 22.9 years (SD = 6.4).

Procedure During class, subjects were administered a questionnaire containing the PPAS and the Eysenck Personality Inventory (Eysenck, Eysenck, & Barrett, 1985) which provides measures of extraversion, neuroticism, and psychoticism. Eysenck’s scale is only used as a beginning measure of comparison, a validity issue warranting much greater study.

Results The mean level of current psychache was 3.35 (SD = 1.84) and the mean level of worst-ever psychache was 7.15 (SD = 1.66). A NOTE ON SHNEIDMAN’S PSYCHOLOGICAL / 303

The associations between current and worst-ever psychache with other variables are shown in Table 1. It can be seen that current psychache was associated significantly with prior suicidal ideation (but not with prior suicide attempts), and with extraversion and neuroticism. Worst-ever psychache was associated with prior suicidal ideation and suicide attempts and with psychoticism. The sum of the rated pain in the 10 pictures was associated with current psychache (see Table 1) but not with worst-ever psychache. The estimated pain perceived in the 10 pictures was subjected to a factor analysis using a Principal Components extraction and a Varimax rotation. Two orthogonal (independent) factors were extracted (see Table 2). Only scores on Factor II were associated with current psychache (Pearson r = 0.18, two-tailed p < .05), and the association was modest. This suggests that some pictures may be more useful as stimulation in this projective test than others. Respondents were asked to check four feelings from a list of 28 which best described their worst-ever psychache. The most common feelings checked (see Table 3) were loneliness, emptiness, and anger. Current psychache was associated only with abandonment and self-hate (both positively), while worst-ever psychache was associated only with checking guilt (negatively). These few associations were no more than would be expected by chance in this many correlations (56).

Table 1. Associations of Psychache with Other Variables (Pearson Correlation Coefficients Shown)

Current Worst-ever psychache psychache

Age 0.13 0.12 Sex 0.01 0.03 Prior suicidal ideation 0.32*** 0.23** Prior suicidal attempts 0.12 0.18* Lethality of prior attempts 0.22 0.33 (n = 16 only) Psychoticism 0.07 0.20* Extraversion –0.30*** 0.03 Neuroticism 0.38*** 0.14 Sum of perceived pain 0.20* 0.06

*Two-tailed p < 0.05. **Two-tailed p < .01. ***Two-tailed p < .001. 304 / LEENAARS AND LESTER

Table 2. Factor Analysis of Psychological Pain Assessment Scale

Factor I Factor II

Old style courtship 0.55# 0.18 Departure for war 0.64# –0.31 Russian woman 0.08 0.65# The strike 0.79# 0.01 Adam, Eve, and Abel 0.72# –0.07 Refugees of war 0.67# –0.04 In the desert 0.66# 0.30 First steps –0.08 0.82# Stolen sweets 0.03 0.67# 19th century man 0.53# 0.38

Current pain 0.13 0.18* Worst pain 0.14 –0.16

*Two-tailed p < 0.05.

Table 3. Feelings Accompanying the Worst Pain

Abandonment 19% Horror 0% Anger 31% Inferiority 5% Anguish 3% Jealousy 4% Anxiety 20% Loneliness 34% Betrayal 14% Loss 22% Confusion 21% Lure of death 7% Despair 17% Powerlessness 14% Deterioration 0% Rejection 8% Emptiness 33% Sadness 28% Failure 16% Self-hate 13% Fear 17% Shame 5% Grief 15% Terror 2% Guilt 11% Worthlessness 10% Helplessness 16% Other 2% Hopelessness 15% A NOTE ON SHNEIDMAN’S PSYCHOLOGICAL / 305

STUDY 2

The purpose of Study 2 was to explore the reliability of the PPAS.

Method

The subjects were 11 male and 30 female undergraduate students, enrolled in social science courses, with a mean age of 25.4 years (SD = 7.5). They were administered the PPAS twice with a 28-day interval. Respondents placed a code name on the questionnaires so that their two tests could be matched. They were given a shortened version of the PPAS, one with only five pictures and with no check-list of feelings. The version was that in Shneidman (1999).

Results

After 28 days, the test-retest correlations were for current psychache 0.26 (ns), worst-ever psychache 0.36 (two-tailed p = .04), and for the sum of the rated psychache in the pictures 0.46 (p =.003) (see Table 4).

DISCUSSION

The PPAS devised by Shneidman (1999) uses a simple rating scale for respondents to rate their current psychache and worst-ever psychache. Current psychache was rated as less than worst-ever psychache, as was expected. Current psychache was associated with a history of suicidal ideation but not with prior attempted suicide, while high worst-ever psychache was associated with both a history of suicidal ideation and suicide attempts, providing some measure of validity for the measure of psychache.

Table 4. Test-Retest Pearson Correlations

Current psychache 0.26 (p = .11) Worst-ever psychache 0.36 (p = .04)

Sum of five picture scores 0.46 (p = .003) Picture 1 0.53 (p < .001) Picture 2 0.59 (p < .001) Picture 3 0.63 (p < .001 Picture 4 0.17 (p = .03) Picture 5 0.65 (p < .001) 306 / LEENAARS AND LESTER

Current psychache was associated with extraversion negatively and neuroticism positively, indicating that neuroticism and introversion are associated with higher levels of current psychache. The worst-ever pain was associated with psychoticism. Thus, together with other findings in these studies, we can tentatively conclude that current and worst-ever psychache are measuring different stimulus. In a recent study, Lester (2000) reported that current and worst-ever psychache were associated with a measure of depression, while worst-ever psychache was associated with a history of suicidal ideation. Taken together, the present results and those of Lester (2000) suggest that this simple measure of psychache has a modest degree of validity; yet, more detailed study is warranted, before a final conclusion can be made. The test-retest results from Study 2 indicate that the reliability of the measures was 0.26 for current psychache and 0.36 for worst-ever psychache. It might be expected that current psychache would not show high test-retest reliability since current feelings may change from day to day. However, worst-ever psychache was expected to show a much higher level of test-retest reliability, whereas the correlation was only 0.36. The test-retest reliability of the psychache portrayed in the pictures was higher, and this could be improved by removing picture number 4 (Adam and Even and Abel). A sound measure of psychache would preferably consist of a multi-item scale, but until such a measure is devised, the simple ratings scales suggested by Shneidman may have some value as components in a battery of tests in psychological studies of suicidality. In all probability, pain and suicide, both complex behaviors, will call for more complex measurement (see, for example, the Thematic Guide for Suicide Prediction (TGSP) (Leenaars, 1992, 2004)). One feature of the PPAS, which may prove to be of utility in research, is the request for an open-ended essay describing the worst-ever psychache. To illustrate the unique stories told be the respondents in Study 1, we offer three vignettes:

1. It was like a burning in my gut. My head pounded at high speed. I sat there like I had nothing else and my life was just a piece of shit. I figured that no one cared about me; I was unloved. So I took a lot of drugs so that I wouldn’t feel myself dying. Fortunately my body must have rejected it and I spent the next few days in a hospital. 2. My grandmother unexpectedly died. I was 10 and I was mad at her for dying. I cried and screamed and hated everybody for a long time. I felt lonely like no one could fix it—ever. I couldn’t understand how I would live without ever seeing, touching, talking to her ever again. There was nothing I could do to make it better. She always made everything better for me. I felt like my life was over. Ten years later I am still mad she left me but now I can understand that there never was anything I could have done to fix it. 3. I lost myself completely in a extremely abusive relationship. Emotionally and mentally was the worst....Ibegan using drugs, self-mutilating myself. A NOTE ON SHNEIDMAN’S PSYCHOLOGICAL / 307

I couldn’t leave the relationship. The days dragged by. All I wanted to do was sleep. I felt everyone turning against me and felt the only person who did care was the scumbag I was with.

REFERENCES Baumeister, R. (1990). Suicide as escape from self. Psychological Review, 97, 90-113. Eysenck, S., Eysenck, H., & Barrett, P. (1985). A revised version of the psychoticism scale. Personality & Individual Differences, 6, 21-29. Leenaars, A. (1992). Suicide notes, communication, and ideation. In R. Maris, A. Berman, J. Maltsberger, & R. Yufit (Eds.), Assessment and prediction of suicide (pp. 337-361). New York: Guilford Press. Leenaars, A. (Ed.). (1999). Lives and deaths: Selections from the work of Edwin S. Shneidman. Philadelphia, PA: Brunner/Mazel. Leenaars, A. (2004). Psychotherapy with suicidal people. Chichester, UK: John Wiley & Sons. Lester, D. (2000). Psychache, depression and personality. Psychological Reports, 87, 940. Menninger, K. (1938). Man against himself. New York: Harcourt, Brace & Co. Murray, H. (1967). Death to the world: The passions of Herman Melville. In E. Shneidman (Ed.), Essays in self-destruction (pp. 3-29). New York: Science House. Shneidman, E. S. (1996). The suicidal mind. New York: Oxford University Press. Shneidman, E. (1999). The Psychological Pain Assessment Scale. Suicide & Life- Threatening Behavior, 29, 287-294.

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