This research was supported by Basic Research Funds, Renmin University of China, by the Central Government of China (12XNLJ05) and Key Laboratory of Mental Health, Institute of Psychology, Chinese Academy of Sciences provided to Dr. Huanhuan Li. Heartfelt thanks are given to all participants in the study. We appreciate the assistance of staff at the Sixth Hospital of Peking University and the Medical Institute of Psychology at the Second Xiangya Hospital of Central South University in conducting this research.
Clarifying the Role of Psychological Pain in the Risks of Suicidal Ideation and Suicidal Acts among Patients with Major Depressive Episodes
Article first published online: 23 SEP 2013
© 2013 The American Association of Suicidology
Suicide and Life-Threatening Behavior
Volume 44, Issue 1, pages 78–88, February 2014
How to Cite
Li, H., Xie, W., Luo, X., Fu, R., Shi, C., Ying, X., Wang, N., Yin, Q. and Wang, X. (2014), Clarifying the Role of Psychological Pain in the Risks of Suicidal Ideation and Suicidal Acts among Patients with Major Depressive Episodes. Suicide and Life-Threat Behavi, 44: 78–88. doi: 10.1111/sltb.12056
- Issue published online: 11 FEB 2014
- Article first published online: 23 SEP 2013
- Manuscript Accepted: 29 JUL 2013
- Manuscript Received: 17 MAR 2013
- Research Funds, Renmin University of China. Grant Number: 12XNLJ05
- Key Laboratory of Mental Health
- Institute of Psychology
- Chinese Academy of Sciences
The role of psychological pain in the risk of suicide was explored using a three-dimensional psychological pain model (pain arousal, painful feelings, pain avoidance). The sample consisted of 111 outpatients with major depressive episodes, including 28 individuals with suicidal histories. They completed the Chinese version of the Beck Scale for Suicide Ideation (BSI), the Beck Depression Inventory (BDI), the Psychache Scale, and the three-dimensional Psychological Pain Scale (TDPPS). A structured clinical interview was conducted to assess the history of suicidal acts. Significant correlations were found among BDI, BSI, and TDPPS scores (p < .01). Stepwise regression analyses showed that only pain avoidance scores significantly predicted suicide ideation at one's worst point (β = .79, p < .001) and suicidal acts (β = .46, p < .001). Pain avoidance was also a better predictor of current suicidal ideation (β = .37, p = .001) than were BDI scores (β = .31, p < .01). Increased levels of pain avoidance during a major depressive episode may be a dominant component of the motivation for suicide. Future clinical assessments for populations at high risk of suicide should include measures of psychological pain to reduce the incidence of suicide.
Suicidal behavior constitutes a major public health problem with huge personal costs and poses a major challenge to health psychologists, clinical psychologists, and psychiatrists due to its limited predictability. A significant demand for research on suicide is evident, for example, in China, where the annual national rate of suicide was estimated to be 23/100,000 in 2007 (Lee et al., 2007), which is 2.3 times greater than the global average. Suicide has become the leading cause of death among young people between 15 and 34 years old in China (Phillips, Li, & Zhang, 2002).
Several competing models of suicide have been proposed, such as escape from the self (Baumeister, 1990), hopelessness (Beck, Brown, & Steer, 1989), and stress-diathesis (Mann, Waternaux, Haas, & Malone, 1999). However, growing evidence suggests that psychological pain plays a central role in suicidal behavior (DeLisle & Holden, 2004; Holden, Mehta, Cunningham, & McLeod, 2001; Reisch et al., 2010). Psychological pain, or psychache, has been defined as “the introspective experience of negative emotions such as dread, despair, fear, grief, shame, guilt, frustrated love, loneliness and loss” (Shneidman, 1996), and is a common theme in suicide notes. After reviewing a large number of such notes, Shneidman (1993) first proposed that suicide would not occur without psychological pain. For a suicidal person, suicide seems to be the only means of escaping the torment of psychological pain. Thus, individuals with greater propensities for suffering associated with psychological pain may be at greater risk of suicidality (Olie, Guillaume, Jaussent, Courtet, & Jollant, 2010). Accumulated research has provided support for the significantly greater predictive effects of psychological pain in comparison with depression on suicidal ideation and suicide attempts in several populations, such as college students (Troister & Holden, 2010), criminal offenders (Mills, Green, & Reddon, 2005), and homeless people (Patterson, 2010).
Psychological pain is a complex and introspective emotional state that may represent a multidimensional construct with regard to suicide. Scherer's (2005) component process model involves five crucial elements of emotion: cognitive appraisal, bodily symptoms, expression, feelings, and action tendencies. Action tendencies are motivational components in the preparation and direction of behavioral responses, and cognitive appraisal enables the evaluation of events and objects. The emotional component process model provides a cue for that action tendency, the key feature of emotional state, which contributed more than other components to behavior response. However, a literature search revealed that most existing instruments designed to assess psychological pain have focused mainly on the intensity of painful feelings and bodily symptoms (Shneidman, 1999; Holden et al., 2001; Orbach, Mikulincer, Sirota, & Gilboa-Schechtman, 2003; Olie et al., 2010). The 14-item Reasons for Attempting Suicide Questionnaire (RASQ; Holden & McLeod, 2000) is used to measure suicidal motivation, including internal perturbation-based reasons, manipulative motivations, and extrapunative motivations. Sufficient psychometric properties of the RASQ have been obtained in a sample of the nonclinical population, with a very instructive conclusion: All three subscale scores differed significantly between suicidal attempters and nonattempters, suggesting that self-destructive motivations were associated with susceptibility to suicidal acts. Among those, the internal perturbation-based reasons subscale measures general internal states rather than specific psychological pain states, typified by phrases such as “Escape for a while from an impossible situation” and “To get relief from a terrible state of mind.” Additionally, the newly-developed 10-item Mee-Bunney Psychological Pain Assessment Scale(MBPPAS) is particularly suitable for clinical use and its psychometric indexes are well-established (Mee et al., 2011). Although one item of the MBPPAS encompasses death as the only way to stop painful feelings, this pilot study did not show particular analyses on the predictive effects of this item for suicidal behavior.
Given that psychological pain leading to a suicide attempt can be readily triggered by several factors, such as loss, social exclusion, and introspective experience of one's physiological defects, we agree with Shneidman (1993) that the precise assessment of this psychological state, rather than depression, should predominate in studies of suicide. Pain avoidance, representing the wish to escape psychological pain, may also be a primary predictor of subsequent suicide, and pain arousal may reflect the cognitive component of psychological pain. We previously developed a three-dimensional Psychological Pain Scale (TDPPS) to assess pain arousal, painful feelings, and pain avoidance and demonstrated that total TDPPS scores were superior to measures of depression for the prediction of suicidal ideation at an individual's worst point. In contrast, however, depression contributed more than TDPPS dimensions to current suicidal ideation in a large sample (N = 1,185) of college students (Fu, Li, & Yin, in press).
Interpretations presented in the existing literature have been limited by several factors. First, the examination of nonsuicidal subjects, such as college students, provides insufficient power to determine the efficacy of psychological pain measures for suicide prediction because the trends of psychological pain and suicide are not continuous in such low-risk populations. Second, most suicide prediction studies have based the identification of suicidal ideation and psychological pain on clinical samples of self-reported data. This approach ignores common methodological biases that may have affected the results.
Research on suicide should target individuals with major depressive disorder. A 25-year follow-up study found that 15/100 patients with major depressive disorder ultimately committed suicide (Blair-West, Mellsop, & Eyeson-Annan, 1997). Up to 86% of individuals who committed suicide were experiencing episodes of major depression at the time (Coryell & Young, 2005). Within this context, the present study was conducted to further investigate the role of psychological pain, measured by the TDPPS, in suicidal ideation and suicidal acts among patients with major depressive episodes. The research questions addressed in the present study were as follows: whether patients with major depressive episodes would score higher on measures of suicide and the three dimensions of psychological pain; and whether the predictive effect of pain avoidance for suicidality would be significantly greater than those of pain arousal, painful feelings, psychache, and depression. Self-reported measures were used to evaluate psychological pain and suicidal ideation, and structured clinical interviews were conducted to assess suicidal acts.
This study was conducted from March to December 2012 as part of a research program undertaken at the Department of Psychology, Renmin University of China. Outpatients with major depressive episodes (N = 111) were recruited from the Sixth Hospital of Peking University and the Medical Institute of Psychology, Second Xiangya Hospital, Central South University. All participants received monetary compensation. The protocol for this study was approved by the international review board of Peking University. Prior to the beginning of the study, participants were informed that the purpose of the research was to examine mental health states associated with depression and suicide and assured that their anonymity and privacy would be fully protected. All participants provided informed consent.
All recruited outpatients were diagnosed with major depressive episodes and mood disorders by senior psychiatrists according to the criteria of the Diagnostic and Statistical Manual of Mental Disorders IV. Patients with mixed episodes, manic episodes, and schizophrenia were excluded.
About one-quarter (n = 28, 25.23%) of participants had suicidal attempt histories. Eight (28.57%) of these patients were male and 20 (71.43%) were female, with ages ranging from 14 to 64 (M = 28.93, SD = 9.37) years. Thirty-three (39.76%) of the 83 participants with no suicidal attempt history were male and 50 (60.24%) were female, with ages ranging from 17 to 57 (M = 33.99, SD = 12.63) years. A chi-squared test revealed no significant difference between patients with and without suicidal attempt histories in terms of gender, medication, diagnosis, and marital status. Quantitative variables between these two groups were compared using an independent samples t test, and the difference was marginally significant for age (p = .054). The demographic and clinical characteristics of patients included in the study are presented in Table 1.
|Characteristic||With suicidal history (n = 28)||No suicidal history (n = 83)||t/χ2||p|
|Male||8 (28.57%)||33 (39.76%)|
|Female||20 (71.43%)||50 (60.24%)|
|Age (years)||28.93 (12.37)||33.99 (12.63)||−1.95||.054|
|Years of education||14.86 (2.46)||13.78 (3.07)||1.68||.096|
|Married||10 (35.71%)||46 (55.42%)|
|Single||17 (60.71%)||34 (40.96%)|
|Divorced||1 (3.57%)||3 (3.61%)|
|Unipolar (onset)||9 (32.14%)||23 (27.71%)|
|Unipolar (relapse)||16 (60.14%)||50 (60.24%)|
|Bipolar (onset)||1 (3.57%)||1 (1.20%)|
|Bipolar (relapse)||0||3 (3.61%)|
|Missing||2 (7.14%)||6 (7.22%)|
|Yes||14 (50.00%)||47 (56.63%)|
|No||14 (50.00%)||36 (43.37%)|
Data were collected through self-reported questionnaires and structured interviews. It took about 25 to 35 minutes to complete the questionnaires. Most participants completed the TDPPS without difficulty in less than 10 minutes. An experienced psychiatrist conducted a structured clinical interview with each patient to obtain information about the planning, method, and frequency of attempted suicide.
The 17-item TDPPS contains three subscales: pain arousal, painful feelings, and pain avoidance. The three subscale scores were composite scores made up of current and worst pain in the past time. The pain arousal subscale included five items that measure pain derived from the memory of past traumatic experiences, such as bereavement, failure/frustration, or social exclusion, typified by phrases such as “Whenever I think of my serious shortcomings, I feel a great deal of pain” and “My experience was very unfortunate, which makes me feel a great deal of pain.” The painful feelings subscale contains nine items measuring subjective feelings and bodily symptoms, typified by phrases such as “The pain feels like my heart crunched up” and “When feeling down, the psychological pain that I felt was more severe and horrible than usual.” Our working definition of pain avoidance is “a strong motivation or action tendency to commit suicide as the only means of pain-relieving.” The pain avoidance subscale included three items that measure the intensity of suicide as a means of escaping from unbearable psychological pain, typified by phrases such as “For me, suicide is relief, because my pain, the psychological pain, would stop,” “My pain hurts so badly that death could be the only way to escape from it,” and “I almost killed myself to make the pain go away.” Responses to each item are structured by a scale ranging from 1 (not at all) to 5 (extremely). We previously demonstrated the reliability and validity of the TDPPS using a large sample (N = 1,185) of college students (Cronbach's α = .80–.91). In exploratory factor analysis, three factors explained 55.55% of variance among scores. Confirmatory factor analysis showed that the standard measurement model fit the data well [χ2 (116) = 454.93, normed fit index = 0.90, non-normed fit index = 0.96, comparative fit index = 0.97, goodness of fit = 0.90, root mean square error of approximation = 0.079; Fu, Li, & Yin, in press]. The internal consistency coefficients for the TDPPS (Cronbach's α = .88) and the three subscales (Pain arousal: Cronbach's α = .68; Painful feelings: Cronbach's α = .84; Pain avoidance: Cronbach's α = .89) were sufficient in the current sample.
The Beck Depression Inventory I (BDI-I; Beck & Steer, 1993) is a 21-item self-report scale to measure the severity of depression. Each item is rated using a 4-point Likert scale (0 = not at all to 3 = extremely) to reflect the severity of a particular depression symptom during the past week. The BDI-I has excellent psychometric properties (Beck, 1988).The BDI-IChinese version (BDI-I-CV) has been validated and widely used in Chinese populations (Zhang, Wang, & Qian, 1990). Internal consistency for the BDI-I-CV was excellent (Cronbach's α = .89) in the current sample.
The Beck Scale for Suicide Ideation (BSI; Beck & Steer, 1991) is a self-report instrument designed to measure the severity of the current wishes and plans to commit suicide. The BSI included two subscales: suicidal ideation at one's worst point and current suicidal ideation. The subjects were required to read 19 groups of statements and provide a response for the two statements in each group that best describes how he or she has been feeling for the past week and most severe past time. Each statement is ranked on a 3-point scale that ranges from 0 (not at all) to 2 (extremely). The Chinese version of BSI (BSI-CV) demonstrated high internal consistency and good test–retest reliability over an interval of 2 weeks in a sample of Chinese adults (Li et al., 2010). The internal consistency coefficients for the two subscales (Current suicidal ideation: Cronbach's α = .90; Suicidal ideation at one's worst point: Cronbach's α = .95) are excellent in the current sample.
The Psychache Scale (PAS; Holden et al., 2001) has been widely used to measure the severity of subjective feelings and bodily symptoms of psychological pain. The PAS consists of 13 items and each item is calibrated with scores ranging from 1 (strongly disagree) to 5 (strongly agree). Psychometric properties of the PAS have been demonstrated in previous studies (DeLisle & Holden, 2004; Mills et al., 2005; Patterson, 2010). An alpha coefficient of .88 for the current sample was obtained.
A structured clinical interview was conducted to assess suicidal acts that include some degree of seriousness and/or lethality. Suicidal acts were gathered only in the context of the current and most severe past depressive episodes. First, the subjects provided a “yes” (score = 1) or “no” (score = 0) response to a question about whether he or she had committed a suicidal act during the past time. The crucial elements in previous suicidal acts are: (1) self-initiated, (2) intention to die or stop living, and (3) nonhabitual behavior (DeLeo, Burgis1, Bertolote, Kerkhof, & Bille-Brahe, 2006). Second, where subjects selected the “Yes” response, they were asked to describe the plan, methods, and frequency of previous suicidal acts.
Statistical analyses were performed using SPSS software (version 17.0 for Windows; SPSS Inc., Chicago, IL, USA). Descriptive analyses of all variables were performed. Data from patients with and without suicide attempt histories were compared using the independent samples t test and chi-squared test. Pearson's correlation coefficients were used to assess the strengths of linear relationships between pairs of variables of interest. To further examine associations between variables of interest and suicide, stepwise regression analyses were conducted to determine the predictive power of TDPPS total and subscale scores, BDI-I-CV scores, and PAS scores for suicidal ideation and suicidal acts. The level of significance was set to p ≤ .05.
Intergroup Differences in Questionnaire Scores
Questionnaire scores and interview results are presented in Table 2. Suicidal ideation at one's worst point (t = −5.70, p < .001), current suicidal ideation (t = −3.43, p = .001), total TDPPS scores (t = −3.27, p = .001), and pain avoidance subscale scores (t = −4.97, p < .001) were significantly higher in the suicidal act group than in the group with no suicidal history. PAS and painful feelings subscale scores differed significantly between groups (both p < .05), and pain arousal subscale scores showed a marginally significant difference. BDI-I-CV scores did not differ significantly between groups. According to Cohen's (1992) effect size guidelines, pain avoidance had a large effect (Hedges' g = 0.98), and the effects of other variables that differed significantly between groups were moderate (Hedges' g = 0.37–0.64).
|No suicidal history||Suicidal history||Effect sizea||t (109)||p|
|Suicidal ideation at one's worst point (BSI-CV)||13.75 (12.55)||30.04 (14.53)||1.12||−5.70||<.001|
|Current suicidal ideation (BSI-CV)||8.75 (11.90)||18.71 (16.84)||0.68||−3.43||.001|
|BDI-I-CV||24.41 (11.00)||28.93 (11.51)||0.37||−1.86||.066|
|PAS||38.46 (11.62)||44.61 (11.56)||0.48||−2.43||.017|
|TDPPS total||53.01 (12.60)||61.89 (11.84)||0.64||−3.27||.001|
|Pain arousal||23.88 (6.02)||26.39 (5.69)||0.38||−1.94||.055|
|Painful feelings||22.33 (5.30)||24.75 (4.39)||0.43||−2.18||.031|
|Pain avoidance||6.81 (3.52)||10.75 (3.96)||0.98||−4.97||<.001|
In addition, the distribution of pain avoidance score within each group (percentage) was plotted in Figure 1. The overlap of scores between suicidal and no suicidal patients for pain avoidance ranges from 3 to 15. Under half (46.43%) of the participants with suicidal attempt history (n = 13) had a higher score in the range of 13–15, while 55.42% of those without suicidal attempt history (n = 46) had a lower score in the range of 3–6.
Relationships among Depression, Suicide, and Psychological Pain
Total TDPPS scores were positively correlated with suicidal ideation at one's worst point (r = .55, p < .001), current suicidal ideation (r = .40, p < .001), and suicidal acts (r = .30, p < .01; Table 3). Nearly, all TDPPS subscale scores were positively correlated with suicidal ideation scores at the p < .001 level, whereas only pain avoidance scores were correlated with suicidal acts scores (r = .43, p < .001).
|1. Suicidal acts (clinical interview)||.25||.44|
|2. Suicidal ideation at one's worst point (BSI-CV)||.48***||18.35||14.72|
|3. Current suicidal ideation (BSI-CV)||.31**||.80***||11.57||14.00|
|4. BDI-I-CV score||.18||.40***||.43***||25.55||11.25|
|5. PAS score||.23*||.44***||.30**||.73***||40.01||11.86|
|6. Total TDPPS score||.30**||.55***||.40***||.66***||.78***||55.25||12.95|
|7. Pain arousal||.18||.42***||.35***||.60***||.66***||.89***||24.51||6.01|
|8. Painful feelings||.20*||.33***||.20*||.50***||.71***||.86***||.61***||22.94||5.18|
|9. Pain avoidance||.43***||.72***||.50***||.58***||.61***||.80***||.57***||.56***||7.80||4.00|
PAS scores were correlated with current suicidal ideation (r = .30, p < .01), suicidal ideation at one's worst point (r = .44, p < .001), and suicidal acts (r = .23, p < .05) scores. BDI-I-CV scores were positively correlated with suicidal ideation at one's worst point (r = .40, p < .001) and current suicidal ideation (r = .43, p < .001) scores, but were not correlated with suicidal acts scores.
In stepwise regression analyses, pain avoidance was the only significant predictor of suicidal ideation at one's worst point (β = .71, p < .001) and of suicidal acts (β = .43, p < .001). Pain avoidance also showed a greater ability to predict current suicidal ideation (β = .38, p < .001) than did BDI-I-IV scores (β = .22, p < .05).
Using data from a sample of outpatients with major depressive episodes, the present study examined the roles of three dimensions of psychological pain in the risk of suicide. This study is the first to quantitatively examine the role of pain avoidance. The results indicate that levels of psychological pain, including components related to pain avoidance, were much higher in patients with suicidal histories than in those with no such history. Pain avoidance contributed to suicidal acts and suicidal ideation more than did depression, psychache, painful feelings, or pain arousal. These findings confirm the hypothesis that a greater tendency for pain avoidance during a major depressive episode would be a strong predictor of suicidal acts and suicidal ideation.
Shneidman (1993) considered psychache, or psychological pain, to be a least common denominator for all suicides. Several competing measures, including the PAS (Holden et al., 2001), Psychological Pain Assessment Scale (Shneidman, 1999), Orbach & Mikulincer Mental Pain Scale (Orbach et al., 2003), Visual Analog Scale (Olie et al., 2010), and Mee-Bunney Psychological Pain Assessment Scale (Mee et al., 2011), have been developed to quantitatively measure the intensity of psychological pain. Although these measures have been validated in samples of healthy subjects and patients with depression, they fail to assess important components such as cognitive appraisal and a strong motivation to escape from “unbearable” psychological pain; this omission may have weakened the predictive power of psychological pain measures for suicidal behavior.
Our results confirm and expand previous findings that the three dimensions of psychological pain measured by the TDPPS play prominent roles in suicidal acts and suicidal ideation. We found that the TDPPS, which can be easily used in clinical practice, showed greater sensitivity values than the PAS or BDI-I-CV in the measurement of psychological pain and prediction of suicide. The painful feelings subscale and PAS were least able to discriminate differences between individuals with and without suicidal histories, indicating that sustained psychological pain is a hallmark feature of suicidal people with depressive episodes. The marginally significant difference in pain arousal scores observed between groups may be interpreted as indicating that cognitive processing of traumatic events resulted in significant subjective (i.e., psychological pain) and behavioral (i.e., suicide) arousal. Moreover, the BDI, the most widely used measure of depression, is not sufficiently sensitive to distinguish between individuals with and without suicidal histories. Regarding the effect of negative mood and emotion on pain (Wiech & Tracey, 2009), our results support previous findings that psychological pain mediates the relationship between depression, a well-documented risk factor, and suicidality (DeLisle & Holden, 2004; Holden & Kroner, 2003), particularly through the presence of pain avoidance.
Regression analyses indicated that pain avoidance was the strongest predictor of all suicidal criteria, including suicidal acts, suicidal ideation at one's worst point, and current suicidal ideation. This finding has three important implications for the three-dimensional psychological pain model of suicidality. First, individuals who reported high levels of pain avoidance were much more likely to have histories of at least one previous suicidal act. Second, depression and psychological pain measured by the PAS were relatively poor predictors of suicidal acts and suicidal ideation at one's worst point. Third, even for current suicidal ideation, pain avoidance showed more predictive power than depression.
The observed effects of pain avoidance on suicide have clear clinical relevance. Comparing the healthy controls, suicidal attempters appear to have a specific impairment in decision making; that is, their tendency to make immediate but disadvantageous choices (Jollant et al., 2005), suggesting that the decision-making impairment was associated with susceptibility to suicidal acts. Further, suicidal attempters showed an impaired regulation of valuation processing, such as attribution of undue importance to signals of rejection and disapproval in others, in contrast to the attribution of insufficient value to risky choices (Jollant et al., 2010). Thus, the association between psychological pain and suicidal acts seems to be partially accounted for by these specific impairments among suicidal attempters. On the one hand, rejection sensitivity (i.e., overreact to social rejection) resulted in individual's significant pain arousal and painful feelings. On the other hand, individuals with a strong motivation to pain avoidance tend to make an immediate but risky choice (i.e., suicide) to relieve pain as soon as possible.
Cognitive inflexibility related to depression could partially account for strong associations between pain avoidance and suicidal acts during a major depressive episode. Researchers have consistently found that cognitive inflexibility may confer a significant risk of suicide (Brent & Mann, 2006; Orbach, Rosenheim, & Hary, 1987), and that cognitive flexibility returns and negative thinking decreases as depression remits (Weishaar, 1996). Cognitive rigidity prevents an individual from developing flexible capabilities to cope with difficulties or to reduce rumination, overgeneralization, and self-critical evaluation. However, we have not measured cognitive inflexibility among participants in the present study. To test the hypothesis that specific patterns of cognitive deficit lead depressive individuals to consider suicide as the only means of escaping extreme psychological pain, it is important to examine in future studies if the pain avoidance contribution to a suicidal act is partially mediated through cognitive inflexibility.
Several limitations of the present study should be noted. All participants were outpatients with at least one previous major depressive episode, but analyses did not control for medication status. The correlative study design prevented the assessment of causal relationships among depression, psychological pain, and suicide. Further longitudinal research including concurrent individual interviews is needed to more fully understand the cognitive process of psychological pain with respect to suicide among depressive patients. Future studies should also seek to specify goal-directed paradigms to investigate neural correlations of pain avoidance among individuals who have attempted suicide using event-related potentials and functional magnetic resonance imaging. Additionally, because this sample consisted of patients with major depressive disorders, caution should be used when generalizing the current findings to individuals with other nonaffective psychotic disorders, including schizophrenia, posttraumatic mental disorder, and personality disorder.
- 1990). Suicide as escape from self. Psychological Review, 97, 90–113. (
- 1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, 77–100. (
- 1989). Prediction of eventual suicide in psychiatric inpatients by clinical ratings of hopelessness. Journal of Consulting and Clinical Psychology, 57, 309–310. , , & (
- 1991). Manual for Beck Scale for Suicide Ideation. San Antonio, TX: Psychological Corporation. , & (
- 1993). Beck Depression Inventory manual. San Antonio, TX: Psychological Corporation. , & (
- 1997). Down-rating lifetime suicide risk in major depression. Acta Psychiatrica Scandinavica, 95, 259–263. , , & (
- 2006). Familial pathways to suicidal behavior — Understanding and preventing suicide among adolescents. New England Journal of Medicine, 355, 2719–2721. , & (
- 1992). A power primer. Psychological Bulletin, 112, 155–159. (
- 2005). Clinical predictors of suicide in primary major depressive disorder. Journal of Clinical Psychiatry, 66, 412–417. , & (
- 2006). Definitions of suicidal behavior. Crisis, 27, 4–15 , , , , & (
- 2004). Depression, hopelessness, and psychache as increasingly specific predictors of suicidal manifestations. Canadian Clinical Psychologist, 15, 7–10. , & (
- Relationship between psychological pain and suicidal ideation: Development and validation of the Three-Dimensional Psychological Pain Scale in a Chinese college student sample. Psychological Reports. , , & (in press).
- 2003). Differentiating suicidal motivations and manifestations in a forensic sample. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement, 35, 35–44. , & (
- 2000). The structure of the Reasons for Attempting Suicide Questionnaire (RASQ) in a nonclinical adult population. Personality and Individual Differences, 29, 621–628. , & (
- 2001). Development and preliminary validation of a scale of psychache. Canadian Journal of Behavioural Science/Revue canadienne des sciences du comportement, 33, 224–232. , , , & (
- et al. (2005). Impaired decision making in suicide attempters. American Journal of Psychiatry, 162, 304–310. , , , , , ,
- et al. (2010). Decreased activation of lateral orbitofrontal cortex during risky choices under uncertainty is associated with disadvantageous decision-making and suicidal behavior. Neuroimage, 51, 1275–1281. , , , , , ,
- et al. (2007). Lifetime prevalence of suicide ideation, plan, and attempt in metropolitan China. Acta Psychiatrica Scandinavica, 116, 429–437. , , , , , ,
- et al. (2010). [Reliability and validity of the Chinese version of Beck Suicide Ideation Scale (BSI -CV) in adult community residents] (in Chinese). Chinese Mental Health Journal, 24, 250–255 , , , , , ,
- 1999). Toward a clinical model of suicidal behavior in psychiatric patients. American Journal of Psychiatry, 156, 181–189. , , , & (
- 2011). Assessment of psychological pain in major depressive episodes. Journal of Psychiatric Research, 45, 1504–1510. , , , , , & (
- 2005). An evaluation of the Psychache Scale on an offender population. Suicide and Life-Threatening Behavior, 35, 570–580. , , & (
- 2010). Higher psychological pain during a major depressive episode may be a factor of vulnerability to suicidal ideation and act. Journal of Affective Disorders, 120, 226–230. , , , , & (
- 2003). Mental pain: A multidimensional operationalization and definition. Suicide and Life-Threatening Behavior, 33, 219–230. , , , & (
- 1987). Some aspects of cognitive functioning in suicidal children. Journal of the American Academy of Child and Adolescent Psychiatry, 26, 181–185. , , & (
- 2010). Psychache and self-harming behaviour among men who are homeless: A test of Shneidman's model. Master of Science, Queen's University, Kingston, Ontario, Canada. (
- 2002). Suicide rates in China, 1995-99. Lancet, 359, 835–840. , , & (
- 2010). An fMRI study on mental pain and suicidal behavior. Journal of Affective Disorders, 126, 321–325. , , , , , & (
- 2005). What are emotions? And how can they be measured? Social Science Information, 44, 695–729. (
- 1993). Suicide as psychache. Journal of Nervous and Mental Disease, 181, 145–147. (
- 1996). The suicidal mind. New York: Oxford University Press. (
- 1999). The psychological pain assessment scale. Suicide and Life-Threatening Behavior, 29, 287–294. (
- 2010). Comparing psychache, depression, and hopelessness in their associations with suicidality: A test of Shneidman's theory of suicide. Personality and Individual Differences, 49, 689–693. , & (
- 1996). Cognitive risk factors in suicide. Frontiers of Cognitive Therapy, 226–249. (
- 2009). The influence of negative emotions on pain: Behavioral effects and neural mechanisms. NeuroImage, 47, 987–994. , & (
- 1990). [Reliability and validity of Beck Depression Inventory (BDI) examined in chinese samples] (in Chinese). Chinese Mental Health Journal, 4, 164–192. , , & (