The Relationship Between Mental Pain, Suicide Risk, and Childhood Traumatic Experiences: Results From a Multicenter Study

J Clin Psychiatry 2022;83(4):21m14176

To cite: Pompili M, Erbuto D, Innamorati M, et al. The relationship between mental pain, suicide, and childhood traumatic experiences: results from a multicenter study. J Clin Psychiatry. 2022;83(4):21m14176.
To share: https://doi.org/10.4088/JCP.21m14176

© Copyright 2022 Physicians Postgraduate Press, Inc.

^aDepartment of Neurosciences, Mental Health, and Sensory Organs, Faculty of Medicine and Psychology, Suicide Prevention Centre, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
^bDepartment of Human Sciences, European University of Rome, Rome, Italy
^cDepartment of Psychiatry, University of Campania “L. Vanvitelli,” Naples, Italy
^dEating Disorders Center, Department of Neuroscience, University of Turin, Turin, Italy
^eDepartment of Clinical and Experimental Sciences, University of Brescia and Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy
^fDepartment of Clinical and Experimental Medicine, Psychiatric Clinic, Azienda Ospedaliero-Universitaria Pisana, University of Pisa, Pisa, Italy
^gPsychiatry Unit, Department of Health Sciences, University of Florence, Florence, Italy
^hPsychiatric Unit, Department of Health Sciences, University Magna Graecia, Catanzaro, Italy
ⁱDepartment of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
^jDepartment of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Rome, Italy
^kDepartment of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
^lDepartment of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
^mDepartment of Translational Medicine, Università del Piemonte Orientale, Novara, Italy; Psychiatry Division, Azienda Ospedaliero Universitaria Maggiore della Carità, Novara, Italy
ⁿDepartment of Neuroscience and Rehabilitation, Institute of Psychiatry, University of Ferrara, Ferrara, Italy
^oDepartment of Human Neurosciences, Sapienza University of Rome, Rome, Italy
^pSection of Psychiatry, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
^qDepartment of Medicine and Surgery, Division of Psychiatry, University of Insubria, Varese, Italy
^rDepartment of Neuroscience, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health, Psychiatry Section, University of Genoa, IRCCS San Martino, Genoa, Italy
^sDepartment of Clinical and Experimental Medicine, AOU Policlinico Hospital, University of Catania, Catania, Italy
^tDepartment of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
^uUnit of Clinical Psychiatry, Department of Neurosciences/DIMSC, School of Medicine and Surgery, Polytechnic University of Marche, Ancona, Italy
*Corresponding author: Maurizio Pompili, MD, PhD, Department of Psychiatry Sant’Andrea Hospital, Sapienza University of Rome, Via di Grottarossa 1035 00189, Rome, Italy (maurizio.pompili@uniroma1.it).

Seminal papers pointed to mental pain (“psychache”) as an explanatory construct of the phenomenology of suicide.¹ According to Shneidman’s model, suicide is an escape from intolerable suffering, which leads to “perturbation of the mind,” referring to how upset (disturbed, agitated, discomposed) the individual is and the state in which suicide is likely to occur.¹ In a meta-analysis, Ducasse et al² reported that mental pain was higher in suicide attempters than nonattempters and in suicide ideators than nonideators.^3,4

Intense mental pain could be a consequence of negative childhood experiences and maltreatment and could be a significant risk factor for several psychiatric disorders.^5–13 Childhood maltreatment is also considered a significant risk factor for impulsive/aggressive behaviors and suicidal behavior.^14–19

Our study aimed to investigate whether mental pain could be a predictor of recent suicide attempts in psychiatric patients and whether it could be associated with childhood traumatic experiences. Specifically, the present study explored to what extent mental pain constitutes a contributor to suicide risk independently of psychiatric diagnoses when recent suicidal attempters versus nonsuicidal individuals are compared, as well as whether childhood traumatic experiences contribute to suicide risk, and whether mental pain mediates this relationship. We hypothesized that those who had recently attempted suicide would have higher levels of mental pain and that childhood adversities would characterize suicidal patients compared to nonsuicidal patients. We also hypothesized that those who had had more severe childhood traumatic experiences would have higher mental pain levels and, in turn, could be at higher risk of suicide.

METHODS

Study Design

A multicenter observational study was organized as a joint project with representatives of numerous mixed Italian academic and clinical settings (represented by the authors’ affiliations). Investigators were trained to use the instruments involved in the study and had constant contact with the coordinating center. The project was first submitted to the Internal Review Board of Sant’Andrea Hospital (RIF.CE: 4646_2017) as part of the Sapienza University of Rome, which was the study coordinator. The protocol was then submitted to the internal review boards of the participating centers by local investigators.

The study was conducted ethically in accordance with the World Medical Association Declaration of Helsinki. Patients participated voluntarily and provided written informed consent following review and approval of each participating center’s research ethics review board.

Inclusion and Exclusion Criteria

Investigators were asked to recruit patients with psychiatric disorders, either inpatients or outpatients, and provide a sample of both suicide attempters and controls. It was agreed that each center, based on preliminary calculations and in-depth discussion, would set the enrollment of patients at 150 consecutive participants: on average, 75 with a recent suicide attempt and 75 nonsuicidal patients. For a proper definition of suicide attempt, we referred to Silverman et al,^20,21 in which type II suicide attempts are described as self-destructive acts with some degree of intent to end one’s life and some identifiable injuries. Suicide attempts were considered recent when they had occurred in the past 3 months, in accordance with the Columbia-Suicide Severity Rating Scale assessment, as this was the main instrument used for this purpose.

Patients were assessed for psychiatric diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)²² criteria, and these diagnoses were confirmed by the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), via psychiatric interviews and the administration of psychometric instruments. The inclusion criterion was to be between 18 and 65 years of age (subjects over 65 were included only if physically fit, that is, they lacked medical comorbidities that reduced quality of life, caused impairments, etc). Exclusion criteria were being unwilling to participate or denial of informed consent and having neurologic diseases (eg, dementia, Parkinson’s disease, epilepsy, etc), cognitive impairments, and language difficulties.

Patients

Patients were recruited from December 2017 to March 2020. Sociodemographic characteristics of the sample are reported in Table 1. Patients were ensured that data would be reported only anonymously and in aggregate form.

A web-based system with codes and anonymous labels was devised for this study. Each center directly entered all data via a guided digital procedure to minimize data entry errors.

Assessment

The following instruments were administered to patients: the Columbia-Suicide Severity Rating Scale (C-SSRS),²³ the Beck Depression Inventory-2 (BDI-2),²⁴ the Childhood Trauma Questionnaire (CTQ),²⁵ the Orbach & Mikulincer Mental Pain Questionnaire (OMMP),²⁶ and the Physical and Psychological Pain Scale (PPPS).²⁷ An ad hoc schedule was used to collect patients’ sociodemographic (gender, age, marital status, occupational status, school attainment, living accommodation) and clinical (psychiatric diagnosis, comorbidities, mental illness in family members) characteristics. An extensive presentation of the measures administered is reported in the Supplementary Methods.

C-SSRS. A rating scale evaluating suicidal ideation in individuals aged 12 years and older.²³ The C-SSRS rates an individual’s degree of suicidal ideation on a scale from “wish to be dead” to “active suicidal ideation with a specific plan and intent.”

BDI-2. A 21-item self-report instrument evaluating the presence/severity of depressive symptoms during the previous 14 days.²⁴

CTQ. A 28-item self-report questionnaire assessing physical, emotional, and sexual abuse and also emotional and physical neglect.²⁵ We considered a 5-factor model: emotional neglect (EN), emotional abuse (EA), sexual abuse (SA), physical abuse (PA), and physical neglect (PN).

OMMP. A 44-item self-report measure of mental pain (usual mental pain).²⁶

PPPS. A self-administered questionnaire that evaluates the intensity of physical and mental pain²⁷; in the present study, we considered scores on the item assessing the maximum pain experienced in relation to the last 15 days (PPPS worst).

Data Analysis

A series of 1-way Fisher exact tests, χ² tests, and independent sample t tests were used to assess differences between groups at the bivariate level. Bonferroni correction was used for controlling multitesting. Effect sizes were reported using Cohen d coefficient (d = 0.2, small effect size; d = 0.5, medium effect size; d = 0.8, large effect size)²⁸ and phi and Cramer v (v = 0.1, small effect size; phi/v = 0.3, medium effect size; phi/v = 0.5, large effect size).

Variables significant in the bivariate analyses were included as independent variables in 2 log-linear models (in the first one, OMMP mental pain scores were included as a predictor in the analysis; in the second one, PPPS worst mental pain scores were used),^27,29,30 with recent suicide attempter status (suicide attempters vs nonattempters) as a criterion. Due to possible multicollinearity, in the log-linear models we included a composite score derived from the sum score of significant CTQ dimensions at the bivariate analyses (CTQ total score = SA + PA + EA). ORs and 95% confidence intervals (95% CI) were calculated as measures of association. The likelihood ratio χ² test was reported as the measure of fit of the model.

Pearson r coefficient was reported as a measure of association between variables: r < 0.10, negligible or null effect; r = 0.10–0.30, small effect; r = 0.30–0.50, medium effect; r ≥ 0.50, large effect.²⁸ Single mediation analyses were carried out to assess whether mental pain mediated the association between childhood trauma and suicidal status. CTQ total score was included in the model as an independent variable, mental pain (OMMP scores in model 1, and PPPS worst mental pain in model 2) as a single mediator, suicidal status as a dependent variable, and depression severity was included in the model as a covariate. All tests were significant at P < .05.

RESULTS

Characteristics of the Sample

A total of 2,137 psychiatric patients (1,313 women and 824 men) were included in the sample: 658 (410 women and 248 men) had been admitted to inpatient units at that time, and 1,479 (902 women and 576 men) to outpatient units (differences between in- and outpatients are noted in Supplementary Table 1 and Supplementary Results). Of the total sample, 315 patients reported having attempted suicide in the past 3 months, as screened by the C-SSRS in the suicidal behavior section (see Table 1). All of the suicide attempters had attempted suicide at least once before (vs. 27.2% of current nonattempers; P < .001).  Of the total sample, 29.1% of patients had MDD, 14.9% had schizophrenia or other psychotic disorders, 21.2% had bipolar disorder (either type I or II), and 18.2% had an anxiety disorder. In addition, more than 21% of patients had a personality disorder, and 8.2%, a borderline personality disorder. Lastly, 47.7% of patients had scores on the BDI-2 indicating moderate to severe depression.

Factors Associated With Recent Suicide Attempts

Differences between groups after correction for multitesting are reported in Table 1. Suicide attempters (compared to nonattempters) more frequently had MDD (38.4% vs 27.5%; P < .001) and personality disorders (16.2% vs 6.9% and 24.4% vs 11.3%, respectively, for borderline personality disorder and other personality disorders; χ²₂ = 81.15, P < .001), and less frequently had bipolar disorder (14.6% vs 22.3%; P = .001) and anxiety disorders (10.2% vs 19.5%; P < .001). Groups did not differ in the number of diagnoses of schizophrenia or other psychotic disorders (12.7% vs 15.3%; P = .13) or the presence of substance abuse (7.6% vs 9.1%; P = .23).

Around 50% of the attempters reported suicidal intent in the last month (with or without a specific plan) on the C-SSRS compared to only 7.3% of the nonattempters (χ²₅ = 574.82, P < .001). Finally, suicide attempters (compared to nonattempters) reported worse mental pain (OMMP: t_2,129 = 7.37, P < .001; PPPS worst: t_429.03 = 7.16, P < .001) and physical pain (t_399.59 = 4.33, P < .001) and had higher scores on the following CTQ dimensions: SA (t_369.09 = 4.30, P < .001), PA (t_385.84 = 3.41, P = .001) and EA (t_398.50 = 4.62, P < .001). Suicide attempters (compared to nonattempters) also had higher BDI-2 scores (t_2,130 = 8.16, P < .001), and 62.4% had BDI-2 scores indicating moderate to severe depression.

Variables significant in the bivariate analyses were included in 2 alternative log-linear models with recent suicide attempter status as a criterion (in the first one, OMMP usual mental pain was included as a predictor in the analysis; in the second one, PPPS worst pain was used) (Table 2). Both models fit the data well, and slight differences were evident in the significance of the predictors (OMMP: likelihood χ²₃₆₈ = 128.14, P = 1.00; PPPS: likelihood χ²₃₆₈ = 140.72, P = 1.00). Recent suicide attempters (compared to nonattempters) had higher odds of reporting worse mental pain (OMMP: OR = 1.02; P < .001; PPPS worst: OR = 1.17; P < .001) and suicidal intent with/without a specific plan (OR = 11.77/11.57; P < .001) but not physical pain (OR = 1.01; P = .49/.57). Suicide attempters (compared to nonattempters) also had higher odds of having a borderline personality disorder (OR = 3.01/2.65; P < .001), other personality disorders (OR = 2.28/1.96; P < .001/.01), and MDD (OR = 1.70/1.62; P < .01/.05). Other diagnoses were not significantly associated with suicide status. The association between suicide status and the CTQ total score was significant only when the PPPS, and not OMMP scores, was included in the model (OR = 1.00/1.02, P = .70/< .05). Depression severity was not significantly associated with suicide status (OR = 0.97/1.12, P = .92/.69). Finally, recent suicide attempters (compared to nonattempters) had higher odds of having lower school attainment (≤ 8 years of schooling: OR = 1.61/1.56; P = .01) and lower odds of living with family members, friends, or other accommodation, eg, rehabilitation centers (OR = 0.41/0.43; P < .001). Thus, recent suicide attempters reported more severe mental pain. This result supports Shneidman’s hypothesis, which considers mental pain to be a major ingredient of suicide.¹

Associations Between Mental Pain, Depression Severity, and Childhood Trauma

The associations between mental pain and other variables are reported in Table 3. Mental pain was strongly associated with depression (r between 0.61 and 0.80; P < .001) and moderately related to physical pain (r between 0.34 and 0.41; P < .001). Associations between mental pain and childhood trauma ranged from negligible (r < 0.10) to weak (r < 0.30). Mental pain was also significantly and weakly associated with the number of lifetime suicide attempts (OMMP: r = 0.26, P < .001; PPPS worst: r = 0.21, P < .001). Single mediation analysis indicated that mental pain partly mediated the relationship between childhood trauma and suicide status (OMMP: standardized total indirect [direct] effect = 0.11 [0.07], SE = 0.01 [0.02], P < .001 [< .001]; PPPS worst: standardized total indirect [direct] = 0.12 [0.06], SE = 0.01 [0.02], P < .001 [< .001]) (Figure 1 and Figure 2). Thus, the presence and severity of childhood trauma were associated with higher usual and worst mental pain in the last 15 days. These were associated with increased suicide risk.

DISCUSSION

In line with our hypothesis, we found that suicide attempters reported more intense mental pain (usual and worst mental pain in the last 15 days). These results align with previous reports from Olié et al²⁷ and Caceda et al³¹ and support Shneidman’s hypothesis that mental pain is the main ingredient of suicide and a common denominator in the array of factors faced by individuals in crisis.¹ The mind considering suicide is perturbed by a transient sense of constriction and a narrowing of the options available.¹ Suicide is therefore a way to stop one’s consciousness experiencing intolerable pain.¹

Recent suicide attempters (compared to nonattempters) also had a more severe childhood physical, sexual, and emotional abuse history but not emotional and physical neglect (for this dimension, we have to consider that reliability was insufficient). Moderated mediation models indicated that childhood trauma was directly and indirectly associated with the presence of a recent suicide attempt. Mental pain (usual and worst mental pain in the last 15 days) partly mediated the relationship between childhood trauma and suicide status. In a recent meta-analysis, Zatti et al³² explored cohort studies that reported the presence of suicide attempts during follow-up. They included an assessment of childhood trauma and reported that sexual, physical, and emotional abuse was associated with the presence of suicide attempts, but this was not the case for emotional neglect. Unlike our results, the authors also reported a significant association between the presence of suicide attempts and physical neglect, despite physical neglect being indicated as contributing to suicide attempts more weakly than other childhood adversities. Provided that childhood trauma constitutes an emotional burden, moderated mediation models suggested that such an experience could influence suicide risk both indirectly via mental pain and directly. We can speculate that childhood experience could influence suicide behaviors via pathways other than mental pain in the latter case. In supporting this hypothesis, we must note that mental pain and suicide risk were associated significantly although only moderately. Such results are line with previous research that found that mental pain had a mediating role in the relationship between childhood trauma and suicidal ideation.^5,33,34

Another well-known factor independently associated with a recent suicide attempt is the presence of more severe suicidal ideation. More than 70% of the suicide attempters reported suicidal ideation in the last month, and 41% of them reported suicidal intent with a specific plan. Although there were some contrasting results,^35–37 this is in line with research indicating that a person is at a heightened risk of suicide after discharge from a psychiatric hospital, especially in those who have had a previous recent suicide attempt,³⁸ suggesting that a specific population of psychiatric patients with a heightened chronic risk of suicide could manifest chronic suicidal ideation in a mental state characterized by intolerable psychache.

Major depression was independently associated with suicide attempts in our sample even when controlling for depression severity and mental pain, indicating that patients with major depression were a population at high suicide risk, consistent with previous studies.^39–42 Recent suicide attempters had higher odds of having a borderline personality disorder or other personality disorders.

As a distinct clinical entity from depression, mental pain may embody an extraordinary experience of suffering, for which subjects may not have appropriate words to describe the experience.⁴³ Scholars have argued that the need to assess mental pain in depressive individuals resides in the fact that mental pain overlaps with some of the core depressive symptoms, such as overresponse to negative stimuli, feelings of guilt, painful rumination, or self-devaluation. Furthermore, such experiences could be linked to altered emotional regulation strategies.⁴⁴ A further fact is that mental pain is often associated with suicide risk. Such facts suggest that the experience of mental pain is complex in terms of both mental and pathophysiologic processes, the understanding of which may shed light on new perspectives on patients’ unmet needs.

Our results also indicated that low educational attainment and living alone (vs living with family, friends, or other accommodation, eg, rehabilitation centers) could be predictors of the presence of recent suicide attempts. Educational attainment has been indicated as a strong predictive factor of increased suicide risk in large prospective studies⁴⁵ and in epidemiologic studies.⁴⁶ Also, living alone is generally considered a risk factor for suicide, especially in older adults,^47–50 probably because it can promote depression and a sense of loneliness, limiting access to the social network if social support is needed and especially when facing powerful stress factors.^51,52

Strengths and Limitations of the Study

To our knowledge, this is one of the most extensive investigations into the role of mental pain in explaining the variance in suicide attempts among psychiatric patients and in pointing to the need to investigate the association between mental pain and childhood traumatic experiences. The large number of centers participating in this research may point to heterogeneity of assessment and evaluation procedures through psychometric instruments. Also, patients had several psychiatric diagnoses, making it difficult to characterize single groups. Unfortunately, some centers did not manage to recruit the number of patients set at the beginning of the study (partial samples were not included), thus influencing the heterogeneity and representativeness of the final sample. Finally, the fact that C-SSRS assessed suicidal intent in the past month, whereas recent suicide attempts were considered to be in the past 3 months, could set the two measures at different times.

CONCLUSIONS

Mental pain, which encompasses psychiatric diagnoses, constitutes a crucial framework for assessing an individual’s need for psychiatric help. Unfortunately, standard diagnostic criteria barely address the level of mental distress and do not consider its main features. Undoubtedly, assessing and taking advantage of mental pain in the care of patients (also exploring differences across diagnoses) is a challenge that should be embraced in mental health because it could unlock some of the causes behind suicide risk. Bridging the gap between clinicians and patients in understanding human suffering is an essential step in suicide prevention. Therefore, clinicians should consider a phenomenological approach when dealing with suffering individuals and explore lifetime experiences, which often guide patients’ global understanding.

Submitted: July 21, 2021; accepted December 14, 2021.
Published online: June 15, 2022.
Relevant financial relationships: No author or an immediate family member has financial relationships with commercial organizations that might appear to represent a potential conflict of interest in the material presented here.
Funding/support: No funds were received for this study.
Author contributions: Drs Pompili and Fiorillo prepared the study design, Drs Pompili and Innamorati prepared the first draft of the manuscript, and Dr Innamorati performed the data analyses. All authors contributed substantially to and approved the final version of the article.
Supplementary material: Available at Psychiatrist.com.

Clinical Points

• Previous studies have shown that mental pain and childhood negative experiences and maltreatment are associated with suicide risk.
• In this study, individuals who had attempted suicide in the previous 3 months reported worse mental pain and suicidal ideation and had higher odds of having personality disorders and major depression. Mental pain partly mediated the relationship between childhood trauma and suicide risk.
• Mental pain represents a critical feature in identifying and assessing suicide risk and may shed light on the reasons behind the wish to die. The contribution of childhood adversities requires further investigation.