Psychache

Psychache (pronounced sahyk-eyk)

Psychological pain, especially when it becomes unbearable, producing suicidal thoughts.

1993: The construct was psyche- + ache.  Psychache was coined by US clinical psychologist Dr Edwin Shneidman (1918-2009) and first appeared in his book Suicide as Psychache: A Clinical Approach to Self-Destructive Behavior (1993).  The prefix psych- was an alternative form of psycho-.  Psycho was from the Ancient Greek ψῡχο- (psūkho-), a combining form of ψυχή (psukhḗ) (soul).  Wit was used with words relating to the soul, the mind, or to psychology.  Ache was from the Middle English verb aken & noun ache (noun), from the Old English verb acan (from the Proto-West Germanic akan, from the Proto-Germanic akaną (to ache)) and the noun æċe (from the Proto-West Germanic aki, from the Proto-Germanic akiz), both from the primitive Indo-European heg- (sin, crime).  It was cognate with the Saterland Frisian eeke & ääke (to ache, fester), the Low German aken, achen & äken (to hurt, ache), the German Low German Eek (inflammation), the North Frisian akelig & æklig (terrible, miserable, sharp, intense), the West Frisian aaklik (nasty, horrible, dismal, dreary) and the Dutch akelig (nasty, horrible).  Historically the verb was spelled ake, and the noun ache but the spellings became aligned after Dr Johnson (Samuel Johnson (1709-1784)) published A Dictionary of the English Language (1755), the lexicographer mistakenly assuming it was from the Ancient Greek ἄχος (ákhos) (pain) due to the similarity in form and meaning of the two words.  As a noun, ache meant “a continuous, dull pain (as opposed to a sharp, sudden, or episodic pain) while the verb was used to mean (1) to have or suffer a continuous, dull pain, (2) to feel great sympathy or pity and (3) to yearn or long for someone or something.  Pyscheache is a noun

Psychache is a theoretical construct used by clinical suicidologists and differs from psychomachia (conflict of the soul).  Psychomachia was from the Late Latin psӯchomachia, the title of a poem of a thousand-odd lines (circa 400) by Roman Christian poet Prudentius (Aurelius Prudentius Clemens; 348-circa 412), the construct being the Ancient Greek Greek psukhē (spirit) + makhē (battle).  The fifth century poem Psychomachia (translated usually as “Battle of Spirits” or “Soul War”) explored a theme familiar in Christianity: the eternal battle between virtue & vice (onto which can be mapped “right & wrong”, “good & evil” etc) and culminated in the forces of Christendom vanquishing pagan idolatry to the cheers of a thousand Christian martyrs.  An elegant telling of an allegory familiar in early Christian literature and art, Prudentius made clear the battle was one which happened in the soul of all people and thus one which all needed to wage, the outcome determined by whether the good or evil in them proved stronger.  The poem’s characters include Faith, Hope, Industry, Sobriety, Chastity, Humility & Patience among the good and Pride, Wrath, Paganism, Avarice, Discord, Lust & Indulgence in the ranks of the evil but scholars of literature caution that although the personifications all are women, in Latin, words for abstract concepts use the feminine grammatical gender and there’s nothing to suggest the poet intended us to read this as a tale of bolshie women slugging it out.  Of interest too is the appearance of the number seven, so familiar in the literature and art of Antiquity and the Medieval period as well as the Biblical texts but although Prudentius has seven virtues defeat seven vices, the characters don’t exactly align with either the canonical seven deadly sins, nor the three theological and four cardinal virtues.  In modern use, the linguistic similarity between psychache and psychomachia has made the latter attractive to those seduced by the (not always Germanic) tradition of the “romance of suicide”.

A pioneer in the field of suicidology, Dr Shneidman’s publication record was indicative of his specialization.

Dr Edwin Shneidman (1918-2009) was a clinical psychologist who practiced as a thanatologist (a practitioner in the field of thanatology (the scientific study of death and the practices associated with it, including the study of the needs of the terminally ill and their families); the construct of thanatology being thanato- (from the Ancient Greek θάνατος (thánatos) (death)) +‎ -logy.  The suffix -ology was formed from -o- (as an interconsonantal vowel) +‎ -logy.  The origin in English of the -logy suffix lies with loanwords from the Ancient Greek, usually via Latin and French, where the suffix (-λογία) is an integral part of the word loaned (eg astrology from astrologia) since the sixteenth century.  French picked up -logie from the Latin -logia, from the Ancient Greek -λογία (-logía).  Within Greek, the suffix is an -ία (-ía) abstract from λόγος (lógos) (account, explanation, narrative), and that a verbal noun from λέγω (légō) (I say, speak, converse, tell a story).  In English the suffix became extraordinarily productive, used notably to form names of sciences or disciplines of study, analogous to the names traditionally borrowed from the Latin (eg astrology from astrologia; geology from geologia) and by the late eighteenth century, the practice (despite the disapproval of the pedants) extended to terms with no connection to Greek or Latin such as those building on French or German bases (eg insectology (1766) after the French insectologie; terminology (1801) after the German Terminologie).  Within a few decades of the intrusion of modern languages, combinations emerged using English terms (eg undergroundology (1820); hatology (1837)).  In this evolution, the development may be though similar to the latter-day proliferation of “-isms” (fascism; feminism et al).

Death and the College Student: A Collection of Brief Essays on Death and Suicide by Harvard Youth (1973) by Dr Edwin Shneidman.  Dr Shneidman wrote many papers about the prevalence of suicide among college-age males, a cross-cultural phenomenon.

Dr Shneidman was one of the seminal figures in the discipline of suicidology, in 1968 founding the AAS (American Association of Suicidology) and the principal US journal for suicide studies: Suicide and Life-Threatening Behavior.  The abbreviation AAS is in this context used mostly within the discipline because (1) it is a specialized field and (2) there are literally dozens of uses of “AAS”.  In Suicide as Psychache: A Clinical Approach to Self-Destructive Behavior (1993) he defined psychache as “intense psychological pain—encompassing hurt, anguish, and mental torment”, identifying it as the primary motivation behind suicide, his theory being that when psychological pain becomes unbearable, individuals may perceive suicide as their only escape from torment.

Although since Suicide as Psychache: A Clinical Approach to Self-Destructive Behavior appeared in 1993 there have been four editions of American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), “psychache” has never appeared in the DSM.  That may seem an anomaly given much in the DSM revolves around psychological disturbances but the reason is technical.  What the DSM does is list and codify diagnosable mental disorders (depression, schizophrenia. bipolar disorder et al), classifying symptoms and behaviors into standardized categories for diagnosis and treatment planning.  By contrast, psychache is not a clinical diagnosis; it is a theoretical construct in suicidology which is used to explain the subjective experience of psychological pain that can lead to patients taking their own lives.  It thus describes an emotional state rather than a psychiatric disorder.

Lindsay Lohan and her lawyer in court, Los Angeles, December, 2011.

Despite that, mental health clinicians do actively use the principles of psychache, notably in suicide risk assessment and prevention and models have been developed including a number of “psychache scales”, self-reporting tools used to generate a metric measuring the intensity of psychological pain (categorized with headings such as shame, guilt, despair et al).  The approaches do in detail differ but most follow Dr Shneidman’s terminology in that the critical threshold is the point at which the patient’s pain becomes unbearable or inescapable and the objective is either to increase tolerance for distress or reframe troublesome thoughts.  Ultimately, the purpose of tools is to improve suicide risk assessments and reduce suicide rates.

DSM-5 (2013).

Interestingly, Suicidal Behavior Disorder (SBD) was introduced in Section III of the DSM-5 (2013) under “Conditions for Further Study”.  Then, SBD chiefly was characterized by a self-initiated sequence of behaviors believed at the time of initiation to cause one’s own death and occurring in the last 24 months.  That of course sounds exact but the diagnostic criteria in the DSM are written like that and the purpose of inclusion in the fifth edition was to create a framework so systematically, empirical studies related to SBD could be reviewed so primary research themes and promising directions for future research could be identified.  Duly, over the following decade that framework was explored but the conclusion was reached there seemed to be little utility in the clinical utility of SBD as a device for predicting future suicide and that more research was needed to understand measurement of the diagnosis and its distinctiveness from related disorders and other self-harming behaviors.  The phase “more research is required” must be one of the most frequently heard among researchers.

In the usually manner in which the APA allowed the DSM to evolve, what the DSM-5s tentative inclusion of SBD did was attempt to capture suicidality as a diagnosis rather than a clinical feature requiring attention.  SBD was characterized by a suicide attempt within the last 24 months (Criterion A) and that was defined as “a self-initiated sequence of behaviors by an individual who, at the time of initiation, expected that the set of actions would lead to his or her own death”.  That sounds uncontroversial but what was significant was the act could meet the criteria for non-suicidal self-injury (ie self-injury with the intention to relieve negative feelings or cognitive state in order to achieve a positive mood state (Criterion B) and cannot be applied to suicidal ideation or preparatory acts (Criterion C).  Were the attempt to have occurred during a state of delirium or confusion or solely for political or religious objectives, then SBD is ruled out (Criteria D & E).  SBD (current) is given when the suicide attempt occurred within the last 12 months, and SBD (in early remission), when it has been 12-24 months since the last attempt.  It must be remembered that while a patient’s behavior(s) may overlap across a number of the DSM’s diagnosises, the AMA’s committees have, for didactic purposes, always preferred to “silo” the categories.

DSM-5-TR (2022).

When in 2022 the “text revision” of the DSM-5 (DSM-5-TR) was released, SBD was removed as a condition for further study in Section III and moved to “Other Conditions That May Be a Focus of Clinical Attention” in Section II. The conditions listed in this section are intended to draw to attention of clinicians to the presence and breadth of additional issues routinely encountered in clinical practice and provide a procedure for their systematic documentation.  According to the APA’s editorial committee, the rationale for the exclusion of SBD from the DSM-5-TR was based on concerns the proposed disorder did not meet the criteria for a mental disorder but instead constituted a behavior with diverse causes and while that distinction may escape most of us, within the internal logic of the history of the DSM, that’s wholly consistent.  At this time, despite many lobbying for the adoption of a diagnostic entity for suicidal behavior, the APA’s committees seem still more inclined to conceptualize suicidality as a symptom rather than a disorder and despite discussion in the field of suicidology about whether suicide and related concepts like psychache should be treated as stand-alone mental health issues, that’s a leap which will have to wait, at least until a DSM-6 is published.

How to and how not to: Informatie over Zorgvuldige Levensbeëindiging (Information about the Careful Ending of Life, 2008) by Stichting Wetenschappelijk Onderzoek naar Zorgvuldige Zelfdoding (The Foundation for Scientific Research into Careful Suicide) (left) and How Not to Kill Yourself: A Phenomenology of Suicide (2023) by Clancy Martin (right).

Informatie over Zorgvuldige Levensbeëindiging (Information about the Careful Ending of Life, 2008) was published by a group of Dutch physicians & and researchers; it contained detailed advice on methods of suicide available to the general public, the Foundation for Scientific Research into Careful Suicide arging “a requirement exists within society for responsible information about an independent and dignified ending of life.”  It could be ordered only from the foundation’s website and had the advantage that whatever might be one’s opinion on the matter, it was at least written by physicians and scientists and thus more reliable than some of the “suicide guides” which are sometimes found on-line.  At the time research by the foundation had found that despite legislation in the Netherlands which permit doctors (acting within specific legal limits) to assist patient commit suicide, there were apparently several thousand cases each year of what it termed “autoeuthanasia” in which no medical staff directly were involved.  Most of these cases involved elderly or chronically ill patients who refused food and fluids and it was estimated these deaths happened at about twice the rate of those carried out under the euthanasia laws.  Since then the Dutch laws have been extended to included those who have no serious physical disease or are suffering great pain; there are people who simply no longer wish to live, something like the tragic figure in Blue Öyster Cult’s (Don't Fear) The Reaper (1976) © Donald Roeser (b 1947):

Came the last night of sadness
And it was clear she couldn't go on
Then the door was open and the wind appeared
The candles blew then disappeared
The curtains flew then he appeared
Saying don't be afraid

There is a diverse literature on various aspects of suicide (tips and techniques, theological & philosophical interpretations, cross-cultural attitudes, history of its treatment in church & secular law etc) and some are quite personal, written variously by those who later would kill themselves or those who contemplated or attempted to take their own lives.  In How Not to Kill Yourself: A Phenomenology of Suicide (2023) by Canadian philosopher Clancy Martin (b 1967), it was revealed the most recent of his ten suicide attempts was “…in his basement with a dog leash, the consequences of which he concealed from his wife, family, co-workers, and students, slipping back into his daily life with a hoarse voice, a raw neck and series of vague explanations.”

BKA (the Bundeskriminalamt, the Federal Criminal Police Office of the FRG (Federal Republic of Germany (the old West Germany)) mug shots of the Red Army Faction's Ulrike Meinhof (left) and Gudrun Ensslin (right).

The song (Don't Fear) The Reaper also made mention of William Shakespeare's (1564–1616) Romeo and Juliet (1597) and in taking her own life (using her dead lover’s dagger) because she doesn’t want to go on living without him, Juliette joined the pantheon of figures who have made the tragedy of suicide seem, to some, romantic.  Politically too, suicide can grant the sort of status dying of old age doesn’t confer, the deaths of left-wing terrorists Ulrike Meinhof (1934–1976) and Gudrun Ensslin (1940–1977) of the West German Red Army Faction (the RAF and better known as the “Baader-Meinhof gang”) both recorded as “suicide in custody” although the circumstances were murky.  In an indication of the way moral relativities aligned during the high Cold War, the French intellectuals Jean-Paul Sartre (1905–1980) and Simone de Beauvoir (1908–1986) compared their deaths to the worst crimes of the Nazis but sympathy for violence committed for an “approved” cause was not the exclusive preserve of the left.  In July, 1964, in his speech accepting the Republican nomination for that year’s US presidential election, proto-MAGA Barry Goldwater (1909–1998) concluded by saying: “I would remind you that extremism in the defense of liberty is no vice!  And let me remind you also that moderation in the pursuit of justice is no virtue!”  The audience response to that was rapturous although a few months later the country mostly didn’t share the enthusiasm, Lyndon Johnson (LBJ, 1908–1973; US president 1963-1969) winning the presidency in one of the greatest landslides in US electoral history.  Given the choice between crooked old Lyndon and crazy old Barry, Americans preferred the crook.

Nor was it just politicians and intellectuals who could resist the appeal of politics being taken to its logical “other means” conclusion, the Canadian singer-songwriter Leonard Cohen (1934-2016) during the last years of the Cold War writing First We Take Manhattan (1986), the lyrics of which were open to interpretation but clarified in 1988 by the author who explained: “I think it means exactly what it says.  It is a terrorist song.  I think it's a response to terrorism.  There's something about terrorism that I've always admired.  The fact that there are no alibis or no compromises.  That position is always very attractive.”   Even in 1988 it was a controversial comment because by then not many outside of undergraduate anarchist societies were still romanticizing terrorists but in fairness to the singer the coda isn’t as often published: “I don't like it when it's manifested on the physical plane – I don't really enjoy the terrorist activities – but Psychic Terrorism.”

First We Take Manhattan (1986) by Leonard Cohen

They sentenced me to twenty years of boredom

For tryin' to change the system from within

I'm coming now, I'm coming to reward them

First we take Manhattan, then we take Berlin

 

I'm guided by a signal in the heavens

I'm guided by this birthmark on my skin

I'm guided by the beauty of our weapons

First we take Manhattan, then we take Berlin

 

I'd really like to live beside you, baby

I love your body and your spirit and your clothes

But you see that line there moving through the station?

I told you, I told you, told you, I was one of those

 

Ah you loved me as a loser, but now you're worried that I just might win

You know the way to stop me, but you don't have the discipline

How many nights I prayed for this, to let my work begin

First we take Manhattan, then we take Berlin

 

I don't like your fashion business, mister

And I don't like these drugs that keep you thin

I don't like what happened to my sister

First we take Manhattan, then we take Berlin

 

I'd really like to live beside you, baby

I love your body and your spirit and your clothes

But you see that line there moving through the station?

I told you, I told you, told you, I was one of those

First We Take Manhattan performed by Jennifer Warnes (b 1947), from the Album Famous Blue Raincoat (1986). 

Whatever they achieved in life, it was their suicides which lent a lingering allure to German-American ecofeminist activist Petra Kelly (1947–1992) & the doomed poet American poet Sylvia Path (1932-1963) and the lure goes back for millennia, the Roman Poet Ovid (Publius Ovidius Naso; 43 BC–17 AD) in his Metamorphoses telling an ancient Babylonian tale in which Pyramus, in dark despair, killed herself after finding her young love lifeless.  Over the centuries it’s been a recurrent trope but the most novel take was the symbolic, mystical death in Richard Wagner's (1813–1883) Tristan und Isolde (1865).  Mortally wounded in a duel before the final act, Tristan longs to see Isolde one last time but just as she arrives at his side, he dies in her arms.  Overwhelmed by love and grief, Isolde sings the famous Liebestod (Love-Death) and dies, the transcendent aria interpreted as the swansong which carries her to join Tristan in mystical union in the afterlife.  This, lawyers would call a “constructive suicide”.

Austrian soprano Helga Dernesch (b 1939) in 1972 performing the Liebestod aria from Wagner’s Tristan und Isolde with the Berlin Philharmonic under Herbert von Karajan (1908–1989).  While she didn’t possess the sheer power of the greatest of the Scandinavian sopranos who in the mid-twentieth century defined Wagner, Dernesch brought passion and intensity to her roles and while, on that night in 1972, the lushness of what Karajan summoned from the strings was perhaps a little much, her Liebestod was spine-tingling.  By then however, Karajan had been forgiven for everything.