Section 1

Section 1: Introduction

Chronic pain presents a significant challenge affecting more than 1.5 billion people globally(1), imposing a substantial burden on patients and healthcare systems. Alarmingly, individuals living with chronic pain face twice the risk of suicide compared to those without chronic pain(2). Despite this troubling statistic, routine suicide risk screening for chronic pain patients is currently lacking. Existing clinical assessment scales designed to directly evaluate suicide risk often generate a high number of false positives, leading to the categorization of low-risk patients as high-risk, thereby raising questions about their clinical effectiveness (3). Consequently, there is an urgent need for a readily accessible and validated tools that can accurately identify chronic pain patients at the highest risk of suicide and guide appropriate treatment interventions.

Numerous studies have consistently demonstrated a strong association between mental defeat and the levels of distress and disability experienced by individuals with chronic pain (4). Importantly, the level of mental defeat has emerged as a precipitating factor for suicide, even when concurrent depression is considered (5,6),. Given the life-threatening implications of living with chronic pain, there is a critical need for a clinical resource that can identify patients with elevated levels of mental defeat, assess their risk of suicidal risk, and guide the development of effective and impactful interventions.

The Pain Self Perception Scale (PSPS) serves as a valuable tool for assessing mental defeat, characterized as a debilitating form of self-perception triggered by recurring episodes of pain, leading to negative self-beliefs (7). The PSPS comprises 24 items that describe adverse thoughts about oneself in relation to pain. From a psychometric perspective, it demonstrates excellent internal consistency (Cronbach's alpha = 0.98) and test-retest reliability (r = 0.92). Originally developed in English, the scale has been translated and validated in both Chinese (8) and Spanish (9). Recent research has revealed that mental defeat surpasses other conventional psychological predictors, including anxiety, depression, hopelessness, self-efficacy, and pain catastrophizing, as a strong predictor of suicide risk in chronic pain patients (10,11). This discovery positions mental defeat as a novel and promising therapeutic target within the realm of chronic pain management, building on its already recognized utility in addressing other health conditions such as psychosis (12). .

This manual is designed for those interested in utilizing the PSPS for clinical and research purposes.

1.1 A word about mental defeat

The concept of "mental defeat" has its origins in the study of post-traumatic stress disorder (PTSD) and depression. In the context of PTSD, mental defeat signifies the "perceived loss of all autonomy" when confronted with uncontrollable traumatic events. Research has shown that individuals who experience a profound sense of defeat tend to exhibit more severe PTSD symptoms and respond less favourably to treatments.

In the realm of depression, defeat is conceptualized as "a sense of failed social struggle, loss, and reduced social rank." Depressed individuals often perceive themselves as trapped in a "subordinate" role, with the perception of defeat correlating with more severe depressive symptoms.

In the field of suicide research, defeat plays a central role in influential models like the Cry of Pain Model (13) and the Schematic Appraisal Model (14). Questionnaire-based studies have revealed that defeat statistically correlates with negative appraisals of social support, poor problem-solving abilities, and suicidality (15). Longitudinal evidence indicates that among young individuals reporting suicidality, a stronger sense of defeat is associated with a heightened risk of increasing suicidality over time, even when baseline symptoms of depression and suicidality are considered (16). Most recently, mental defeat has been implicated as as a significant predictor of suicide risk or intent among patients with chronic pain (10,17). These findings collectively suggest that the concept of defeat has the potential to shed light on how symptom severity, distress, and disability evolve across various disorders.

Recent research in health psychology has begun to apply the concept of mental defeat to the context of chronic pain, yielding promising outcomes. Repetitive bouts of intractable pain are believed to serve as recurrent triggers for the experience of defeat, activating negative self-appraisals concerning pain. These thoughts have been validated to measure the presence of pain-related mental defeat. Studies have demonstrated that chronic pain patients exhibit significantly higher levels of mental defeat compared to individuals with acute pain or anxiety disorders. Furthermore, recent research has shown a link between levels of mental defeat in chronic pain and an increased risk of suicide.