Recognizing Suicide Risk Using the Pucker Factor Scale

Everyone is overjoyed with the recent heroic intervention by three young Americans and a Brit who took down a heavily armed man intent on mass murder on a French train before he could launch hell.

We ask ourselves: Could I have done that?

Unless similarly tested, we will never know.

But we should know that none of us could have acted at all had we not first noticed that something was wrong.

Whether preventing homicide or suicide, perception of potential risk before something bad happens is everything.

Observing a civilian carrying an AK-47 boarding a train somewhere in rural Pakistan is one thing; it is quite another thing if that civilian is boarding a train in a city in anywhere USA or in the EU.

Once potential danger was recognized, the actors on the French train all experienced a measurable “pucker factor” event – a sudden physiological reaction to extreme fear.  Activated by the most reliable human emotion (fear), our heroes leapt into quick, bold, positive action rather than freeze or flee and hope for the best.

The Pucker Factor

The “pucker factor” is, of course, military slang for a tightening of the buttocks caused by fear of immediate death if action is not taken. Enemy coming through your wire. The scream of incoming. An angry drill sergeant bearing down on you. People pay good money to watch horror movies or jump out of perfectly good airplanes to experience the PF response for all the fun it can be when you know – deep down – that you are not actually going to die in the next few seconds.

The pucker response is only triggered when the observer “sees” or “hears” a danger signal of sufficient strength to trigger a huge dose of adrenaline to flush through the nervous system, causing the classic freeze-fight-or-flight survival response.  Research shows that fear travels faster through our nervous systems than cognition and that only fools pay it no mind, often exiting the gene pool earlier than they really had to.

Here’s the Pucker Factor Scale edited to my satisfaction.  You rate what you think our heroes experienced in the split second between recognizing a man with AK-47 on that French train and taking action:

0.0 = Absolutely unconcerned that anything bad will happen.
2.5 = Optimistic that nothing bad will happen.
5.0 = Maybe something bad will happen, but let’s wait.
7.5 = Something really bad is about to happen so get ready.
10 = Holy Crap, Batman! Take immediate corrective action!

Using Fear to Prevent Suicide

Now let’s apply the PF Scale to preventing suicide.  Most suicidal people send what are called suicide warning signs before they make a suicide attempt, which may or may not lead to death.  These are observable signals or communications that something really bad is about to happen.

Since you can’t respond to a warning sign you don’t know and can’t recognize, our current public health mission is to train the public in what a suicide warning sign is, how it sounds, what it looks like, what words are used, and what meaning can be derived from verbal, written, or behavioral communications that frequently precede an act of suicidal self-directed violence.

Of note, these markers are the same for murder-suicides, since the decision to die by suicide is made first and warning signs are also usually present before the shooting begins.

But exactly what warning signs to teach is a much bigger challenge than you might guess.

When expressing their desire, intent, or plan to die by suicide, and no doubt due to stigma, fear, and shame, some suicidal people use oblique or indirect language to express their deadly thinking and plans, perhaps as a way to test our ability to read between the lines and interpret their true meaning.

Example. A police officer under investigation for a minor crime remarks to a co-worker, “The way things are going in my life, I’m going to have to eat my gun.”

No, the gun is not made of chocolate.  Yes, police officers kill themselves with their service pistols almost all the time.  No, this statement did not sound like a joke.

What is your PF score to such a statement?

If not at least 5, you need more training.

“I’m going to kill myself” is a loud horn blast if said plainly with earnest affect and requires no interpretation, whereas, “You’ll all be better off without me” requires a query (the Q in QPR) to draw out and clarify the true meaning of what the speaker may be intending to do.  Once the word suicide is on the table, no one’s PF score should be below 5, but you would be amazed how at many people stay at zero, 1 or 2.

And, yes, it is all about the context and who is speaking to whom. To paraphrase one young woman’s note to her lover, “Things are so boring around here this summer I think I’ll take my jump rope and hang myself.”

PF score?

Without more info about the context, speaker and hearer, you can’t even guess.

But if you know this line is in a love note from Jacqueline Lee Bouvier to John F. Kennedy while they were dating, you understand that the PF score is zero.

Bottom line: If a warning sign does not trigger a fear response, it is not – by definition – a warning sign.

To earn its pay, the presence of a suicide warning sign should lead to its instant recognition and the triggering of what is called the amygdala-cortical alarm system – our body’s response to sources of danger, i.e., a pucker. This physiological arousal network has evolved over millions of years to alert us to sources of threat without the need for thoughtful conscious appraisal of that threat.  The only automatic fear response all primates, including us, can really count on is when we encounter spiders, snakes, heights, and strangers; all the other fears we need to survive must be taught.

Suicide Warning Signs Research Needed

The Office of Occupational Safety and Health Administration has trained millions of us to recognize and respond to the loud beeping of a machine in backup mode.  All of us escape injury and death when shopping in Costco or Home Depot because forklifts in reverse automatically begin bleating out blasts of noise that cause a PF score of 7.

We need something equally effective to train all of us to recognize and respond to suicide warning signs.  A life is at risk, and we need to jump into action, just as our heroes did on the French train.

I therefore invite researchers to conduct an experimental study of the currently published suicide warning signs to see if they actually warn and cause observers to leap into life-saving action. Excellent research designs for this experiment are readily available.

I’d do this work myself, but I’m not much good at algebra, let alone real scientific research. Had I passed organic chemistry, mathematics, and mastered solving for X in high school I’d probably have gone on to win a Nobel Prize in physics or something, but as a science dropout I found my way first into English and writing, and then into psychology where my rehab went rather well.

Psychology taught me to be as good a person as I possibly could be and to help others – thus causing my mother a warm heart and my father indigestion.

Dr. Paul

One thought on “Recognizing Suicide Risk Using the Pucker Factor Scale”

  1. Paul,
    It is so sad a suicide itself generates no PF at all in our general population, much less when a friend or colleague makes a statement that should stimulate at least some kind of PF response. Our son told people he’d been trying to die by suicide numerous times and was caught in the act on at least one occasion. None of these incidents generated more than a 2.5 resulting in advice to “Take a shower and you’ll feel better,” but not a call to us, his parents. His score of 15 on the Beck Depression Survey (with 5 a definite positive) in the last clinic he went to for help got the same response – “Take these pills and call me in a few weeks if you are not feeling better.” What was that, a PF of, maybe 4? On returning home, he told his best friend “I answered ‘Yes’ to every question about suicide and still they said they couldn’t refer me for help. I give.” He was dead 10 days later.

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