{"paper_id":"1d9b3675-48f7-41dc-b7e5-1289b41b4f26","body_text":"Psychological pain as existential grief in midlife: a constructivist grounded theory | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Psychological pain as existential grief in midlife: a constructivist grounded theory Mahmoud Hakimnia, Ahmad Borjali, Zohreh Rafezi, Abolghasem Isamorad, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8698936/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Psychological pain is a well-established predictor of suicidal ideation and behavior. However, the ways in which this pain is subjectively experienced and made sense of during midlife, particularly among individuals who experience this period as a crisis, remain insufficiently understood. Midlife often involves intensified existential reflection and confrontation with discrepancies between imagined and lived life trajectories, a process that may be especially salient in non-Western sociocultural contexts where qualitative evidence remains limited. Within this context, the present study examined how adults who self-identified as experiencing a midlife crisis understand, describe, and live with psychological pain. Methods Using a qualitative design, in-depth semi-structured interviews were conducted with 18 urban Iranian adults aged 40 to 57 years who reported experiencing a midlife crisis. Data were analyzed following Charmaz’s constructivist grounded theory approach, with data collection and analysis proceeding concurrently. Results Psychological pain emerged not as a discrete emotional state, but as a dynamic and cyclical process conceptualized as existential grief. This process arose through confrontation with an irreversible discrepancy between the ideal self and the lived self. Participants described ongoing mourning for symbolic losses, including unrealized life possibilities and foreclosed identities. Regret, sorrow, helplessness, and profound loneliness were closely intertwined and mutually reinforcing. This experience unfolded as a self-perpetuating cycle, in which unresolved symbolic losses continuously reactivated psychological pain. Midlife-specific pressures and the lack of effective emotional relationships further intensified this process. When unresolved, existential grief culminated in psychological burnout, crisis of meaning, and suicidal ideation. Conclusion These findings suggest that psychological pain in midlife is better understood as an unfinished grieving process for symbolic, self-related losses rather than as emotional distress alone. Conceptualizing psychological pain as existential grief may sharpen clinical assessment by directing attention to self-discrepancy, histories of symbolic loss, and pain-related escape cognitions, with implications for suicide risk formulation and meaning-oriented clinical work with midlife adults. psychological pain existential grief midlife grounded theory symbolic loss self-discrepancy Figures Figure 1 Introduction Psychological pain has emerged as one of the strongest independent predictors of suicidal ideation and behavior, especially given that suicide constitutes a major global public health crisis, claiming approximately 700,000 lives annually and exacting profound emotional and socioeconomic costs 1 , 2 . Effective prevention requires identification of modifiable proximal risk factors. Recent longitudinal evidence from high-risk cohorts demonstrates that intense psychological pain over brief periods is an independent predictor of suicidal acts, even after controlling for depression severity 3 . Two high-quality syntheses confirm these associations: a systematic review of 42 studies 4 and a meta-analysis of 20 studies 5 both concluded that psychological pain is a significant suicide risk factor even in the absence of diagnosed psychiatric disorders and is often a stronger predictor than depression alone. Studies further indicate that the dimension of pain avoidance, the perceived necessity of escaping unbearable psychological pain, is a particularly robust predictor of suicidal ideation and attempts, often outperforming depression and other traditional risk factors 6 . Deepening theoretical and empirical understanding of this multidimensional construct is thus essential for advancing suicide prevention. Despite its centrality, psychological pain remains conceptually fragmented and terminologically heterogeneous 7 , 8 . Definitions vary widely, ranging from negative self-appraisal linked to perceived failures to more enduring and irreversible disruptions in the self and its functioning 9 . This lack of conceptual coherence has led to the development of numerous assessment instruments that differ substantially in focus and scope 10 , 11 . Although several newer measures have been proposed, many have been developed with limited qualitative grounding and minimal direct input from individuals with lived experience, raising concerns about their content validity and ecological relevance 12 . As a result, much of the existing quantitative literature captures the intensity of psychological pain while offering limited insight into how it is experienced, interpreted, and shaped over time. Addressing this gap requires rigorous qualitative inquiry, particularly during developmentally vulnerable life stages. Midlife represents a critical yet still under-explored context for understanding psychological pain. Developmental research characterizes this period as one marked by the accumulation of demanding and often competing roles, including spousal, parental, caregiving, and professional responsibilities, alongside ongoing identity transitions 13 , 14 . Large-scale cross-national studies consistently show a U-shaped pattern of psychological distress, with risk peaking in midlife across indicators such as suicide, severe depression, and alcohol dependence 15 , 16 . Notably, this vulnerability persists even after rigorous statistical controls and often coincides with peak earning years, suggesting that distress is driven less by material deprivation than by age-related physical decline, stalled life trajectories, empty-nest transitions, and confrontation with mortality and irretrievable aspirations (Jaques, 1965, cited in 16 ). Although emerging evidence also points to neurobiological correlates of midlife stress 17 , most existing work remains quantitative. As a result, qualitative investigations that examine how psychological pain is subjectively experienced, organized over time, and imbued with meaning during midlife remain scarce, despite the well-established link between psychological pain and suicidality. To address the conceptual ambiguity surrounding psychological pain and the well-documented yet qualitatively underexplored vulnerability of midlife, the present study adopts Charmaz’s constructivist grounded theory approach 18 . This methodology was selected because psychological pain in midlife appears to be a processual, temporally embedded, and meaning-laden experience that cannot be adequately captured through predefined categories alone. Rather than aiming to generate a formal or generalizable theory, the study seeks to develop a contextually grounded conceptual framework closely anchored in participants’ accounts. Grief theory was used as an initial sensitizing lens to support early analytic attention to experiences of symbolic loss, such as unrealized aspirations, foreclosed identities, and disrupted life narratives, and to related processes of meaning reconstruction 19 . Importantly, this lens functioned as a heuristic point of orientation rather than a prescriptive framework, and analytic decisions remained guided by constant comparison and emergent categories. The resulting conceptual model therefore reflects participants’ meanings and experiences, rather than the prior imposition of grief-based assumptions. The present study aims to clarify how psychological pain is structured and experienced during midlife by examining its developmental context and subjective meaning. By foregrounding participants’ own accounts, the study seeks to articulate a conceptually grounded understanding of psychological pain that is sensitive to both developmental timing and sociocultural context, while addressing the limited qualitative representation of non-WEIRD populations in this literature. Rather than proposing intervention models or clinical techniques, the study is intended to inform future theoretical work, qualitative inquiry, and clinically oriented reflection on psychological pain in midlife. Methods Study design and philosophical underpinnings This study adopted a qualitative research design informed by constructivist grounded theory as articulated by Charmaz 18,20 . From a constructivist–interpretivist standpoint, meaning is understood as contextually situated and co-constructed through interaction between the researcher and participants, rather than as an objective reality waiting to be discovered. Accordingly, data generation and analysis were approached as reflexive and iterative processes embedded within participants’ sociocultural and historical contexts. While the study was theoretically anchored in Charmaz’s constructivist grounded theory, a limited number of analytic techniques commonly used across grounded theory approaches were employed in a pragmatic manner. These included constant comparative analysis and theoretical sampling, which are widely regarded as methodological procedures rather than theory-bound epistemological commitments 21 . In addition, a paradigm-oriented diagram was used as an analytic aid to support the exploration of relationships among categories, without implying adherence to the epistemological assumptions of the Strauss and Corbin tradition. Importantly, this paradigm-oriented tool functioned as a sensitizing and organizational device rather than as a prescriptive analytic framework. Its function was to support the systematic yet flexible examination of relationships among conditions, actions, and consequences, while explicitly avoiding linear or deterministic causal interpretations 21 . This approach facilitated a process-oriented and cyclical mode of analysis that remained closely grounded in participants’ narratives, and fully consistent with constructivist assumptions regarding meaning-making and interpretation. Consistent with the aims of constructivist grounded theory, the study sought to generate a contextually grounded conceptual framework rather than a formal or generalizable theory 18 . To enhance transparency and reporting quality, the study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist 22 (see Additional File 1). Research team and reflexivity All interviews were conducted by the first author, who also assumed primary responsibility for data analysis. He is a male doctoral candidate in clinical psychology, aged 51, with formal training in qualitative interviewing and constructivist grounded theory completed prior to the commencement of data collection. Consistent with constructivist grounded theory, the researcher’s positioning as a midlife adult was approached reflexively, acknowledging its dual role as a potential source of analytic insight and a possible influence on interpretation 18 . Reflexivity was treated as an ongoing and systematic analytic practice through which the researcher critically examined how personal biography, professional training, and experiential proximity to the phenomenon under study could shape both data generation and interpretation 23-24 . Rather than attempting to eliminate subjectivity, the study sought to make its influence visible and analytically accountable throughout the research process. To manage insider positioning and reduce the risk of over-identification with participants’ narratives, multiple reflexive strategies were implemented. These included the preparation of reflexive memos immediately following each interview to capture emotional responses, emerging assumptions, and potential countertransference reactions. In addition, twice monthly peer debriefing meetings were held with two senior supervisors, one with expertise in qualitative methodology and one in existential psychotherapy, during which analytic decisions, category development, and emerging interpretations were subjected to critical discussion. Reflexivity was further supported through sustained analytic memo-writing across all stages of coding, with particular attention to documenting interpretive shifts and instances where personal assumptions were deliberately bracketed in favor of participants’ accounts. Together, these procedures enhanced analytic transparency and methodological rigor, while allowing the researcher’s clinical sensitivity to inform the analysis without unduly shaping or constraining the emergent conceptual framework. Participants Midlife was defined as the ages 40–65, consistent with developmental frameworks that emphasize generativity, identity reevaluation, and existential concerns during this life period 13,25,26 . Participants were urban Iranian adults who self-identified as experiencing a midlife crisis, operationalized through an initial screening question. Inclusion criteria were: being within the defined midlife age range; current employment; minimum bachelor-level education; affirmative response to the screening question “In recent years, have you gone through a period of profound doubt, reevaluation, or distress regarding your life direction, identity, or achievements?”; and the ability to participate in an approximately one-hour interview. Exclusion criteria included current psychiatric treatment, severe substance-use disorder, or bereavement within the previous year. The final sample comprised 18 participants (12 women and 6 men) aged 40–57 years (M = 45.5). All participants were highly educated, employed, urban residents of Tehran, Iran. Detailed demographic characteristics are presented in Table 1, and participant-level information with exemplar initial themes is summarized in Table 2. Sampling strategy and recruitment Sampling was guided by constructivist grounded theory principles, combining purposive and theoretical sampling 18 . Initial purposive sampling (n = 8) sought to recruit individuals who met the inclusion criteria and could provide rich descriptions of psychological pain during midlife. Participants were recruited through open voluntary calls posted on social media platforms, including Instagram, LinkedIn, and Telegram groups focused on personal development and midlife-related topics, as well as through personal networks. Interested individuals contacted the researcher directly. Theoretical saturation was reached after 16 interviews, when no new properties or relationships emerged, and existing categories were deemed robustly defined across diverse within the sample. Two additional interviews were conducted to confirm the stability of the emerging model, resulting in a final sample of 18 participants. Table 1 Participant characteristics (N = 18) Characteristic n (%) or M (Range) Age (years) 45.5 (40–57) Female 12 (66.6%) Male 6 (33.3%) Married 13 (72.2%) Divorced 3 (16.7%) Single 2 (11.1%) Has children 12 (66.7%) Bachelor’s 8 (44.4%) Master’s 7 (38.9%) PhD 3 (16.7%) Occupation Managerial/Professional/Academic (100%) Interview duration (min) 53 (46–62) Note. All participants were employed, urban residents of Tehran, Iran, and self-identified as experiencing a midlife crisis. The uniform occupational category reflects the purposive sampling focus on employed adults, which may introduce selection bias (see Limitations). Table 2 Participant demographics and exemplar initial themes from open coding (N = 18) Code Age Gender Marital Status Children Education Occupation Duration (min) Exemplar initial themes P1 43 F Divorced Yes Master’s Manager 56 Regret for shattered life scripts; existential emptiness P2 40 F Married No PhD Consultant 48 Indecisiveness; profound sorrow; deep loneliness P3 45 F Divorced Yes Bachelor’s Trainer 51 Relational isolation; confusion; accumulated failures P4 40 F Married Yes Bachelor’s Trainer 58 Pervasive sorrow; despair P5 40 F Married Yes Master’s Teacher 53 Deep dissatisfaction; regret for paths not taken P6 45 M Married No Bachelor’s Engineer 50 Suppressed anger; dissatisfaction; relational dysfunction; uncertainty about future P7 44 F Single No Master’s Consultant 47 Pervasive sorrow; helplessness; longing P8 55 F Married Yes Master’s Social worker 52 Pervasive sorrow; suppressed anger; relational dissatisfaction; emerging healing processes P9 48 F Married Yes Bachelor’s Freelancer 48 Suppressed anger; accumulated failures; relational dissatisfaction P10 42 M Married No PhD Manager 58 Existential emptiness; anhedonia (lack of pleasure) P11 57 F Married Yes PhD Teacher 62 Pervasive sorrow; profound loneliness; relational dissatisfaction; emerging meaning crisis P12 43 M Married Yes Bachelor’s Manager 46 Excessive dissatisfaction; suppressed anger P13 40 F Married Yes Bachelor’s Manager 49 Suppressed anger; dissatisfaction; accumulated failures; regret P14 53 M Married Yes Bachelor’s Engineer 58 Indecisiveness; profound relational problems; midlife pressures P15 40 M Single No Master’s Specialist 51 Profound loneliness; shame; lack of connection; longing for past relationships P16 44 M Married Yes Bachelor’s Manager 48 Deep sorrow; profound loneliness; existential emptiness; midlife pressures P17 50 F Divorced Yes Master’s Teacher 54 Pervasive sorrow; longing; emotional weariness P18 50 F Married Yes Master’s Consultant 62 Profound sorrow; loneliness; regret; relational isolation [Please insert Table2 here] Data collection Data were collected through in-depth semi-structured interviews specifically designed to explore experiences of psychological pain during midlife. The interview guide was developed based on a systematic review of literature on psychological pain 2 , midlife transitions 27 , and recent empirical research 16 . Guide development followed a structured process that included conceptual clarification of the phenomenon, drafting open-ended questions, and multiple rounds of iterative review by members of the research team with expertise in psychological science (assessment, clinical intervention, and qualitative research). The final guide (see the interview protocol section in the Supplementary Materials) adopted a funnel structure, beginning with broad prompts and progressing to more focused exploration of emotional, cognitive, interpersonal, and existential dimensions. Example questions included: “How would you describe the pain you feel inside?”, “When you think about the life you imagined versus the life you have, what comes up for you?”, “How do you cope with this pain?”, and “How has this experience affected your sense of meaning in life?” Interviews were conducted in Persian, either face-to-face in private consultation rooms or via encrypted video calls, and lasted between 46 and 62 minutes. All interviews were audio-recorded with informed consent and transcribed verbatim by the first author. Field notes documenting non-verbal cues and emotional tone were recorded immediately after each interview. Given the sensitive nature of the research topic, participant distress was carefully monitored throughout the interview process. The interviewer, who has formal clinical training, remained attentive to verbal and non-verbal indicators of emotional overload or heightened distress. When participants referred to thoughts related to death or suicide, these experiences were explored in a supportive and non-assumptive manner to clarify their temporal context and subjective meaning. Across interviews, such descriptions were understood as passive or historical rather than indicative of imminent risk. Participants were informed of their right to pause or discontinue the interview at any time, and information about local mental health resources was available if needed. Key quotations were translated into English by the first author, who is bilingual in Persian and English. Selected excerpts were subsequently back-translated by an independent bilingual colleague to ensure semantic accuracy and preservation of cultural meaning. Data analysis Data analysis followed the principles of constructivist grounded theory as outlined by Charmaz 18 . The process was iterative, with data collection and analysis occurring concurrently, ensuring that emerging concepts were continuously refined and integrated. Interviews were transcribed verbatim and analyzed using MAXQDA 24. The analysis unfolded in three phases: open coding, focused coding, and theoretical coding. Initial open coding was conducted in direct collaboration with an analytic consultant (Zahra Aghayan, acknowledged in the manuscript) to ensure inter-coder consistency and depth. In the open coding phase, the data were analyzed line-by-line to generate initial codes, which captured the finest-grained aspects of participants' experiences. During focused coding, these initial codes were grouped into categories, guided by constant comparative analysis. Theoretical coding then integrated the categories into a comprehensive framework. To ensure theoretical saturation and analytic depth, a saturation grid was employed, which is provided as Supplementary Table S1. This grid allowed us to track the emergence of new categories and ensure that data collection was stopped once theoretical saturation was achieved. The saturation grid included tracking the number of interviews, the categories developed, and the emergence (or lack thereof) of new concepts. We reached theoretical saturation after 16 interviews, with no new themes emerging. Two additional interviews were conducted to confirm saturation, ensuring that the categories were stable and comprehensive. To further enhance methodological rigor, we engaged in peer debriefing with two experienced qualitative methodologists and conducted member checking with five participants (one male, P6) and four females P1, P2, P5, P11) to confirm that the findings and emerging categories accurately reflected their lived experiences. All five participants affirmed the resonance of the conceptual model, with minor suggestions for nuance that were incorporated into the final interpretations. Negative and discrepant cases were actively sought and integrated into the analysis; for instance, while maladaptive coping strategies predominated, a few participants described transient adaptive responses (e.g., channeling energy into caregiving roles), which were incorporated as variations within the \"Strategies/Responses\" category to ensure the robustness and breadth of the model. This approach, including constant comparison and the use of the saturation grid, ensured that the data analysis was both thorough and responsive to emerging insights, and that the theoretical framework was well-grounded in the participants' lived experiences while remaining methodologically sound. Trustworthiness Trustworthiness was ensured using criteria appropriate for constructivist qualitative research 18,28 . Credibility was supported through prolonged engagement with the data, iterative analysis, and member checking with five participants, who confirmed that the interpretations reflected their experiences. Ongoing peer debriefing with two experienced supervisors (a qualitative methodologist and an existential psychotherapist) provided critical examination of emerging interpretations and helped challenge potential assumptions. Dependability and confirmability were enhanced through a comprehensive audit trail, including analytic memos, coding iterations, and reflexive documentation of key decision-making processes. Discrepant and negative cases were actively sought and integrated to refine categories and ensure analytic robustness. Transferability was supported through thick description of the research context and the use of illustrative participant quotations. Collectively, these strategies ensured that the findings were grounded in participants’ lived experiences while maintaining analytic rigor and reflexive transparency. Results A constructivist grounded theory analysis of 18 in-depth interviews indicated that participants experienced psychological pain in midlife not as a transient emotional state, but as a dynamic and cyclical process conceptualized as existential grief. Participants consistently described their suffering as an ongoing mourning for unrealized life possibilities, lost aspirations, and an ideal self-perceived as permanently unattainable. The core category, existential grief, emerged through participants’ accounts of confronting an enduring ideal–actual self-discrepancy and served to organize the relationships among the other categories identified in the analysis (Figure 1). Emergence of the theoretical model The theoretical model was developed through iterative constructivist grounded theory procedures, including initial line-by-line coding, focused coding, and theoretical coding, guided by constant comparative analysis 18 . Theoretical sampling facilitated exploration of variation in experiences of loss and unrealized life goals. Theoretical saturation was reached after 16 interviews, with two additional interviews conducted to confirm category stability. The resulting model organizes participants’ accounts into interrelated categories reflecting historical experiences, midlife contextual pressures, relational conditions, coping responses, and reported outcomes (Table 3). Table 3. Summary of major categories, subcategories, and exemplar quotations Major Category Core Theoretical Construct (where applicable) Subcategory Exemplar Quotation (Participant ID) Causal Conditions Ideal–Actual Self-Discrepancy Shattered life scripts “I didn't get what I was looking for...! I can't be kind to myself” (P1). Developmental trauma “As a child, I was humiliated a lot” (P3). Suppressed emotions “Everything is inside me and I keep everything good on the outside” (P4). Contextual Conditions Multidimensional midlife pressures Sandwich-generation “Everything rests on my shoulders alone” (P16). Cultural-social pressures “My mother's opinion is that you have to endure and that's life “(P5). Economic-financial pressures “The economic and work situation is not the same as before; this also worries me” (P6). Intervening Conditions Not applicable Lack of effective emotional relationship \"The emotional connection between us has been broken\" (P6). Foreclosed opportunities “Now there’s no chance left” (P1). Central Phenomenon Existential Grief Regret “I wish I had overcome my fears sooner” (P18). Sorrow “A constant sorrow that no one sees” (P2) Helplessness “Nothing works!” (P13). Profound loneliness “I feel lonely in the middle of a crowd” (P15). Strategies/Responses Not applicable Maladaptive (dominant) “I smoke a little weed, it calms me down” (P12). Transient adaptive “I devote all my energy and time to my daughter” (P11). Consequences Not applicable Psychological burnout “I’m only alive because of my daughter” (P16). Crisis of meaning “I keep telling myself how meaningless life is” (P6). Suicidal ideation “I lack the courage for suicide; otherwise, I would have done it” (P6). Causal conditions: the historical seeds of grief Causal conditions were organized around a central axial process of cumulative ideal–actual self-discrepancy, which became acutely salient during midlife. Participants described psychological pain as emerging from the realization that their lived life trajectories had diverged irreversibly from long-held aspirations, values, and imagined futures. This discrepancy was not experienced as transient dissatisfaction, but as a sustained confrontation with lost possibilities and an unfinished mourning for unrealized aspects of the self. Three interrelated axial conditions constituted the historical foundation through which this core discrepancy developed and intensified: shattered life scripts, unresolved developmental trauma, and long-suppressed emotions. The first and most explicit manifestation of ideal–actual self-discrepancy was articulated through shattered life scripts. Participants frequently mourned the collapse of idealized narratives that had once provided direction, coherence, and hope. These scripts, formed around expectations of achievement, autonomy, intimacy, or moral success, were described as no longer attainable within the constraints of current reality. The resulting gap between the envisioned ideal self and the accumulated outcomes of lived experience generated pervasive regret, self-blame, and a sense of existential failure. One participant reflected, “All those fantasies I built in my mind since childhood… none of them came true. They all crashed into a wall” (P1). Similarly, another stated, “The dreams of my youth and the opportunities I could have had are gone!” (P14). These accounts illustrate how midlife functioned as a temporal checkpoint that rendered discrepancies between imagined and actual selves undeniable and emotionally overwhelming. The second axial condition involved developmental trauma and unresolved injuries that shaped both the formation of idealized self-representations and the fragility of self-worth across the lifespan. Many participants linked their current psychological pain to early experiences of emotional neglect, rejection, or chronic invalidation. These experiences were not described as resolved historical events, but as enduring vulnerabilities that resurfaced during the heightened self-evaluation characteristic of midlife. Participants reported that such injuries undermined their sense of legitimacy, agency, and deservingness, thereby amplifying the emotional impact of later perceived failures. One participant stated, “I was constantly rejected… I can never forgive my mother” (P2). Another noted, “From childhood, there was no one to really see me or hold my pain. It feels like I have been carrying this injury forever” (P5). In this way, developmental trauma functioned as a structural condition that intensified the consequences of ideal–actual self-discrepancy. The third axial condition comprised long-suppressed emotions, particularly anger, grief, and sorrow, which participants reported containing for years in response to familial, cultural, or social expectations. Emotional suppression was described as adaptive earlier in life but increasingly unsustainable in midlife, when accumulated losses and disappointments demanded acknowledgment. Participants portrayed these emotions as resurfacing with force, contributing to the subjective unbearability of psychological pain. One participant explained, “Sometimes I feel like fighting someone in the street just to let it out” (P12). Another reflected, “I've been holding back my pain for all these years, but now it feels as though my capacity is full. There is anger over lost time and what could have been, but you know better. You have to keep up your usual appearance and put on a mask. ‘You're fine.’” (P15). Suppressed emotions thus acted as an affective amplifier, intensifying the lived experience of existential grief once self-discrepancy became fully conscious. Together, these causal conditions formed the historical and developmental context through which participants described the emergence of existential grief as an unfinished mourning process for irretrievable aspects of the self and life trajectory. Consistent with constructivist grounded theory, participants did not describe their suffering as episodic distress but rather as a cumulative process rooted in unresolved losses across the life course. Midlife was described as a critical temporal context in which participants reflected on growing discrepancies between the lives they had once imagined for themselves and how their lives had actually unfolded, alongside relational injuries and long-suppressed affects, shaping how psychological pain was experienced and organized. Contextual conditions: multidimensional midlife pressures Contextual conditions were characterized by multifaceted and cumulative midlife pressures that positioned individuals at the center of a complex force field, severely constraining opportunities for reflection, repair, or mourning. These pressures emerged along three primary and interacting dimensions derived from the data. First, intergenerational pressures manifested as \"sandwich-generation\" responsibilities, with participants simultaneously caring for aging parents and dependent children while managing professional demands. Crucially, cultural-social pressures stemmed from traditional societal expectations for occupational stability, familial success, and obligatory social participation (e.g., \"Expectations from relatives to attend all gatherings\" (P11). Simultaneously, economic-financial pressures involved heavy livelihood responsibilities and the role of the \"leading generation,\" further exacerbated by inflation and financial instability. This triaxial convergence generated unrelenting demands, forcing participants to prioritize functionality despite profound internal distress. The narratives revealed a pervasive sense of burden, often feeling that “Everything rests on my shoulders alone.... Ageing parents, child, work, and finances” (P16). Participants emphasized the necessity to endure, stating, \"I’m forced to stay on my feet\" (P2), and expressed deep-seated anxieties about the future, particularly regarding dependent children in the face of macro-economic crises: \"With this inflation and crisis, I’m terrified for my daughter’s future\" (P13). These interacting pressures created an erosive context that profoundly challenged resilience and resource availability, with participants describing midlife as a period marked by cumulative constraints that limited opportunities for reflection, repair, or mourning. This convergence intensified the salience of earlier losses and narrowed perceived options for change, shaping how participants experienced the persistence and depth of psychological pain during this stage of life. Intervening conditions: amplifiers of existential grief Two intervening conditions were identified as critical amplifiers of existential grief: lack of effective emotional relationship and perceived foreclosed opportunities. Despite being embedded in family and social networks, participants frequently described profound emotional isolation and lack of validation. Intimate relationships were experienced as emotionally unavailable or dismissive of psychological pain. One participant stated, “My spouse doesn’t even see my pain. I’ve been sleeping in my daughter’s room for years” (P5). Others emphasized the absence of confidants with whom they could share their distress, resulting in an experience of existential loneliness: “No one truly experiences my loneliness” (P16). The second amplifier involved acute awareness of time passing and the perception that opportunities for meaningful change were no longer available. Midlife was framed as a point of irreversibility, where the future felt closed rather than open. As one participant reflected, “Ten years ago I thought I still had time… now there’s no chance left” (P1). This sense of temporal closure was particularly acute: “At 53 I can’t start my life over” (P14). This perception eliminated hope for reparation and intensified grief by rendering losses final. Central phenomenon: existential grief The central phenomenon, existential grief arising from confrontation with accumulated discrepancies between past expectations and lived life trajectories, manifested through four interdependent dimensions: regret, sorrow, helplessness, and profound loneliness. Participants described these dimensions as inseparable and mutually reinforcing, forming a cyclical dynamic in which each intensified the others and sustained the experience of psychological pain. As one participant summarized, “mourning for the life I was supposed to live” (P1). Regret represented a cognitive and emotional preoccupation with irreversible choices and missed opportunities. Participants repeatedly engaged in counterfactual reflections on alternative life paths. One participant stated, “I wish I had gotten divorced when I was thirty... I wasted twenty years of my life” (P17). Regret functioned as a primary entry point into the grieving process, often tied to shattered early narratives. Sorrow was described as a pervasive, enduring sadness that colored daily experience. Unlike transient sadness, this sorrow was experienced as constant and depleting. One participant described it as “a constant sorrow that no one sees, that melts you drop by drop” (P2). Sorrow deepened the mourning process and contributed to emotional exhaustion. Helplessness reflected a perceived loss of agency and inability to envision or enact change. Participants described feeling trapped within their circumstances, stating, “I don’t know how to get out of this state... Nothing works!” (P13). This sense of powerlessness was heightened by midlife pressures and foreclosed time: “Now at this age, what can I do?” (P11). Profound loneliness captured an existential isolation that persisted even in the presence of others. Participants described feeling fundamentally misunderstood and disconnected. One participant stated, “I feel lonely in the middle of a crowd. No one understands this pain” (P15). This loneliness intensified other dimensions of grief by depriving individuals of shared meaning or emotional containment: “A pain that makes you want to escape this world” (P2). Strategies/Responses: coping with existential grief Participants employed a range of strategies to cope with existential grief, which were predominantly maladaptive. These strategies included emotional withdrawal, over-engagement in work or activities, distraction, and escapist ideation. Such responses provided temporary relief but failed to address the underlying grief. One participant summarized this pattern succinctly: “You retreat into your shell” (P1). Additional examples included overwork or intellectual distractions: “I try to occupy my mind by learning a new language” (P6). Less frequently, participants reported transient adaptive strategies, such as dedicating themselves to caregiving roles or engaging in spiritual practices. For example, one participant stated, “To cope with this pain, I devote all my energy and time to my daughter” (P11). However, these strategies were described as providing only temporary relief from psychological pain and were experienced as insufficient and unsustainable, with participants reporting that pain continued to recur. Consequences: burnout, crisis of meaning, and suicidal ideation While transient adaptive strategies offered temporary alleviation of psychological pain, they proved insufficient in resolving the underlying existential grief, thereby perpetuating its cyclical recurrence and contributing to eventual burnout and crisis of meaning. The predominant consequences of unresolved existential grief were psychological burnout and a crisis of meaning, with several participants reporting passive or historical suicidal ideation. Burnout was described in terms of emotional exhaustion, diminished vitality, and continuing daily life primarily out of obligation rather than desire. One participant stated, “I’m only alive because of my daughter” (P16). Participants also described a loss of meaning and identity confusion, often expressed as a pervasive sense of futility. For example, one participant noted, “Things that used to make me happy no longer bring pleasure… life and the future appear dark and meaningless” (P6). In some accounts, suicidal ideation was described as a way of thinking about escape from ongoing psychological pain rather than as an immediate intention or plan. One participant reflected, “I lack the courage for suicide; otherwise, I would have done it” (P6). These descriptions were reported as passive or historical in nature, and no imminent risk was identified during the interviews, with the distress protocol implemented as outlined in the Methods section. Discussion Principal findings and theoretical contribution This study contributes to the psychological pain literature by offering a rigorously grounded, developmentally situated, and culturally contextualized conceptual model that conceptualizes psychological pain in midlife as existential grief understood in relation to confrontation with accumulated self-related losses and discrepancies between past expectations and lived life trajectories. Unlike dominant quantitative approaches that operationalize psychological pain primarily as an intensity-based affective construct or proximal suicide risk marker 2,5 , the present findings frame psychological pain as a processual and cyclical phenomenon rooted in accumulated symbolic losses. Rather than focusing solely on symptom intensity, this perspective emphasizes how psychological pain becomes organized over time around experiences of irreversible loss. This reconceptualization responds to longstanding calls to clarify the internal structure and lived processes of psychological pain, which remain obscured by measurement heterogeneity and symptom overlap with depression and anxiety 7,8,29 . The core category integrates historical losses (e.g., unrealized aspirations and developmental trauma), midlife-specific contextual pressures (e.g., sandwich-generation responsibilities and economic precarity), and relational and temporal amplifiers, including the absence of effective emotional relationships and the perception of foreclosed future possibilities. Participants described these elements as interrelated aspects of their experience, contributing to a sense of ongoing psychological pain that unfolded over time rather than as a reaction to isolated stressors. Importantly, participants rarely framed their suffering as a temporary response to situational demands; instead, it was described as an unfinished mourning process for aspects of the self and life trajectory that were experienced as no longer attainable. This perspective situates psychological pain within a developmental and existential context, particularly in a non-WEIRD urban Iranian setting where intergenerational obligations and socioeconomic pressures may shape how loss and regret are lived and understood. Positioning psychological pain relative to depression and related constructs A central contribution of this study is its differentiation of psychological pain from depression and other related constructs that are often conflated in both research and clinical practice. As illustrated in Table 4, existential grief is conceptualized as distinct from these constructs based on the present analysis. Although depressive symptomatology was present in participants’ narratives, existential grief was not reducible to depression. Depression is typically characterized by mood disturbance, neurovegetative symptoms, and impaired functioning 30 . In contrast, participants spoke less about low mood per se and more about the unbearable quality of inner pain and its perceived inescapability. Psychological pain in this study was defined primarily by subjective unbearability, loss of meaning, and an urgent desire for escape, even in the absence of a diagnosable mood disorder. This distinction aligns with prior research indicating that psychological pain predicts suicidality independently of depression severity 3,4 . Further distinctions emerged between psychological pain and demoralization. Demoralization centers on helplessness and hopelessness with a future-oriented focus in which meaning may still be restorable 31,32 . By contrast, helplessness in the present study was anchored in losses that participants experienced as final rather than reversible. Participants’ experiences of helplessness were tied to irretrievable past losses and a perceived closure of future possibilities, rendering meaning reconstruction subjectively less accessible. While complicated or prolonged grief involves persistent yearning after death-related loss and disrupted meaning reconstruction 19,33 , the present findings extend grief processes to non-finite, symbolic losses such as unrealized identities, without requiring bereavement. Participants were not grieving someone who had died, but versions of themselves that could no longer be lived. This extension broadens the applicability of grief frameworks to identity-related losses that lack social recognition or ritualized mourning. Existential distress, which emphasizes death anxiety, isolation, and freedom–responsibility conflicts 34,35 , overlaps with the dimension of profound loneliness identified in existential grief. However, existential concerns here were less abstract and more tightly bound to life review and perceived temporal closure. In the present model, existential concerns were specifically intensified by midlife self-discrepancy and temporal foreclosure, rather than by mortality awareness alone. The dimensions of existential grief function not as discrete symptoms but as interacting grief processes over time. Regret reflects preoccupation with irreversible choices; sorrow denotes chronic mourning rather than episodic sadness; helplessness indexes perceived foreclosure of agency; and loneliness represents existential disconnection rather than social isolation. These processes unfolded together rather than sequentially, reinforcing one another across time. Although these dimensions partially overlap with depressive cognitions, they differ in phenomenology, temporal orientation, and clinical implications (Table 4). Taken together, these distinctions suggest that existing diagnostic and conceptual categories capture only part of the experience described by participants. Psychological pain, as articulated in this study, was consistently experienced as exceeding any single construct, including depression, demoralization, complicated grief, or existential distress alone. Its defining quality lay in the convergence of subjectively unbearable affect with losses that were experienced as irreversible and self-relevant. Within participants’ accounts, this convergence shaped how escape-related thoughts, including suicidal ideation, were understood, in a manner consistent with pain-avoidance perspectives on suicide 6 . Table 4. Analytical comparison of psychological pain with related constructs Construct Core phenomenology Temporal focus Relation to meaning Association with suicide Key references Psychological pain (existential grief) Unbearable inner pain; mourning for symbolic losses; urgency to escape Past (irretrievable losses) and closed future Central loss of meaning; identity rupture Very strong, often independent of diagnosis 2,5,8,9 Major depression Persistent low mood, anhedonia, neurovegetative symptoms Present-oriented Meaning loss possible but not central Moderate–strong, mediated by severity 30 Demoralization Helplessness, hopelessness, subjective incompetence Future-oriented Meaning threatened but potentially restorable Moderate 31,32 Complicated / prolonged grief Persistent yearning, sorrow after loss Past-focused (death-related loss) Meaning reconstruction disrupted Elevated 19,33 Existential distress Death anxiety, isolation, freedom-responsibility conflict Lifespan-oriented Core existential meaning threat Variable 34,35 Integration with existing theoretical frameworks The conceptual model converges with, yet meaningfully extends, several established theoretical frameworks across developmental psychology, loss, and contemporary suicidology. 1. Developmental and self-theories The ideal–actual self-discrepancy identified in this study resonates with Higgins’ (1987) Self-Discrepancy Theory 36 . However, the findings suggest that in midlife, when lost time and opportunities are perceived as non-correctable, such discrepancies are experienced less as motivational discomfort and more as finalized loss. This shift can be understood as transforming discrepancy-related dejection into grief. The findings also align with the concept of possible selves 37 , highlighting how confrontation with unrealized future selves in midlife amplifies regret and sorrow. In this way, existential grief frames midlife distress as a response to foreclosed developmental possibilities rather than individual psychological failure. 2. Grief and loss frameworks The model aligns with theories of ambiguous and disenfranchised grief 38,39 . Participants’ losses, including missed life trajectories and fragmented identities, represent non-death losses that lack social acknowledgment and mourning rituals. This disenfranchised quality appears to intensify isolation and prolong suffering, contributing to the cyclical nature of existential grief. 3. Suicidology models The model provides developmental depth to current models in suicidology. The convergence of profound loneliness and helplessness (core components of existential grief) directly parallels the motivational constructs of Thwarted Belongingness and Perceived Burdensomeness in Joiner’s Interpersonal Theory of Suicide 40,41 . Furthermore, the conceptual framework resonates with the Integrated Motivational-Volitional (IMV) model 42 , where the defeat and entrapment arising from accumulated losses and midlife pressures serve as key motivational factors leading to ideation. Participants’ reliance on suppressed emotions and maladaptive coping suggests that pain avoidance acts as a volitional moderator, potentially facilitating the transition to suicidal behavior. Similarly, the conceptual model extends the Three-Step Theory 43 by framing existential grief as the primary source of the pain-hopelessness combination that initiates ideation. This ideation is amplified by the acquired capability for suicide, which is qualitatively informed by cumulative relational and developmental losses experienced across the life course. The existential grief framework adds developmental depth by demonstrating how these suicidal states arise from cumulative life review processes characteristic of midlife. This integration responds directly to calls for developmentally informed suicide models 13,16 . Comparison with existential and meaning reconstruction perspectives on grief The present conceptualization of psychological pain as existential grief resonates with contemporary existential and meaning-oriented approaches to grief, while extending them beyond death-related bereavement. Existential perspectives emphasize isolation, meaninglessness, and freedom–responsibility tensions as core dimensions of prolonged suffering 34,35 . Similarly, meaning reconstruction models highlight the centrality of narrative rupture and the struggle to restore coherence following loss 44 . The current findings align with these frameworks but locate the source of existential disruption in symbolic, non-finite losses characteristic of midlife, such as unrealized identities and foreclosed possible selves. Unlike bereavement-focused models, existential grief in this study emerges from confrontation with irreversibility rather than mortality per se, suggesting that meaning collapse in midlife may arise from failed life narratives rather than loss of a loved one. This extension broadens grief theory by situating existential suffering within developmental self-evaluation processes and underscores the need to recognize symbolic loss as a legitimate target of clinical and theoretical attention. Clinical implications for assessment Beyond standard symptom-based assessment, the findings suggest the clinical value of explicitly evaluating existential loss processes during midlife. Clinicians working with midlife adults may benefit from assessing not only current mood states, but also perceived irreversibility of missed life paths, unresolved regret related to ideal–actual self-discrepancy, and beliefs regarding the intolerability of psychological pain. Particular attention should be paid to existential loneliness that persists despite social embeddedness, as this dimension emerged as a critical amplifier of psychological pain. Framing such experiences as forms of existential grief, rather than as personal failure or psychopathology alone, may facilitate validation, reduce shame, and support meaning-oriented formulation. While the present study does not prescribe specific interventions, it underscores the importance of integrating symbolic loss and meaning disruption into suicide risk formulation and therapeutic dialogue with midlife adults. Methodological strengths The study was grounded in a constructivist grounded theory orientation 18 and supported by sustained reflexive practice and adherence to COREQ reporting guidelines 22 , allowing for a careful and context-sensitive exploration of the phenomenon. Alongside core constructivist procedures, a limited number of analytic techniques drawn from other grounded theory traditions were used pragmatically, not as prescriptive frameworks but as tools to support analytic coherence and conceptual integration 21 . Ongoing memo-writing and regular peer debriefing strengthened theoretical sensitivity while keeping the analysis closely anchored in participants’ accounts. This flexible methodological approach enabled the development of a cyclical conceptual model that captures the layered and culturally situated nature of lived experience within a non-WEIRD context. Limitations Several limitations of the present study should be acknowledged. First, the sample consisted of highly educated, employed adult residents of urban Tehran, who self-identified as experiencing a midlife crisis. This relative homogeneity may have constrained theoretical variation and limits the transferability of the findings to individuals from rural settings, lower socioeconomic backgrounds, or those who do not explicitly frame their experiences within a midlife crisis narrative. Second, the predominance of women in the sample (66.6%) represents both a methodological limitation and a contextually meaningful characteristic of participation. This imbalance may reflect gendered patterns of emotional disclosure, help-seeking, and engagement with self-reflective research in Middle Eastern societies 45 . At the same time, cultural norms surrounding masculinity in Iran may discourage men from articulating existential distress, potentially leading to underrepresentation of male perspectives rather than their absence in lived experience. Third, the exclusion of participants who were receiving active psychiatric treatment enhanced ethical safety and analytic clarity. However, this decision may have narrowed the range of clinical severity represented in the data, particularly with respect to acute suicidal states, and should be considered when interpreting the scope of the conceptual model. Fourth, the cross-sectional nature of the data limits insight into how experiences of existential grief evolve over time. Participants’ accounts capture temporally saturated narratives, but the study design does not allow direct observation of developmental change or fluctuation in psychological pain across the midlife period. Finally, and importantly, although the present study offers an integrated and theoretically informed conceptual framework, the model of psychological pain as existential grief should be understood as an interpretive, contextually grounded account rather than a comprehensive, diagnostic, or generalizable theory. Its purpose is to clarify experiential structure, developmental context, and meaning-making processes associated with psychological pain in midlife, not to replace existing diagnostic categories or to establish causal explanations. The value of the framework lies in its conceptual coherence and clinical sensibility, and its broader applicability depends on resonance with other contexts and populations rather than statistical generalization. Recommendations for future research Building on the present grounded theory model, several theoretically informed directions for future research emerge that may advance the understanding of midlife psychological pain beyond symptom-based or stage-based accounts. First, given the processual and temporally saturated nature of existential grief identified in this study, longitudinal qualitative investigations are warranted to examine how symbolic losses, self-discrepancies, and meaning erosion unfold and intensify over time. Such designs could illuminate how psychological pain evolves across midlife, particularly how foreclosed futures and unresolved mourning accumulate and potentially converge toward suicidal ideation. Second, future studies should further examine the conceptual boundaries between existential grief and depressive disorders. Comparative qualitative or mixed-methods research may help clarify whether psychological pain in midlife is primarily driven by mood dysregulation or by irreversibility cognitions, narrative collapse, and perceived failure of the ideal self. Distinguishing existential grief from clinical depression may have important implications for assessment, diagnosis, and intervention, especially for individuals who experience profound suffering without meeting formal diagnostic thresholds. Third, the findings suggest that midlife psychological pain may represent a form of disenfranchised or socially unrecognized grief. Future research could therefore explore cultural, familial, and clinical discourses that shape the visibility or invisibility of existential loss in midlife, particularly in non-Western contexts. Such studies may examine how cultural expectations regarding productivity, sacrifice, and emotional restraint contribute to the suppression or misinterpretation of existential suffering during this life stage. Fourth, the present model invites a reconsideration of the dominant conceptualization of midlife crisis as a transient developmental phase. Further theoretical and empirical work is needed to explore midlife crisis as a potential existential rupture marked by irreversible losses, disrupted life narratives, and sustained discrepancies between the ideal and actual self. Cross-cultural and cross-generational studies may help determine whether this rupture is culturally contingent or reflects a broader developmental vulnerability. Finally, future research may focus on developing clinically meaningful assessment frameworks grounded in qualitative indicators of existential grief, such as unresolved regret, foreclosed future narratives, and chronic loneliness. Rather than prioritizing standardized symptom scales alone, such frameworks could support more nuanced, culturally sensitive approaches to identifying psychological pain in midlife and tailoring interventions accordingly. Conclusion This study conceptualizes psychological pain in midlife as existential grief, understood as an unfinished mourning for symbolic losses shaped by developmental timing, cultural expectations, and relational contexts. Participants’ accounts suggest that midlife may represent a confrontation with the realization that certain life possibilities, identities, and aspirations can no longer be lived or revised. In this sense, psychological pain was experienced not merely as distress, but as grief for lost opportunities to become and to live a once-imagined life. The proposed model illustrates how this form of grief unfolds as a cyclical process in which accumulated self-discrepancies, unresolved emotional wounds, and contextual pressures converge, generating a persistent experience of unbearable inner pain. Although conceptually resonant with classic grief formulations, the findings indicate that mourning in midlife does not follow a linear or stage-based bereavement trajectory. Instead, it is characterized by recurring movements between regret, sorrow, helplessness, and profound loneliness, shaped by the perceived closure of time and foreclosed life paths. By reframing psychological pain as existential grief rather than symptom severity alone, this study highlights the importance of attending to symbolic loss, irreversible self-discrepancies, meaning disruption, and pain-avoidance cognitions in midlife adults. While further research across diverse contexts is needed, the present findings offer a cautious yet integrative conceptual framework for understanding the progression from symbolic loss to suicidal ideation in midlife, an understudied and clinically vulnerable stage of adulthood. As an exploratory qualitative study, this work is intended to clarify the experiential structure and meaning of psychological pain in midlife rather than to provide exhaustive or definitive explanations, thereby opening avenues for further theoretical refinement and empirical investigation. Declarations Ethics approval and consent to participate This study was performed in line with the principles of the Declaration of Helsinki. Ethical approval was obtained from the Research Ethics Committee of Allameh Tabataba’i University (IR.ATU.REC.1403.152). Written informed consent was obtained from all participants. Confidentiality, voluntary participation, and the right to withdraw were emphasized. A structured distress protocol was implemented to manage emotional discomfort during interviews. Passive suicidal ideation was operationalized as the presence of a desire to die without active planning or immediate intent (e.g., wishing for a natural death or not waking up). This was addressed sensitively during the interview process. Thresholds for immediate escalation and intervention were clearly predefined: the safety protocol was designed to be activated if the participant disclosed active ideation (specific plan, intent, or means) within the past week, or reported acute distress that compromised immediate safety. In the present study, while passive ideation was reported, no imminent risk was identified, and no emergency referrals were made. Participants were provided with information on counseling services and local mental health resources before and after the interview. All data were anonymized and securely stored. To maintain fidelity in translation from Persian to English, back-translation by an independent bilingual colleague was used for key quotations and themes. Consent for publication Not Applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. It was conducted as part of the first author's doctoral dissertation at Allameh Tabataba’i University, Tehran, Iran. Authors' contributions M.H. conceived and designed the study, conducted the interviews, performed data analysis using a constructivist grounded theory approach, developed the conceptual model, and drafted the manuscript. A.B. supervised the overall research process, provided existential therapeutic expertise, and offered continuous guidance throughout all stages of the study. He also contributed to the refinement and integration of codes, assisted in conceptual refinement, and critically reviewed the initial manuscript drafts. Z.R. contributed to analytic consultation during coding, assisted in the refinement and integration of codes and the development of the analytical model, and helped design the research instruments. A.E. provided ongoing consultation throughout the research process and contributed to conceptual discussions during data analysis and interpretation. A.M. contributed methodological guidance and provided expertise in gerontology, particularly regarding developmental and aging-related considerations relevant to midlife. All authors reviewed and approved the final version of the manuscript. Acknowledgements The authors gratefully acknowledge the participants for sharing their experiences, which made this study possible. The authors also thank Zahra Aghayan, clinical psychologist, for her analytic consultation during the initial open coding phase, which contributed to inter-coder consistency and depth of analysis. AI tools were used only to refine language and style; all analytic decisions and data interpretation were conducted by the authors. The authors assume full responsibility for the content and integrity of the manuscript. References World Health Organization. Suicide worldwide in 2021: global health estimates. Geneva: World Health Organization; 2024. https://www.who.int/publications/i/item/9789240110069 Shneidman ES. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8698936\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":598906048,\"identity\":\"2f8dc316-a898-47a5-b2e0-5cc83d11e11f\",\"order_by\":0,\"name\":\"Mahmoud Hakimnia\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYFACHgbGBgMGBjYG5gNQEcYGYrWwJTAcIF4LhGHAcACvSijQbeA9+HFGwbY8PvYzHz9/bGOQ529gbvuAT4vZAb5kyQ0Gt4vZeHI3SxxsYzCccYCxeQZ+LTwGkg8Mbie2MeRuAGlh3MDA2IzXYUAtxj/BWvjfPP4B1GJPjBYzkMMS2yRy2EC2JBKlxXIGWMszM4sz5ySSZxwmwmE3e/7cTpzfn/z4RkWZjW1/e/tjvFoY5B+gcCUYGJjxaxgFo2AUjIJRQAQAAMSqSiM014QiAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"Allameh Tabataba’i University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Mahmoud\",\"middleName\":\"\",\"lastName\":\"Hakimnia\",\"suffix\":\"\"},{\"id\":598906049,\"identity\":\"798a5b77-934b-4dac-925d-fcfa69f5e013\",\"order_by\":1,\"name\":\"Ahmad Borjali\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Allameh Tabataba’i University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ahmad\",\"middleName\":\"\",\"lastName\":\"Borjali\",\"suffix\":\"\"},{\"id\":598906050,\"identity\":\"d72f0011-7875-4488-9874-e98505ffabdc\",\"order_by\":2,\"name\":\"Zohreh Rafezi\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Allameh Tabataba’i University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Zohreh\",\"middleName\":\"\",\"lastName\":\"Rafezi\",\"suffix\":\"\"},{\"id\":598906051,\"identity\":\"80087f51-17f7-4c52-ac64-7af0c9f44d8f\",\"order_by\":3,\"name\":\"Abolghasem Isamorad\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Allameh Tabataba’i University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Abolghasem\",\"middleName\":\"\",\"lastName\":\"Isamorad\",\"suffix\":\"\"},{\"id\":598906052,\"identity\":\"fce129f5-784f-4846-ac98-201bd554f2e3\",\"order_by\":4,\"name\":\"Abdollah Moatamedy\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Allameh Tabataba’i University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Abdollah\",\"middleName\":\"\",\"lastName\":\"Moatamedy\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-01-26 09:57:03\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8698936/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8698936/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":103840846,\"identity\":\"b03a4545-b56e-4260-888f-3dd077e50a98\",\"added_by\":\"auto\",\"created_at\":\"2026-03-03 14:42:14\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":213560,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eConceptual model of psychological pain as existential grief in midlife: a cyclical process. \\u003c/strong\\u003eThe model illustrates the cyclical, self-perpetuating nature of existential grief, with feedback loops reinforcing the process (constructed using constructivist grounded theory\\u003csup\\u003e18\\u003c/sup\\u003e).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8698936/v1/2bebca95ca1552346b49a49a.jpg\"},{\"id\":104401022,\"identity\":\"d9f4c269-ac7a-4672-a00d-33c899e7ddae\",\"added_by\":\"auto\",\"created_at\":\"2026-03-11 12:11:41\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1727820,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8698936/v1/3b31954d-d496-4c96-8db4-2585ff52d884.pdf\"},{\"id\":103840845,\"identity\":\"6c1191db-08ab-4e81-bc02-bf8f9ea0db1f\",\"added_by\":\"auto\",\"created_at\":\"2026-03-03 14:42:13\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":21304,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryMaterial.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8698936/v1/ec13728fdae2968bdf165cae.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Psychological pain as existential grief in midlife: a constructivist grounded theory\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003ePsychological pain has emerged as one of the strongest independent predictors of suicidal ideation and behavior, especially given that suicide constitutes a major global public health crisis, claiming approximately 700,000 lives annually and exacting profound emotional and socioeconomic costs\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e\\u003c/sup\\u003e. Effective prevention requires identification of modifiable proximal risk factors. Recent longitudinal evidence from high-risk cohorts demonstrates that intense psychological pain over brief periods is an independent predictor of suicidal acts, even after controlling for depression severity\\u003csup\\u003e\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e. Two high-quality syntheses confirm these associations: a systematic review of 42 studies\\u003csup\\u003e\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u003c/sup\\u003e and a meta-analysis of 20 studies\\u003csup\\u003e\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u003c/sup\\u003e both concluded that psychological pain is a significant suicide risk factor even in the absence of diagnosed psychiatric disorders and is often a stronger predictor than depression alone. Studies further indicate that the dimension of pain avoidance, the perceived necessity of escaping unbearable psychological pain, is a particularly robust predictor of suicidal ideation and attempts, often outperforming depression and other traditional risk factors\\u003csup\\u003e\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u003c/sup\\u003e. Deepening theoretical and empirical understanding of this multidimensional construct is thus essential for advancing suicide prevention.\\u003c/p\\u003e \\u003cp\\u003eDespite its centrality, psychological pain remains conceptually fragmented and terminologically heterogeneous\\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u003c/sup\\u003e. Definitions vary widely, ranging from negative self-appraisal linked to perceived failures to more enduring and irreversible disruptions in the self and its functioning\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e. This lack of conceptual coherence has led to the development of numerous assessment instruments that differ substantially in focus and scope\\u003csup\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e\\u003c/sup\\u003e. Although several newer measures have been proposed, many have been developed with limited qualitative grounding and minimal direct input from individuals with lived experience, raising concerns about their content validity and ecological relevance\\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e. As a result, much of the existing quantitative literature captures the intensity of psychological pain while offering limited insight into how it is experienced, interpreted, and shaped over time. Addressing this gap requires rigorous qualitative inquiry, particularly during developmentally vulnerable life stages.\\u003c/p\\u003e \\u003cp\\u003eMidlife represents a critical yet still under-explored context for understanding psychological pain. Developmental research characterizes this period as one marked by the accumulation of demanding and often competing roles, including spousal, parental, caregiving, and professional responsibilities, alongside ongoing identity transitions\\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e. Large-scale cross-national studies consistently show a U-shaped pattern of psychological distress, with risk peaking in midlife across indicators such as suicide, severe depression, and alcohol dependence\\u003csup\\u003e\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e\\u003c/sup\\u003e. Notably, this vulnerability persists even after rigorous statistical controls and often coincides with peak earning years, suggesting that distress is driven less by material deprivation than by age-related physical decline, stalled life trajectories, empty-nest transitions, and confrontation with mortality and irretrievable aspirations (Jaques, 1965, cited in\\u003csup\\u003e16\\u003c/sup\\u003e). Although emerging evidence also points to neurobiological correlates of midlife stress\\u003csup\\u003e\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e, most existing work remains quantitative. As a result, qualitative investigations that examine how psychological pain is subjectively experienced, organized over time, and imbued with meaning during midlife remain scarce, despite the well-established link between psychological pain and suicidality.\\u003c/p\\u003e \\u003cp\\u003eTo address the conceptual ambiguity surrounding psychological pain and the well-documented yet qualitatively underexplored vulnerability of midlife, the present study adopts Charmaz\\u0026rsquo;s constructivist grounded theory approach\\u003csup\\u003e\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u003c/sup\\u003e. This methodology was selected because psychological pain in midlife appears to be a processual, temporally embedded, and meaning-laden experience that cannot be adequately captured through predefined categories alone. Rather than aiming to generate a formal or generalizable theory, the study seeks to develop a contextually grounded conceptual framework closely anchored in participants\\u0026rsquo; accounts.\\u003c/p\\u003e \\u003cp\\u003eGrief theory was used as an initial sensitizing lens to support early analytic attention to experiences of symbolic loss, such as unrealized aspirations, foreclosed identities, and disrupted life narratives, and to related processes of meaning reconstruction\\u003csup\\u003e\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u003c/sup\\u003e. Importantly, this lens functioned as a heuristic point of orientation rather than a prescriptive framework, and analytic decisions remained guided by constant comparison and emergent categories. The resulting conceptual model therefore reflects participants\\u0026rsquo; meanings and experiences, rather than the prior imposition of grief-based assumptions.\\u003c/p\\u003e \\u003cp\\u003eThe present study aims to clarify how psychological pain is structured and experienced during midlife by examining its developmental context and subjective meaning. By foregrounding participants\\u0026rsquo; own accounts, the study seeks to articulate a conceptually grounded understanding of psychological pain that is sensitive to both developmental timing and sociocultural context, while addressing the limited qualitative representation of non-WEIRD populations in this literature. Rather than proposing intervention models or clinical techniques, the study is intended to inform future theoretical work, qualitative inquiry, and clinically oriented reflection on psychological pain in midlife.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eStudy design and philosophical underpinnings\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study adopted a qualitative research design informed by constructivist grounded theory as articulated by Charmaz\\u003csup\\u003e18,20\\u003c/sup\\u003e. From a constructivist\\u0026ndash;interpretivist standpoint, meaning is understood as contextually situated and co-constructed through interaction between the researcher and participants, rather than as an objective reality waiting to be discovered. Accordingly, data generation and analysis were approached as reflexive and iterative processes embedded within participants\\u0026rsquo; sociocultural and historical contexts.\\u003c/p\\u003e\\n\\u003cp\\u003eWhile the study was theoretically anchored in Charmaz\\u0026rsquo;s constructivist grounded theory, a limited number of analytic techniques commonly used across grounded theory approaches were employed in a pragmatic manner. These included constant comparative analysis and theoretical sampling, which are widely regarded as methodological procedures rather than theory-bound epistemological commitments\\u003csup\\u003e21\\u003c/sup\\u003e. In addition, a paradigm-oriented diagram was used as an analytic aid to support the exploration of relationships among categories, without implying adherence to the epistemological assumptions of the Strauss and Corbin tradition.\\u003c/p\\u003e\\n\\u003cp\\u003eImportantly, this paradigm-oriented tool functioned as a sensitizing and organizational device rather than as a prescriptive analytic framework. Its function was to support the systematic yet flexible examination of relationships among conditions, actions, and consequences, while explicitly avoiding linear or deterministic causal interpretations\\u003csup\\u003e21\\u003c/sup\\u003e. This approach facilitated a process-oriented and cyclical mode of analysis that remained closely grounded in participants\\u0026rsquo; narratives, and fully consistent with constructivist assumptions regarding meaning-making and interpretation.\\u003c/p\\u003e\\n\\u003cp\\u003eConsistent with the aims of constructivist grounded theory, the study sought to generate a contextually grounded conceptual framework rather than a formal or generalizable theory\\u003csup\\u003e18\\u003c/sup\\u003e. To enhance transparency and reporting quality, the study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist\\u003csup\\u003e22\\u003c/sup\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e(see Additional File 1).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResearch team and reflexivity\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAll interviews were conducted by the first author, who also assumed primary responsibility for data analysis. He is a male doctoral candidate in clinical psychology, aged 51, with formal training in qualitative interviewing and constructivist grounded theory completed prior to the commencement of data collection. Consistent with constructivist grounded theory, the researcher\\u0026rsquo;s positioning as a midlife adult was approached reflexively, acknowledging its dual role as a potential source of analytic insight and a possible influence on interpretation\\u003csup\\u003e18\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eReflexivity was treated as an ongoing and systematic analytic practice through which the researcher critically examined how personal biography, professional training, and experiential proximity to the phenomenon under study could shape both data generation and interpretation\\u003csup\\u003e23-24\\u003c/sup\\u003e. Rather than attempting to eliminate subjectivity, the study sought to make its influence visible and analytically accountable throughout the research process.\\u003c/p\\u003e\\n\\u003cp\\u003eTo manage insider positioning and reduce the risk of over-identification with participants\\u0026rsquo; narratives, multiple reflexive strategies were implemented. These included the preparation of reflexive memos immediately following each interview to capture emotional responses, emerging assumptions, and potential countertransference reactions. In addition, twice monthly\\u003c/p\\u003e\\n\\u003cp\\u003epeer debriefing meetings were held with two senior supervisors, one with expertise in qualitative methodology and one in existential psychotherapy, during which analytic decisions, category development, and emerging interpretations were subjected to critical discussion. Reflexivity was further supported through sustained analytic memo-writing across all stages of coding, with particular attention to documenting interpretive shifts and instances where personal assumptions were deliberately bracketed in favor of participants\\u0026rsquo; accounts.\\u003c/p\\u003e\\n\\u003cp\\u003eTogether, these procedures enhanced analytic transparency and methodological rigor, while allowing the researcher\\u0026rsquo;s clinical sensitivity to inform the analysis without unduly shaping or constraining the emergent conceptual framework.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eParticipants\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eMidlife was defined as the ages 40\\u0026ndash;65, consistent with developmental frameworks that emphasize generativity, identity reevaluation, and existential concerns during this life period \\u003csup\\u003e13,25,26\\u003c/sup\\u003e. Participants were urban Iranian adults who self-identified as experiencing a midlife crisis, operationalized through an initial screening question.\\u003c/p\\u003e\\n\\u003cp\\u003eInclusion criteria were: being within the defined midlife age range; current employment; minimum bachelor-level education; affirmative response to the screening question \\u0026ldquo;In recent years, have you gone through a period of profound doubt, reevaluation, or distress regarding your life direction, identity, or achievements?\\u0026rdquo;; and the ability to participate in an approximately one-hour interview. Exclusion criteria included current psychiatric treatment, severe substance-use disorder, or bereavement within the previous year.\\u003c/p\\u003e\\n\\u003cp\\u003eThe final sample comprised 18 participants (12 women and 6 men) aged 40\\u0026ndash;57 years (M = 45.5). All participants were highly educated, employed, urban residents of Tehran, Iran. Detailed demographic characteristics are presented in Table 1, and participant-level information with exemplar initial themes is summarized in Table 2.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSampling strategy and recruitment\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eSampling was guided by constructivist grounded theory principles, combining purposive and theoretical sampling\\u003csup\\u003e18\\u003c/sup\\u003e. Initial purposive sampling (n = 8) sought to recruit individuals who met the inclusion criteria and could provide rich descriptions of psychological pain during midlife. Participants were recruited through open voluntary calls posted on social media platforms, including Instagram, LinkedIn, and Telegram groups focused on personal development and midlife-related topics, as well as through personal networks. Interested individuals contacted the researcher directly. Theoretical saturation was reached after 16 interviews, when no new properties or relationships emerged,\\u0026nbsp;and existing categories were deemed robustly defined across diverse within the sample. Two additional interviews were conducted to confirm the stability of the emerging model, resulting in a final sample of 18 participants.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1 Participant characteristics (N = 18)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCharacteristic\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003en (%) or M (Range)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eAge (years)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e45.5 (40\\u0026ndash;57)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eFemale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e12 (66.6%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eMale\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e6 (33.3%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e13 (72.2%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eDivorced\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e3 (16.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eSingle\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2 (11.1%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eHas children\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e12 (66.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eBachelor\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e8 (44.4%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eMaster\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e7 (38.9%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003ePhD\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e3 (16.7%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eOccupation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eManagerial/Professional/Academic (100%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eInterview duration (min)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e53 (46\\u0026ndash;62)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eNote. All participants were employed, urban residents of Tehran, Iran, and self-identified as experiencing a midlife crisis. The uniform occupational category reflects the purposive sampling focus on employed adults, which may introduce selection bias (see Limitations).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2 Participant demographics and exemplar initial themes from open coding (N = 18)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCode\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAge\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eGender\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMarital Status\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eChildren\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eEducation\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eOccupation\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eDuration (min)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eExemplar initial themes\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e43\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eDivorced\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMaster\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eManager\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e56\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eRegret for shattered life scripts; existential emptiness\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePhD\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eConsultant\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e48\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eIndecisiveness; profound sorrow; deep loneliness\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e45\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eDivorced\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eBachelor\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eTrainer\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e51\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eRelational isolation; confusion; accumulated failures\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eBachelor\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eTrainer\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e58\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePervasive sorrow; despair\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMaster\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eTeacher\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e53\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eDeep dissatisfaction; regret for paths not taken\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e45\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eBachelor\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eEngineer\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e50\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSuppressed anger; dissatisfaction; relational dysfunction; uncertainty about future\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e44\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSingle\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMaster\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eConsultant\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e47\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePervasive sorrow; helplessness; longing\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e55\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMaster\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSocial worker\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e52\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePervasive sorrow; suppressed anger; relational dissatisfaction; emerging healing processes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e48\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eBachelor\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eFreelancer\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e48\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSuppressed anger; accumulated failures; relational dissatisfaction\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e42\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePhD\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eManager\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e58\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eExistential emptiness; anhedonia (lack of pleasure)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP11\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e57\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePhD\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eTeacher\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e62\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePervasive sorrow; profound loneliness; relational dissatisfaction; emerging meaning crisis\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP12\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e43\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eBachelor\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eManager\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e46\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eExcessive dissatisfaction; suppressed anger\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP13\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eBachelor\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eManager\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e49\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSuppressed anger; dissatisfaction; accumulated failures; regret\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP14\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e53\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eBachelor\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eEngineer\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e58\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eIndecisiveness; profound relational problems; midlife pressures\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e40\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSingle\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNo\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMaster\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSpecialist\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e51\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eProfound loneliness; shame; lack of connection; longing for past relationships\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP16\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e44\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eM\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eBachelor\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eManager\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e48\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eDeep sorrow; profound loneliness; existential emptiness; midlife pressures\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP17\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e50\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eDivorced\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMaster\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eTeacher\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e54\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePervasive sorrow; longing; emotional weariness\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eP18\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e50\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMarried\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMaster\\u0026rsquo;s\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eConsultant\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e62\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eProfound sorrow; loneliness; regret; relational isolation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e[Please insert Table2 here]\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData collection\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eData were collected through in-depth semi-structured interviews specifically designed to explore experiences of psychological pain during midlife. The interview guide was developed based on a systematic review of literature on psychological pain\\u003csup\\u003e2\\u003c/sup\\u003e, midlife transitions\\u003csup\\u003e27\\u003c/sup\\u003e, and recent empirical research\\u003csup\\u003e16\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eGuide development followed a structured process that included conceptual clarification of the phenomenon, drafting open-ended questions, and multiple rounds of iterative review by members of the research team with expertise in psychological science (assessment, clinical intervention, and qualitative research). The final guide (see the interview protocol section in the Supplementary Materials)\\u0026nbsp;adopted a funnel structure, beginning with broad prompts and progressing to more focused exploration of emotional, cognitive, interpersonal, and existential dimensions.\\u003c/p\\u003e\\n\\u003cp\\u003eExample questions included: \\u0026ldquo;How would you describe the pain you feel inside?\\u0026rdquo;, \\u0026ldquo;When you think about the life you imagined versus the life you have, what comes up for you?\\u0026rdquo;, \\u0026ldquo;How do you cope with this pain?\\u0026rdquo;, and \\u0026ldquo;How has this experience affected your sense of meaning in life?\\u0026rdquo;\\u003c/p\\u003e\\n\\u003cp\\u003eInterviews were conducted in Persian, either face-to-face in private consultation rooms or via encrypted video calls, and lasted between 46 and 62 minutes. All interviews were audio-recorded with informed consent and transcribed verbatim by the first author. Field notes documenting non-verbal cues and emotional tone were recorded immediately after each interview.\\u003c/p\\u003e\\n\\u003cp\\u003eGiven the sensitive nature of the research topic, participant distress was carefully monitored throughout the interview process. The interviewer, who has formal clinical training, remained attentive to verbal and non-verbal indicators of emotional overload or heightened distress. When participants referred to thoughts related to death or suicide, these experiences were explored in a supportive and non-assumptive manner to clarify their temporal context and subjective meaning. Across interviews, such descriptions were understood as passive or historical rather than indicative of imminent risk. Participants were informed of their right to pause or discontinue the interview at any time, and information about local mental health resources was available if needed.\\u003c/p\\u003e\\n\\u003cp\\u003eKey quotations were translated into English by the first author, who is bilingual in Persian and English. Selected excerpts were subsequently back-translated by an independent bilingual colleague to ensure semantic accuracy and preservation of cultural meaning.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData analysis\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eData analysis followed the principles of constructivist grounded theory as outlined by Charmaz\\u003csup\\u003e\\u003cspan dir=\\\"RTL\\\"\\u003e18\\u003c/span\\u003e\\u003c/sup\\u003e. The process was iterative, with data collection and analysis occurring concurrently, ensuring that emerging concepts were continuously refined and integrated. Interviews were transcribed verbatim and analyzed using MAXQDA 24. The analysis unfolded in three phases: open coding, focused coding, and theoretical coding. Initial open coding was conducted in direct collaboration with an analytic consultant (Zahra Aghayan, acknowledged in the manuscript) to ensure inter-coder consistency and depth. In the open coding phase, the data were analyzed line-by-line to generate initial codes, which captured the finest-grained aspects of participants\\u0026apos; experiences. During focused coding, these initial codes were grouped into categories, guided by constant comparative analysis. Theoretical coding then integrated the categories into a comprehensive framework.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTo ensure theoretical saturation and analytic depth, a saturation grid was employed, which is provided as Supplementary Table S1. This grid allowed us to track the emergence of new categories and ensure that data collection was stopped once theoretical saturation was achieved. The saturation grid included tracking the number of interviews, the categories developed, and the emergence (or lack thereof) of new concepts. We reached theoretical saturation after 16 interviews, with no new themes emerging. Two additional interviews were conducted to confirm saturation, ensuring that the categories were stable and comprehensive.\\u003c/p\\u003e\\n\\u003cp\\u003eTo further enhance methodological rigor, we engaged in peer debriefing with two experienced qualitative methodologists and conducted member checking with five participants (one male, P6) and four females P1, P2, P5, P11) to confirm that the findings and emerging categories accurately reflected their lived experiences. All five participants affirmed the resonance of the conceptual model, with minor suggestions for nuance that were incorporated into the final interpretations. Negative and discrepant cases were actively sought and integrated into the analysis; for instance, while maladaptive coping strategies predominated, a few participants described transient adaptive responses (e.g., channeling energy into caregiving roles), which were incorporated as variations within the \\u0026quot;Strategies/Responses\\u0026quot; category to ensure the robustness and breadth of the model.\\u003c/p\\u003e\\n\\u003cp\\u003eThis approach, including constant comparison and the use of the saturation grid, ensured that the data analysis was both thorough and responsive to emerging insights, and that the theoretical framework was well-grounded in the participants\\u0026apos; lived experiences while remaining methodologically sound.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTrustworthiness\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTrustworthiness was ensured using criteria appropriate for constructivist qualitative research\\u003csup\\u003e18,28\\u003c/sup\\u003e. Credibility was supported through prolonged engagement with the data, iterative analysis, and member checking with five participants, who confirmed that the interpretations reflected their experiences. Ongoing peer debriefing with two experienced supervisors (a qualitative methodologist and an existential psychotherapist) provided critical examination of emerging interpretations and helped challenge potential assumptions.\\u003c/p\\u003e\\n\\u003cp\\u003eDependability and confirmability were enhanced through a comprehensive audit trail, including analytic memos, coding iterations, and reflexive documentation of key decision-making processes. Discrepant and negative cases were actively sought and integrated to refine categories and ensure analytic robustness. Transferability was supported through thick description of the research context and the use of illustrative participant quotations. Collectively, these strategies ensured that the findings were grounded in participants\\u0026rsquo; lived experiences while maintaining analytic rigor and reflexive transparency.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eA constructivist grounded theory analysis of 18 in-depth interviews indicated that participants experienced psychological pain in midlife not as a transient emotional state, but as a dynamic and cyclical process conceptualized as existential grief. Participants consistently described their suffering as an ongoing mourning for unrealized life possibilities, lost aspirations, and an ideal self-perceived as permanently unattainable. The core category, existential grief, emerged through participants\\u0026rsquo; accounts of confronting an enduring ideal\\u0026ndash;actual self-discrepancy and served to organize the relationships among the other categories identified in the analysis (Figure 1).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEmergence of the theoretical model\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe theoretical model was developed through iterative constructivist grounded theory procedures, including initial line-by-line coding, focused coding, and theoretical coding, guided by constant comparative analysis\\u003csup\\u003e18\\u003c/sup\\u003e. Theoretical sampling facilitated exploration of variation in experiences of loss and unrealized life goals. Theoretical saturation was reached after 16 interviews, with two additional interviews conducted to confirm category stability. The resulting model organizes participants\\u0026rsquo; accounts into interrelated categories reflecting historical experiences, midlife contextual pressures, relational conditions, coping responses, and reported outcomes (Table 3).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 3. Summary of major categories, subcategories, and exemplar quotations\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMajor Category\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCore Theoretical Construct (where applicable)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSubcategory\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eExemplar Quotation (Participant ID)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCausal Conditions\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eIdeal\\u0026ndash;Actual Self-Discrepancy\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eShattered life scripts\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;I didn\\u0026apos;t get what I was looking for...! I can\\u0026apos;t be kind to myself\\u0026rdquo; (P1).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eDevelopmental trauma\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;As a child, I was humiliated a lot\\u0026rdquo; (P3).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSuppressed emotions\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;Everything is inside me and I keep everything good on the outside\\u0026rdquo; (P4).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eContextual Conditions\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMultidimensional midlife pressures\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSandwich-generation\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;Everything rests on my shoulders alone\\u0026rdquo; (P16).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eCultural-social pressures\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;My mother\\u0026apos;s opinion is that you have to endure and that\\u0026apos;s life \\u0026ldquo;(P5).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eEconomic-financial pressures\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;The economic and work situation is not the same as before; this also worries me\\u0026rdquo; (P6).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eIntervening Conditions\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eLack of effective emotional relationship\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026quot;The emotional connection between us has been broken\\u0026quot; (P6).\\u003c/span\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eForeclosed opportunities\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;Now there\\u0026rsquo;s no chance left\\u0026rdquo; (P1).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCentral Phenomenon\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eExistential Grief\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eRegret\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;I wish I had overcome my fears sooner\\u0026rdquo; (P18).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSorrow\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;A constant sorrow that no one sees\\u0026rdquo; (P2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eHelplessness\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;Nothing works!\\u0026rdquo; (P13).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eProfound loneliness\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;I feel lonely in the middle of a crowd\\u0026rdquo; (P15).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eStrategies/Responses\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eMaladaptive (dominant)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;I smoke a little weed, it calms me down\\u0026rdquo; (P12).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eTransient adaptive\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;I devote all my energy and time to my daughter\\u0026rdquo; (P11).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eConsequences\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePsychological burnout\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;I\\u0026rsquo;m only alive because of my daughter\\u0026rdquo; (P16).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eCrisis of meaning\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;I keep telling myself how meaningless life is\\u0026rdquo; (P6).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eSuicidal ideation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u0026ldquo;I lack the courage for suicide; otherwise, I would have done it\\u0026rdquo; (P6).\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCausal conditions: the historical seeds of grief\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eCausal conditions were organized around a central axial process of cumulative ideal\\u0026ndash;actual self-discrepancy, which became acutely salient during midlife. Participants described psychological pain as emerging from the realization that their lived life trajectories had diverged irreversibly from long-held aspirations, values, and imagined futures. This discrepancy was not experienced as transient dissatisfaction, but as a sustained confrontation with lost possibilities and an unfinished mourning for unrealized aspects of the self. Three interrelated axial conditions constituted the historical foundation through which this core discrepancy developed and intensified: shattered life scripts, unresolved developmental trauma, and long-suppressed emotions.\\u003c/p\\u003e\\n\\u003cp\\u003eThe first and most explicit manifestation of ideal\\u0026ndash;actual self-discrepancy was articulated through shattered life scripts. Participants frequently mourned the collapse of idealized narratives that had once provided direction, coherence, and hope. These scripts, formed around expectations of achievement, autonomy, intimacy, or moral success, were described as no longer attainable within the constraints of current reality. The resulting gap between the envisioned ideal self and the accumulated outcomes of lived experience generated pervasive regret, self-blame, and a sense of existential failure. One participant reflected, \\u0026ldquo;All those fantasies I built in my mind since childhood\\u0026hellip; none of them came true. They all crashed into a wall\\u0026rdquo; (P1). Similarly, another stated, \\u0026ldquo;The dreams of my youth and the opportunities I could have had are gone!\\u0026rdquo; (P14). These accounts illustrate how midlife functioned as a temporal checkpoint that rendered discrepancies between imagined and actual selves undeniable and emotionally overwhelming.\\u003c/p\\u003e\\n\\u003cp\\u003eThe second axial condition involved developmental trauma and unresolved injuries that shaped both the formation of idealized self-representations and the fragility of self-worth across the lifespan. Many participants linked their current psychological pain to early experiences of emotional neglect, rejection, or chronic invalidation. These experiences were not described as resolved historical events, but as enduring vulnerabilities that resurfaced during the heightened self-evaluation characteristic of midlife. Participants reported that such injuries undermined their sense of legitimacy, agency, and deservingness, thereby amplifying the emotional impact of later perceived failures. One participant stated, \\u0026ldquo;I was constantly rejected\\u0026hellip; I can never forgive my mother\\u0026rdquo; (P2). Another noted, \\u0026ldquo;From childhood, there was no one to really see me or hold my pain. It feels like I have been carrying this injury forever\\u0026rdquo; (P5). In this way, developmental trauma functioned as a structural condition that intensified the consequences of ideal\\u0026ndash;actual self-discrepancy.\\u003c/p\\u003e\\n\\u003cp\\u003eThe third axial condition comprised long-suppressed emotions, particularly anger, grief, and sorrow, which participants reported containing for years in response to familial, cultural, or social expectations. Emotional suppression was described as adaptive earlier in life but increasingly unsustainable in midlife, when accumulated losses and disappointments demanded acknowledgment. Participants portrayed these emotions as resurfacing with force, contributing to the subjective unbearability of psychological pain. One participant explained, \\u0026ldquo;Sometimes I feel like fighting someone in the street just to let it out\\u0026rdquo; (P12). Another reflected, \\u0026ldquo;I\\u0026apos;ve been holding back my pain for all these years, but now it feels as though my capacity is full. There is anger over lost time and what could have been, but you know better. You have to keep up your usual appearance and put on a mask. \\u0026lsquo;You\\u0026apos;re fine.\\u0026rsquo;\\u0026rdquo; (P15). Suppressed emotions thus acted as an affective amplifier, intensifying the lived experience of existential grief once self-discrepancy became fully conscious.\\u003c/p\\u003e\\n\\u003cp\\u003eTogether, these causal conditions formed the historical and developmental context through which participants described the emergence of existential grief as an unfinished mourning process for irretrievable aspects of the self and life trajectory. Consistent with constructivist grounded theory, participants did not describe their suffering as episodic distress but rather as a cumulative process rooted in unresolved losses across the life course. Midlife was described as a critical temporal context in which participants reflected on growing discrepancies between the lives they had once imagined for themselves and how their lives had actually unfolded, alongside relational injuries and long-suppressed affects, shaping how psychological pain was experienced and organized.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eContextual conditions: multidimensional midlife pressures\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eContextual conditions were characterized by multifaceted and cumulative midlife pressures that positioned individuals at the center of a complex force field, severely constraining opportunities for reflection, repair, or mourning.\\u003c/p\\u003e\\n\\u003cp\\u003eThese pressures emerged along three primary and interacting dimensions derived from the data. First, intergenerational pressures manifested as \\u0026quot;sandwich-generation\\u0026quot; responsibilities, with participants simultaneously caring for aging parents and dependent children while managing professional demands. Crucially, cultural-social pressures stemmed from traditional societal expectations for occupational stability, familial success, and obligatory social participation (e.g., \\u0026quot;Expectations from relatives to attend all gatherings\\u0026quot; (P11). Simultaneously, economic-financial pressures involved heavy livelihood responsibilities and the role of the \\u0026quot;leading generation,\\u0026quot; further exacerbated by inflation and financial instability.\\u003c/p\\u003e\\n\\u003cp\\u003eThis triaxial convergence generated unrelenting demands, forcing participants to prioritize functionality despite profound internal distress. The narratives revealed a pervasive sense of burden, often feeling that \\u0026ldquo;Everything rests on my shoulders alone.... Ageing parents, child, work, and finances\\u0026rdquo; (P16). Participants emphasized the necessity to endure, stating, \\u0026quot;I\\u0026rsquo;m forced to stay on my feet\\u0026quot; (P2), and expressed deep-seated anxieties about the future, particularly regarding dependent children in the face of macro-economic crises: \\u0026quot;With this inflation and crisis, I\\u0026rsquo;m terrified for my daughter\\u0026rsquo;s future\\u0026quot; (P13).\\u003c/p\\u003e\\n\\u003cp\\u003eThese interacting pressures created an erosive context that profoundly challenged resilience and resource availability, with participants describing midlife as a period marked by cumulative constraints that limited opportunities for reflection, repair, or mourning. This convergence intensified the salience of earlier losses and narrowed perceived options for change, shaping how participants experienced the persistence and depth of psychological pain during this stage of life.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eIntervening conditions: amplifiers of existential grief\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTwo intervening conditions were identified as critical amplifiers of existential grief: lack of effective emotional relationship and perceived foreclosed opportunities. Despite being embedded in family and social networks, participants frequently described profound emotional isolation and lack of validation. Intimate relationships were experienced as emotionally unavailable or dismissive of psychological pain. One participant stated, \\u0026ldquo;My spouse doesn\\u0026rsquo;t even see my pain. I\\u0026rsquo;ve been sleeping in my daughter\\u0026rsquo;s room for years\\u0026rdquo; (P5). Others emphasized the absence of confidants with whom they could share their distress, resulting in an experience of existential loneliness: \\u0026ldquo;No one truly experiences my loneliness\\u0026rdquo; (P16).\\u003c/p\\u003e\\n\\u003cp\\u003eThe second amplifier involved acute awareness of time passing and the perception that opportunities for meaningful change were no longer available. Midlife was framed as a point of irreversibility, where the future felt closed rather than open. As one participant reflected, \\u0026ldquo;Ten years ago I thought I still had time\\u0026hellip; now there\\u0026rsquo;s no chance left\\u0026rdquo; (P1). This sense of temporal closure was particularly acute: \\u0026ldquo;At 53 I can\\u0026rsquo;t start my life over\\u0026rdquo; (P14). This perception eliminated hope for reparation and intensified grief by rendering losses final.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCentral phenomenon: existential grief\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe central phenomenon, existential grief arising from confrontation with accumulated discrepancies between past expectations and lived life trajectories, manifested through four interdependent dimensions: regret, sorrow, helplessness, and profound loneliness. Participants described these dimensions as inseparable and mutually reinforcing, forming a cyclical dynamic in which each intensified the others and sustained the experience of psychological pain. As one participant summarized, \\u0026ldquo;mourning for the life I was supposed to live\\u0026rdquo; (P1).\\u003c/p\\u003e\\n\\u003cp\\u003eRegret represented a cognitive and emotional preoccupation with irreversible choices and missed opportunities. Participants repeatedly engaged in counterfactual reflections on alternative life paths. One participant stated, \\u0026ldquo;I wish I had gotten divorced when I was thirty... I wasted twenty years of my life\\u0026rdquo; (P17). Regret functioned as a primary entry point into the grieving process, often tied to shattered early narratives.\\u003c/p\\u003e\\n\\u003cp\\u003eSorrow was described as a pervasive, enduring sadness that colored daily experience. Unlike transient sadness, this sorrow was experienced as constant and depleting. One participant described it as \\u0026ldquo;a constant sorrow that no one sees, that melts you drop by drop\\u0026rdquo; (P2). Sorrow deepened the mourning process and contributed to emotional exhaustion.\\u003c/p\\u003e\\n\\u003cp\\u003eHelplessness reflected a perceived loss of agency and inability to envision or enact change. Participants described feeling trapped within their circumstances, stating, \\u0026ldquo;I don\\u0026rsquo;t know how to get out of this state... Nothing works!\\u0026rdquo; (P13). This sense of powerlessness was heightened by midlife pressures and foreclosed time: \\u0026ldquo;Now at this age, what can I do?\\u0026rdquo; (P11).\\u003c/p\\u003e\\n\\u003cp\\u003eProfound loneliness captured an existential isolation that persisted even in the presence of others. Participants described feeling fundamentally misunderstood and disconnected. One participant stated, \\u0026ldquo;I feel lonely in the middle of a crowd. No one understands this pain\\u0026rdquo; (P15). This loneliness intensified other dimensions of grief by depriving individuals of shared meaning or emotional containment: \\u0026ldquo;A pain that makes you want to escape this world\\u0026rdquo; (P2).\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStrategies/Responses: coping with existential grief\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eParticipants employed a range of strategies to cope with existential grief, which were predominantly maladaptive. These strategies included emotional withdrawal, over-engagement in work or activities, distraction, and escapist ideation. Such responses provided temporary relief but failed to address the underlying grief. One participant summarized this pattern succinctly: \\u0026ldquo;You retreat into your shell\\u0026rdquo; (P1). Additional examples included overwork or intellectual distractions: \\u0026ldquo;I try to occupy my mind by learning a new language\\u0026rdquo; (P6). Less frequently, participants reported transient adaptive strategies, such as dedicating themselves to caregiving roles or engaging in spiritual practices. For example, one participant stated, \\u0026ldquo;To cope with this pain, I devote all my energy and time to my daughter\\u0026rdquo; (P11). \\u0026nbsp;However, these strategies were described as providing only temporary relief from psychological pain and were experienced as insufficient and unsustainable, with participants reporting that pain continued to recur.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsequences: burnout, crisis of meaning, and suicidal ideation\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWhile transient adaptive strategies offered temporary alleviation of psychological pain, they proved insufficient in resolving the underlying existential grief, thereby perpetuating its cyclical recurrence and contributing to eventual burnout and crisis of meaning.\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003eThe predominant consequences of unresolved existential grief were psychological burnout and a crisis of meaning, with several participants reporting passive or historical suicidal ideation. Burnout was described in terms of emotional exhaustion, diminished vitality, and continuing daily life primarily out of obligation rather than desire. One participant stated, \\u0026ldquo;I\\u0026rsquo;m only alive because of my daughter\\u0026rdquo; (P16). Participants also described a loss of meaning and identity confusion, often expressed as a pervasive sense of futility. For example, one participant noted, \\u0026ldquo;Things that used to make me happy no longer bring pleasure\\u0026hellip; life and the future appear dark and meaningless\\u0026rdquo; (P6). In some accounts, suicidal ideation was described as a way of thinking about escape from ongoing psychological pain rather than as an immediate intention or plan. One participant reflected, \\u0026ldquo;I lack the courage for suicide; otherwise, I would have done it\\u0026rdquo; (P6). These descriptions were reported as passive or historical in nature, and no imminent risk was identified during the interviews, with the distress protocol implemented as outlined in the Methods section.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003ePrincipal findings and theoretical contribution\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study contributes to the psychological pain literature by offering a rigorously grounded, developmentally situated, and culturally contextualized conceptual model that conceptualizes psychological pain in midlife as existential grief understood in relation to confrontation with accumulated self-related losses and discrepancies between past expectations and lived life trajectories. Unlike dominant quantitative approaches that operationalize psychological pain primarily as an intensity-based affective construct or proximal suicide risk marker\\u003csup\\u003e2,5\\u003c/sup\\u003e, the present findings frame psychological pain as a processual and cyclical phenomenon rooted in accumulated symbolic losses. Rather than focusing solely on symptom intensity, this perspective emphasizes how psychological pain becomes organized over time around experiences of irreversible loss. This reconceptualization responds to longstanding calls to clarify the internal structure and lived processes of psychological pain, which remain obscured by measurement heterogeneity and symptom overlap with depression and anxiety\\u003csup\\u003e7,8,29\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eThe core category integrates historical losses (e.g., unrealized aspirations and developmental trauma), midlife-specific contextual pressures (e.g., sandwich-generation responsibilities and economic precarity), and relational and temporal amplifiers, including the absence of effective emotional relationships and the perception of foreclosed future possibilities. Participants described these elements as interrelated aspects of their experience, contributing to a sense of ongoing psychological pain that unfolded over time rather than as a reaction to isolated stressors. Importantly, participants rarely framed their suffering as a temporary response to situational demands; instead, it was described as an unfinished mourning process for aspects of the self and life trajectory that were experienced as no longer attainable. This perspective situates psychological pain within a developmental and existential context, particularly in a non-WEIRD urban Iranian setting where intergenerational obligations and socioeconomic pressures may shape how loss and regret are lived and understood.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePositioning psychological pain relative to depression and related constructs\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eA central contribution of this study is its differentiation of psychological pain from depression and other related constructs that are often conflated in both research and clinical practice. As illustrated in Table 4, existential grief is conceptualized as distinct from these constructs based on the present analysis. Although depressive symptomatology was present in participants\\u0026rsquo; narratives, existential grief was not reducible to depression. Depression is typically characterized by mood disturbance, neurovegetative symptoms, and impaired functioning\\u003csup\\u003e30\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eIn contrast, participants spoke less about low mood per se and more about the unbearable quality of inner pain and its perceived inescapability. Psychological pain in this study was defined primarily by subjective unbearability, loss of meaning, and an urgent desire for escape, even in the absence of a diagnosable mood disorder. This distinction aligns with prior research indicating that psychological pain predicts suicidality independently of depression severity\\u003csup\\u003e3,4\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eFurther distinctions emerged between psychological pain and demoralization. Demoralization centers on helplessness and hopelessness with a future-oriented focus in which meaning may still be restorable\\u003csup\\u003e31,32\\u003c/sup\\u003e. By contrast, helplessness in the present study was anchored in losses that participants experienced as final rather than reversible. Participants\\u0026rsquo; experiences of helplessness were tied to irretrievable past losses and a perceived closure of future possibilities, rendering meaning reconstruction subjectively less accessible.\\u003c/p\\u003e\\n\\u003cp\\u003eWhile complicated or prolonged grief involves persistent yearning after death-related loss and disrupted meaning reconstruction\\u003csup\\u003e19,33\\u003c/sup\\u003e, the present findings extend grief processes to non-finite, symbolic losses such as unrealized identities, without requiring bereavement. Participants were not grieving someone who had died, but versions of themselves that could no longer be lived. This extension broadens the applicability of grief frameworks to identity-related losses that lack social recognition or ritualized mourning.\\u003c/p\\u003e\\n\\u003cp\\u003eExistential distress, which emphasizes death anxiety, isolation, and freedom\\u0026ndash;responsibility conflicts\\u003csup\\u003e34,35\\u003c/sup\\u003e, overlaps with the dimension of profound loneliness identified in existential grief. However, existential concerns here were less abstract and more tightly bound to life review and perceived temporal closure. In the present model, existential concerns were specifically intensified by midlife self-discrepancy and temporal foreclosure, rather than by mortality awareness alone.\\u003c/p\\u003e\\n\\u003cp\\u003eThe dimensions of existential grief function not as discrete symptoms but as interacting grief processes over time. Regret reflects preoccupation with irreversible choices; sorrow denotes chronic mourning rather than episodic sadness; helplessness indexes perceived foreclosure of agency; and loneliness represents existential disconnection rather than social isolation. These processes unfolded together rather than sequentially, reinforcing one another across time. Although these dimensions partially overlap with depressive cognitions, they differ in phenomenology, temporal orientation, and clinical implications (Table 4).\\u003c/p\\u003e\\n\\u003cp\\u003eTaken together, these distinctions suggest that existing diagnostic and conceptual categories capture only part of the experience described by participants. Psychological pain, as articulated in this study, was consistently experienced as exceeding any single construct, including depression, demoralization, complicated grief, or existential distress alone. Its defining quality lay in the convergence of subjectively unbearable affect with losses that were experienced as irreversible and self-relevant. Within participants\\u0026rsquo; accounts, this convergence shaped how escape-related thoughts, including suicidal ideation, were understood, in a manner consistent with pain-avoidance perspectives on suicide\\u003csup\\u003e6\\u003c/sup\\u003e.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 4. Analytical comparison of psychological pain with related constructs\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellpadding=\\\"0\\\"\\u003e\\n \\u003cthead\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eConstruct\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eCore phenomenology\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTemporal focus\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRelation to meaning\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eAssociation with suicide\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eKey references\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/thead\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003ePsychological pain (existential grief)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eUnbearable inner pain; mourning for symbolic losses; urgency to escape\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003ePast (irretrievable losses) and closed future\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eCentral loss of meaning; identity rupture\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eVery strong, often independent of diagnosis\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e2,5,8,9\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eMajor depression\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003ePersistent low mood, anhedonia, neurovegetative symptoms\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003ePresent-oriented\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eMeaning loss possible but not central\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eModerate\\u0026ndash;strong, mediated by severity\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e30\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eDemoralization\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eHelplessness, hopelessness, subjective incompetence\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eFuture-oriented\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eMeaning threatened but potentially restorable\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eModerate\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e31,32\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eComplicated / prolonged grief\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003ePersistent yearning, sorrow after loss\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003ePast-focused (death-related loss)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eMeaning reconstruction disrupted\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eElevated\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e19,33\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eExistential distress\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eDeath anxiety, isolation, freedom-responsibility conflict\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eLifespan-oriented\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eCore existential meaning threat\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003eVariable\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd\\u003e\\n \\u003cp\\u003e34,35\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eIntegration with existing theoretical frameworks\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe conceptual model converges with, yet meaningfully extends, several established theoretical frameworks across developmental psychology, loss, and contemporary suicidology.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1. Developmental and self-theories\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe ideal\\u0026ndash;actual self-discrepancy identified in this study resonates with Higgins\\u0026rsquo; (1987) Self-Discrepancy Theory\\u003csup\\u003e36\\u003c/sup\\u003e. However, the findings suggest that in midlife, when lost time and opportunities are perceived as non-correctable, such discrepancies are experienced less as motivational discomfort and more as finalized loss. This shift can be understood as transforming discrepancy-related dejection into grief.\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003eThe findings also align with the concept of possible selves\\u003csup\\u003e37\\u003c/sup\\u003e, highlighting how confrontation with unrealized future selves in midlife amplifies regret and sorrow. In this way, existential grief frames midlife distress as a response to foreclosed developmental possibilities rather than individual psychological failure.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2. Grief and loss frameworks\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe model aligns with theories of ambiguous and disenfranchised grief \\u003csup\\u003e38,39\\u003c/sup\\u003e. Participants\\u0026rsquo; losses, including missed life trajectories and fragmented identities, represent non-death losses that lack social acknowledgment and mourning rituals. This disenfranchised quality appears to intensify isolation and prolong suffering, contributing to the cyclical nature of existential grief.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3. Suicidology models\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe model provides developmental depth to current models in suicidology.\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003eThe convergence of profound loneliness and helplessness (core components of existential grief) directly parallels the motivational constructs of Thwarted Belongingness and Perceived Burdensomeness in Joiner\\u0026rsquo;s Interpersonal Theory of Suicide\\u003csup\\u003e40,41\\u003c/sup\\u003e. Furthermore, the conceptual framework resonates with the Integrated Motivational-Volitional (IMV) model\\u003csup\\u003e42\\u003c/sup\\u003e, where the defeat and entrapment arising from accumulated losses and midlife pressures serve as key motivational factors leading to ideation. Participants\\u0026rsquo; reliance on suppressed emotions and maladaptive coping suggests that pain avoidance acts as a volitional moderator, potentially facilitating the transition to suicidal behavior. Similarly, the conceptual model extends the Three-Step Theory\\u003csup\\u003e43\\u003c/sup\\u003e by framing existential grief as the primary source of the pain-hopelessness combination that initiates ideation. This ideation is amplified by the acquired capability for suicide, which is qualitatively informed by cumulative relational and developmental losses experienced across the life course. The existential grief framework adds developmental depth by demonstrating how these suicidal states arise from cumulative life review processes characteristic of midlife. This integration responds directly to calls for developmentally informed suicide models \\u003csup\\u003e13,16\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eComparison with existential and meaning reconstruction perspectives on grief\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe present conceptualization of psychological pain as existential grief resonates with contemporary existential and meaning-oriented approaches to grief, while extending them beyond death-related bereavement. Existential perspectives emphasize isolation, meaninglessness, and freedom\\u0026ndash;responsibility tensions as core dimensions of prolonged suffering\\u003csup\\u003e34,35\\u003c/sup\\u003e. Similarly, meaning reconstruction models highlight the centrality of narrative rupture and the struggle to restore coherence following loss\\u003csup\\u003e44\\u003c/sup\\u003e. The current findings align with these frameworks but locate the source of existential disruption in symbolic, non-finite losses characteristic of midlife, such as unrealized identities and foreclosed possible selves. Unlike bereavement-focused models, existential grief in this study emerges from confrontation with irreversibility rather than mortality per se, suggesting that meaning collapse in midlife may arise from failed life narratives rather than loss of a loved one. This extension broadens grief theory by situating existential suffering within developmental self-evaluation processes and underscores the need to recognize symbolic loss as a legitimate target of clinical and theoretical attention.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eClinical implications for assessment\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eBeyond standard symptom-based assessment, the findings suggest the clinical value of explicitly evaluating existential loss processes during midlife. Clinicians working with midlife adults may benefit from assessing not only current mood states, but also perceived irreversibility of missed life paths, unresolved regret related to ideal\\u0026ndash;actual self-discrepancy, and beliefs regarding the intolerability of psychological pain. Particular attention should be paid to existential loneliness that persists despite social embeddedness, as this dimension emerged as a critical amplifier of psychological pain. Framing such experiences as forms of existential grief, rather than as personal failure or psychopathology alone, may facilitate validation, reduce shame, and support meaning-oriented formulation. While the present study does not prescribe specific interventions, it underscores the importance of integrating symbolic loss and meaning disruption into suicide risk formulation and therapeutic dialogue with midlife adults.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethodological strengths\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was grounded in a constructivist grounded theory orientation\\u003csup\\u003e18\\u003c/sup\\u003e and supported by sustained reflexive practice and adherence to COREQ reporting guidelines\\u003csup\\u003e22\\u003c/sup\\u003e, allowing for a careful and context-sensitive exploration of the phenomenon. Alongside core constructivist procedures, a limited number of analytic techniques drawn from other grounded theory traditions were used pragmatically, not as prescriptive frameworks but as tools to support analytic coherence and conceptual integration\\u003csup\\u003e\\u003cspan dir=\\\"RTL\\\"\\u003e21\\u003c/span\\u003e\\u003c/sup\\u003e. Ongoing memo-writing and regular peer debriefing strengthened theoretical sensitivity while keeping the analysis closely anchored in participants\\u0026rsquo; accounts. This flexible methodological approach enabled the development of a cyclical conceptual model that captures the layered and culturally situated nature of lived experience within a non-WEIRD context.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eLimitations\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eSeveral limitations of the present study should be acknowledged. First, the sample consisted of highly educated, employed adult residents of urban Tehran, who self-identified as experiencing a midlife crisis. This relative homogeneity may have constrained theoretical variation and limits the transferability of the findings to individuals from rural settings, lower socioeconomic backgrounds, or those who do not explicitly frame their experiences within a midlife crisis narrative.\\u003c/p\\u003e\\n\\u003cp\\u003eSecond, the predominance of women in the sample (66.6%) represents both a methodological limitation and a contextually meaningful characteristic of participation. This imbalance may reflect gendered patterns of emotional disclosure, help-seeking, and engagement with self-reflective research in Middle Eastern societies\\u003csup\\u003e45\\u003c/sup\\u003e. At the same time, cultural norms surrounding masculinity in Iran may discourage men from articulating existential distress, potentially leading to underrepresentation of male perspectives rather than their absence in lived experience.\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThird, the exclusion of participants who were receiving active psychiatric treatment enhanced ethical safety and analytic clarity. However, this decision may have narrowed the range of clinical severity represented in the data, particularly with respect to acute suicidal states, and should be considered when interpreting the scope of the conceptual model.\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFourth, the cross-sectional nature of the data limits insight into how experiences of existential grief evolve over time. Participants\\u0026rsquo; accounts capture temporally saturated narratives, but the study design does not allow direct observation of developmental change or fluctuation in psychological pain across the midlife period.\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFinally, and importantly, although the present study offers an integrated and theoretically informed conceptual framework, the model of psychological pain as existential grief should be understood as an interpretive, contextually grounded account rather than a comprehensive, diagnostic, or generalizable theory. Its purpose is to clarify experiential structure, developmental context, and meaning-making processes associated with psychological pain in midlife, not to replace existing diagnostic categories or to establish causal explanations. The value of the framework lies in its conceptual coherence and clinical sensibility, and its broader applicability depends on resonance with other contexts and populations rather than statistical generalization.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eRecommendations for future research\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eBuilding on the present grounded theory model, several theoretically informed directions for future research emerge that may advance the understanding of midlife psychological pain beyond symptom-based or stage-based accounts. First, given the processual and temporally saturated nature of existential grief identified in this study, longitudinal qualitative investigations are warranted to examine how symbolic losses, self-discrepancies, and meaning erosion unfold and intensify over time. Such designs could illuminate how psychological pain evolves across midlife, particularly how foreclosed futures and unresolved mourning accumulate and potentially converge toward suicidal ideation.\\u003c/p\\u003e\\n\\u003cp\\u003eSecond, future studies should further examine the conceptual boundaries between existential grief and depressive disorders. Comparative qualitative or mixed-methods research may help clarify whether psychological pain in midlife is primarily driven by mood dysregulation or by irreversibility cognitions, narrative collapse, and perceived failure of the ideal self. Distinguishing existential grief from clinical depression may have important implications for assessment, diagnosis, and intervention, especially for individuals who experience profound suffering without meeting formal diagnostic thresholds.\\u003c/p\\u003e\\n\\u003cp\\u003eThird, the findings suggest that midlife psychological pain may represent a form of disenfranchised or socially unrecognized grief. Future research could therefore explore cultural, familial, and clinical discourses that shape the visibility or invisibility of existential loss in midlife, particularly in non-Western contexts. Such studies may examine how cultural expectations regarding productivity, sacrifice, and emotional restraint contribute to the suppression or misinterpretation of existential suffering during this life stage.\\u003c/p\\u003e\\n\\u003cp\\u003eFourth, the present model invites a reconsideration of the dominant conceptualization of midlife crisis as a transient developmental phase. Further theoretical and empirical work is needed to explore midlife crisis as a potential existential rupture marked by irreversible losses, disrupted life narratives, and sustained discrepancies between the ideal and actual self. Cross-cultural and cross-generational studies may help determine whether this rupture is culturally contingent or reflects a broader developmental vulnerability.\\u003c/p\\u003e\\n\\u003cp\\u003eFinally, future research may focus on developing clinically meaningful assessment frameworks grounded in qualitative indicators of existential grief, such as unresolved regret, foreclosed future narratives, and chronic loneliness. Rather than prioritizing standardized symptom scales alone, such frameworks could support more nuanced, culturally sensitive approaches to identifying psychological pain in midlife and tailoring interventions accordingly.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThis study conceptualizes psychological pain in midlife as existential grief, understood as an unfinished mourning for symbolic losses shaped by developmental timing, cultural expectations, and relational contexts. Participants\\u0026rsquo; accounts suggest that midlife may represent a confrontation with the realization that certain life possibilities, identities, and aspirations can no longer be lived or revised. In this sense, psychological pain was experienced not merely as distress, but as grief for lost opportunities to become and to live a once-imagined life.\\u003c/p\\u003e\\n\\u003cp\\u003eThe proposed model illustrates how this form of grief unfolds as a cyclical process in which accumulated self-discrepancies, unresolved emotional wounds, and contextual pressures converge, generating a persistent experience of unbearable inner pain. Although conceptually resonant with classic grief formulations, the findings indicate that mourning in midlife does not follow a linear or stage-based bereavement trajectory. Instead, it is characterized by recurring movements between regret, sorrow, helplessness, and profound loneliness, shaped by the perceived closure of time and foreclosed life paths.\\u003c/p\\u003e\\n\\u003cp\\u003eBy reframing psychological pain as existential grief rather than symptom severity alone, this study highlights the importance of attending to symbolic loss, irreversible self-discrepancies, meaning disruption, and pain-avoidance cognitions in midlife adults. While further research across diverse contexts is needed, the present findings offer a cautious yet integrative conceptual framework for understanding the progression from symbolic loss to suicidal ideation in midlife, an understudied and clinically vulnerable stage of adulthood.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003eAs an exploratory qualitative study, this work is intended to clarify the experiential structure and meaning of psychological pain in midlife rather than to provide exhaustive or definitive explanations, thereby opening avenues for further theoretical refinement and empirical investigation.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eEthics approval and consent to participate\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis study was performed in line with the principles of the Declaration of Helsinki.\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003eEthical approval was obtained from the Research Ethics Committee of Allameh Tabataba\\u0026rsquo;i University (IR.ATU.REC.1403.152). Written informed consent was obtained from all participants. Confidentiality, voluntary participation, and the right to withdraw were emphasized.\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003eA structured distress protocol was implemented to manage emotional discomfort during interviews. Passive suicidal ideation was operationalized as the presence of a desire to die without active planning or immediate intent (e.g., wishing for a natural death or not waking up). This was addressed sensitively during the interview process. Thresholds for immediate escalation and intervention were clearly predefined: the safety protocol was designed to be activated if the participant disclosed active ideation (specific plan, intent, or means) within the past week, or reported acute distress that compromised immediate safety. In the present study, while passive ideation was reported, no imminent risk was identified, and no emergency referrals were made.\\u003c/p\\u003e\\n\\u003cp\\u003eParticipants were provided with information on counseling services and local mental health resources before and after the interview. All data were anonymized and securely stored. To maintain fidelity in translation from Persian to English, back-translation by an independent bilingual colleague was used for key quotations and themes.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot Applicable.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAvailability of data and materials\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no competing interests\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. It was conducted as part of the first author\\u0026apos;s doctoral dissertation at Allameh Tabataba\\u0026rsquo;i University, Tehran, Iran.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u0026apos; contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eM.H.\\u0026nbsp;conceived and designed the study, conducted the interviews, performed data analysis using a constructivist grounded theory approach, developed the conceptual model, and drafted the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eA.B.\\u0026nbsp;supervised the overall research process, provided existential therapeutic expertise, and offered continuous guidance throughout all stages of the study. He also contributed to the refinement and integration of codes, assisted in conceptual refinement, and critically reviewed the initial manuscript drafts.\\u003c/p\\u003e\\n\\u003cp\\u003eZ.R.\\u0026nbsp;contributed to analytic consultation during coding, assisted in the refinement and integration of codes and the development of the analytical model, and helped design the research instruments.\\u003c/p\\u003e\\n\\u003cp\\u003eA.E.\\u0026nbsp;provided ongoing consultation throughout the research process and contributed to conceptual discussions during data analysis and interpretation.\\u003c/p\\u003e\\n\\u003cp\\u003eA.M.\\u0026nbsp;contributed methodological guidance and provided expertise in gerontology, particularly regarding developmental and aging-related considerations relevant to midlife.\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors reviewed and approved the final version of the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors gratefully acknowledge the participants for sharing their experiences, which made this study possible. The authors also thank Zahra Aghayan, clinical psychologist, for her analytic consultation during the initial open coding phase, which contributed to inter-coder consistency and depth of analysis. AI tools were used only to refine language and style; all analytic decisions and data interpretation were conducted by the authors.\\u003cspan dir=\\\"RTL\\\"\\u003e\\u0026nbsp;\\u003c/span\\u003eThe authors assume full responsibility for the content and integrity of the manuscript.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eWorld Health Organization. Suicide worldwide in 2021: global health estimates. Geneva: World Health Organization; 2024. https://www.who.int/publications/i/item/9789240110069 \\u003c/li\\u003e\\n\\u003cli\\u003eShneidman ES. Suicide as psychache. J Nerv Ment Dis. 1993 Mar;181(3):145-7. doi: 10.1097/00005053-199303000-00001. PMID: 8445372.\\u003c/li\\u003e\\n\\u003cli\\u003eP\\u0026eacute;rez-Balaguer A, Pe\\u0026ntilde;uelas-Calvo I, Granda-Beltr\\u0026aacute;n AM, Merayo-Cano JM, Ezquerra B, Alacreu-Crespo A, et al. Association between psychological pain and suicidal behaviour in a cohort of patients at high risk of suicide. Eur J Psychiatry. 2025; 39:100299. doi:10.1016/j.ejpsy.2025.100299 \\u003c/li\\u003e\\n\\u003cli\\u003eVerrocchio MC, Carrozzino D, Marchetti D, Andreasson K, Fulcheri M, Bech P. Mental Pain and Suicide: A Systematic Review of the Literature. Front Psychiatry. 2016 Jun 20;7:108. doi: 10.3389/fpsyt.2016.00108. PMID: 27378956; PMCID: PMC4913233.\\u003c/li\\u003e\\n\\u003cli\\u003eDucasse D, Holden RR, Boyer L, Art\\u0026eacute;ro S, Calati R, Guillaume S, Courtet P, Oli\\u0026eacute; E. Psychological Pain in Suicidality: A Meta-Analysis. J Clin Psychiatry. 2018 May/Jun;79(3):16r10732. doi: 10.4088/JCP.16r10732. PMID: 28872267.\\u003c/li\\u003e\\n\\u003cli\\u003eLi H, Fu R, Zou Y, Cui Y. Predictive Roles of Three-Dimensional Psychological Pain, Psychache, and Depression in Suicidal Ideation among Chinese College Students. Front Psychol. 2017 Sep 12;8:1550. doi: 10.3389/fpsyg.2017.01550. PMID: 28955271; PMCID: PMC5601061.\\u003c/li\\u003e\\n\\u003cli\\u003eTossani E. The concept of mental pain. Psychother Psychosom. 2013;82(2):67-73. doi: 10.1159/000343003. Epub 2012 Dec 22. PMID: 23295405.\\u003c/li\\u003e\\n\\u003cli\\u003eSensky T. Mental Pain and Suffering: The \\u0026quot;Universal Currencies\\u0026quot; of the Illness Experience? Psychother Psychosom. 2020;89(6):337-344. doi: 10.1159/000509587. Epub 2020 Aug 11. PMID: 32781446.\\u003c/li\\u003e\\n\\u003cli\\u003eOrbach I, Mikulincer M, Sirota P, Gilboa-Schechtman E. Mental pain: a multidimensional operationalization and definition. Suicide Life Threat Behav. 2003 Fall;33(3):219-30. doi: 10.1521/suli.33.3.219.23219. PMID: 14582833.\\u003c/li\\u003e\\n\\u003cli\\u003eFava GA, Tomba E, Brakemeier EL, Carrozzino D, Cosci F, E\\u0026ouml;ry A, Leonardi T, Schamong I, Guidi J. Mental Pain as a Transdiagnostic Patient-Reported Outcome Measure. Psychother Psychosom. 2019;88(6):341-349. doi: 10.1159/000504024. Epub 2019 Oct 30. PMID: 31665739.\\u003c/li\\u003e\\n\\u003cli\\u003eCosci F, Mansueto G, Benemei S, Chiarugi A, De Cesaris F, Sensky T. Mental pain as a global person-centered outcome measure. CNS Spectr. 2022 Oct;27(5):652-658. doi: 10.1017/S1092852921000699. Epub 2021 Jul 27. PMID: 34311805. \\u003c/li\\u003e\\n\\u003cli\\u003eCharvet C, Boutron I, Morvan Y, Le Berre C, Touboul S, Gaillard R, Fried E, Chevance A. How to measure mental pain: a systematic review assessing measures of mental pain. Evid Based Ment Health. 2022 Nov;25(4):e4. doi: 10.1136/ebmental-2021-300350. Epub 2022 Jul 28. PMID: 35902215; PMCID: PMC10231614. \\u003c/li\\u003e\\n\\u003cli\\u003eInfurna FJ, Gerstorf D, Lachman ME. Midlife in the 2020s: Opportunities and challenges. Am Psychol. 2020 May-Jun;75(4):470-485. doi: 10.1037/amp0000591. PMID: 32378943; PMCID: PMC7347230. \\u003c/li\\u003e\\n\\u003cli\\u003eBurke V, Grandey AA. \\u0026ldquo;Midlife crisis\\u0026rdquo; on the road to successful workforce aging. Ind Organ Psychol. 2020;13(3):388-94. doi:10.1017/iop.2020.62 \\u003c/li\\u003e\\n\\u003cli\\u003eBlanchflower DG. Is happiness U-shaped everywhere? Age and subjective well-being in 145 countries. J Popul Econ. 2021;34(2):575-624. doi: 10.1007/s00148-020-00797-z. Epub 2020 Sep 9. PMID: 32929308; PMCID: PMC7480662. \\u003c/li\\u003e\\n\\u003cli\\u003eGiuntella O, McManus S, Mujcic R, Oswald AJ, Powdthavee N, Tohamy A. The midlife crisis. Economica. 2023;90:65-110. doi:10.1111/ecca.12452 \\u003c/li\\u003e\\n\\u003cli\\u003eKiesow H, Uddin LQ, Bernhardt BC, Kable J, Bzdok D. Dissecting the midlife crisis: disentangling social, personality and demographic determinants in social brain anatomy. Commun Biol. 2021 Jun 17;4(1):728. doi: 10.1038/s42003-021-02206-x. PMID: 34140617; PMCID: PMC8211729. \\u003c/li\\u003e\\n\\u003cli\\u003eCharmaz K. Constructing grounded theory. 2nd ed. London: Sage; 2014. \\u003c/li\\u003e\\n\\u003cli\\u003eWorden JW. Grief counseling and grief therapy: a handbook for the mental health practitioner. 5th ed. New York: Springer Publishing Company; 2018. doi:10.1891/9780826134752 \\u003c/li\\u003e\\n\\u003cli\\u003eCharmaz K. \\u0026ldquo;With constructivist grounded theory you can\\u0026rsquo;t hide\\u0026rdquo;: social justice and the possibilities of resistance in qualitative inquiry. Qual Inq. 2020;26(6):604-8. https://doi.org/10.1177/1077800419879081\\u003c/li\\u003e\\n\\u003cli\\u003eCorbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. 4th ed. Thousand Oaks: Sage; 2015. \\u003c/li\\u003e\\n\\u003cli\\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007 Dec;19(6):349-57. doi: 10.1093/intqhc/mzm042. Epub 2007 Sep 14. PMID: 17872937. \\u003c/li\\u003e\\n\\u003cli\\u003eFinlay L. \\u0026quot;Outing\\u0026quot; the researcher: the provenance, process, and practice of reflexivity. Qual Health Res. 2002 Apr;12(4):531-45. doi: 10.1177/104973202129120052. PMID: 11939252. \\u003c/li\\u003e\\n\\u003cli\\u003eOlmos-Vega FM, Stalmeijer RE, Varpio L, Kahlke R. A practical guide to reflexivity in qualitative research: AMEE Guide No. 149. Med Teach. 2022 Apr 7:1-11. doi: 10.1080/0142159X.2022.2057287. Epub ahead of print. PMID: 35389310.\\u003c/li\\u003e\\n\\u003cli\\u003eErikson EH. Childhood and society. New York: Norton; 1950. \\u003c/li\\u003e\\n\\u003cli\\u003eLachman ME. Development in midlife. Annu Rev Psychol. 2004;55:305-31. doi: 10.1146/annurev.psych.55.090902.141521. PMID: 14744218.\\u003c/li\\u003e\\n\\u003cli\\u003eLevinson DJ. The seasons of a man\\u0026apos;s life. New York: Knopf; 1978. \\u003c/li\\u003e\\n\\u003cli\\u003eLincoln YS, Guba EG. Naturalistic inquiry. Beverly Hills: Sage; 1985. \\u003c/li\\u003e\\n\\u003cli\\u003eMeerwijk EL, Weiss SJ. Toward a unifying definition: response to \\u0026apos;The concept of mental pain\\u0026apos;. Psychother Psychosom. 2014;83(1):62-3. doi: 10.1159/000348869. Epub 2013 Nov 19. PMID: 24281693.\\u003c/li\\u003e\\n\\u003cli\\u003eAmerican Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed., text rev. Washington, DC: American Psychiatric Association; 2022. doi:10.1176/appi.books.9780890425787 \\u003c/li\\u003e\\n\\u003cli\\u003eKissane DW, Clarke DM, Street AF. Demoralization syndrome--a relevant psychiatric diagnosis for palliative care. J Palliat Care. 2001 Spring;17(1):12-21. PMID: 11324179. \\u003c/li\\u003e\\n\\u003cli\\u003eClarke DM, Kissane DW. Demoralization: its phenomenology and importance. Aust N Z J Psychiatry. 2002 Dec;36(6):733-42. doi: 10.1046/j.1440-1614.2002.01086.x. PMID: 12406115. \\u003c/li\\u003e\\n\\u003cli\\u003ePrigerson HG, Horowitz MJ, Jacobs SC, Parkes CM, Aslan M, Goodkin K, Raphael B, Marwit SJ, Wortman C, Neimeyer RA, Bonanno GA, Block SD, Kissane D, Boelen P, Maercker A, Litz BT, Johnson JG, First MB, Maciejewski PK. Prolonged grief disorder: Psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med. 2009 Aug;6(8):e1000121. doi: 10.1371/journal.pmed.1000121. Epub 2009 Aug 4. Erratum in: PLoS Med. 2013 Dec;10(12). doi:10.1371/annotation/a1d91e0d-981f-4674-926c-0fbd2463b5ea. Bonanno, George [corrected to Bonanno, George A]. PMID: 19652695; PMCID: PMC2711304.\\u003c/li\\u003e\\n\\u003cli\\u003eYalom ID. Existential psychotherapy. New York: Basic Books/Hachette Book Group; 1980. \\u003c/li\\u003e\\n\\u003cli\\u003eBoston P, Bruce A, Schreiber R. Existential suffering in the palliative care setting: an integrated literature review. J Pain Symptom Manage. 2011 Mar;41(3):604-18. doi: 10.1016/j.jpainsymman.2010.05.010. Epub 2010 Dec 8. PMID: 21145202.\\u003c/li\\u003e\\n\\u003cli\\u003eHiggins ET. Self-discrepancy: a theory relating self and affect. Psychol Rev. 1987;94(3):319-40. doi:10.1037/0033-295X.94.3.319 \\u003c/li\\u003e\\n\\u003cli\\u003eMarkus H, Nurius P. Possible selves. Am Psychol. 1986;41(9):954-69. doi:10.1037/0003-066X.41.9.954 \\u003c/li\\u003e\\n\\u003cli\\u003eBoss P. Ambiguous loss: learning to live with unresolved grief. Cambridge: Harvard University Press; 1999. \\u003c/li\\u003e\\n\\u003cli\\u003eDoka KJ. Disenfranchised grief: new directions, challenges, and strategies for practice. Champaign: Research Press; 2002. \\u003c/li\\u003e\\n\\u003cli\\u003eJoiner TE. Why people die by suicide. Cambridge: Harvard University Press; 2005. \\u003c/li\\u003e\\n\\u003cli\\u003eVan Orden KA, Witte TK, Cukrowicz KC, Braithwaite SR, Selby EA, Joiner TE Jr. The interpersonal theory of suicide. Psychol Rev. 2010 Apr;117(2):575-600. doi: 10.1037/a0018697. PMID: 20438238; PMCID: PMC3130348. \\u003c/li\\u003e\\n\\u003cli\\u003eO\\u0026apos;Connor RC, Kirtley OJ. The integrated motivational-volitional model of suicidal behaviour. Philos Trans R Soc Lond B Biol Sci. 2018 Sep 5;373(1754):20170268. doi: 10.1098/rstb.2017.0268. PMID: 30012735; PMCID: PMC6053985. \\u003c/li\\u003e\\n\\u003cli\\u003eKlonsky ED, May AM, Saffer BY. Suicide, Suicide Attempts, and Suicidal Ideation. Annu Rev Clin Psychol. 2016;12:307-30. doi: 10.1146/annurev-clinpsy-021815-093204. Epub 2016 Jan 11. PMID: 26772209.\\u003c/li\\u003e\\n\\u003cli\\u003eNeimeyer RA. Meaning reconstruction in bereavement: Development of a research program. Death Stud. 2019;43(2):79-91. doi: 10.1080/07481187.2018.1456620. PMID: 30907718.\\u003c/li\\u003e\\n\\u003cli\\u003eElshamy F, Hamadeh A, Billings J, Alyafei A. Mental illness and help-seeking behaviours among Middle Eastern cultures: A systematic review and meta-synthesis of qualitative data. PLoS One. 2023 Oct 26;18(10):e0293525. doi: 10.1371/journal.pone.0293525. PMID: 37883515; PMCID: PMC10602270.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-psychology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"psyo\",\"sideBox\":\"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"BMC Psychology\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"psychological pain, existential grief, midlife, grounded theory, symbolic loss, self-discrepancy\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8698936/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8698936/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003ePsychological pain is a well-established predictor of suicidal ideation and behavior. However, the ways in which this pain is subjectively experienced and made sense of during midlife, particularly among individuals who experience this period as a crisis, remain insufficiently understood. Midlife often involves intensified existential reflection and confrontation with discrepancies between imagined and lived life trajectories, a process that may be especially salient in non-Western sociocultural contexts where qualitative evidence remains limited. Within this context, the present study examined how adults who self-identified as experiencing a midlife crisis understand, describe, and live with psychological pain.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eUsing a qualitative design, in-depth semi-structured interviews were conducted with 18 urban Iranian adults aged 40 to 57 years who reported experiencing a midlife crisis. Data were analyzed following Charmaz\\u0026rsquo;s constructivist grounded theory approach, with data collection and analysis proceeding concurrently.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003ePsychological pain emerged not as a discrete emotional state, but as a dynamic and cyclical process conceptualized as existential grief. This process arose through confrontation with an irreversible discrepancy between the ideal self and the lived self. Participants described ongoing mourning for symbolic losses, including unrealized life possibilities and foreclosed identities. Regret, sorrow, helplessness, and profound loneliness were closely intertwined and mutually reinforcing. This experience unfolded as a self-perpetuating cycle, in which unresolved symbolic losses continuously reactivated psychological pain. Midlife-specific pressures and the lack of effective emotional relationships further intensified this process. When unresolved, existential grief culminated in psychological burnout, crisis of meaning, and suicidal ideation.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eThese findings suggest that psychological pain in midlife is better understood as an unfinished grieving process for symbolic, self-related losses rather than as emotional distress alone. Conceptualizing psychological pain as existential grief may sharpen clinical assessment by directing attention to self-discrepancy, histories of symbolic loss, and pain-related escape cognitions, with implications for suicide risk formulation and meaning-oriented clinical work with midlife adults.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Psychological pain as existential grief in midlife: a constructivist grounded theory\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-03-03 14:42:09\",\"doi\":\"10.21203/rs.3.rs-8698936/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-03-27T16:32:20+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"283392870057758536743197562226304007242\",\"date\":\"2026-03-06T11:57:22+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-02-25T05:52:35+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-02-23T12:55:52+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-02-02T05:38:54+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-01-30T20:36:05+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Psychology\",\"date\":\"2026-01-30T20:27:48+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-psychology\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"psyo\",\"sideBox\":\"Learn more about [BMC Psychology](http://bmcpsychology.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"\",\"title\":\"BMC Psychology\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"21529e40-771a-42ff-9406-cd4f487f80fb\",\"owner\":[],\"postedDate\":\"March 3rd, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-03-03T14:42:09+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-03-03 14:42:09\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8698936\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8698936\",\"identity\":\"rs-8698936\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}