The Silent Hill series, particularly the second installment, frequently utilizes psychology and symbolism: Pyramid Head represents James's wish to be punished for Mary's death.

He has also made an appearance outside of the Silent Hill series as a selectable character in the 2008 Nintendo DS title New International Track & Field, Super Bomberman R, and Dead by Daylight as a playable Killer in 2020.

[10] According to Silent Hill 2's character designer Takayoshi Sato, he appears as a "distorted memory of the executioners" and of the town's past as a place of execution.

[3][12] Christophe Gans, the director of the film adaptation of Silent Hill, suggested that Pyramid Head "was one of the executioners in the original history of the town" and "there is not one particular or exclusive manifestation of him as an entity.

[16] Pyramid Head, under the new moniker "Bogeyman", makes a significant appearance in 2008 installment Silent Hill: Homecoming, but his role is limited to non-interactive scenes,[17] appearing only twice to the game's main protagonist Alex Shepherd (once in the Grand Hotel in Silent Hill and, much later, in a church, where he executes Alex's father by splitting him in half).

[20] Mindful of Pyramid Head's role in Silent Hill 2, the developers chose to include him as "the embodiment of a myth [that] parents started to keep the children out of trouble" and "the accretion of the activities going on in the town of Shepherd’s Glen.

"[21] Pyramid Head appears as a boss in the 2007 first-person shooter Silent Hill: The Arcade,[22] as well as Silent Hill: The Escape, but with a composite design with the Butcher, and as a super-deformed selectable character in the 2008 Nintendo DS title New International Track & Field, an installment of the Track & Field series, another spin-off Krazy Kart Racing alongside Robbie the Rabbit, and in 2017's Super Bomberman R as Pyramid Bomber, alongside Simon Belmont from the Castlevania series, and Gradius's Vic Viper.

[23][24] The 2007 game Silent Hill: Origins also included a similar monster named "The Butcher",[25][26] whom the protagonist occasionally encounters killing other monsters (unlike other versions of Pyramid Head, the Butcher can and must be fought and killed in combat) and a painting of Pyramid Head is seen in the burning house of Alessa.

Pyramid Head's most recent appearance was in 2012's Silent Hill: Book of Memories, where he is a monster that can spawn randomly to fight the player.

[28] Pyramid Head was included as a purchasable killer for the survival horror game Dead by Daylight with the release of the CHAPTER 16:Silent Hill DLC on June 16, 2020.

Pyramid Head is also seen controlling the carousel where Heather and Alessa face off against each other, then it kills the cult leader Claudia Wolf after the amulet shows her inner, monstrous nature.

"[38] Additionally, the character was portrayed from October 2 to 31, 2009, in the haunted attraction Sinister Pointe, based on Silent Hill, in Orange County, California, United States.

[43] Specifically, in the case of Silent Hill 2's primary player character James Sunderland, the version of the town he explores is influenced by him.

[47] During her last days alive, she became physically repulsive as a result of the illness and treated James abusively, ordering him to leave one moment and begging him to comfort her the next.

The developer's intent was for James to obtain the other half of the scissors later in the game, symbolizing Pyramid Head's role as a reflection of his psyche.

According to Christina González of The Escapist, Pyramid Head acts as "judgement personified, a dark butcher," and "James' masochistic delusion" which punishes him for Mary's death.

[60][61][62] GameSpot compared Pyramid Head's appearance to Leatherface, the main antagonist of The Texas Chainsaw Massacre series of slasher films, and found him the most terrifying monster in Silent Hill 2.

"[66] Den of Geek noted its popularity and said that "before we knew exactly what Pyramid Head was, the mere sight of the monster triggered something inside of us that overcome our cynicism and defenses.

[74] In a 2009 retrospective on the survival horror genre, IGN noted that Silent Hill 2 incorporated "a 'stalker' element similar to Clock Tower and Resident Evil 3," and wrote: "To this day, Pyramid Head is remembered as one of gaming's most frightening villains.

Critics generally agreed that Pyramid Head's appearance in Homecoming struck them as fan service, though Chris Hudak of GameRevolution called it "damned effectively-employed.

[81][82] DVD Reviews praised Campanella's portrayal of Pyramid Head and another monster, writing: "These are without a doubt some of the most striking bogeymen that I have seen on screen in a long time.