Suicidal thoughts are a significant health concern in the U.S. today. In 2008-2009, 8.3 million people over age 18, corresponding to 3.7% of adults, reported having suicidal thoughts during the previous year. Based on self-report, this is undoubtedly an underestimate as many are hesitant to admit having such thoughts.
Sometimes what appears to be suicidal ideation is actually a form of Obsessive Compulsive Disorder. There are a number of factors differentiating suicidal thoughts and suicidal obsessions, yet given the high degree of overlap, determining the scope of the problem for each individual requires a comprehensive evaluation and regular follow-up.
Suicidal Thoughts and Behavior
The seriousness of suicidal thoughts can be difficult to ascertain since sometimes they may be fleeting while other times there may be a detailed plan in place for carrying out the behavior.
In general, those intent on committing suicide will not provide any indication of their plans and deny the intention if confronted. This is one of the most traumatic aspects of successful suicides for friends and relatives of the victim – the idea that somehow they should have seen it coming despite reassurance from professionals that there was no way to know beforehand.
Most individuals with suicidal intent are actually ambivalent, wavering between wanting to live and wanting to die. Other individuals have no intention of actually dieing but make a suicidal gesture to get others attention or as a call for help.
Thus, suicidal thoughts and behavior are complex problems with a significant risk of death even when not intended.
Suicidal Obsessive Compulsive Disorder (S-OCD)
Suicidal obsessions are invasive, repetitive, unwanted thoughts of suicide that result in significant distress. While S-OCD is conceptualized as having only obsessive symptoms or as a “Pure O” type, this is a misnomer.
The disorder does include compulsions involving either mental acts or behaviors resulting from the anxiety created by the obsessions. Engaging in the compulsions allows the individual to escape the thoughts lowering the anxiety. The decreased anxiety reinforces the link between the obsessions and compulsions and maintains the disorder.
Suicidal obsessions differ from suicidal thoughts in that they do not reflect a true desire to kill oneself; in fact individuals with these obsessions often feel the opposite. They don’t want to kill themselves, typically oppose suicide on moral or religious grounds and are terrified their thoughts could inadvertently cause them to do something that results in their death.
Suicidal obsessions may be spontaneous, seeming to appear from nowhere, or triggered by various activities. The fear of them re-occurring creates secondary anxiety with attempts to identify triggers in order to avoid them soon realizing this isn’t possible.
Over time, it’s likely the frequency of these thoughts will increase until the fill much of the day with obsession, rumination over countering the suicidal thoughts, or engaging in actions to provide reassurance no suicidal behavior has occured.
Individuals who suffer from S-OCD are not ambivalent – they are opposed to committing suicide or even considering it. If suicidal plans enter their thoughts the anxiety worsens, as they fear the more detailed their thoughts become the harder they will be to resist.
Obsessions and Compulsions in S-OCD
Suicidal obsessions often involve the fear of losing control and being unable to resist killing themselves despite not wanting to do so. Thus, the specific thoughts usually follow the form of “What if . . . and end up killing myself before I come to my senses? The “What if. . .” part of the thought can include the following:
What if go crazy and don’t know what I’m doing . . .?
What if I don’t pay enough attention to my thoughts to avoid following them and . . .?
What if the impulse to jump of a building or cliff overwhelms me. . .?
What if I become severely depressed . . .?
What if I can’t resist the impulse to jump in front of a bus or subway . . .?
What if I’m harming myself somehow without knowing it . . .?
What if I’m purposely putting myself in harms way without realizing it . . .?
What if I can’t stop myself from driving off a bridge . . .?
What if I become so distracted by my thoughts that I can’t pay attention to what I’m doing and . . .?
What if I take a handful of pills when I think I’m just taking one or two . . .?
Suicidal compulsions involve maintaining control by obtaining information, making sure there’s no actual suicidal intent and/or they haven’t unknowing engaged in self harm, or manipulation of the environment. Four categories of compulsions include:
- Mentally checking “real” intentions regarding self harm; Checking memories for any time they may have hurt themselves; Checking reasons why they wouldn’t kill themselves and any that could indicate the opposite
- Checking actions and conversations to ensure nothing done or said indicates suicidal intent
- Checking written items to ensure none indicate suicidal intent
- Checking to ensure no lethal items are accessible in their home
- Checking their body to ensure there’s no indication or self harm that occurred without their awareness
- Avoidance of others who make them feel negatively about themselves or trigger a negative mood or memory
- Avoidance of places associated with unwanted thoughts such as subway stations or high buildings
- Avoidance of lethal items in others homes or public places
- Avoidance of being alone so the presence of others will inhibit any suicidal impulses or stop them from acting on any impulses if they can’t resist without help
- Avoidance of boredom or inactivity as physical and/or mental stimulation creates distraction from unwanted thoughts; Avoidance of relaxation including going to bed as they fear “letting down their guard” will allow unwanted thoughts to return
- Avoidance of violent or scary movies to prevent the visual representation of violence from triggering unwanted thoughts; Avoidance of hearing or reading the news to prevent exposure to negative stories
- Avoiding the ability to hurt themselves by keeping their hands in their pockets or sitting on them
- Obtaining confirmation that others don’t believe the individual would kill themselves
- Asking others to confirm the individual has never hurt themselves without remembering
- Sharing unwanted thoughts in the hopes others will say they don’t believe this makes the individual a bad person since the thoughts don’t fit with what they know about the individual
- Spending a lot of time on the internet researching to reassure themselves they have nothing in common with people who kill themselves
- Ruminating about why they would never kill themselves, that they’re opposed to suicide, that they have no desire to kill themselves and that they always fight off the unwanted thoughts
- Replacing unwanted thoughts with pleasant thoughts that contradict suicide such as future related images
- Purposely flooding themselves with thoughts of suicide to prove such thoughts disgust them
- Engaging in compulsive prayer or superstitious behavior that they believe will prevent them from acting out their thoughts
- Instructing themselves to begin a task over again repeatedly until they complete the task without having any unwanted thoughts
While these compulsions may at times lower thought related anxiety, most of the time they are ineffective since they are either impossible to accomplish or alienate the individual from others in several ways.
- They individual will realize that it’s impossible to ensure nothing potentially harmful exists in their home much less others homes or public places where they have no control.
- While they may find nothing written indicating suicidal intent they can’t ensure they’ve checked everything assuming they wouldn’t remember doing so.
- Asking others for reassurance can seem odd such that the individual is avoided, leading to the conclusion the avoidance is due to others not wanting to admit they believe the individual actually could commit suicide.
Reasons Suicidal Compulsions are Ineffective
It is practically impossible to prevent the obsessions from occurring with other thoughts, since obsessions can’t be predicted and generally become more frequent over time until they occur almost constantly. Therefore, the individual is already overwhelmed by the intrusive thoughts before they’re able to engage in mental strategies to counter the obsessions and anxiety.
When such strategies are effective they reinforce the relationship between the obsessions and compulsions by lowering anxiety. When they are become ineffective the individual develops worsening anxiety as well as other serious co-morbid psychological difficulties including other anxiety disorders, mood disorders and substance abuse, which is often an attempt to self medicate the thoughts away.
Research indicates that OCD will not remit without treatment. One main reason for this is that what are considered attempts to cope with the unwanted thoughts are actually compulsions and actually part of the disorder.
Suicidal Thoughts vs. Suicidal Obsessions
Distinctions between suicidal thoughts and suicidal obsessions include the following:
- When associated with depression suicidal thoughts are ego-syntonic or congruent with the individuals thoughts and mood state. For instance, they may have suicidal thoughts related to a feeling hopeless about the future will be better or that they are worthless and don’t deserve to live.
In comparison suicidal obsessions are ego dystonic or incongruent with the individuals intentions and beliefs. Despite the thoughts they belief suicide is wrong and are opposed to any type of self harm.
- Individuals with suicidal thoughts, even when ambivalent, will often want to act on the thoughts, whereas those with suicidal obsessions want to prevent the act, attempting to avoid or escape even the thoughts themselves.
Suicidal thoughts are more likely to be associated with previously reported ideation, self harm and suicide attempts compared to suicidal obsessions. Suicidal obsessions rarely result in self harm in the absence of true suicidal thoughts.
· Those who have suicidal thoughts often ruminate about methods for carrying out the act whereas individuals with suicidal obsessions ruminate about reasons why they’d never commit suicide.
While the characteristics of suicidal thoughts and suicidal obsessions may seem easily diffentiated, this is not always the case. The distinction may not be clear-cut given the large overlap between the two categories of thoughts in individuals suffering from S-OCD.
Manifestations of Suicidal Thoughts in OCD
There are several formulations of the ways in which suicidal thoughts and/or ideation are found in OCD, which help determine how best to treat the disorder.
1) The first category involves OCD with suicidal thoughts, none of which are obsessions.
This could describe a person who, for example, has contamination type OCD with symptoms that are frequent enough to interrupt normal daily functioning. The individual may feel hopeless about the problem improving and become depressed over their inability to prevent themselves from having thoughts and engaging in behavior they recognize as unreasonable. This can lead to thoughts such as “I’d be better off dead than living this way”. Thus, the thoughts are consistent with the individuals mood state, and the act of self-harm seems reasonable in light of the thoughts.
2) The next category involves OCD with suicidal thoughts that are exclusively obsessions. Such obsessions lead to the fear they may not be able to prevent themselves from committing suicide despite their opposition to self-harm. Individuals with suicidal obsessions believe that given their disgust related to self-harm that the fact they are having uncontrollable suicidal thoughts indicates underlying pathology that they can’t predict or fully understand. Yet the risk of self-harm in cases where there are only suicidal obsessions is significantly reduced compared to individuals with true suicidal ideation.
3) Some individuals who suffer from S-OCD possess both suicidal obsessions and suicidal thoughts. While this condition combines both low and high risk thought types the overall risk of the individual attempting suicide is higher than when either type of thought exists alone. This is due to the confusion resulting from the two opposing sets of thoughts.
The individual may not want to commit suicide and fights the suicidal obsessions using mental or behavioral acts to prevent inadvertent self-harm. Yet they may also be suffering from depression related to the condition and simultaneously experience actual suicidal thoughts such as “life isn’t worth living”.
These opposing belief systems can become overwhelming due to the inability to make sense of how these conflicting thought patterns can exist together. The individual may become so confused regarding the inability to define their true beliefs that they may engage in suicidal behavior impulsively.
It is often difficult to definitively categorize all suicidal related thoughts an individual with S-OCD may be experiencing. However, effective empirically validated treatments for S-OCD and depression with suicidal ideation exist. It is important for individuals who are experiencing any type of suicidal thoughts to work with a trained professional to treat the complete range of symptoms involving suicidal ideation and obsessions.
S-OCD often results in extreme distress, emotional pain, confusion and social alienation, whether or not actual suicidal ideation is also present. Yet the prognosis following therapy is quite good for S-OCD for each symptom pattern and almost all these individual return to a state of normal functioning whereby they can once more experience a satisfying and enjoyable quality of life.