Suicidal Thoughts vs. Suicidal Obsession in OCD
As discussed in the previous article, suicidal thoughts are different from suicidal obsessions, although there is overlap between the two. Suicidal thoughts are generally consistent with a person’s mood, most often experienced alongside a mood disorder or other significant psychological problem that engenders hopelessness and helplessness. Suicidal obsessions are not consistent with an individual’s mood state and usually go against their long held beliefs, perceptions, and preferences. Whereas someone with suicidal thoughts may be ambivalent about actually killing themselves, someone with suicidal obsessions are usually extremely fearful that they will do something to harm themselves without being aware enough to stop themselves or without intending the harm.
Reasons Compulsions Used in Suicide Related OCD are Ineffective
Compulsions develop as a countermeasure to obsessions because it is practically impossible to prevent obsessive thoughts by using other thoughts or cognitive strategies. This is because the obsessions can’t be predicted and they often become more frequent over time until they occur almost constantly. Therefore, once the individual attempts to engage in thought related strategies triggered by the onset of the obsessions they will likely already feel overwhelmed by the intrusive thoughts. This will also likely eclipse any mental strategies a person might try to use to counter their obsessions.
Compulsions are usually aimed at decreasing the anxiety caused by the obsessions by carrying out a behavior that correlated with the thoughts. So someone who is obsessing about germs and dirt will wash, someone who is obsessing about leaving the oven on with check to make sure it is off. Yet with S-OCD the compulsions are more complex as they are aimed at preventing themselves from some type of self harm or reassuring themselves that they haven’t done anything that might indicate self-harm or the intention to attempt suicide.
In S-OCD the compulsions are either impossible to accomplish or they create a sense of alienation between the individual and others. These problems occur in several of ways.
The individual will realize that it is impossible to ensure that there is nothing that could be potentially harmful in a home as many things can be utilized in a manner to injure oneself. Similarly they will also realize it’s unrealistic to avoid contact with such things in others homes or public places where they have no control and aren’t aware of what may be in the space that they should avoid. This means that the compulsion of attempting to get rid of or avoid things that might be harmful actually increases the anxiety instead of decreasing it as they know that no matter how hard they try they can never succeed.
While they may find nothing in writing indicating suicidal intent they will never be able to ensure they’ve checked everything they wrote. This is underscored by the assumption that if they are checking it means they won’t remember having written such information and that if it indicates suicidal intent they will likely have hidden it. These thought processes can seriously confuse the individual because they are certain they do not want to commit suicide in their conscious awareness but worry that at some point perhaps they do when they are not aware. They have great difficulty over the inability to reconcile this dichotomy.
Asking others for reassurance can appear odd and eccentric such that the individual is avoided. Along with the loss of social support, the individual will likely conclude the avoidance is due to others not wanting to admit they believe the individual is capable of committing suicide or that the individual said or did something that was cause for concern.
Research has indicated that OCD is a group of disorders that will not remit without treatment by a trained professional. One main reason for this is that what are considered attempts to cope with the unwanted thoughts – the compulsions – are actually part of the disorder. When these strategies work they reinforce the relationship between the obsessions and compulsions. When these strategies become ineffective the individual frequently develops severely escalating anxiety related to the OCD as well as other severe co-morbid psychological difficulties such as other anxiety disorders and mood disorders. Substance use disorders also often develop in an effort to self medicate the thoughts and anxiety away.
Differentiating Between Suicidal Thoughts and Suicidal Obsessions in OCD
Distinctions between suicidal thoughts and suicidal obsessions can often be made based on the characteristics of the cognitions.
When associated with depression suicidal thoughts are ego-syntonic or are congruent with the individual’s thoughts and mood state. For instance, the person may have suicidal thoughts related to a sense of hopelessness that things will get better, the belief that they are worthless and don’t deserve to live, or the feeling that they can’t stand the suffering any longer. In comparison suicidal obsessions are ego dystonic or are incongruent with the individual’s intentions and beliefs- specifically their strong opposition to committing suicide.
Individuals with suicidal thoughts, even when ambivalent, will often want to act on the thoughts, whereas those with suicidal obsessions desire to prevent themselves from acting on their suicidal thoughts and they attempt to avoid or escape the thoughts altogether.
Suicidal thoughts are more likely to be associated with previously reported ideation, self harm and suicide attempts compared to suicidal obsessions. It’s extremely rare that suicidal obsessions in the absence of true suicidal thoughts result in self harm.
Those who have suicidal thoughts often ruminate about a plan to carry 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 appear at first glance to be easily differentiated this is not always the case. The distinction is not always clear-cut given the high degree of overlap between the two categories of thoughts in individuals suffering from S-OCD. Several scenarios are possible which can make accurate diagnosis difficult.
The Manifestations of Suicidal Thoughts in OCD
There are several different ways suicidal thoughts and/or ideation may be incorporated into OCD which determine how best to treat the disorder.
The first categories are straightforward and can be addressed as such. These include suicidal thoughts in the absence of OCD such that the thoughts are not obsessions and OCD in the absence of any type of suicidal thoughts (e.g. someone with contamination related obsessions and compulsions).
The individual has OCD and suicidal thoughts but none are obsessions. This would describe a person who for example has checking obsessions and compulsions that are frequent enough to interrupt normal daily functioning. In such a case, the individual may feel hopeless about the problem improving and become depressed over the inability to prevent themselves from having thoughts and engaging in behavior that they recognize as unreasonable. This can lead to thoughts such as “I’d be better off dead than living this way,” or “I can’t take this any more, I’d rather be dead”.
The individual has suicidal thoughts that are exclusively obsessions. Such obsessions may involve scary, violent, horror inducing images and thoughts involving suicidal behaviors which they fear they may not be able to prevent themselves from acting on despite their deep seated opposition to self harm or suicide. Individuals with suicidal obsessions believe that given their attitudes, viewpoints and dispositions that strongly oppose the commission of self harm or suicide that the fact they are have such thoughts they can’t prevent indicates underlying severe pathology that they are unable to predict or fully understand. Yet the risk of self-harm or suicide attempts/completion in the cases where there are suicidal obsessions in the absence of actual suicidal ideation is significantly reduced compared to individuals with true suicidal ideation.
Some individuals who suffer from S-OCD possess both suicidal obsessions and suicidal thoughts. While this condition combines both low and high risk suicidal thought types the overall risk or 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. While the individual may be certain they do not want to commit suicide which is accompanied by attempts to fight the thoughts and protect themselves from inadvertently acting on them they may also be suffering from depression related to the condition and simultaneously experience 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 entirely conflicting thoughts can exist together and the individual may become so confused regarding the ability to define their true beliefs that they may engage in suicidal behavior impulsively.
Unfortunately, it can be difficult to definitively categorize the large number of suicidal related thoughts an individual with S-OCD may be experiencing in terms of whether they are all ego-dystonic, ego-syntonic or a mix of both. Luckily there are empirically validated treatments for depression and other conditions that may result in suicidal ideation and suicidal obsessions found in OCD. The important thing for individuals who are experiencing any type of suicidal thoughts is to work with a professional trained to treat the complete range of symptoms involving suicidal ideation and obsessions. While suicide related OCD with suicidal obsessions alone or in combination with actual suicidal thoughts frequently results in extreme distress, pain and social alienation for the individual, the prognosis following therapy is quite good and almost all these individual return to a state of normal functioning whereby they can return to a satisfying and enjoyable quality of life.
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© 2017 Natalie Frank