Natalie Frank, a Ph.D. in clinical psychology, is the Managing Editor for Novellas & Serials at LVP Publishers. She also publishes fiction.
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.
© 2017 Natalie Frank
Natalie Frank (author) from Chicago, IL on November 12, 2018:
Rowna - offhand I don't know of anyone. Let me ask around and I'll pm you if I find someone.
Rowna on November 09, 2018:
Natalie, do you know of any professionals in the UK who have knowledge or experience in dealing with S-OVD?
Natalie Frank (author) from Chicago, IL on November 09, 2018:
Rowna - I am so sorry to hear of your experiences though happy that you are now in a good place with your anxiety. Anxiety is such a tricky disorder and when you add the hormonal and other physiological changes involved in pregnancy it only is added to. Being forced to come off of your meds suddenly is also never a good thing, especially with antidepressants or antianxiety meds. It usually causes a huge escalation of the symptoms and with antidepressants, even if you aren't depressed but are taking them for anxiety as there is a large overlap between the two, discontinuing an antidepressant cold turkey can still lead to depression along with the anxiety. Then there are the hormonal changes and other physiological changes that happen as a result of birth. I'm sure you're aware of post - partum so understand that there can be strong mood difficulties following birth. When you already are experiencing them before hand the birth is only likely to make matters worse. There are also all the emotions that go along with having a baby and the life changes one involves. You already also had another small child in the home you were raising.
What you describe in terms of the panic when your husband left in the morning is not an unusual thing. Many women experience it as you have this tiny little being totally dependent on you who needs you have to anticipate and meet. Babies can't tell you what they need or when something is wrong and so there is the constant concern over whether or not you may be missing something. My own mother experienced something similar when my oldest brother was born. She also was in the home alone with him, and had 't had a lot of experience with babies or young children. Although she doesn't really experience anxiety or depression other than probably small amounts here and there, she would panic and not know if she was taking care of him properly. Luckily it passed.
Anxiety and depression symptoms often co-occur and when they do things get mixed up and feel terribly hard. There are mood symptoms, physical symptoms, cognitive symptoms and behavioral symptoms all of which combine to create a really hard experience for the person. With the OCD type symptoms which begin with the cognitive component, in particular the intrusive thoughts you can't get rid of and don't know how to resist it makes you feel very out of control.
I am glad you have found your way through the dark times and wish you nothing but happiness and health for the future.
Thanks for writing in and sharing your experiences.
Rowna on November 08, 2018:
Thank you so much for this article.
I am reading it while in a good place mentally but during pregnancy six years ago S-OCD was an enormous issue for me after coming off anti-depressants quickly (due to pregnancy) which had been prescribed for anxiety and I had been on for four years.
-except I had never heard of S-OCD until reading your article tonight!
I went through 9 weeks of torture and literally climbing the walls before the birth and after the birth it took 7 months for antidepressants to help. (Venlafaxine). No health professional ever called it “OCD” but it was termed Generalised Anxiety (I’m in UK). I can see how being able to give it a name might have helped me a little at the time. Someone did describe it as “intrusive thoughts” which did help me understand it and gave me some comfort.
I can hardly express strongly enough the mental torture and anguish I faced at the time (while caring for a new baby and 3 year old). I was terrified being on my own and rushed to my parents house every morning as soon as my husband left for work.
I know it must sound crazy to someone who has never experienced it.
If you are suffering know that it can get better.
I do have to say though -six years on, I am still on the antidepressant. Moreso because I experience awful withdrawal symptoms if I try to reduce (I think typical with this drug). I enjoy other therapies like mindfulness and really believe I am seeing a benefit from “clean” eating, avoiding sugars and taking things like walnuts and porridge which are known to be good for anxiety. I am keen to keep trying to lower the drug and ‘replace’ it with these therapies.
Thank you again for your info and blog on this and thank you on behalf of others I’m sure you have helped.
Natalie Frank (author) from Chicago, IL on July 25, 2018:
First, just let me say I am sorry you are suffering so. I obviously don't know your entire history, and am not sure if you are depressed with or without OCD. So, I couldn't recommend any specific options other that encourage you to keep trying. The key with any type of treatment, especially for this type of problem, is to recognize that you are entering into a relationship. Therefore, like any other relationship you need to find someone (or someones), who you are comfortable with, feel confident in their abilities to help you, sense they care about you getting better and will listen to you in terms of what is making a difference and what isn't to fine tune what it is they are using to help you. Sometimes when things get to the point that they feel like they are spiraling out of control, an inpatient program or partial treatment program can help you get out of your stressful life circumstances and provide you with a therapeutic environment where you can just focus on getting better. Like anything else, there are good and not so good hospital programs so finding one that has a good reputation for treating they types of problems you have and doesn't just hold people and drug them is crucial. A program that is comprehensive and includes multiple components is generally the most helpful. Identifying new antidepressants (I don't know what you have tried and what you haven't but there are approaches that combine antidepressants with other medications that can boost their effects and as a doctor I'm sure you are aware that there are many new antidepressants and approaches to medications that are available). The best programs focus on cutting edge approaches to treatment and that will try a variety of approaches as opposed to using a cookie cutter approach. I don't know where you live but if there isn't a program you feel will help near you, you might want to consider the possibility of going somewhere that might have one. A program should include a multidisciplinary team committed to providing patient-centered care that ensures nonjudgmental, respectful, compassionate treatment, addressing individual, patient-specific needs. They should also address continuity of care and ensure that the next steps will help you maintain and continue your improvement. If you feel suicidal, please call 911 for help, even if you feel you have done this and nothing came of it or are convinced it won't do anything. Sometimes just having enough time to step away from things can avert a crisis long enough for you find the help you need. I don't mean to offer cliches here, just to provide the hope that whatever it is that you need to get better is out there. It just may take more time and more searching. I know you undoubtedly don't want to do more of this and just want to feel better, but know there are people out there that can help though they may not be in traditional roles you might expect for this and it may take some more time until you find them. Talk to trusted others who might know of services. Consider non-traditional avenues such as alternative medicine and holistic options. Do something to change your thinking and the rut you are in as far as your thoughts and behaviors. Make yourself go on an outing, connect with a friend or family member, go to a museum or to the beach, anything you once enjoyed but haven't had the energy to do, no matter how hard it may seem. Find a support group who will let you know you aren't alone and will likely have suggestions and resources you haven't tried. Look for a professional psychotherapy program for people who are in professional careers such as you are. Ask trusted colleagues for recommendations for providers, programs and alternative options, especially those who are likely to have patients in need of mental health care. Know that there are those out there that care about what happens to you even if you may have never met them before. I truly hope you find what you need soon and will be well on you way to improvement and re-establishing a life of health and happiness. Be well and take care.
biggles22 on July 18, 2018:
I've had this problem for 6 years now and am a doctor. My life has fallen to pieces despite extensive attempts at treatment. this is similar to the story of Anthony Bourdain. Is there anything that may help that we may not have tried ( already had some 30 antidepressants, ECT, 600 hours of psychotherapy, hypnosis?
Natalie Frank (author) from Chicago, IL on March 18, 2018:
It would depend on the specifics of the person's condition. They would do a full assessment but if there is any doubt at all as to whether the person could potentially harm themselves they would hospitalize to protect them and provide intensive therapy.
Crystal on March 17, 2018:
So if you think you have socd would they automatically impatient you?
Natalie Frank (author) from Chicago, IL on March 15, 2018:
Most people don't think about the difference so you are certainly not alone Lauren. Thanks for the comment and for stopping by.
Lauren on January 25, 2018:
There are so many points raised here that I never thought about before. Describing the difference between suicide obsessions vs. regular thoughts wouldn't have meant anything to me before reading your article. Suicidal is suicidal right? Well, I guess not so right after all. What an interesting hub. You've given me something to think about for some time to come. Thanks!