What Are the Differences Between Suicidal Thoughts and Suicidal Obsessions?
Suicidal thoughts are a major health concern in the U.S. and many parts of the world today. In 2016 it was estimated that 3.7 percent of the U.S. population or, 8.3 million adults, experienced serious suicidal thoughts. As significant as this number is, it is believed to be a gross underestimate given it’s based on self-report and many people are reluctant to report suicidal thoughts.
Caution in interpreting suicidal thought must be exercised as in some cases, what may appear to be suicidal thoughts or thought patterns actually reflect a form of Obsessive Compulsive Disorder. In such instances, the thoughts are actually suicidal obsessions, which are often notably different from regular thoughts of suicide. There are a number of factors, which differentiate the two types of thoughts. At the same time there is a high degree of overlap between the two categories. Determining the parameters of each of the two conditions requires a comprehensive and careful assessment and regular evaluation conducted at follow-up.
Suicidal Thoughts and Behavior
While many individuals believe suicidal thoughts only result from serious depression, such thoughts can occur as part of practically every type of psychological disorder, physical illnesses and injury. Such thoughts may even occur in individuals who are entirely healthy.
The severity of suicidal thoughts can be difficult to determine as s sometimes they may be short lived and non-specific while other times there may be a well thought out plan in place for carrying out the suicide..
For the most part, those who are determined to commit suicide will not provide any indication of their plans and they will also deny having thoughts of suicide as well. This is one of the most traumatic parts of suicide for survivors – the belief that they should been able to predict it. This occurs despite assertions from professionals that there was no way to see it coming. Even trained professionals have cases of suicide when they themselves also feel as if they should have been able to prevent it.
Most individuals with suicidal ideation are actually ambivalent, alternating between wanting to live and wanting to die. Others have no real intention of dying but make an attempt which is serious enough to get the attention of others, doing so as a call for help. These individuals are unaware of other options to obtain the help they need. Unfortunately, some of these people, although not truly wanting to die, make a miscalculation and what was meant to be a cry for help winds up being fatal.
Thus, suicidal thoughts and behavior are complicated difficulties with a serious risk of death even when this is not the intended outcome
Suicidal Obsessive Compulsive Disorder (S-OCD)
Suicidal obsessions, like other forms of obsessions found with OCD, are persistent cognitions, images or drives that invade a person's mind. While S-OCD is thought of as having only obsessions without the compulsive symptoms or a “Pure O” type, this is not entirely correct. In reality, the symptoms do include compulsions but these involve either rumination or different types of behaviors.
Suicide obsessions create a sense of anxiety just like other types of obsessions. This anxiety then results in the subsequent mental or behavioral acts that allows avoidance or escape from the thoughts and associated anxiety. The relief felt at not having the thoughts or anxiety reinforces the compulsions which maintains the symptoms of the disorder. This occurs since the individual never learns that they can tolerate the thoughts or anxiety or that failure to engage in the ruminative or behavioral response does not result in a catastrophe.
Suicidal obsessions are defined as intrusive, repetitive, undesired thoughts of suicide that result in notable distress. They differ from suicidal thoughts in that they do not result from the genuine desire to kill oneself; actually people with these types of obsessions often feel exactly the opposite. They don’t want to commit suicide, are often against suicide morally or religiously and feel terrified by the possibility that their thoughts could unintentionally cause them to act in a manner that accidently leads to their death.
Suicidal obsessions can occur at any time or any place, frequently seem to come out of nowhere, and can be triggered by either pleasant or unpleasant activities. The fear that they will re-occur creates what’s referred to as secondary anxiety, along with attempts to identify possible triggers so they can avoid them. Yet as with other obsessions they soon learn there’s nothing they can do to avoid them entirely and over time the rate of these cognitions increase until they occur throughout the day with much of their time taken up by the obsessions, ruminating in an attempt to counteract the suicidal thoughts, or carrying out behaviors that confirms that they haven’t actually attempted to commit suicide.
Those who experience S-OCD are not ambivalent – they are entirely against committing suicide, making a gesture to get help or even thinking about it. If detailed plans enter their thoughts as to how they might carry out an attempt the anxiety grows significantly as they are concerned that the more specific their thoughts become the more difficult they will be to resist.
Some theorize that those with suicidal obsessions are actually suffering from true suicidal ideation except that it is unconscious. They further posit that the symptoms which look like OCD are actually an elaborate defense mechanism hiding unacceptable impulses. However, research has suggested that this is not accurate. There is significant evidence that a type of OCD involving suicidal obsessions exists and that this form can be differentiated from true suicidal ideation.
Obsessions and Compulsions in S-OCD
Suicidal obsessions generally involve the fear of something happening which causes the individual to lose control of their actions whereby they are unable to resist killing themselves despite not wanting to do so. Thus, the specific thoughts usually follow the form of “What if . . . and I end up killing myself before I can prevent it? The “What if. . .” part of the thought can involve the following:
- What if I have a nervous breakdown . . . ?
- What if go nuts and can’t recognize what I’m doing . . .?
- What if I don’t notice my thoughts in time to prevent myself from following them . . .?
- What if impulsively, I jump of a high building or bridge. . .?
- What if I become severely depressed without knowing it and . . .?
- What if I’m harm myself (e.g. poisoning self) but don’t realize it . . .?
- What if I intentionally put myself in danger without recognizing it . . .?
- What if I can’t prevent myself from driving off a cliff . . .?
- What if I become so focused on my thoughts that I can’t pay attention to what I’m doing and . . .?
- What if I impulsively take a of bunch of pills when I mean to just take one or two . . .?
- What if I black out and do something to hurt myself without being aware I’m doing it?
The compulsions that result from suicidal obsessions often involve the individual remaining under control at all costs by gathering information or manipulating their environment. This often involves reality testing to guarantee that they truly don’t intend to kill themselves and/or that they haven’t done anything that demonstrates the desire to kill themselves without knowing it. These types of compulsions fall into four categories.
Mentally checking “actual” intentions to harm oneself, checking the way they act in front of others and what they say to others to ensure nothing indicates suicidal ideation; Checking memories for instances they may have harmed themselves or attempted to harm themselves; Checking their reasoning regarding why they wouldn’t want to kill themselves and anything that indicates they might potentially do so
Checking anything they have written to ensure nothing can be seen as a suicide note or the desire to attempt suicide
Checking to ensure there is nothing lethal that is accessible at home including poisons, dangerous tools, heavy objects, rope, sharp items, etc.
Checking themselves physically to ensure there isn’t any sign that they’ve harmed themselves without realizing it.
Avoidance of other people who have the tendency to make them feel bad about themselves or who trigger a bad mood or negative memories
Avoidance of locations they associate with a potential intrusive and unwanted thought such as bus station where they fear they won’t be able to resist jumping in front of the bus when the thought to do so occurs.
Avoidance of potentially deadly items in the homes of friends and family or in public locations
Avoidance of being alone due to the belief they are unlikely to hurt themselves if they are around others or if they do act on a thought to harm themselves, then the others who are present will prevent them from seriously harming themselves
Avoidance of boredom or lack of something interesting to do such that they are always engaged in a variety of activities sometimes to the point of exhaustion in an effort to distract themselves from undesirable thoughts. Relaxation is also avoided for the same reason. This includes the refusal to go to sleep until it is impossible for them to stay awake any longer as they are afraid if they “let down their guard” this will permit the suicidal obsessions to occur.
Avoidance of horror movies involving violence in an attempt to prevent suicidal obsessions from being triggered as well as due to the belief that the visual representation of violence or trauma or even pleasant scenes that might possibly trigger memories that evoke longing or sadness could prevent them from being able to resist thoughts of self harm.
Avoidance of reading the newspaper or watching the television news to prevent exposure to anticipated negative or violent coverage that might trigger suicidal obsessions
Avoidance of instances of harming themselves by keeping their hands in their pockets or sitting on them
Seeking confirmation that other people believe the individual would never kill themselves
Seeking confirmation that other people know the individual has never harmed themselves on purpose
Sharing unwanted thoughts with the hope that other people will respond that the individual shouldn’t feel guilty because such thoughts aren’t consistent with what they know about the individual
Spending significant amounts of time on the internet and in other endeavors researching details about others who have killed themselves to prove that they have nothing in common with people who commit suicide
Ruminating on the reasons why they would never commit, suicide
Trying to replace suicidal obsessions with pleasant thoughts that are incompatible with suicide
Purposely thinking about suicide to prove it disgusts and horrifies them
Engaging in prayer or superstitions in response to suicidal obsessions believing this will prevent them from acting out their thoughts
Over-correcting by continuing to begin an activity over and over again until they complete the task without any undesirable thought intruding
Summary and Conclusions
In conclusion, suicidal thoughts and suicidal obsessions are different processes resulting from different internal and external factors. Similar to other obsessions found in OCD, suicidal obsessions are believed to be largely neurobiological though environment can contribute to their onset and sometimes in triggering them once they develop. However, whereas suicidal thoughts often are consistent with a person's general mood and depressive thought patterns, suicidal obsessions do not. Usually, suicidal obsessions go against the person’s beliefs and preferences and they fear they will do something to hurt themselves without intending it or being aware of it at the time. As such, many of the compulsive behaviors they engage in are aimed at avoiding anything potentially dangerous and reassuring themselves that they have not said or done anything that suggests they have or will harm themselves. This differs from those who have suicidal thoughts in that when suicidal thoughts are associated with actions, the actions are intentional and the person is fully aware of the plans they are making to carry them out.
The follow-up article will discuss the reasons why the compulsions discussed here are not usually effective at preventing the suicidal obsessions from continuing to occur, how to differentiate between suicidal thoughts and suicidal obsessions, how suicidal thoughts may manifest in cases of OCD,