Suicidal fears

What is OCD related to fear of suicide?

Suicide OCD involves unwanted, intrusive, fearful thoughts about committing suicide. These thoughts often take the form of a “what if” statement, such as “What if I got a rope and hung myself?” “What if I ran my car off the road and killed myself?” “What if I swallowed a bottle of pills and died?”  These thoughts do not reflect a desire or intention to carry out any act, or a desire to die. Rather, the thoughts are upsetting and trigger anxiety or fear. It is crucial to distinguish these thoughts from thoughts that stem from a desire to die or to end one’s life, which are typically due to unrelenting depression, sadness, or hopelessness. Compared to other forms of OCD, fear of suicidal OCD themes can be especially distressing to people who suffer from them because of the content of the thoughts. The experience can be extremely upsetting, bewildering, and confusing. People with fear of suicide themes in Harm OCD often mistakenly think that these thoughts have some meaning or indicate some truth about them, such as revealing a subconscious desire to die.  They may interpret the thoughts as a prediction that they are likely to kill themselves at some time in the future; this error is called “thought-action fusion,” or the belief that thoughts, even unwanted or insignificant ones, must correlate with actions. A person who suffers from suicidal OCD may see images of themselves dead from suicide, or in the act of trying to kill themselves. Understandably, these images are very frightening and bewildering.  These thoughts can lead to a person’s world shrinking as they eliminate behaviors that are perceived as risky, such as driving, using knives in food preparation, or being alone. A person with these thoughts may become isolated and closed off from others, fearing that if others learn about their thoughts they will be mistaken for true suicidal ideation and a desire to die. This is a very real concern, given the caring responsibility many people feel to identify people who are at high risk for suicide and intervene with appropriate treatment.

Suicide related OCD – Common Obsessions

• What if I snap some day and kill myself?
• What if I become so depressed that I kill myself?
• What if I drive my car off this bridge?
• What if I jump off this bridge or balcony? 
• What if I really want to end my life?
• What if I swallowed this whole bottle of pills?
• What would it take to make me feel suicidal?
• Was that thought I had actually suicidality?  
• Images of doing fatal harm to oneself

Common triggers

For people with Suicide themes in Harm OCD, intrusive thoughts may be triggered by situations involving any potential means by which people could kill themselves, hearing about people who have killed themselves, learning that a friend or loved one has killed themselves, or movies in which a character commits suicide. Celebrity suicides and the suicides of children or youth receive a great deal of media attention and are often followed by a series of ‘copycat’ suicides. These can trigger a person with suicide OCD to have more intrusive thoughts and develop fears that they will become suicidal or make a suicide attempt.

Triggers for people with OCD fear of suicide include:

• High, open balconies
• Bridges
• Firearms
• Sharp knives
• Razors 
• Ropes 
• Stories of people who have killed themselves
• Hearing about friends or family members who have killed themselves
• Movies or TV shows in which a suicide takes place

How can I tell if it’s suicide OCD fears and not a sign that I actually want to end my life?

People who experience fear of suicide sometimes wonder if their intrusive thoughts indicate a true, albeit subconscious, desire to die. To differentiate between suicide themes in Harm OCD and true suicidality, it is important to understand the dynamics of OCD and how it begins. 

OCD begins when a thought, idea, or image is recognized by the brain as a potential threat or danger. The brain is wired to register potential threats and respond to them with anxiety, which motivates a person to neutralize the threat. If the person treats the thought like a fleeting anomaly and moves on without giving it much attention, OCD does not develop. But when a person gives an insignificant or unwanted thought attention and importance, thinks about it and explores what it might mean about them, and experiences anxiety related to these thoughts, the thought becomes an obsession, and OCD may develop. 

For someone with OCD, the brain registers obsessions about suicide as real threats that must be addressed. Compulsions then result, as the person tries to reason with or reassure themselves that they don’t really want to end their life, feeling unable to trust themselves and their intentions. They may avoid anything that triggers these thoughts in an effort to avoid feeling the associated anxiety. As these behaviors are repeated, the OCD cycle becomes entrenched, often involving an underlying fear of losing control. 

In contrast, true suicidal ideation is a desire to give up or find relief from suffering. It is typically associated with severe, prolonged depression and hopelessness. The person with true suicidal ideation is not upset at the thought of dying in the same way a person with OCD is, as they may see death as a release from suffering and struggle.

Common compulsions

When people with suicide themes in Harm OCD experience intrusive thoughts, images, feelings, or urges that cause distress, they will perform compulsions in an attempt to resolve or reduce their distress. 

They may ruminate on what their thoughts mean about them, in order to determine with certainty that they are not truly suicidal. They might worry that these thoughts indicate that they will eventually kill themselves. They could engage in compulsive internet research for answers to their fears or to find others with similar experiences. They may look for that one secret tip that will end their struggle once and for all. 

Less obvious compulsive behaviors include self-reassurance, such as listing reasons they really want to live and all they have to live for. Especially disruptive compulsions could involve getting rid of any means by which they could kill themselves, such as firearms, sharp knives, razor blades, or medications. They may consciously avoid any situations or people that they fear may trigger their thoughts. 

Compulsions performed mentally or physically by people with suicide OCD include:

• Rumination
• Self-reassurance
• Internet searching 
• Avoiding places that trigger their thoughts, such as bridges; high, open balconies; or media dealing with suicide

How to treat fear of suicide

Seeking treatment for suicide OCD can be quite stressful. Since therapists are trained to be vigilant in monitoring clients for suicidal ideation with the intention to end one’s life, divulging intrusive thoughts about suicide may seem especially risky. 

In this regard, accurate diagnosis is crucial. Some people with suicide OCD have reported being detained in a behavioral health setting inappropriately because their therapist mistook their presentation for true suicidality. But a therapist who specializes in treating OCD will be able to distinguish suicide themes in OCD from true suicidality, and can help people with this debilitating condition get better. 

By doing exposure and response prevention (ERP) therapy with the guidance of a trained professional, people with suicide themes in Harm OCD can learn not to place undue importance on their intrusive thoughts and can learn to tolerate the anxiety that comes from passing, unwanted thoughts. Typically, with several weeks of consistent ERP treatment, people find that their intrusive thoughts occur much less frequently, their anxiety decreases, and they are able to tolerate anxiety to a greater degree. 

Some people also find pharmacotherapy to be helpful in augmenting ERP treatment. SSRIs have been shown to help with the anxiety related to intrusive thoughts, but medication alone is not a sufficient treatment for any form of OCD and is most often not necessary for recovery. 

I encourage you to learn about NOCD’s accessible, evidence-based approach to treatment. At NOCD, all therapists specialize in OCD and receive ERP-specific training. ERP is most effective when the therapist conducting the treatment has experience with OCD and training in ERP.

We look forward to working with you.