All thoughts of suicide or self-harm should be taken seriously. If you or someone you know has reported thoughts of self-harm, please call 911 or contact your local emergency room number immediately. In the United States, you may also call the National Suicide Prevention Lifeline at 1-800-273-8255 or text the Crisis Text Line. This line is available to you all day, every day.
Obsessive-compulsive disorder (OCD) is a chronic mental health condition characterized by recurrent and intrusive thoughts, urges, feelings, sensations, or images, and compulsions, which are repetitive behaviors or mental acts to reduce anxiety or try to neutralize a thought. Some better known subtypes of OCD include a fear of contamination or an intense need for order and symmetry. However, one particular theme of OCD that is not well understood is suicidal OCD.
Suicidal OCD is linked to unwanted thoughts or impulses about ending your life. These thoughts differ from suicidal ideation, and actually stem from a desire to protect oneself. People with suicidal OCD may find themselves caught in a cycle of self-doubt and worry about the presence of these thoughts, which only exacerbates their anxiety.
Understanding suicidal OCD is crucial for effective treatment, as it requires a nuanced approach that distinguishes it from genuine suicidal ideation. And if you think you may be experiencing suicidal OCD yourself, please have hope—this condition is highly treatable.
Suicidal OCD symptoms
Intrusive thoughts about suicide are relatively common even for people who don’t have OCD, but these thoughts generally only last a few seconds at most. For example, it’s not unusual to wonder, “What happens if I jump?” when leaning off a balcony. When this happens, most people will let it go and continue on with their day.
On the other hand, someone with suicidal OCD might ask themselves: What if one day I do this? What if I want to do this in the future? What if I tried this already and I don’t know that I tried it?
Suicidal OCD is a subtype of OCD that includes obsessions related to killing oneself. It is closely associated with harm OCD and is also known as harm OCD with suicidal obsessions.
Suicidal thoughts should always be taken seriously. However, people with suicidal OCD are not more likely to commit suicide than people with other OCD subtypes. In fact, the opposite is true: suicidal OCD is driven by the need to protect oneself from potential self-harm.
Rather than seeking out opportunities to harm themselves, someone with suicidal OCD may avoid places they know will trigger suicidal thoughts or stay away from scenarios where they have a chance to cause harm to themselves.
For someone with suicidal OCD, thoughts of self-harm will go on and on and won’t leave until they find temporary relief through their compulsions, whether that’s checking, reassurance, or avoidance, to dismiss these concerns.
Suicidal OCD obessions
While this is not an exhaustive list, here are some examples of the thoughts and urges that people with suicidal OCD might experience, leading to intense distress and compulsive responses:
- Intrusive and graphic images of hurting oneself in specific ways
- Experiencing an urge to jump when looking below from a mountain, skyscraper, or balcony
- Experiencing an urge to drive one’s car off of a cliff or bridge or into oncoming traffic
- Wondering what it would feel like to jump from a balcony
- Experiencing an image of hurting oneself with a knife
- Leaning on the railing of a boat and experiencing an urge to jump into the water
- Imagining jumping in front of the train when standing on a train platform
Suicidal OCD compulsions
Thoughts like the ones listed above lead people with suicidal OCD to perform compulsions. Ruminating on these obsessions can lead to the following compulsions:
Reassurance seeking: If you have suicidal OCD, you may reach out to friends or family to seek reassurance about whether what you’re experiencing is normal. You may ask questions like, “This might be a weird question, but do you ever think about jumping in front of a train?” Similarly, you might ask, “Do you think worrying about falling from a balcony is normal?” These questions are meant to reassure someone with suicidal OCD they are not in danger of taking their own life.
Mental review: You may also engage in mental reviewing to convince and reassure yourself that you are not in danger of ending your life. You could review every time you have gone on the same hike and looked at the same view without anything happening as a way to prove to yourself that you are not suicidal. You may mentally try and answer questions like, “How likely is it that I will act on these thoughts?” or, “Do other people experience these thoughts, too?” You may spend hours researching these questions online.
Avoidance: If you have suicidal OCD, you may feel compelled to get rid of any object in your house that could be used to cause yourself harm, including ones you may need, like a kitchen knife or scissors. You may avoid places where suicidal thoughts or images are more likely to be activated, like a balcony or a bridge.
Comparison: It’s common for someone with suicidal OCD to spend a lot of time researching cases of suicide and comparing themselves to the person who died. You may think, “This person was 27, and I am 27. Does this mean I’m in danger?” or, “This person was an only child, and I’m an only child. Is there any significance to this?”
Suicidal OCD vs. suicidal ideation
It’s important to reiterate that there are differences between suicidal OCD and suicidal ideation.
“Suicidal ideation is something that we take very seriously, so we want to know what’s going on,” says NOCD’s Chief Clinical Officer Dr. Patrick McGrath. “Does the person have an actual plan, intent, a desire, a want [to end their life]? On the other hand, if they are asking themselves “what if” questions followed by some kind of compulsion, be it a mental or physical compulsion—that is OCD.”
In suicidal OCD, the thoughts are often driven by fear and anxiety rather than a genuine desire to die. People may find themselves imagining scenarios that create distress, leading them to engage in compulsive behaviors to alleviate their anxiety. For someone experiencing suicidal ideation, however, there is a more direct contemplation of self-harm, which often includes methods and intent, which requires immediate intervention.
“Purchasing a gun or giving away items—those kinds of things are a potential 911 call,” McGrath says. If you’re experiencing suicidal ideation, it’s important that you reach out to an emergency contact, go to the emergency room, and make sure you have a safety plan in play, advises McGrath.
Treatment for suicidal OCD and suicidal ideation
The best course of treatment for suicidal OCD is exposure and response prevention (ERP) therapy, an evidence-based treatment created specifically for OCD. As part of ERP therapy, you’ll track your obsessions and compulsions and list how distressing each thought is. In partnership with a therapist, you’ll work to slowly put yourself into situations that bring on your obsessions. A therapist trained in ERP will ensure that you’re gradually building towards reducing your compulsions, rather than moving too quickly and overwhelming you with exposures.
Let’s use a specific example: A person experiences an intrusive and unwanted urge to jump in front of a train when they commute to work. When working with their therapist, they might start by just reading stories about people who died on train tracks, allowing themself to feel anxious as they read. With their therapist, they will work to become more comfortable with these uncomfortable feelings—then, they can take their exercises to the train station itself.
They might start by just delaying leaving the platform—it may only be a couple of seconds at first. But over the weeks of treatment, it may extend to an entire minute. Eventually, they’ll find they can stay on the platform for five whole minutes. Soon, their anxiety subsides to the point where they can comfortably commute to work, at ease with the fact that they won’t act on intrusive impulses. We can’t guarantee that ERP will be easy or make all your intrusive thoughts go away. However, this is a safer way to approach intrusive thoughts rather than having to confront them on your own.
For someone experiencing suicidal ideation, treatment would focus on assessing the severity of thoughts and determining if there’s a plan or intent behind them. This may include cognitive-behavioral therapy (CBT) focused on challenging the harmful beliefs associated with these thoughts of self-harm.
Additionally, a therapist would work collaboratively to create a safety plan, which may include coping strategies, emergency contacts, and resources for immediate help. “The safety plan can be a reminder of what to do when feeling overwhelmed,” McGrath says. “Many people may feel in a time of crisis that there is nowhere to turn to, and the plan is a tangible reminder of steps to take.”
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Where to go for help
It’s an unfortunate reality that people with suicidal OCD are often misdiagnosed as experiencing suicidal ideation. Suicidal OCD is terrifying, but it’s also fundamentally different from suicidal ideation—it’s actually driven by a concern to protect oneself rather than harm oneself. Sadly, many people who need treatment for OCD may hold back from seeking help, fearing that their symptoms will be misunderstood.
A mental health professional who specializes in OCD will be able to make an accurate diagnosis, so it’s crucial to find someone with the right specialized training and experience in OCD. Having recurrent intrusive and unwanted thoughts of suicide can be incredibly painful—but there is treatment available, and you don’t have to feel this way forever.