Distinguishing Suicidal Obsessions from Suicidal Ideation: A First-Person Suicide Image Pilot Study

Individuals with obsessive-compulsive disorder (OCD) experience unwanted and intrusive thoughts that cause anxiety and/or distress. The content of these thoughts can vary widely. Suicidal obsessions (SOs) are unwanted, intrusive, and distressing thoughts about suicide, death, or self-harm. Their clinical presentation differs markedly from that of suicidal ideation (SI), yet most suicide risk assessments fail to distinguish between the two phenomena. The distinction is critical, as SOs and SI differ in their clinical risk and require different treatments. This pilot study compares the self-reported affective ratings of first-person suicide images (FPSIs) by individuals with OCD presenting suicidal obsessions to ratings by individuals with OCD with suicidal ideation. Compared with those with SI, those with SOs found the images less pleasant, more threatening, more arousing, less aligned with behaviors they could imagine themselves engaging in, and less aligned with their sense of self. The difference in imagined behavioral engagement was statistically significant. After controlling for depressive and OCD symptom severity, regression models indicated a large negative effect for arousal (β = -1.05), medium effects for ego syntonicity (β = 0.64), behavioral relatedness (β = 0.58), and a sense of threat (β = -0.68, p = 0.55), and a small positive effect for pleasantness ratings (β = 0.33). These effects did not individually reach statistical significance in this pilot study but serve to guide future work. Differentiating between SI and SOs is clinically imperative as it frames treatment planning. The use of FPSIs may supplement traditional suicide measures and functional assessment in making this key distinction.