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Suicidal Obsessions or Suicidal Ideation? A Case Report and Practical Guide for
Differential Assessment
Article in Cognitive and Behavioral Practice · October 2022

DOI: 10.1016/j.cbpra.2022.09.002
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Suicidal Obsessions or Suicidal Ideation? A Case Report and Practical Guide

for Differential Assessment
Elizabeth F. Mattera, Terence H. W. Ching, Brian A. Zaboski, Stephen A.

Kichuk
PII: S1077-7229(22)00138-9
DOI: https://doi.org/10.1016/j.cbpra.2022.09.002
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To appear in: Cognitive and Behavioral Practice
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Revised Date: 4 September 2022
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Please cite this article as: E.F. Mattera, T. H. W. Ching, B.A. Zaboski, S.A. Kichuk, Suicidal Obsessions or
Suicidal Ideation? A Case Report and Practical Guide for Differential Assessment, Cognitive and Behavioral
Practice (2022), doi: https://doi.org/10.1016/j.cbpra.2022.09.002
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SUICIDAL OBSESSIONS OR IDEATION 1
Suicidal Obsessions or Suicidal Ideation? A Case Report and Practical Guide for
Differential Assessment
Elizabeth F. Mattera, Yale University School of Medicine and Massachusetts General Hospital
Terence H. W. Ching, Brian A. Zaboski, Stephen A. Kichuk, Yale University School of Medicine
There was no funding received for this research.

EFM and THWC claim co-first authorship. EFM and SAK conceptualized the initial scope of this research. EFM
conducted the initial literature search and drafted the initial version of this manuscript. THWC, BAZ, and SAK
completed additional literature searches and provided multiple rounds of revisions to this manuscript. All authors
contributed to the critical review and final version of the manuscript.
We have no known conflicts of interest to disclose.
The authors would like to thank the individual in the case example for consenting to the deidentified use of their
experiences for the manuscript.
Address correspondence to Elizabeth F. Mattera, Yale University School of Medicine, 333 Cedar Street, New
Haven, CT 06510; email: elizabeth.mattera@yale.edu
Highlights
 Suicidal obsessions (SO) can be challenging to distinguish from suicidal ideation (SI).
 Inaccurate assessment of SO vs. SI can lead to inappropriate treatment.
 We present a practical guide with a case example to help differentiate SO from SI.
 We show how these differences functionally interrelate with each other in SO and SI.
Abstract
Suicidal obsessions (SO) can be challenging to distinguish from suicidal ideation (SI). This can
be in part due to low familiarity with diverse presentations of OCD, as well as the limited scope
of common measurement tools for assessing suicide-themed thoughts within a cognitive,
affective, and behavioral framework. Inaccurate assessment increases the risk of misdiagnosis
and inappropriate treatment, which are critical to prevent. Therefore, we present a practical guide
with a case example highlighting potential cognitive, affective, and behavioral criteria to
consider in differentiating SO from SI, grounded upon a cognitive-behavioral framework and the
extant literature regarding the phenomenology and assessment of OCD and suicidality. Through
illustrative figures we also demonstrate examples of SO and SI with resulting cognitive,
affective, and behavioral responses, and how they functionally interrelate with each other. We
conclude with suggestions for future research validating the criteria provided in this guide. In
summary, using this evidence-based guide to assess suicide-themed thoughts, emotions, and
behaviors may help clinicians accurately distinguish between SO and SI, in turn optimizing
interventions for their clients.
Keywords: suicide; obsessions; ideation; differential diagnosis; functional assessment

SYMPTOMS of obsessive-compulsive disorder (OCD) may center on a wide variety of themes.
Obsessions focused on “unacceptable” or taboo content, including those with themes of suicide
or violent harm toward the self, make up a core symptom dimension in OCD (Bloch et al., 2008;
Williams et al., 2013). Specifically, suicidal obsessions (SO) involve recurrent, unwanted,
intrusive, and distressing thoughts focused on one’s suicide (Rachamallu et al., 2017; Wetterneck
et al., 2016). Importantly, SO does not by itself indicate that a person is suicidal. This is
reflective of the nature of obsessions in OCD, which are typically experienced as alien to one’s
sense of self or values (i.e., ego-dystonic). Just as someone may have obsessions of violence
toward others with no inclination toward perpetrating violence, someone may have obsessions
about suicide but maintain a strong desire to live.
A distinct but potentially challenging to distinguish phenomenon from SO, suicidal
ideation (SI) involves thoughts of deliberately engaging in harmful behaviors that would end
one’s life (Nock & Favazza, 2009). Similar to SO, SI may be experienced as ego-dystonic.
Additionally, SI can be experienced as ego-syntonic or, in other words, congruent with one’s
sense of self or with current desires or views.
To complicate the process of differentiating between SO and SI, a substantial proportion
of people with OCD have been found to experience SI (Angelakis et al., 2015; Hellberg et al.,
2022; Torres et al., 2007, 2011). For instance, in one sample, approximately 27% of psychiatric
patients with OCD reported previous suicide attempts (Kamath et al., 2007). A meta-analysis of
48 studies showed a large association between OCD and SI (Hedges’s g = 0.86), with a moderate
association between OCD and suicide attempts (g = 0.64; Angelakis et al., 2015). Additional
research found a unique association between violent obsessions and suicidality in an OCD
analog sample of college students (Ching et al., 2017).
Another important factor may be the presence of major depression, which is often
comorbid with OCD (Kessler et al., 2005; Kessler et al., 2012). Major depression often features
SI and is a risk factor for suicidal behavior (Hawton et al., 2013). Comorbid depression may
contribute to SI risk and complicate the differential diagnosis of SI and SO in a person with
OCD.
Since SI and SO have different functional consequences and different levels of clinical
risk, accurately distinguishing between the two phenomena is necessary. Inaccurate diagnosis
may lead to significant consequences, such as the implementation of ineffective or even harmful
treatments. For instance, misdiagnosing recurrent, intense SI as SO may divert from safety
planning, crisis intervention, or other suicide prevention strategies. Conversely, when well-
intentioned clinicians misinterpret patients’ report of persistent SO as SI and create safety plans
for patients to adhere to, these interventions may have the unwanted consequence of being turned
into compulsive reassurance-seeking rituals (e.g., patients compulsively reaching out to support
figures whenever they experience SO), ultimately reinforcing and maintaining the disorder. In
the same vein, when clinicians step up crisis interventions for patients with SO that they have
misdiagnosed as SI, wrongful hospitalization may occur, accompanied by rupture of the
therapeutic relationship, guardedness, or dropout. These are important consequences to prevent
through effective differential assessment, since researchers have found that unacceptable/taboo
obsessions, including SO, may have longer-term morbidity and poorer treatment response than
other symptom dimensions (e.g., contamination; Brakoulias et al., 2013; Williams et al., 2013).
At the same time, safety planning and crisis interventions may be needed in certain cases of SO
(and OCD in general), as long as the suicidal thoughts are not solely obsessional in nature.
In other cases of misdiagnosis, treatment targets may be missed entirely. Some research
has found that 70% of patients who meet diagnostic criteria for OCD do not receive a diagnosis
and do not receive appropriate treatment (Wahl et al., 2010). More specifically, obsessions with
unacceptable/taboo themes, including harm, aggression, and suicidal content, are at higher risk of
being misdiagnosed as a condition other than OCD (Glazier et al., 2013, 2015). Presumably, the
stigma and perceived dangerousness associated with taboo or harm-related obsessions, as well as
low clinician familiarity with the diversity of OCD presentations, may complicate the assessment
process (Homonoff & Sciutto, 2019; McCarty et al., 2017). As a result, people with OCD may be
reluctant to disclose prominent SO for fear of it being mistaken as SI. Indeed, in our clinical
experience, it is common for people with SO (and other harm obsessions) to be concerned it will
be misjudged and to be cautious about disclosing. Therefore, the onus lies with clinicians to
improve their accuracy of differential assessment of SO vs. SI.
Within the context of assessment, various self-report and clinician-administered rating
scales are commonly used, but clinicians should be alert to the potential for these scales to
conflate SI and SO. For example, the self-reported Quick Inventory of Depressive
Symptomatology (QIDS; Rush et al., 2003) queries suicidality with a single item, and this has
been used to assess suicide risk in OCD (Hellberg et al., 2022). This item asks whether a person
may “think of suicide or death several times a week.” As another example, an item on the
clinician-administered Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2008)
asks, “Have you actually had any thoughts of killing yourself?” While both measures may aid in
capturing various manifestations of SI, without more nuanced assessment, the clinically distinct
and generally separable phenomena of SI and SO may be conflated. Thus, in clinical practice, it
is recommended that suicidality scales, whether self-report or clinician-administered, be used
within a larger functional assessment.
To assist in clinical differentiation of SO and SI, we present the following practical guide.
Throughout, we refer to a case example from our clinic to highlight criteria useful in differential
diagnosis. Our intent is to enable clinicians to distinguish between SI and SO and to facilitate
appropriate and effective treatment planning.
Case Example
Sam (pseudonym) is a 25-year-old non-Hispanic White cisgender woman who completed
a 25-minute phone prescreen at the Yale OCD Research Clinic. After a board-certified
psychiatrist and a licensed psychologist (BAZ) reviewed Sam’s reported symptoms, she then met
with the first author (EFM) for an intake to formally determine eligibility for the clinic’s ongoing
studies. EFM was trained to conduct intakes by an experienced interviewer (SAK) and licensed
psychologist (BAZ) and supervised by the latter. The intake evaluation included a semistructured
psychosocial interview and administration of the Mini International Neuropsychiatric Interview
(MINI-7; Sheehan et al., 1998).
During the clinical interview, Sam’s chief complaint entailed “unwanted and distressing
thoughts of violent harm” to herself. These “intrusive thoughts” included “intentionally walking
in front of a bus while crossing the street” or “jumping off a cliff while hiking.” She also
reported unwanted and distressing thoughts of “randomly injuring” herself. For example, she
reported that when using knives, she would experience sudden fears of cutting herself. Examples
of her thoughts included questions and ideas of, "What if I stab myself in the heart?" or "It would
be so easy to slit my wrists right now, wouldn’t it?" or “If I pick up a knife now, who will stop
me from slitting my wrists right now?” Her current intrusive thoughts also consisted of
overdosing on medications when alone, and images of being found unconscious or dead by loved
ones.
Sam elaborated that because these thoughts were highly distressing, she would store her
knives and medications in hard-to-access places (e.g., locked cabinets or lockboxes), constantly
reassure herself of her personal safety, and try her best to avoid thinking about or watching
anything harmful or violent (e.g., movies). She explained that although she knew she had no
current intention of harming herself, the intrusions made her feel “crazy, doubtful, and not in
control,” as if having these thoughts made it more likely that “[she] will actually kill [herself].”
Relatedly, she reported secondary current intrusive thoughts of making mistakes with
“disastrous” consequences. These thoughts included getting fired for minor typos in work emails
or leaving the stove on and burning down her apartment complex. These were typically
accompanied by excessive checking (e.g., that there were no typos in her work emails, and that
the stove was turned off).
Sam also experienced several major depressive episodes, which began in her teenage
years. Along with other depressive symptoms, she endorsed a “past desire to die or otherwise
thoughts of not wanting to exist anymore” during her early depressive episodes. In response to
those past thoughts, Sam often cut more “concealable parts” of her body with razor blades, such
as her upper arms and inner thighs.
Notably, she also reported a suicide attempt 2 years prior to the intake. This occurred
after she moved into her own apartment and was preceded by several months of intense
depressed mood, loneliness, and persistent feelings of hopelessness. Sam elaborated that on the
afternoon of the attempt, she was experiencing “rather intense suicidal thoughts while preparing
lunch,” which led her to run her fingers along the blade of her “sharpest kitchen knife.” At that
moment, she decided to slit her wrists with the knife with the intent to die. However, she aborted
the attempt when her mother unexpectedly called to check in. She denied following through with
the attempt after the call ended and denied any attempts since that time. She explained that she
“had come to [her] senses” and “did not want to hurt the people closest to [her] by committing
suicide.” Importantly, Sam emphasized that her current intrusive suicidal thoughts (not her pre-
attempt ideation) had escalated in frequency and intensity since her aborted attempt.
One year prior to the evaluation, Sam disclosed her the same current intrusive suicidal
obsessions to her psychiatrist. As a result, she was involuntarily hospitalized in a psychiatric
inpatient unit for a week. This hospitalization made her feel angry and misunderstood; she
described the experience as "dehumanizing" (see also other negative hospitalization experiences
in Hom et al., 2020), and expressed regret over telling her therapist about her intrusive suicidal
obsessions.
Since her discharge, Sam reported that she engaged in “countless hours” of independent
research by reading OCD-related scientific and popular press articles and internet forum posts.
She appeared convinced that her current intrusive suicidal thoughts were obsessive and not truly
ideational in nature. She expressed that she was able to independently differentiate these
thoughts from her past suicidal thoughts that preceded her aborted suicide attempt. When probed
about how she arrived at this conclusion, she explained that 2 years prior, she felt depressed and
hopeless, wanted to slit her wrists, and wanted to die. In contrast, at time of this evaluation, when
queried with the Suicidality section of the MINI-7, she denied any suicidal intent or desire to die
and expressed a strong desire to live and a fear of death. Even so, she felt "out of control and
unsafe." Regardless of her insight, Sam reported a 5% chance on item B19 that she may try to
kill herself in the next 3 months, explaining, “There is probably a 0% chance, but you never
know. I have so much doubt when it comes to these thoughts, even if I truly don’t want to hurt or
kill myself.”
Distinguishing Suicidal Obsessions from Suicidal Ideation
Sam’s responses highlighted significant fear, doubt, and confusion attributable to what
she described as intrusive suicidal thoughts. However, given the significant comorbidity between
OCD and suicidality (Angelakis et al., 2015; Ching et al., 2017), as well as the risk of
inappropriate intervention stemming from misdiagnosis (Glazier et al., 2013, 2015), a strategy
for effectively distinguishing SO from SI is needed. In the following guide, using a cognitive-
behavioral framework, we first highlight cognitive, affective, and behavioral differences across
these phenomena. We then situate these differences within a functional assessment framework to
help improve the likelihood of accurate differential assessment.
Cognitive Differences
The first domain to consider is how the individual appraises their thoughts in terms of
their values and self-concept. Appraisals of thoughts as ego-dystonic (inconsistent with one’s
values/self-concept) vs. ego-syntonic (consistent with one’s values) theoretically lie on opposite
ends of the cognitive spectrum (see Figure 1). However, it is important to recognize that thoughts
may vary along that spectrum.
In OCD, obsessions are definitionally appraised as ego-dystonic (Figure 1) in that they
are inconsistent with an individual’s views, desires, values, personality, or experience of self
(Purdon & Clark, 1999). For example, just as a highly religious patient with scrupulosity
obsessions may report their blasphemous thoughts as unwanted, intrusive, or in some way
inconsistent with their worldview, someone with SO may also appraise their thoughts of harming
themselves or ending their life as unwanted and intrusive. Importantly, ego-dystonic cognitions
tend to correlate strongly with negative affective responses, such as fear, disgust, and anxiety
(Hart et al., 2018). On the other hand, as shown in Figure 1, appraisals of suicidal ideation may
be more likely to range across the entire cognitive spectrum from ego-dystonic to ego-syntonic
(Brådvik & Berglund, 2000, 2011). Therefore, suicidal thoughts that present to a higher degree
as ego-syntonic—or consistent with current desires or views—are more likely ideational than
obsessional. The experience of an ego-syntonic suicidal thought is essentially that, “I had the
thought that I want to die, and part of me agrees with that.” Suicidal thoughts, especially when
experienced as more strongly ego-syntonic, may also be correlated with positive or at least
neutral emotional responses (Crane et al., 2012).
However, some research has found that SI was more commonly experienced as ego-
dystonic among a sample of people treated for severe depression (Brådvik & Berglund, 2000).
Additionally, it was found that a history of ego-dystonic SI was more common among men who
completed suicide. These authors proposed that while ego-syntonic SI is a component of major
depression, ego-dystonic ideation may be psychotic in nature. While that is a possibility, we
argue for additional possibilities, that ego-dystonic suicidal thoughts may at times reflect
cognitive distortions related to shame and low self-esteem (e.g., "I don't necessarily want to kill
myself, but I know my loved ones will be better off if I'm gone") and/or obsessions (and perhaps
undiagnosed OCD).
A detailed retrospective review of individuals’ symptoms over time may be useful to
identify differences. We have found that many clients who have experienced both SI and SO are
able to clearly identify the two as distinct phenomena. In Sam’s case, her consistent report of her
current suicidal thoughts as unwanted and contrary to what she “knew”—i.e., the clearly
identified absence of desire, intent, or drive to harm herself or die—indicate her thoughts were
ego-dystonic. This intrusiveness, paired with the repeated, distressing quality indicates
obsessionality. In contrast, her previous suicidal thoughts and her “desire to die” prior to her
suicide attempt are better identified as ego-syntonic and ideational.
Another distinguishing feature may be qualitative differences in the content of SO vs. SI.
SO is often characterized by doubt and uncertainty (Rachamallu et al., 2017; Wetterneck et al.,
2016), which may influence how these thoughts are experienced. Specifically, multiple anecdotal
reports and clinical observations (e.g., Abramowitz & Deacon, 2005) illustrate how obsessions
are often structured as questions that spur uncertainty (e.g., “What are the actual chances that I’ll
drive my car into a tree?”) (Figure 1). These types of thoughts are also likely to prompt fear and
distress, followed by compulsions to neutralize these feelings. For example, in Sam’s case, her
current intrusive suicidal thoughts often take on the form of doubt-inducing questions: “What are
the chances that I will actually kill myself? Will I stab myself impulsively, like the last time I
tried to kill myself?” This presentation is characteristic of obsessions.
SI, on the other hand, is often experienced as self-statements or questions that entertain or
even welcome the prospect of death (Crane et al., 2012). These statements or questions may be
formulated like, “I don’t want to live anymore,” or “Maybe killing myself will help end the pain
for good.” Additionally, SI may also contain images of suicide methods, self-injury, or one’s
funeral, or be followed by definitive, ego-syntonic appraisals, such as, “No one would care if I
died,” or “It makes sense to kill myself then” (Crane et al., 2012). It is important to note that
while similar images may occur in SO, they are typically met with anxiety, fear, or distress (see
next section). In Sam’s experience of suicidal thoughts prior to her attempt, she shared that
whenever she had a suicidal thought, it was also followed by other thoughts like “A big part of
me feels as though life is not worth living,” or “I really don’t want to continue living anymore.”
Thus, these self-statements, in addition to being ego-syntonic (hence, more consistent with
ideation than obsessions), are also cognitively distinct from OCD-like obsessions.
Corroborative evidence for cognitive differences between SO and SI can also arise from
other contextual information. For instance, individuals with OCD often experience obsessions
from two or more OCD symptom dimensions (Torresan et al., 2013). Therefore, the presence of
additional obsessive concerns (e.g., contamination, symmetry/ordering) could corroborate the
presence of SO. Additionally, one might consider an individual’s obsessive beliefs, such as
catastrophic or otherwise dysfunctional interpretations of obsessive thoughts (Abramowitz et al.,
2019; Obsessive Compulsive Cognitions Working Group, 2003, 2005). For instance, individuals
with SO might fear that their thoughts will “infect” a loved one with suicidality and put that
person at risk for suicide as well (Coughtrey et al., 2013). They may also believe that thinking
about suicide is as harmful, immoral, or irreversible as engaging in the suicidal behaviors
themselves (indicating underlying thought-action fusion; Shafran et al., 1996). For Sam, her
current intrusive suicidal thoughts indeed appeared exacerbated by thought-action fusion,
evidenced by her statement that “[It often seems] as if having these thoughts make it more likely
that I will actually kill myself.”
Affective Differences
The affective response to suicide-related content is another variable to consider.
Individuals with SO vs. SI likely differ in their affective response to suicidal stimuli, including
suicide-related thoughts, descriptions of suicide in books, depictions of suicide in the media, etc.
Specifically, those with SO tend to experience distress triggered by the content of their
obsessions (Figure 1), such as anxiety, fear, doubt, and uncertainty (Lee et al., 2005). Many
people with SO are also able to identify the distress as excessive or disproportionate. On the
other hand, some individuals experiencing SI may rate suicide-related stimuli as more pleasant,
less arousing, and less threatening than people without SI (Jaroszewski et al., 2020; Nock et al.,
2010). This may include feelings of anticipation and relief, for example, through the prospect of
a definitive “escape” from psychological pain (Crane et al., 2012). Although people with SI may
also experience distress in response to their suicidal thoughts (Brådvik & Berglund, 2011), taken
together, this suggests that an individual with SI may experience a wider range of affect in
response to suicide-related stimuli than someone with SO.
In Sam’s case, these affective differences were evident. Regarding her suicidal thoughts
leading to her aborted suicide attempt, she reported experiencing them as somewhat emotionally
positive, consistent with her stated desire to die. Her affective response towards the suicidal
thoughts provides some evidence of these thoughts as ideational. In contrast, Sam consistently
reported distress (and an absence of positive emotions) in response to the intrusive suicidal
thoughts experienced around time of the intake, suggesting that these thoughts are obsessional in
nature.
Behavioral Differences
The third domain involves the individual’s behavioral responses to suicidal thoughts. The
main question here centers on whether a person’s behaviors are oriented toward either approach
or avoidance of self-harm or suicide (Figure 1). In OCD, avoidance is particularly common,
whether in response to obsessions or to situations that trigger obsessions or compulsions (Bey et
al., 2020; Ettelt et al., 2008; Starcevic et al., 2011b). Specifically, individuals with OCD tend to
excessively avoid people, places, objects, or other stimuli implicated in their obsessive concerns.
Harm obsessions, including obsessions about suicide or harm to the self, are strongly associated
with avoidance (Starcevic et al., 2011b). For example, individuals with suicidal or self-harm
obsessions may persistently avoid knives or other sharp objects in the home due to the fear of
harming or killing themselves (McGuire et al., 2011).
A related point to consider is the presence of compulsions, a hallmark behavioral
characteristic of OCD. Compulsions observed in OCD are functionally related to obsessions
(Reid et al., 2021) in that they are performed with the purpose of preventing feared outcomes
(Starcevic et al., 2011a) or of relieving distress, such as anxiety or fear. In the context of SO,
overt compulsions may include excessive reassurance-seeking from loved ones or mental health
professionals, or excessive body checking for signs of physical harm. Covert compulsions may
include mentally reviewing aspects of their life that are worth living for, engaging in some sort
of stereotyped or excessive affirmation of their desire to live, or excessive praying or
neutralization with “good” words or self-statements (Williams et al., 2011).
Clinicians should also consider whether behavioral responses to suicidal thoughts are
influenced by intolerance of uncertainty or a sense of “not-just-rightness.” Both are characteristic
processes underlying obsessions and compulsions in OCD (Coles & Ravid, 2016; Sica et al.,
2015) and can indicate the presence of SO as opposed to SI. For instance, individuals with SO
may engage in various mental or physical compulsions with the goal of attaining absolute
certainty that they will not kill themselves against their will, and/or they may perform such
compulsions until they feel “just right” (Grayson, 2010).
In any such case, the behaviors in response to SO are oriented at moving away from or
avoiding not just the acts of self-harm or suicide, but also the thoughts themselves. Based on our
collective clinical experience, compulsions seen in OCD tend to differ from avoidance behaviors
in SI in that the latter tend not to be associated as reliably or closely in time to suicidal thoughts
as compulsions are to obsessions. Compulsions in OCD also tend to be high-frequency
behaviors, and likely more excessive than avoidance behaviors in SI.
In contrast to the significant avoidance-orientation related to SO, behavioral responses to
SI may range the entire approach-avoidance spectrum. For example, some individuals with SI
may avoid weapons or potentially dangerous situations due to the fear that they will not be able
to refrain from harming themselves. They may also exhibit approach-oriented behavioral
responses that include preparatory behaviors, such as researching suicide methods, writing
suicide notes, stockpiling medications, gathering potentially lethal instruments, and creating a
suicide plan (Goodfellow et al., 2018). We have also observed that some individuals even
deliberately use thoughts of suicide to regulate their emotions or mood more generally. In
essence, by generating thoughts of suicide, it reminds them they have an ultimate “way out” if
they ever so chose, even though there may be no actual intent at the time (see also Crane et al.,
2012). This serves a direct function of reducing general distress by acting as a sort of “pressure
relief valve.”
Underlying motivations should be examined. In certain cases, a person with SI may
arrange for a family member to lock up all knives or medications in the house in order to prevent
them from attempting suicide. This may appear primarily avoidant, but may actually be driven
by an approach-oriented motivation. In other words, the reason they are having the knives or
medications locked up may be because of recurrent impulses to use them for a suicide attempt.
This preventive act is also clearly and logically connected to the intended goal (suicide
prevention), as opposed to the more high-frequency or excessive aspect of compulsive avoidance
(e.g., avoiding anything that might trigger thoughts about ending one’s life, such as a violent
movie). An additional point of consideration is the presence of nonsuicidal self-injury (NSSI).
Since NSSI predicts risk of SI and suicidal behaviors (Whitlock et al., 2013), the presence of
NSSI in a client may indicate a higher probability of SI occurring.
In Sam’s case, her current intrusive suicidal thoughts and fears of self-harm were
consistently accompanied by various immediate, excessive behaviors aimed at preventing or
avoiding harm to herself (e.g., storing sharp objects, avoiding movies with violent content). This
is contrasted with the approach-oriented behavioral responses to suicidal thoughts preceding her
suicide attempt (i.e., running her fingers along the blade of a knife, occasional cutting). Sam also
reported excessive distress due to her inability to know “for sure” that she would never act on her
current intrusive suicidal thoughts. Additionally, her behavioral responses—hiding all dangerous
objects and avoiding all threatening movies and shows—were consistently tied to the goal of
achieving the absolute certainty that she would not kill herself. Further, Sam endorsed concurrent
excessive checking in various domains, a classic OCD compulsion (Bloch et al., 2008), in
response to secondary concerns around making mistakes. According to her report, these
additional behaviors were qualitatively similar (e.g., in their immediacy, consistency, frequency
and overall “feel”) to the avoidance behaviors in response to her current intrusive suicidal
thoughts. These phenomenological and functional differences in her previous and current
suicide-themed thoughts provided some evidence in differentiating her prior suicidal thoughts as
ideational and current thoughts as obsessional.
Importantly, no single criterion in assessing suicidal thoughts should be considered in
isolation, as it may lead to an inaccurate clinical formulation. Clinical assessment should instead
be based on a simultaneous consideration of multiple criteria. For this reason, a functional
assessment can be used to integrate the cognitive, affective, and behavioral information into a
comprehensive conceptualization of the suicidal thoughts in question.
Differential Functional Assessments for Suicidal Obsessions and Suicidal Ideation
A functional assessment, an important component of cognitive-behavioral theory,
recognizes the interrelationships among one’s thoughts, feelings, and behaviors (Zaboski et al.,
2021). The functional assessment creates a detailed clinical model of an individual’s behaviors
that is linked to their thoughts and emotions (Tolin, 2016). A sound functional assessment is
sensitive to the idiosyncratic relationships among an individual’s thoughts, emotions, and
behaviors, and views them as functionally linked. By considering the cognitive, affective, and
behavioral differences highlighted above, a functional assessment can be used to differentiate
between SO and SI. Figures 2A and 2B illustrate an example of SO and SI, respectively.
In someone with SO (Figure 2A), an intrusive thought that they could kill themselves is
typically experienced as ego-dystonic and often manifests as a question (e.g., “How can I be sure
that I won’t kill myself?”). This elicits strong, distressing feelings such as anxiety, fear, shock,
and self-doubt. In response, the person engages in various compulsions, such as excessive
reassurance-seeking and harm avoidance. These compulsions are intended to reduce the distress
from the intrusive thought and/or establish a sense of certainty or security or feel “just right”
about their safety.
By contrast, a similar thought of suicide in someone with SI (Figure 2B), while
commonly experienced as ego-dystonic, may sometimes be perceived as ego-syntonic. In the
latter case, ego-syntonic SI may elicit feelings of relief or anticipation. However, it is possible
that both ego-dystonic and ego-syntonic SI may prompt approach/preparatory behaviors (e.g.,
suicide plans; Brådvik & Berglund, 2011; Nock et al., 2008). This underscores the point that SI
may prompt a wide range of behavioral responses, given that the phenomenology of ideation to
action is diverse and dynamic among patients with SI (Milner et al., 2017). These behavioral
responses in SI contrast with the more specific behavioral responses seen with SO. The
behavioral responses in SI may be aimed not (or not just) at reducing distress or uncertainty from
a specific thought or achieving “just-rightness,” but rather to end one’s life and escape from
psychological pain. Behaviors aimed at preventing suicide may be present but these may be
reflective of an underlying motivation or pull toward suicidal behavior.
Additional considerations within a functional assessment include contextual factors, like
internal, cognitive-affective antecedents. For example, suicidal thoughts may be triggered by
internal antecedents including hopelessness and perceived burdensomeness (related to thwarted
belongingness, or the lack of social relationships; Van Orden et al., 2010), both of which have
been shown to predict SI and suicide attempts (Kleiman et al., 2014). External antecedent events
may include the death of a loved one, the loss of a job, a divorce or breakup, traumatic events, as
well as prior suicide attempts. Prior suicide attempts are also predictive of subsequent SI and
suicide attempts (Ribeiro et al., 2016; Walsh et al., 2017). In Sam’s case, feelings of
hopelessness preceded her aborted suicide attempt in response to SI. This suicide attempt also
appeared to precipitate her SO. While these antecedents were not useful in differentiating
between her SI and SO, they add meaningful context to her clinical case conceptualization.
Applied to Sam’s case, Figure 3A illustrates how her current report of intrusive suicidal
thoughts can be conceptualized as SO. Specifically, the intrusive possibility of stabbing herself
in the heart with a kitchen knife is experienced as an uncertainty-inducing, ego-dystonic
question. This prompts a fear response that activates various immediate and repetitive physical
and mental compulsions, including avoidance of situations and stimuli that may trigger the same
thought. Per her own report, these compulsions were intended to gain certainty about her
personal safety.
On the other hand, Figure 3B illustrates how a similar thought Sam had of slitting her
wrist can be conceptualized as SI. This thought took the form of an ego-syntonic statement, was
accompanied by feelings of relief, and subsequently functionally related approach/preparatory
behaviors (e.g., touching the sharp edge of a knife) that culminated in her decision to attempt
suicide.
Discussion
SO are often misunderstood and misdiagnosed (Glazier et al., 2013, 2015), and when
they are inaccurately assessed as SI or vice versa, undesirable consequences can ensue from
inappropriate interventions. In this guide, with a case example, we have highlighted cognitive,
affective, and behavioral differences between SO and SI. These differences are summarized in
Figure 1. We have also integrated these domains within a functional assessment to assist in
differentiating between SO and SI, as shown in Figures 2A-B and 3A-B.

We encourage clinicians to use this guide to aid in differential assessment between SO
and SI and to inform effective interventions. To facilitate this process, we recommend asking the
questions listed in Table 1 for each domain, modified as needed to ensure they are understood by
each client, and with follow-up questions when necessary. While these questions are not meant
to be exhaustive, we believe that they will help elicit sufficient information for clinicians to
arrive at an accurate assessment of the nature of the client’s suicide-themed thoughts. We also
recommend that clinicians integrate the cognitive, affective, and behavioral information gathered
through these questions into a functional conceptualization of clients’ suicide-themed thoughts.
This process can be completed independently by the clinician, guided by the following
considerations: How are the suicide-themed thoughts, emotional responses, and behavioral
responses related together? What is the purpose of these behaviors in response to the thoughts
and/or associated emotions?
It is important to point out that this guide may not capture all clinical ambiguities
between SO and SI, and there may be particular scenarios where differential assessment may be
more complicated and nuanced. For instance, clients may present with a consistent report of ego-
dystonic suicidal thoughts, distress, and avoidance behaviors, which make it difficult to rule out
either SO or SI. Nuanced behavioral features, like brief avoidant responses not immediately or
consistently tied to the suicidal thoughts, may also be missed. In these cases, clinicians will
likely have to rely on their clinical judgment and prior experience in treating OCD. We also
recommend ongoing consultation with or supervision by other clinicians more experienced in
treating OCD.
Suggestions for Future Research

It is important for future research to validate the cognitive, affective, and behavioral
differences between SO and SI reviewed in this guide. For instance, our clinic is employing a
previously identified methodology (Jaroszewski et al., 2020) of examining responses to first-
person suicide-related images. We will be testing this in an OCD sample with SI and an OCD
sample with SO. We will then follow up with self-report measures targeting hypothesized
differences in cognitive, affective, and behavioral responses. In these self-reports, we will
include items assessing the extent to which participants view these images as syntonic or
dystonic to their current selfhood or values in life. We will also include open-ended items
assessing the content and structure of participants’ immediate cognitive responses to images of
suicidal content. Self-reports of participants’ range of negative to positive emotional responses,
as well as their avoidance, compulsive, and self-injurious urges, will also be included.
In terms of multimodal assessment of these differences, the same images from
Jaroszewski et al. (2020) can also be integrated into a computer-and-joystick-based approach-
avoidance task (AAT), in which participants pull the joystick to bring the images closer from the
fixation point on the computer screen (i.e., approach), or push the joystick to move the images
further away on the computer screen (i.e., avoid), when presented. In this paradigm, the mean
push/avoidance-minus-pull/appproach reaction time is a behavioral measure of approach (net
negative) vs. avoidance (net positive) tendencies to presented stimuli (see Weil et al., 2017 for a
variation). Last, skin conductance response and heart rate variability could also be assessed as
physiological markers of distress in response to presented images. Future studies may examine
brain-level responses using either resting state measures or treatment paradigms (e.g., functional
magnetic resonance imaging or electroencephalography; Rance et al., 2018; Zaboski et al.,
2021).
Conclusions
The clinical consequences of misinterpreting SO as SI and vice versa are significant.
These may include the ineffective or inappropriate treatment or wrongful hospitalization of
clients who are experiencing SO and who are not actually actively suicidal. Other consequences
can include a loss of trust and feelings of betrayal between clients and clinicians. We hope that
by using this evidence-based guide to assess suicide-themed thoughts, emotions, and behaviors,
clinicians will be able to accurately distinguish between SO and SI and optimize interventions
for clients.
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Table 1
Recommended Questions to Assess Differences Between Suicidal Obsessions and Suicidal
Ideation
Domain Suggested Questions

Cognitive  “How aligned are these suicidal thoughts with your current
sense of self or your current values?
 “How aligned have these suicidal thoughts been over time

with your sense of self or your values?”
 “What do the suicidal thoughts tend to sound like?” “In other

words, other than images, if at all, what form do these
suicidal thoughts tend to take? Do they take the form of
“What if…” questions, self-statements, or something
different?”
 “Other than these suicidal thoughts, do you have any other

intrusive thoughts?”
 “What beliefs do you have about these suicidal thoughts

and/or your other intrusive thoughts?” (This can be followed
by appropriate psychoeducation around common types of
obsessive beliefs and probing if patients endorse these
beliefs about their suicidal and/or other intrusive thoughts.)
Affective  “What do you feel when you have these suicidal thoughts?
What emotions do you tend to have in response to these
suicidal thoughts?”
 If a client describes emotions solely on the negative

spectrum: “What exceptions, if any, are there to these
feelings of anxiety/fear/etc. over time? Have you ever had
any neutral or positive emotional responses to the same
suicidal thoughts in your life?”
Behavioral  “What do you do when you experience these suicidal

thoughts and/or the emotions associated with them?”
 “Why do you do these behaviors? What is the goal? Do you

do these behaviors to approach or avoid the scenarios in your
suicidal thoughts? Has it always been this way?”
 “How immediately or reliably do you do these behaviors in

response to your current suicidal thoughts and/or associated
emotions? Has it always been this way?”
 “How much time in your waking day is occupied by these

behaviors?”
 “What is the outcome of doing these behaviors? What impact

do your behaviors have on your suicidal thoughts and/or
associated emotions?”
 “Do you engage in any self-injurious behaviors, whether in

response to these thoughts or not?”
Cognitive Differences
Ego-dystonic Ego-syntonic
Questions Statements
SI
SO
Affective Differences
Negative Positive
SI
SO
Behavioral Differences
Avoidance Approach
SI
SO
Figure 1. Differences between suicidal obsessions (SO) and suicidal ideation (SI) in the
cognitive, affective, and behavioral domains.

Cognition
A.
Often as questions Ego-dystonic appraisal
“What are the chances
“Why on earth would I
of killing myself right
think that??”
now?”
Negative affect
Fear, shock, doubt,

Avoidant behaviors uncertainty, etc.
Circumscribed goals
Excessive reassurance-seeking,
avoid dangerous situations or
objects, etc., to gain certainty
about personal safety
Cognition
B. Often as statements Ego-syntonic appraisal
“Yeah, that makes sense.
“I could kill myself
That may help take away
right now.”
the pain…”
Positive affect
Relief, anticipation,
etc.
Approach behaviors
Research methods, create

suicide plan, proceed with
attempt, etc.
Figure 2. Examples of functional relationships among cognition, affect, and behavior in suicidal
obsessions (A) and suicidal ideation (B). The dashed line from behavior to cognition highlight
the possibility of a reinforcement cycle, in which maladaptive behavioral responses to affect
triggered by suicidal cognitions (and emotional relief) increase the likelihood of these thoughts
recurring over time in either case.

Cognition
A.
Often as questions Ego-dystonic appraisal
“What if I stab myself in
the heart with this knife “Not this thought again!”
right now?”
Negative affect
Fear, shock, doubt,

Avoidant behaviors uncertainty, etc.
Circumscribed goals
Storing sharp objects away,

avoiding violent movies, etc.,
to gain certainty about her
safety
Cognition
B. Often as statements Ego-syntonic appraisal
“It would be so easy “Sounds like a good idea.
to slit my wrists and I don’t want to live
die right now.” anymore…”
Positive affect
Relief, anticipation,
etc.
Approach behaviors
Running fingers across knife

blade, proceed with attempt
Figure 3. Examples of functional relationships among cognition, affect, and behavior in suicidal
obsessions (A) and suicidal ideation (B) for Sam’s case. The dashed line from behavior to
cognition highlight the possibility of a reinforcement cycle, in which maladaptive behavioral
responses to affect triggered by suicidal cognitions (and emotional relief) increase the likelihood
of these thoughts recurring over time in either case.
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Article in Cognitive and Behavioral Practice · October 2022

Terence H. W. Ching Brian A Zaboski

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Suicidal Obsessions or Suicidal Ideation? A Case Report and Practical Guide

Elizabeth F. Mattera, Terence H. W. Ching, Brian A. Zaboski, Stephen A.

To appear in: Cognitive and Behavioral Practice

Received Date: 15 July 2022

There was no funding received for this research.

 Inaccurate assessment of SO vs. SI can lead to inappropriate treatment.

of common measurement tools for assessing suicide-themed thoughts within a cognitive,

illustrative figures we also demonstrate examples of SO and SI with resulting cognitive,

interventions for their clients.

Keywords: suicide; obsessions; ideation; differential diagnosis; functional assessment

SYMPTOMS of obsessive-compulsive disorder (OCD) may center on a wide variety of themes.

about suicide but maintain a strong desire to live.

A distinct but potentially challenging to distinguish phenomenon from SO, suicidal

sense of self or with current desires or views.

To complicate the process of differentiating between SO and SI, a substantial proportion

analog sample of college students (Ching et al., 2017).

misdiagnosed as SI, wrongful hospitalization may occur, accompanied by rupture of the

therapeutic relationship, guardedness, or dropout. These are important consequences to prevent

improve their accuracy of differential assessment of SO vs. SI.

Within the context of assessment, various self-report and clinician-administered rating

is recommended that suicidality scales, whether self-report or clinician-administered, be used

within a larger functional assessment.

appropriate and effective treatment planning.

Sam (pseudonym) is a 25-year-old non-Hispanic White cisgender woman who completed

psychosocial interview and administration of the Mini International Neuropsychiatric Interview

(MINI-7; Sheehan et al., 1998).

the stove was turned off).

as her upper arms and inner thighs.

obsessions to her psychiatrist. As a result, she was involuntarily hospitalized in a psychiatric

Distinguishing Suicidal Obsessions from Suicidal Ideation

help improve the likelihood of accurate differential assessment.

may vary along that spectrum.

In OCD, obsessions are definitionally appraised as ego-dystonic (Figure 1) in that they

neutral emotional responses (Crane et al., 2012).

depression, ego-dystonic ideation may be psychotic in nature. While that is a possibility, we

A detailed retrospective review of individuals’ symptoms over time may be useful to

suicide attempt are better identified as ego-syntonic and ideational.

tried to kill myself?” This presentation is characteristic of obsessions.

additional obsessive concerns (e.g., contamination, symmetry/ordering) could corroborate the

catastrophic or otherwise dysfunctional interpretations of obsessive thoughts (Abramowitz et al.,

about suicide is as harmful, immoral, or irreversible as engaging in the suicidal behaviors

current intrusive suicidal thoughts indeed appeared exacerbated by thought-action fusion,

that I will actually kill myself.”

The affective response to suicide-related content is another variable to consider.

response to suicide-related stimuli than someone with SO.

or avoidance of self-harm or suicide (Figure 1). In OCD, avoidance is particularly common,

whether in response to obsessions or to situations that trigger obsessions or compulsions (Bey et

harming or killing themselves (McGuire et al., 2011).

A related point to consider is the presence of compulsions, a hallmark behavioral

characteristic of OCD. Compulsions observed in OCD are functionally related to obsessions

of stereotyped or excessive affirmation of their desire to live, or excessive praying or

neutralization with “good” words or self-statements (Williams et al., 2011).

influenced by intolerance of uncertainty or a sense of “not-just-rightness.” Both are characteristic

compulsions until they feel “just right” (Grayson, 2010).

as compulsions are to obsessions. Compulsions in OCD also tend to be high-frequency

behaviors, and likely more excessive than avoidance behaviors in SI.

In contrast to the significant avoidance-orientation related to SO, behavioral responses to

Underlying motivations should be examined. In certain cases, a person with SI may