Sexual obsessions and suicidal behaviors in patients with mood disorders, panic disorder and schizophrenia

Sexual obsessions are shown to be included onto the “unacceptable/forbidden thoughts” category [1, 2] and may comprise ego-dystonic, intrusive, recurrent and persistent thoughts, images or concerns about sexual matters that do not usually prompt sexual behavior. Thus, sexual obsessions can be considered a form of obsessive compulsive disorder (OCD) themselves [3].

The latent symptom structure of OCD was best defined by four specific dimensions: (a) obsessions and checking (e.g., aggressive, sexual, religious, and somatic obsessions and checking compulsions); (b) symmetry and ordering (e.g., symmetry and exactness obsessions, repeating, counting, and arranging compulsions); (c) contamination and cleaning (e.g., contamination obsessions and cleaning/washing compulsions); and (d) hoarding [2]. In patients with OCD, obsessions and checking were found to be more diffuse (92.78%) and associated with a greater overall functional and lifestyle impairment than other categories of symptoms [4].

In this study, we focused only on sexual obsessions, since the severity of obsessions, but not compulsions, was found to be related to impairment across several domains of life [5, 6].

The literal content of sexual obsessions may resemble other types of iterative sexual ideation, as seen in paraphilia, post-traumatic stress disorder, and normal sexual fantasy of the general population. Intrusive thoughts are frequently reported by nonclinical samples of adults (80%–88%) [7]. However, most people are able to dismiss them, whereas clinical sexual obsessions are perceived as personally significant, upsetting, and relentlessly recurrent [8]. Patients who experience such a type of “pure obsessions” (i.e., obsessions that are often characterized by the absence of overt compulsions) appraise intrusive thoughts as dangerous and overly important and, thus, struggle to control their thoughts [9]. Therefore, these patients feel greater distress about unacceptable thoughts than nonclinical populations in terms of the extent of distress, frustration, time lost, and impairment [10].

Sexual obsessions are common symptoms among OCD patients, with prevalence of 13.3-24.9%, [11] and 30.2% in combination with religious obsessions [12]. Hasler et al. [13] found that people with certain sets of OCD symptoms were more like to have certain comorbidities than others. In particular, about 82.1% of OCD patients with sexual obsessions was found to have a comorbid Axis I diagnosis [11]. OCD and depressed patients were found to have in common some dysfunctional appraisals about their most disturbing obsessions: guilt, unacceptability, likelihood thought would come true, danger, and responsibility for having the intrusive thoughts [14]. Other studies have related bipolar disorder to this cluster of symptoms [15] highlighting the need of further studies if we consider that these patients, besides depressed ones, often report sexual dysfunctions and these are associated with increased suicidality [16]. Although these are not uncommon symptoms, the topic of sexual obsessions as a psychiatric symptom and the presence of sexual obsessions within patients with a primary psychiatric diagnosis other than OCD have not been well researched.

In schizophrenia, obsessive compulsive symptoms were reported by 10% [17] to 26.7% of patients, the frequent obsessions being that of contamination, sexual and aggressive thoughts [18]. Although OCD co-occurs in a substantial proportion of schizophrenia patients [19], the rate of occurrence and the clinical effect of sexual obsessions have been scarcely investigated in these patients. Even though the rate of sexual obsessions was not investigated, 23% of patients with a diagnosis of panic disorder were also found to have general obsessive compulsive symptoms [20].

Gender is a relevant factor that should be taken into account when evaluating patients with obsessive symptoms, as a significantly higher frequency of sexual obsessions was observed in males than in females [21].

People with OCD feel a great distress about unacceptable thoughts, to the point that some studies found an association between obsessive compulsive spectrum and suicidality [22, 23]. Suicide is defined as the act of intentionally ending one's own life. Its immediate precursors are suicidal behaviors that include suicidal ideation, plans, and attempts [24]. Suicidal ideation consists of thoughts about suicide, which varies greatly from a desire to be dead (passive) to a formulation of intent (active). Suicidal plans refer to making detailed plans to commit suicide, without the suicidal act itself. A suicide attempt consists of a failed act of suicide. The estimated lifetime prevalence of suicidal ideation, plan and attempt in a large overall cross-national sample (N = 84 850) was 9.2%, 3.1% and 2.7%, respectively [24].

Recently, the severity of obsessive compulsive symptomatology, the presence of major depression and aggressive obsessions, and high levels of anxiety or hopelessness have been suggested that could lead patients to consider or attempt suicide to escape from their distressing symptoms [25].

Suicidal behaviors were found to be more common in patients with mood disorders than in other psychiatric disorders, followed by patients with anxiety disorders and impulse-control disorders [24]. Suicidal behaviors are also a frequent complication of schizophrenia with prevalence ranging between 20% and 40% [26‐28]. Nevertheless, features of suicidality in schizophrenia patients remain poorly understood [29].

In summary, a large literature indicates an association of OCD and other psychiatric disorders with suicidal behaviors. A much less extensive but consistent literature indicates comorbidities between OCD and other psychiatric disorders. Nevertheless, the influence of subtypes of OCD, such as sexual obsessions, on suicidal behaviors, in patients with a psychiatric diagnosis, was scarcely investigated. A recent study [23] is the only one published article addressing this issue. Results indicated that 36% of patients with OCD reported lifetime suicidal thoughts, 20% had made suicidal plans and 11% had already attempted suicide. In this sample, variables associated with lifetime suicidal thoughts and plans were socio-demographic variables (lower social class, not having children, and religious practice), comorbid mental disorders (major depression, posttraumatic stress disorder, substance use, and impulse-control disorders) and sexual/religious obsessions [23]. Suicide attempts were predicted only by mental disorders.

The purpose of this study was twofold:

This paper addresses a critical issue in the relationship between sexual obsessions and psychiatric diagnosis that is quite neglected in the literature. A possible reason for that is the tendency of researchers and clinicians to group sexual obsessions with aggressive and religious obsessions that make it difficult to identify the contribution of each to the individual distress [13, 37]. Furthermore, some research categorizes sexual obsessions and compulsivity together with deviant behavior, although deviant individuals experience thoughts, impulses, and behaviors as enjoyable, and not distressing [38]. Another reason may be the tendency, shown by patients, to deny or minimize their sexual obsessions [11].

Results of this study show that sexual obsessions affect more than half of patients with schizophrenia and over a third of those with mood disorders. This finding may be consistent with studies in the literature reporting a high proportion of obsessive compulsive symptoms in depressed patients [11]. About schizophrenia, instead, the presence of obsessive symptoms appears to be more relevant in this study than in the literature (54% v s. 10-26%) [17, 18]. It may be due to differences in measuring sexual obsessions between studies.

The proportion of sexual obsessions reported by panic disorder patients in this study was similar to that of obsessive compulsive symptoms reported by these patients in the literature (20% vs. 23%) [20]. Finally, sexual obsessive symptoms seem to affect a minority of non-psychiatric subjects (11%) as previous observations suggested [39].

About gender, males reported more sexual obsessions than females among non-psychiatric subjects, as expected [21]. Conversely, no difference between genders was found among all groups of patients. This result is congruent with a study indicating that, among patients with sexual obsessions, 53.8% were female [11]. Altogether, there is a need to explore, accurately, the prevalence of sexual obsessions in patients with different psychiatric diagnoses of both genders.

Another finding of this study concerns the prevalence and differences between groups and genders on suicidal behaviors. Patients with mood disorders reported higher suicidal ideation, plan and attempt than the other groups of patients and non-psychiatric subjects, as expected. In fact, the recurrence of suicidal ideation was high across depressive episodes [40‐43]. Also, the presence of mixed symptoms such as pseudo-unipolar depression substantially increases the risk of both attempted and committed suicide [43‐45]. In a recent study, 62% of patients with psychotic mood disorders and 56% of patients with non-psychotic mood disorders reported suicidal ideation [27].

In this study, schizophrenia patients also reported more suicidal behaviors than non-psychiatric subjects and this rate was in the range of that of other studies (20-40%) [26‐28], although in this study suicidal ideation and plans were much more frequent than attempts (44% vs. 17%).

There were no differences between genders in almost all study groups except in patients with schizophrenia. Among them, females reported more frequently suicidal behaviors than males, as it was found in the literature for patients with mental disorders and the general population [24].

Another important objective of the present study was to explore the possible effect of sexual obsessions on suicidal behaviors, taking into account also socio-demographic characteristics and different psychiatric diagnoses. Results show that among genders, being female is associated with suicidal behaviors, whereas none of the other socio-demographic factors is related to suicidal behaviors. In a large cross-national sample, risk of each suicidal behavior was found to be significantly related to female gender, younger age, having fewer years of formal education, and ever being married [24]. Nevertheless, the ORs were remarkably modest in magnitude, with the exception of age that decreased as the risk of each suicidal behavior increased. The different results regarding age could be explained by the different composition of the two study samples. The reference group to calculate the ORs in the study by Nock et al. [24] was an age >64 years, whereas in this study the maximum age was 60 years and 50% of cases were about 35 years old. Employment status was unrelated to suicidal behaviors in both studies.

Mental disorders also contribute to the likelihood of reporting lifetime suicidal behaviors, with a substantial contribution coming from mood disorders, followed by schizophrenia, and panic disorder. This result is partially consistent with the results of Nock et al. [24] observing that mood disorders were strongly associated with suicidal behaviors, although in the present study this contribution was stronger (OR = 11.5 vs. 3.4-5.9). The contribution of panic disorder in this study was in the range of that of anxiety disorders (a broader category including panic disorder) in Nock et al. [24] study (OR = 2.9-3.0 vs. 2.8-4.8). Unfortunately, we cannot compare the contribution of schizophrenia to suicidal behaviors in the two studies, because the cross-national survey excluded this mental disorder. Nevertheless, suicide behaviors are a relevant issue to be studied in schizophrenia as suicide attempt was found to be a predictor of suicide in these patients (OR = 3.66) [46].

Finally, sexual obsessions add a significant contribution to the tested models, almost triplicating the likelihood of a suicidal behavior (ideation, plan or attempt) among all the study samples. This result is consistent with that of a recent study by Torres et al. [23] that found an association between sexual obsessions, although grouped with religious obsessions, and suicidal thoughts and plans in OCD patients. A difference between the two studies concerns the diagnoses of participants: Torres et al. [23] involved a large sample of OCD patients with various comorbidities, while this study involved both patients with a primary diagnosis other than OCD and non-psychiatric subjects.

Some individuals have a great deal of difficulty controlling their frequent, intrusive thoughts about sex and their gender identity. The present study suggests that these symptoms may have relevance characterizing phenotypes respect to suicidality, in patients with psychiatric diagnoses. Our findings, taken together, stress the clinical relevance of sexual obsessions, and raise the question about the possible psychopathological mechanisms able to explain the link between unwanted sexual thoughts and suicide precursors. It can be hypothesized that sexual obsessions can elicit suicidality when their disturbing content assumes a personal meaning so high as to be able to reduce considerably self-esteem, inducing pathological guilt and self-depreciation. Cognitive theories of OCD posit that obsessions and thoughts appraised as important and personally significant are expected to be persistent and highly upsetting [8]. If individuals regard their sexual obsessions as immoral, sinful, or as potential causes of a complete loss of control or horrific actions, they can favor suicide plans as a possible solution to feelings of shame and guilt. Bordelau [47] suggests that suicide may reveal a form of repressed self-hate and appear as a solution to the individual’s problem. This hypothesis would be worth to be tested with further investigation.

In conclusion, this study suggests that is necessary to detect, accurately, the presence of sexual obsessions, which are a source of psychological burden that could be associated with suicide ideation or attempt.

Sexual obsessive symptoms are often misunderstood by both clinicians and patients. They may be misdiagnosed as fantasies or wishes by mental health professionals and misinterpreted as anxiety or depressive ruminations by patients. Such misconceptions can result in errors in treatment that may increase symptoms and contribute to develop suicidal ideation [49]. The sensitive nature of unwanted sexual thoughts and the great potential for misdiagnosis make essential that these symptoms are identified and well-understood by clinicians to aid to improve diagnosis and treatment.

In terms of psychotherapeutic intervention, research on OCD suggests that, compared to most other forms (i.e., contamination, checking, etc.), sexual obsessions take longer to treat and response may be less robust [50‐52]. Therefore, particular attention should be given to establish effective strategies of treatment for these symptoms.

Future studies should include analyses of symptoms from epidemiological studies and investigation of treatment outcomes, to provide greater insight into these often misunderstood symptoms [53].

LDO and CCar participated to the conception and design of the study, the interpretation of the data, the draft and critical revision of the article. GC, MC, CCon and PG participated to the interpretation of the data, the draft and critical revision of the article. All authors agreed to be cited as co-authors, accepting the order of authorship, and approved the final version of the manuscript and the manuscript submission to Annals of General Psychiatry.