When teenagers — and even children — have suicidal thoughts or fantasies, they are usually the result of great distress. Suicide appeals to them as a way to end suffering.

But some young people have suicidal thoughts of a very different kind: intrusive thoughts that they should, or might, kill themselves. These children aren’t attracted to suicide; they are terrified of it. And their unwanted visions of committing suicide — What if I jumped out this window? What if I ran out in front of this truck? What if I take too many pills? — are a form of obsessive-compulsive disorder.

Unfortunately for these kids, their suicidal obsessions are not always recognized as OCD. When they confess their thoughts to parents, their families are shocked that their children seem to be suicidal and worried that they might act on those thoughts.

Clinicians, too, may mistakenly assume they are at risk of attempting suicide, and the priority becomes protecting them from themselves.

“A lot of these kids who have obsessions about suicide or harming themselves get misdiagnosed as having suicidal depression,” explains Jerry Bubrick, PhD, a clinical psychologist at the Child Mind Institute. “A lot of them go to emergency rooms, and, unfortunately, end up spending time in psychiatric hospitals for being suicidal.”

Dr. Bubrick adds that this misdiagnosis is what leads to hospitalization for kids with OCD more often than anything else. “We’ve had case after case after case of kids who come in, having been in some hospital setting for some extended period, having been diagnosed as suicidal depressed, but they’re not. They have OCD.”

One child’s story

Maisy was eight years old when she told her mother, on the way to school, that she had a secret. “She said, ‘It’s really bad,’ ” her mother, Kaitlyn, recalls. “I said, ‘Okay, I would like to know your secret. Could tell me your secret?’ And she said, ‘My brain is telling me that I need to get a knife, and I need to stab myself in the heart, and kill myself.’ ”

Unlike a lot of kids in her situation, Maisy had already been diagnosed with OCD.

Kaitlyn recalls asking her where she thought the voice in her brain was coming from. “She said, ‘I think it’s that bad OCD in my brain.’ I said, ‘How do you feel about that?’ I was trying to get to whether or not she was feeling like she needed to die. She said, ‘I don’t want to die. I’m just a kid.’ ”

Kaitlyn immediately reported the conversation to the school psychologist, and then to Maisy’s therapist.

“They had us come that afternoon, and they questioned her along the same lines that I did. ‘How does this make you feel?’ ” Kaitlyn said. “They wanted to know if she had a plan for doing it. She said, ‘No, it’s just the voice in my head that’s telling me I need to go get a knife.’ The doctor said, ‘How would you do that?’ She said, ‘I can’t, I’m not even allowed to touch knives.’ ”

After about maybe 45 minutes of questioning, Kaitlyn said, they concluded that it was just intrusive thoughts, and that Maisy didn’t want to die. “She doesn’t want to hurt herself. That was scary, but, apparently, it’s just OCD.”

Reinforcing fears

When parents or therapists mistake this kind of OCD for real suicidality, the misunderstanding can actually make the child’s OCD worse.

If a child has been hospitalized from a mistaken belief that he is actually suicidal, his family will be given strict instructions to keep him safe, Dr. Bubrick notes. “Take away all the knives. Don’t have sharp things around. Make sure someone’s got eyes on them all the time.”

For kids with OCD, these intense precautions only serve to reinforce their intrusive fears that they might hurt themselves. “It totally reinforces, for the kid, the need to be safe,” he explains, “and the sense that the OCD is real.”

The response is comparable to what would happen if a child who has OCD fears of contamination is told that, yes, he is at extreme risk for infection, he shouldn’t touch anything, and if he touches something, he should wash his hands repeatedly, Dr. Bubrick adds. “Imagine how much that would reinforce the child’s fear of contamination.”

How OCD works

Kids with OCD whose obsessions center on suicide are not unlike those with other, more familiar obsessions. Kids who worry about contamination, for instance, wash their hands obsessively, avoid touching things they fear could make them sick, and seek reassurance from parents that, say, their food isn’t contaminated and if they eat it, they’re not going to get sick.

Kids obsessed with suicide worry that they will harm themselves — or sometimes others — and they avoid things and places where that it might happen, like sharp things or balconies or the edge of subway platforms. And they worry out loud to their parents, confessing suicidal fantasies and asking for reassurance that it won’t happen.

Rather than welcoming these thoughts of suicide as an end to their pain, as a person with depression might, they are disturbed by the thoughts, and want them to go away. “What’s wrong with me? Why am I suicidal? I love my life. I don’t want to die! I don’t like this thought.”

Their worries are like other forms of OCD, Dr. Bubrick notes. “If you ask the kids, ‘Are you saying you are going to do this, or are you worried about the possibility that you might?’ If they have OCD, they’ll say, ‘I’m worried about the possibility.’ This is just like another child might say, ‘I’m worried about the possibility of getting AIDS from sitting on this red spot.’ Or, ‘I’m worried about the possibility of having bad luck if I step on this crack.’ It’s just another symptom in of OCD.”

 Reassurance

 Parents of children who express thoughts of suicide are likely to try to respond by reassuring them that they don’t — or shouldn’t — want to kill themselves. “They’re constantly reassuring the kids,” Dr. Bubrick says. “ ‘No, sweetie, of course you don’t want to hurt yourself. You shouldn’t be thinking like that. You have a great life.’ ”

This is a natural response for parents — when a child is feeling worried, you want to tell her that she’s safe and the thing she is worried about won’t hurt her. But one of the most insidious aspects of OCD is that this kind of reassurance can actually help perpetuate the disorder. That’s because asking for help can become a compulsion, or something a child does to manage the fear.

After being reassured kids may feel better in the moment, but it only makes them more anxious in the long term, and relying on that reassurance can actually become a barrier to getting better.

Treatment for OCD  

For children with OCD who fear suicide, the treatment is the same as for other forms of OCD. Parents are trained not to offer reassurance, as it strengthens the fears. Chidren are taught to recognize that their fears are their OCD talking, and to talk back to the OCD instead of avoiding it.

In a form of cognitive behavioral therapy called exposure and response prevention, children are exposed to triggers for their fear, and trained to tolerate the fear without resorting to avoidance or asking for reassurance. Over time, the fear diminishes. The therapist might take the child onto a balcony, or on a train platform, or have her practice holding a knife until the fear wanes.

As for Maisy, whose OCD was telling her she wanted to kill herself, her mother reports that the therapists told her to ignore that voice in her brain, and talk back to it. They suggested that she tell her OCD all of the things that she had told them: “I’m not allowed to touch knives! I don’t want to hurt myself! I don’t want to hurt anybody else! You need to back off!”