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Sexual Obsessions and Suicidal Behaviors in Patients with Mood Disorders, Panic Disorder and Schizophrenia

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Sexual Obsessions and Suicidal Behaviors in Patients with Mood Disorders, Panic Disorder and Schizophrenia Dell’Osso et al. Annals of General Psychiatry 2012, 11:27 http://www.annals-general-psychiatry.com/content/11/1/27 PRIMARY RESEARCH Open Access Sexual obsessions and suicidal behaviors in patients with mood disorders, panic disorder and schizophrenia Liliana Dell’Osso1, Giulia Casu2, Marina Carlini3, Ciro Conversano1, Paola Gremigni2 and Claudia Carmassi1* Abstract Background: The topic of sexual obsessions as a psychiatric symptom has not been well investigated. The aim of this study was twofold: 1) to explore the presence of sexual obsessions in patients with mood disorders (n=156), panic disorder (n=54) and schizophrenia (n=79), with respect to non-psychiatric subjects (n=100); 2) to investigate the relationship between sexual obsessions and suicidal behaviors, taking into account socio-demographic variables ad mental disorders. Methods: 289 psychiatric patients with mood disorders, panic disorder or schizophrenia, were recruited at the Italian University departments of psychiatry along with 100 non-psychiatric subjects, who presented for a routine eye exam at the ophthalmology department of the same Universities. The assessments included: the Structured Clinical Interview for DSM-IV-TR, the Brief Psychiatric Rating Scale (BPRS), the Obsessive-Compulsive Spectrum Self-Report (OBS-SR), for sexual obsession, and the Mood Spectrum-Self Report lifetime version (MOODS-SR). Suicidality was assessed by means of 6 items of the MOODS-SR. Results: Sexual obsessions were more frequent in schizophrenia (54.4%), followed by mood disorders (35.9%). Among schizophrenia patients, males reported more sexual obsessions than females (P<0.01). Subjects who were more likely to report suicidal behaviors (suicidal ideation, plans and attempts) were female (adjusted OR=1.99), patients with mental disorders, specifically mood disorders (adjusted OR=11.5), schizophrenia (adjusted OR=3.7) or panic disorder (adjusted OR=2.9), and subjects who reported lifetime sexual obsessions (adjusted OR= 3.6). Sexual obsessions remained independently associated with all aspects of suicidal behaviors. Age, education, marital and employment status were not related to suicidal behaviors. Conclusions: Special attention should be given to investigate and establish effective strategies of treatment for sexual obsessions, especially those with comorbid mood disorders or schizophrenia. Keywords: Sexual obsessions, Suicidal ideation, Suicidal plans, Suicidal attempt, Mood disorders, Panic disorder, Schizophrenia Introduction sexual obsessions can be considered a form of obsessive Sexual obsessions are shown to be included onto the compulsive disorder (OCD) themselves [3]. “unacceptable/forbidden thoughts” category [1,2] and The latent symptom structure of OCD was best may comprise ego-dystonic, intrusive, recurrent and per- defined by four specific dimensions: (a) obsessions and sistent thoughts, images or concerns about sexual mat- checking (e.g., aggressive, sexual, religious, and somatic ters that do not usually prompt sexual behavior. Thus, 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 obses- * Correspondence: [email protected] 1Department of Clinical and Experimental Medicine, University of Pisa, Via sions and cleaning/washing compulsions); and (d) Roma 67, 56127, Pisa, Italy hoarding [2]. In patients with OCD, obsessions and Full list of author information is available at the end of the article © 2012 Dell'Osso et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Dell’Osso et al. Annals of General Psychiatry 2012, 11:27 Page 2 of 9 http://www.annals-general-psychiatry.com/content/11/1/27 checking were found to be more diffuse (92.78%) and not investigated, 23% of patients with a diagnosis of associated with a greater overall functional and lifestyle panic disorder were also found to have general obsessive impairment than other categories of symptoms [4]. compulsive symptoms [20]. In this study, we focused only on sexual obsessions, Gender is a relevant factor that should be taken into since the severity of obsessions, but not compulsions, account when evaluating patients with obsessive symp- was found to be related to impairment across several toms, as a significantly higher frequency of sexual obses- domains of life [5,6]. sions was observed in males than in females [21]. The literal content of sexual obsessions may resemble People with OCD feel a great distress about un- other types of iterative sexual ideation, as seen in para- acceptable thoughts, to the point that some studies philia, post-traumatic stress disorder, and normal sexual found an association between obsessive compulsive fantasy of the general population. Intrusive thoughts are spectrum and suicidality [22,23]. Suicide is defined as frequently reported by nonclinical samples of adults the act of intentionally ending one's own life. Its im- (80%–88%) [7]. However, most people are able to dis- mediate precursors are suicidal behaviors that include miss them, whereas clinical sexual obsessions are per- suicidal ideation, plans, and attempts [24]. Suicidal ceived as personally significant, upsetting, and ideation consists of thoughts about suicide, which var- relentlessly recurrent [8]. Patients who experience such ies greatly from a desire to be dead (passive) to a for- a type of “pure obsessions” (i.e., obsessions that are often mulation of intent (active). Suicidal plans refer to characterized by the absence of overt compulsions) ap- making detailed plans to commit suicide, without the praise intrusive thoughts as dangerous and overly im- suicidal act itself. A suicide attempt consists of a failed portant and, thus, struggle to control their thoughts [9]. act of suicide. The estimated lifetime prevalence of sui- Therefore, these patients feel greater distress about un- cidal ideation, plan and attempt in a large overall acceptable thoughts than nonclinical populations in cross-national sample (N = 84 850) was 9.2%, 3.1% terms of the extent of distress, frustration, time lost, and and 2.7%, respectively [24]. impairment [10]. Recently, the severity of obsessive compulsive symp- Sexual obsessions are common symptoms among tomatology, the presence of major depression and ag- OCD patients, with prevalence of 13.3-24.9%, [11] and gressive obsessions, and high levels of anxiety or 30.2% in combination with religious obsessions [12]. hopelessness have been suggested that could lead Hasler et al. [13] found that people with certain sets of patients to consider or attempt suicide to escape from OCD symptoms were more like to have certain comor- their distressing symptoms [25]. bidities than others. In particular, about 82.1% of OCD Suicidal behaviors were found to be more common in patients with sexual obsessions was found to have a patients with mood disorders than in other psychiatric comorbid Axis I diagnosis [11]. OCD and depressed disorders, followed by patients with anxiety disorders patients were found to have in common some dysfunc- and impulse-control disorders [24]. Suicidal behaviors tional appraisals about their most disturbing obsessions: are also a frequent complication of schizophrenia with guilt, unacceptability, likelihood thought would come prevalence ranging between 20% and 40% [26-28]. true, danger, and responsibility for having the intrusive Nevertheless, features of suicidality in schizophrenia thoughts [14]. Other studies have related bipolar dis- patients remain poorly understood [29]. order to this cluster of symptoms [15] highlighting the In summary, a large literature indicates an association need of further studies if we consider that these patients, of OCD and other psychiatric disorders with suicidal besides depressed ones, often report sexual dysfunctions behaviors. A much less extensive but consistent litera- and these are associated with increased suicidality [16]. ture indicates comorbidities between OCD and other Although these are not uncommon symptoms, the topic psychiatric disorders. Nevertheless, the influence of sub- of sexual obsessions as a psychiatric symptom and the types of OCD, such as sexual obsessions, on suicidal presence of sexual obsessions within patients with a pri- behaviors, in patients with a psychiatric diagnosis, was mary psychiatric diagnosis other than OCD have not scarcely investigated. A recent study [23] is the only one been well researched. published article addressing this issue. Results indicated In schizophrenia, obsessive compulsive symptoms that 36% of patients with OCD reported lifetime suicidal were reported by 10% [17] to 26.7% of patients, the fre- thoughts, 20% had made suicidal plans and 11% had quent obsessions being that of contamination, sexual already attempted suicide. In this sample, variables asso- and aggressive thoughts [18]. Although OCD co-occurs ciated with lifetime suicidal thoughts and plans were in a substantial proportion of schizophrenia patients socio-demographic variables (lower social class, not hav- [19], the rate of occurrence and the clinical effect of sex- ing children, and religious practice), comorbid mental ual obsessions have been scarcely investigated in these disorders (major depression,
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