Descriptive Psychopathology: The Signs and Symptoms of ...

288 Section 3: Examination domainsas self-generated, not imposed by an external source. While obsessions occurprimarily in obsessive–compulsive spectrum conditions, they are also observed inpatients with melancholia, mania, and to a lesser extent in schizophrenia.Ruminations are similar to obsessions. They are repeatedly experienced and arefelt to be less intrusive. The sufferer occasionally recognizes the content as false orexaggerated. Ruminations are linked to abnormal emotion, the valence typicallyreflected in the content of the thoughts. Persistent ruminations are typical ofmelancholia.Non-delusional abnormal thought contentSuicidal thoughtsRecurrent suicidal ideas indicate psychopathology. The most common cause ofsuicidal thought is mood disorder, and 50–70% of persons who kill themselvesare depressed at the time of suicide. Melancholic patients are most likely to killthemselves. 67 Suicidal thoughts are also expressed by persons with personalityand substance abuse disorders. Sixty-four percent of persons said to have borderlinepersonality disorder attempt suicide at least once. 68 Transient suicidalthoughts are seen in states of intoxication and are also expressed by patients withsevere general medical illness associated with chronic dysfunction or pain. Suicidalthoughts are associated with sadness, despondency, overwhelming apprehension,or anger toward another person. While many studies delineate the riskfactors and circumstances of suicide attempts and completed suicides, similarattention is not given to suicidal thoughts.Reported prevalence rates for suicidal thoughts vary across studies and geographicregion. In Asian countries, lifetime suicidal thought is reported in 6–8%of the population. In one Norwegian study, the prevalence was found to be 40%.Suicide is the third leading cause of death among adolescents in the USA. In onestudy, almost one in five adolescents reported serious consideration of suicide inthe prior year. 69 Some suicidal behavior is shaped by cultural pressures. 70Not everyone who experiences a suicidal thought attempts suicide, but thepresence of suicidal thoughts increases the risk of suicide. A thorough behavioralevaluation always includes suicide risk assessment, and patients are asked directlyabout self-destructive thoughts and actions. Chapter 5 details the examination forsuicide risk.Homicidal thoughtsHomicide and aggressive behavior is better studied than are isolated homicidalthoughts. The lifetime population prevalence of homicidal thought is unknown,