A 28-year-old woman presents with a 3-year history of intrusive thoughts about contamination and a fear that she will harm her family members. She spends 2–3 hours daily washing her hands and cleaning her home, which provides temporary relief but the anxiety returns within hours. She recognizes these thoughts as irrational and is distressed by them. Her Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score is 32. She has never received any treatment. What is the most appropriate next step in management?

Explanation

## First-Line Management of OCD **Key Point:** CBT with exposure and response prevention (ERP) is the gold-standard first-line psychological treatment for OCD, regardless of severity, and should be offered before or alongside pharmacotherapy. ### Evidence Base - ERP is superior to pharmacotherapy alone in long-term outcomes [cite:DSM-5 Diagnostic Criteria for OCD] - The patient has moderate-to-severe OCD (Y-BOCS 32, threshold ≥16) with clear functional impairment and distress - She has never received treatment, making ERP the logical entry point ### Mechanism of ERP 1. **Exposure:** Deliberate confrontation with contamination triggers (e.g., touching "contaminated" surfaces) 2. **Response Prevention:** Resisting the compulsive urge to wash or clean 3. **Habituation:** Repeated exposure without compulsion leads to extinction of anxiety **Clinical Pearl:** The temporary relief from washing is a **negative reinforcement trap** — it strengthens the compulsion-anxiety cycle. ERP breaks this cycle by preventing the reinforcement. ### Pharmacotherapy Role - SSRIs (fluoxetine, sertraline, paroxetine, clomipramine) are second-line or adjunctive - Indicated if: patient refuses ERP, ERP unavailable, partial response to ERP, or comorbid depression/anxiety - Monotherapy with SSRI is less effective than ERP or ERP + SSRI combined **High-Yield:** In NEET PG, remember: **ERP first for OCD**, not medication. Medication is for augmentation or when ERP is declined/unavailable. ### When DBS or Inpatient Admission? - **DBS:** Reserved for treatment-resistant OCD (failed ≥2 adequate trials of SSRI + adequate ERP) — this patient is treatment-naive - **Inpatient:** Only if acute safety risk (e.g., severe self-harm compulsions, suicidality) — not indicated here