A 28-year-old woman presents with a 2-year history of intrusive thoughts about contamination and repeated hand-washing rituals lasting 3–4 hours daily. She recognizes the thoughts as irrational but cannot resist the compulsions. Her Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score is 28. She has no prior psychiatric treatment. What is the most appropriate next step in management?

Explanation

## Diagnosis and First-Line Management of OCD **Key Point:** The patient meets DSM-5 criteria for OCD (obsessions + compulsions causing significant distress/dysfunction). First-line treatment combines pharmacotherapy and psychotherapy. ### Evidence-Based First-Line Approach For moderate-to-severe OCD (Y-BOCS ≥ 16), the gold standard is: 1. **SSRI monotherapy** — sertraline, paroxetine, fluoxetine, or clomipramine (tricyclic with serotonergic properties) - Sertraline is a first-line choice; typical starting dose 50 mg daily, titrated to 100–200 mg/day - Response may take 8–12 weeks at therapeutic doses 2. **Concurrent psychotherapy** — Cognitive-Behavioural Therapy (CBT) with Exposure and Response Prevention (ERP) - ERP is the gold-standard psychotherapy for OCD - Patients are exposed to anxiety-provoking stimuli (e.g., contamination cues) while refraining from compulsions - Combination SSRI + ERP yields superior outcomes vs. either alone **High-Yield:** The Y-BOCS score of 28 indicates moderate-to-severe OCD; this mandates active treatment, not observation or benzodiazepines alone. **Clinical Pearl:** Benzodiazepines (e.g., alprazolam) provide short-term anxiety relief but do not treat the core OCD pathology and risk dependence; they are NOT first-line and should be avoided as monotherapy. ### Why This Patient Needs Both Modalities | Intervention | Role | Evidence | | --- | --- | --- | | SSRI (sertraline) | Reduces intrusive thought frequency/intensity; addresses serotonergic dysregulation | RCTs show 40–60% symptom reduction | | ERP (CBT) | Breaks compulsion–anxiety cycle; teaches habituation | Superior long-term relapse prevention | | Combined approach | Synergistic; faster response, better adherence | Meta-analyses favour combination | **Mnemonic: FIRST for OCD Management** — **F**luoxetine/Fluv/Fluvoxamine (SSRIs), **I**ntensive ERP, **R**eferral to trained therapist, **S**ertraline/Supportive care, **T**reatment duration 8–12 weeks minimum. **Tip:** In NEET PG, when you see "recognized as irrational" + "cannot resist" + moderate Y-BOCS, always choose SSRI + CBT/ERP. Benzodiazepines and antipsychotics are second-line or adjunctive only.