A 29-year-old man spends four hours a day washing his hands, driven by intrusive thoughts that he will contaminate his family with a deadly pathogen. He recognises the thoughts as irrational but cannot resist the compulsions. His work performance is significantly impaired. What is the first-line treatment combination for OCD?
- A Benzodiazepines plus supportive psychotherapy
- B Cognitive restructuring alone without exposure exercises
- C Antipsychotic monotherapy to suppress obsessional thinking
- D Exposure and response prevention (ERP) plus a serotonin reuptake inhibitor (SSRI or clomipramine) ✓
Explanation
The evidence-based first-line treatment for OCD is a combination of exposure and response prevention (ERP), which directly targets the obsession-compulsion cycle by habituating the patient to obsessional triggers without performing rituals, and pharmacotherapy with an SRI. SSRIs (e.g., fluvoxamine, fluoxetine, sertraline, paroxetine) are first-line agents; clomipramine (a tricyclic SRI) is equally effective but less tolerable. OCD often requires higher SSRI doses and longer trials than depression. Antipsychotic augmentation may be used in treatment-resistant cases but is not first-line.
Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.
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