Exposure and response prevention for residual OCD on an SRI (MEQ)

(i) Definition and cycle. ERP/EX/RP is structured behavioural treatment in which the patient confronts obsession-evoking cues while systematically refraining from compulsions and other safety behaviours.[13] Obsessions/triggers raise distress; rituals (washing, checking, reassurance) reduce distress short-term; that negative reinforcement maintains OCD. ERP breaks the relief loop so expectancy violation and inhibitory safety learning can occur.[12][13]

(ii) Assessment and hierarchy. Confirm OCD dimensions, time occupied, covert rituals, depression/suicide risk, insight, and goals. Measure severity with Y-BOCS.[14] Inventory partner reassurance and any family cleaning/checking (accommodation). Build a collaborative hierarchy from moderate public-contact and bathroom-related tasks up to higher items (e.g. toilet seat contact) with explicit response-prevention rules (delayed/no washing; no reassurance questions; limited checking). Include imaginal items if harm fears co-travel with checking. Plan therapist-assisted then self-directed practices and partner coaching to stop accommodation.[13]

(iii) Evidence for offering EX/RP now. Foa 2005: EX/RP superior to clomipramine alone; combination not clearly better than EX/RP alone at 12 weeks in that design — supports behavioural treatment as a potent standalone and combined modality.[1] For SRI residual symptoms, Simpson 2008 showed EX/RP superior to stress management augmentation; Simpson 2013 showed EX/RP superior to risperidone and placebo augmentation — aligning with his preference to add EX/RP rather than antipsychotic first when acceptable and available.[2][3] Prior "supportive CBT" was not adequate-dose ERP, so he has not yet had an evidence-based behavioural trial.

(iv) Fidelity failures. Examples: no between-session exposures; allowing washing/reassurance after contact; therapist providing repeated safety reassurance; hierarchy never leaving mild items; sessions without agenda/homework review; family undoing practice at home.[13][15]

(v) Integration and step-up. Continue sertraline 200 mg oral daily if tolerated (monitor activation, sexual side effects, hyponatraemia risk, interactions) while delivering twice-weekly or high-homework weekly EX/RP; do not stop SRI solely to "start therapy."[2][3] Step up if non-response after adequate ERP dose/fidelity: intensify schedule/residential ERP, review SRI optimisation or clomipramine pathway, treat depression/risk, specialist OCRD service — not premature polypharmacy without behavioural trial.[13]