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Clinical Atlas Prestige · Evidence-first

Psych VivasGeneral adult psychiatry — OCRD

Psych Vivas · General adult psychiatry — OCRD

Obsessive-compulsive disorder — structured clinical viva

Fellowship viva on treatment-refractory OCD: adequacy of prior trials, ERP, antipsychotic augmentation, deep TMS evidence, DBS meta-analytic pathway.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the psychiatry registrar. A 34-year-old man with severe checking OCD (Y-BOCS in the severe range) has failed two adequate SSRI trials (sertraline 200 mg; fluoxetine 80 mg) and a partial trial of clomipramine stopped for anticholinergic intolerance. He has never completed ERP because 'the psychologist only talked.' His partner asks about 'brain stimulation' and whether an antipsychotic will 'cure' him. Discuss assessment of refractoriness, next steps, augmentation evidence, deep TMS, and when DBS might be considered.

Interpretation

Reveal interpretation

This is treatment-resistant OCD only if prior treatments were truly adequate. Two high-dose SSRIs meet pharmacological adequacy signals, but ERP has not been delivered — “talking therapy” without exposure and response prevention does not count. First priority: specialist ERP while continuing an SRI, addressing family accommodation and suicide/depression risk.[1][5]

Antipsychotic augmentation is evidence-based for SRI-refractory OCD (systematic review support) but is not a “cure,” requires metabolic/EPS monitoring, and was inferior to CBT as an augmenter in the Simpson randomised trial when ERP had not been given.[1][2]

Deep TMS has positive multicentre randomised sham-controlled evidence and is a legitimate specialised discussion for patients failing medication and CBT pathways — frame consent, access, and realistic effect sizes.[3]

DBS/neurosurgery is a rare tertiary pathway for severe chronic refractory OCD after exhaustive specialist care; meta-analysis shows responses in selected cohorts but with surgical risk and ethical consent requirements — not a casual next step after two SSRIs without ERP.[4][5]

Key points

Refractory means adequate trials

Dose, duration, adherence, and true ERP — not labels alone.

ERP before brain surgery

Specialist ERP and guideline pharmacotherapy precede neuromodulation/DBS discussions.

Deep TMS ≠ DBS

Deep TMS is non-invasive specialised stimulation with RCT evidence; DBS is neurosurgical for extreme refractory cases.
[1] [3] [4]

References

  1. [1]Simpson HB, Foa EB, Liebowitz MR, et al. Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial JAMA Psychiatry, 2013.PMID 24026523
  2. [2]Bloch MH, Landeros-Weisenberger A, Kelmendi B, et al. A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder Mol Psychiatry, 2006.PMID 16585942
  3. [3]Carmi L, Tendler A, Bystritsky A, et al. Efficacy and Safety of Deep Transcranial Magnetic Stimulation for Obsessive-Compulsive Disorder: A Prospective Multicenter Randomized Double-Blind Placebo-Controlled Trial Am J Psychiatry, 2019.PMID 31109199
  4. [4]Alonso P, Cuadras D, Gabriëls L, et al. Deep Brain Stimulation for Obsessive-Compulsive Disorder: A Meta-Analysis of Treatment Outcome and Predictors of Response PLoS One, 2015.PMID 26208305
  5. [5]Koran LM, Hanna GL, Hollander E, et al. Practice guideline for the treatment of patients with obsessive-compulsive disorder Am J Psychiatry, 2007.PMID 17849776