Obsessive-compulsive disorder — assessment and stepped management (MEQ)

(i) Definition and differentials. OCD: recurrent obsessions and/or compulsions that are time-consuming or impairing, typically ego-dystonic, not better explained by substance/medical illness or another mental disorder. Here: contamination obsessions with washing compulsions, good insight, multi-hour rituals — classic OCD within OCRD. Differentials: OCPD — ego-syntonic perfectionism without intrusion–ritual anxiety cycle; psychosis — primary delusions/hallucinations/thought disorder without compulsive neutralising structure; ASD — preferred sameness/routines vs ego-dystonic dread; BDD — appearance defect focus. Also depression comorbidity, substance, late-onset organic if atypical. Discriminators: insight, content, ego-dystonicity, developmental history, MSE for psychosis.^[6]

(ii) Assessment and Y-BOCS. Chronology; hours/day; avoidance; family accommodation (partner washing handles); prior “CBT” fidelity (no exposures = not ERP); medication adequacy (50 mg × 3 weeks is inadequate dose and duration); depression and suicide risk (passive death wishes need full risk assessment, means, protective factors); substances; medical baseline before higher-dose SSRI. Y-BOCS: clinician-rated severity across obsession and compulsion domains (time, interference, distress, resistance, control) — tracks severity/response, does not diagnose alone. Serial scores support measurement-based care.^[1][5]

(iii) ERP plan. Psychoeducation on negative reinforcement. Collaborative hierarchy of contamination exposures (e.g. touching “contaminated” surfaces) with strict response prevention (no washing, no partner cleaning accommodation, limit reassurance). In-session and homework exposures; reduce family accommodation with partner sessions. Specialist ERP therapist preferred. Evidence supports exposure and ritual prevention as first-line psychological care.^[2][5]

(iv) Pharmacotherapy optimisation. Do not stop after 3 weeks at 50 mg. Discuss sexual side-effects (timing, dose, switching options) and shared decision. Example: continue sertraline, titrate toward 100–200 mg oral daily as tolerated, plan 8–12 weeks at therapeutic dose with early review for activation/suicidality and side-effects; electrolytes if risk; combine with ERP. Alternatives if intolerant: another SSRI (e.g. fluoxetine) with same adequacy rules. Clomipramine is a later option with ECG/anticholinergic cautions.^[3][5]

(v) Non-response next steps. Re-check diagnosis, adherence, substances, true ERP delivery. Switch SSRI or move to clomipramine after adequate failures. Prefer ERP augmentation of SRI when therapy not yet delivered — randomised evidence showed CBT superior to risperidone augmentation. If SRI-resistant after adequate trials, consider low-dose antipsychotic augmentation (e.g. risperidone or aripiprazole) with metabolic monitoring. Specialist pathways for deep TMS or rare neurosurgery/DBS only after exhaustive specialised care.^[4][5]