Obsessive-compulsive disorder — structured clinical viva

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]