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Treatment-Resistant OCD — MRCPsych Paper B MCQ

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HardAnxiety & Stress-Related DisordersTreatment-Resistant OCDMRCPsych Paper B

A 30-year-old man has severe obsessive-compulsive disorder. Adherence and dose adequacy have been confirmed, but he has had no response to a full trial of SSRI monotherapy, a full trial of combined SSRI treatment and CBT including exposure and response prevention, and a full trial of clomipramine monotherapy. He is reviewed by a specialist multidisciplinary OCD team. Which pharmacological augmentation strategy is specifically listed by NICE for consideration at this stage?

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Correct answer: C — Add an antipsychotic to an SSRI or clomipramine

The correct answer is C. NICE lists adding an antipsychotic to an SSRI or clomipramine as an option following specialist multidisciplinary review when there has been no response to an adequate SSRI trial, combined SSRI plus CBT with ERP, and clomipramine monotherapy. NICE does not specify a preferred antipsychotic or an optimal sequence among the listed specialist options. Crucially, antipsychotic augmentation is not the immediate NICE step after failure of only one SSRI plus ERP; at that earlier stage, a different SSRI or clomipramine should be offered. Lithium, pregabalin and mirtazapine augmentation are not listed in this NICE treatment sequence. Benzodiazepines do not treat the core OCD syndrome and anxiolytics should not normally be used, except cautiously and briefly for early SSRI activation.

Reference: National Institute for Health and Care Excellence. Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG31), recommendations 1.5.4.3 and 1.5.4.5–1.5.4.7. Published 2005; last reviewed 2024. https://www.nice.org.uk/guidance/cg31/chapter/Recommendations