Retraining the OCD Brain: ERP and Beyond - PsyQ Episode 10

In this episode, we tackle one of psychiatry's most complex challenges: Obsessive-Compulsive Disorder. We begin with a deep dive into the landmark 2005 Foa et al. trial, a methodologically rigorous study that definitively established the superior efficacy of intensive Exposure and Ritual Prevention (ERP) over potent pharmacotherapy with clomipramine. Using this foundational evidence, we build a practical, stepped-care algorithm for managing treatment-resistant OCD (TR-OCD). The discussion navigates the nuances of maximizing first-line SRIs, evidence-based augmentation with antipsychotics and glutamatergic agents, and the role of advanced neuromodulation techniques like TMS and Deep Brain Stimulation. We'll synthesize these disparate treatments through the unifying neurobiological lens of the Cortico-Striato-Thalamo-Cortical (CSTC) circuit, providing trainees with a cohesive framework for treating their most challenging OCD patients.Article:Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S., Campeas, R., Franklin, M. E., ... & Tu, X. (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 162(1), 151-161. This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit upathak.substack.com