Worked example 1
A patient with checking compulsions spends two hours daily verifying appliances are off. CBT alone has had limited success.
(a) Outline exposure and response prevention (ERP) for this patient. [4 marks] (b) Evaluate the use of SSRIs combined with CBT for OCD. Refer to treatment guidelines. [6 marks]
Show solution outline
(a) AO1 — ERP applied:
- Exposure: Deliberate contact with trigger — leave house without checking oven/plugs (graded hierarchy from brief to extended absence).
- Response prevention: Block checking ritual — resist urge to return and verify.
- Mechanism: Anxiety rises then habituates without negative reinforcement — breaks operant maintenance cycle.
- Therapist supports patient through distress; homework between sessions.
(b) AO3 — SSRI + CBT evaluation:
- AO1: NICE/guidelines recommend CBT/ERP first-line; add SSRI (e.g. fluoxetine at higher dose) if moderate-severe or partial CBT response.
- Strengths: RCTs show combination superior to SSRI alone for OCD — addresses both serotonin dysfunction and cognitive-behavioural maintenance.
- Strengths: SSRIs may reduce anxiety enough for patient to engage with ERP — practical synergy.
- Limitations: SSRIs have side effects (nausea, sexual dysfunction); 4–12 weeks to full effect; relapse if medication stopped without CBT skills.
- Comparison: ERP alone effective for many — drugs add benefit when severity high (as in this case after limited CBT).
Judgement: For this patient, intensive ERP + SSRI is evidence-based escalation — combination addresses biological vulnerability and learned ritual maintenance.