A physician-validated, board-style question from the Active Transport QBank. Try it, then check the reasoning for every option.
A 23-year-old man presents to an outpatient psychiatrist complaining of anxiety and a persistent feeling that “something terrible will happen to my family.” He describes 1 year of vague, disturbing thoughts about his family members contracting a “horrible disease” or dying in an accident. He believes that he can prevent these outcomes by washing his hands of “the contaminants” any time that he touches something and by performing praying and counting rituals each time that he has unwanted, disturbing thoughts. The thoughts and rituals have become more frequent recently, making it impossible for him to work, and he expresses feeling deeply embarrassed by them. Which of the following is the most effective treatment for this patient's disorder?
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A
Cognitive behavioral therapy and clonazepamIncorrect. Benzodiazepines do not treat the core symptoms of OCD and carry dependence risk; they are not part of first-line OCD therapy.
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B
Cognitive behavioral therapy and fluoxetineCorrect. First-line OCD treatment is the combination of CBT (specifically exposure and response prevention) plus an SSRI such as fluoxetine.
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C
Psychodynamic psychotherapy and citalopramIncorrect. Psychodynamic psychotherapy lacks evidence for OCD; CBT with exposure and response prevention is the specific evidence-based behavioral intervention.
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D
Psychodynamic psychotherapy and aripiprazoleIncorrect. Aripiprazole is an antipsychotic used only as augmentation in SSRI-refractory OCD — not first-line monotherapy or initial combination.
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E
Exposure and response prevention with bupropionIncorrect. Bupropion is a norepinephrine-dopamine reuptake inhibitor used for depression and smoking cessation; it lacks evidence for OCD, where serotonergic agents (SSRIs) are required.
↑ Tap an answer to reveal the reasoning
Answer: B. This patient has obsessive-compulsive disorder (OCD): time-consuming, ego-dystonic, anxiety-provoking obsessions (fear of harm to family, contamination thoughts) paired with ritualized compulsions (handwashing, praying, counting) that he recognizes as excessive and that impair function. The combination is diagnostic; he is also embarrassed by the symptoms, supporting ego-dystonic OCD rather than OCPD (which is ego-syntonic).
First-line treatment for OCD is the combination of cognitive behavioral therapy — specifically exposure and response prevention (ERP) — plus an SSRI. SSRIs used for OCD often require higher doses and longer trials (12 weeks) than for depression. Fluoxetine, fluvoxamine, sertraline, and paroxetine are all FDA-approved. Clomipramine (a tricyclic) is also effective but has more side effects and is reserved for refractory cases.
Benzodiazepines like clonazepam do not treat OCD core symptoms and carry dependence risk in a 23-year-old. Psychodynamic psychotherapy has not shown evidence-based efficacy for OCD; CBT/ERP is the specific behavioral intervention proven to work. Antipsychotics like aripiprazole are used only as augmentation for SSRI-refractory OCD, not first-line.
**Why each option:**
**A.** Benzodiazepines do not treat the core symptoms of OCD and carry dependence risk; they are not part of first-line OCD therapy.
**B.** Correct. First-line OCD treatment is the combination of CBT (specifically exposure and response prevention) plus an SSRI such as fluoxetine.
**C.** Psychodynamic psychotherapy lacks evidence for OCD; CBT with exposure and response prevention is the specific evidence-based behavioral intervention.
**D.** Aripiprazole is an antipsychotic used only as augmentation in SSRI-refractory OCD — not first-line monotherapy or initial combination.