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Introduction: Six in ten patients with obsessive-compulsive disorder (OCD) do not respond to the first-line treatments with serotonin reuptake inhibitor (SRI) or cognitive behavioural therapy including exposure and response prevention (CBT/ERP), and several do not respond to second-line treatments, i.e., SRI-second generation antipsychotic (SGA) or SRI-CBT/ERP augmentation. Evidence on third-line treatments is inconsistent., Objective: We investigated the 1-year response to SRI-CBT/ERP-SGA combination in patients with severe treatment-resistant OCD, who failed to respond to SRI and to SRI-SGA or SRI-CBT/ERP augmentation., Methods: Twenty-eight patients were consecutively recruited and treated with SRI (drug(s) and doses previously administered), SGA (risperidone median dosage 1 mg/day in 14 cases, aripiprazole median dosage 3 mg/day in 14 cases) and CBT/ERP (median hours 32.5). Exclusion criteria: mental retardation and organic brain syndrome., Results: The mean Y-BOCS total score reduction at 12 months was 28.2%, 60.7% of patients improved, 46.4% partially responded, 32.1% responded, and 28.6% remitted. Patients previously resistant to SRI-SGA and SRI-CBT/ERP did not significantly differ in the rates of improvement, partial response, response and remission., Conclusions: This study suggests that SRI-SGA-CBT/ERP combination could be useful for severe treatment-resistant OCD. Small sample size is a limitation.Key pointsUp to 6 in 10 patients with OCD do not respond to first line treatments (CBT/ERP or SRIs) and several to second-line treatments (SRI-SGA or SRI CBT/ERP augmentation).In our study, patients with OCD resistant to the first and the second line treatment improved (61%), partially responded (46%), responded (32%), or remitted (29%) combining SRI, SGA and CBT/ERP.In our patients the SRI-SGA-CBT/ERP augmentation improved working/school, social and family impairment.SRI-SGA-CBT/ERP augmentation is easier to use than other treatments for severe treatment-resistant OCD.

An exaggerated sense of responsibility is currently considered as the ground for the obsessive-compulsive disorder. Obsessive-like behaviors, such as hesitations and checks, may be induced in non-clinical subjects by increasing perceived responsibility (i.e., perceived personal influence on negative outcomes). In line with Salkovskis' proposal [The cognitive approach to anxiety: threat beliefs, safety-seeking behavior, and the special case of health anxiety and obsessions, in: P.M. Salkovskis (Ed.), Frontiers of Cognitive Therapy, Guilford, New York], we tested the hypothesis that reduced coping abilities (i.e., an exaggerated expectation of failure) are another effectual factor contributing to obsessive-like behaviors. We examined 47 normal volunteers in a visuo-spatial memory task, and manipulated their perceived personal influence and expectation of failure by giving differential instructions and feedback about their performance. Increase of perceived personal influence induced slowness, hesitations and checks without enhancing performance. Expectation of failure exacerbated obsessive-like behaviors, again without affecting performance. These results confirm the role of responsibility in obsessive-like behavior and indicate that reduced coping abilities may contribute to worsen dysfunctional strategies.