The Role of a Psychiatrist in Treating OCD and Other Disorders

I remember my first week at WBMA when a parent brought in their teenage son for OCD treatment. They’d spent two years in weekly therapy – good therapy, evidence-based exposure work – but he was getting worse, not better. The intrusive thoughts had multiplied. The compulsions now take three hours each morning. His therapist was skilled, motivated, and doing everything right. So what was missing?

That question changed how I think about OCD treatment. Could it be that therapy alone, no matter how good, sometimes can’t address what’s happening in the brain? The answer, I’ve learned through treating hundreds of OCD patients, is yes. And that’s exactly where the role of a psychiatrist in treating OCD becomes not just helpful, but necessary.

Here’s what nobody tells you about OCD – it’s not a thinking problem you can reason away. Your brain chemistry is working against you, creating loops that willpower alone can’t break. I’m going to walk you through what psychiatrists actually do for OCD that makes the difference between years of struggling and actual relief.

The Three Mistakes That Keep OCD Patients Stuck

Most people try treating OCD backwards. They assume that if they just think differently, feel differently, or try harder in therapy, the obsessions will stop. I see this every week in consultations.

The first mistake? Believing OCD is purely psychological. You might think this sounds reasonable – after all, OCD involves thoughts and behaviors, so shouldn’t psychological treatment handle it? But OCD shows up on brain scans. Specific neural circuits fire differently in people with OCD. The orbitofrontal cortex, the anterior cingulate cortex, and the striatum get stuck in overdrive. When serotonin pathways misfire at this level, you’re not dealing with a thinking problem – you’re dealing with a medical condition that happens to affect your thoughts.

The second mistake is assuming therapy can work at any severity level. Exposure and response prevention is the gold standard behavioral treatment for OCD, yes. But here’s what I’ve observed across years of practice – when anxiety is severe enough that you physically cannot sit with the discomfort exposure requires, therapy can’t gain traction. It’s like telling someone with a broken leg to run before the bone heals. The structure isn’t there to support the work.

The third mistake? Trying standard antidepressant doses for treating OCD. Your primary care doctor means well when they prescribe 20mg of fluoxetine. That dose helps depression. But treating OCD requires 60-80mg. I’ve seen countless patients conclude “medication doesn’t work for me” when actually, they never reached a therapeutic dose for OCD specifically. The medication wasn’t the problem – the approach was.

Now, you might be wondering – does this mean everyone with OCD needs a psychiatrist? Not necessarily. Mild OCD sometimes responds to therapy alone. But moderate to severe OCD, OCD with co-occurring conditions, or OCD that hasn’t improved with therapy? That’s when psychiatric evaluation becomes essential, not optional.

What Makes Psychiatric Training Different

Let me be direct about something – psychiatrists and therapists both help treat OCD patients, but we do completely different things. Understanding this distinction will save you months or years of mismatched treatment.

Psychiatrists are medical doctors. We complete four years of medical school studying neuroscience, brain function, and how medications interact with neural systems. Then we spend four years in psychiatric residency learning psychopharmacology – the science of how drugs affect mental states. We’re trained to see OCD as a neurobiological condition that requires medical intervention.

This medical training means I can:

• Diagnose complex presentations – OCD rarely shows up alone. Depression, generalized anxiety, panic disorder, ADHD, autism spectrum conditions – these often appear together. I’m trained to identify how these conditions interact and which symptoms come from which disorder. This matters because treating only the OCD while missing the underlying depression, for instance, leaves you still suffering.
• Prescribe and manage medications – I know which SSRIs work specifically for OCD, at what doses, for how long. I understand augmentation strategies when first-line medications fail. I can prescribe clomipramine, the older tricyclic antidepressant that’s actually most effective for OCD but requires careful monitoring. Your therapist, no matter how skilled, cannot do any of this.
• Rule out medical causes – Certain autoimmune conditions trigger OCD symptoms. PANDAS and PANS in children create sudden-onset OCD that needs medical treatment, not just therapy. Thyroid disorders can worsen anxiety. I order appropriate labs and coordinate with other specialists to ensure we’re not missing something medical.
• Coordinate brain modulation therapies – When medication and therapy aren’t enough, options like transcranial magnetic stimulation for OCD can target the specific overactive brain circuits. This requires medical oversight and integration with your other treatments.

Therapists, on the other hand, specialize in behavioral interventions. They teach you exposure techniques, help you resist compulsions, and guide you through the anxiety. That skill-building is absolutely necessary – I’m not diminishing it. But when your brain chemistry prevents you from even attempting exposures because anxiety feels unbearable, psychiatric medication creates the neurological foundation that makes therapy possible.

Think of it this way. Therapy teaches you how to swim. Psychiatry makes sure you’re not trying to swim with weights tied to your ankles. Both matter. Neither alone is enough for moderate to severe OCD.

How We Actually Diagnose OCD in Psychiatric Practice

OCD diagnosis seems straightforward until you’re actually sitting with a patient whose symptoms don’t fit the textbook. Real diagnostic work requires understanding the infinite variations of how OCD manifests.

When someone comes to WBMA for OCD evaluation, I start by listening to the specific nature of their obsessions and compulsions. Not because I’m checking boxes, but because the pattern reveals what’s actually happening neurologically and what treatment approach will work.

I’m assessing several dimensions simultaneously:

• Obsession patterns and themes – What triggers the intrusive thoughts? Contamination fears are different from harm obsessions, which are different from symmetry concerns or religious scrupulosity. The content itself matters less than understanding what your brain perceives as threatening. This guides which exposures will be most effective in therapy and helps me predict medication response.
• Compulsion types and visibility – Physical rituals like hand-washing or checking are obvious. But mental compulsions – counting, praying, reviewing, reassurance-seeking – often go unrecognized for years. Patients tell me, “I don’t do compulsions,” while describing hours of mental rituals. If we don’t identify mental compulsions, treatment stays incomplete because we’re only addressing half the disorder.
• Time burden and life impact – How many hours per day do obsessions consume? Can you work, maintain relationships, and care for yourself? A patient who spends 30 minutes daily on rituals needs a different intervention than someone whose entire morning is lost to compulsions. Severity determines urgency and treatment intensity.
• Co-occurring conditions – This is where psychiatric training becomes critical. Is the depression driving the OCD, or is the OCD causing the depression? Does ADHD make it harder to engage in exposure therapy? Is there trauma underneath the obsessions? Each condition requires specific treatment, and treating them in the wrong order can make everything worse.
• Age of onset and course – Childhood OCD has different considerations than adult-onset OCD. Sudden onset in children might indicate PANDAS. Gradual worsening over decades suggests one treatment path, while acute deterioration suggests another. The timeline tells me things about prognosis and appropriate interventions.

Sometimes I use the Yale-Brown Obsessive Compulsive Scale to quantify severity. This standardized assessment gives us objective numbers to track over time – are we actually getting better, or does it just feel that way? But the real diagnostic insight comes from conversation, from understanding how OCD operates in your specific life, in your unique brain.

One more thing about diagnosis that matters – I’m always watching for OCD mimics. Body-focused repetitive behaviors like skin picking aren’t quite OCD, though they’re related. Psychotic disorders can look like OCD, but require completely different medication. Autism can involve rigid thinking patterns that resemble obsessions but stem from different neural processes. Getting the diagnosis precisely right determines whether treatment will work.

The Medication Reality – What Actually Works

Let’s talk about what psychiatric medication actually does for OCD, because most of what patients believe is wrong.

SSRIs don’t “cure” OCD – they reduce the neurological noise enough that you can engage in the behavioral work that creates lasting change. Think of OCD as a fire alarm that won’t stop blaring. Medication turns down the volume. Therapy teaches you that even when the alarm goes off, you don’t have to evacuate the building.

Here’s the part that frustrates me – treating OCD requires higher SSRI doses than depression or generalized anxiety, but most patients never reach therapeutic levels because doctors trained in general psychiatry don’t know this. While 20mg of fluoxetine helps with depression, OCD typically needs 60-80mg. Sertraline for OCD often requires 200mg, double the standard antidepressant dose.

The medications I prescribe most frequently for treating OCD:

• Fluoxetine (Prozac) at 40-80mg daily – My usual first choice because it’s effective, well-tolerated, and has a long half-life that forgives missed doses. But it takes 10-12 weeks at full dose to see maximum benefit. Most patients quit at week six, right before it would have worked.
• Sertraline (Zoloft) at 150-200mg daily – Some patients respond better to this than fluoxetine. I often start here if someone has co-occurring panic disorder since sertraline addresses both.
• Fluvoxamine (Luvox) at 200-300mg daily – Specifically FDA-approved for OCD, though less commonly prescribed. When other SSRIs haven’t worked, this sometimes does. The twice-daily dosing is less convenient, but effectiveness matters more than convenience.
• Paroxetine (Paxil) at 40-60mg daily – Effective but has more discontinuation symptoms, so I reserve this for patients who haven’t responded to other options. The withdrawal issues are real and need management.
• Clomipramine (Anafranil) at 150-250mg daily – The most effective medication for treating OCD, period. Research shows this old tricyclic antidepressant beats modern SSRIs in head-to-head trials. But it requires more monitoring, has more side effects, and can affect heart rhythm at high doses. I use this when SSRIs have failed, and often see remarkable responses.

When first-line medications provide partial but insufficient relief – which happens in about 40% of cases – I consider augmentation. Adding low-dose aripiprazole (Abilify) or risperidone to an SSRI can significantly improve outcomes. This isn’t standard antidepressant treatment, so many psychiatrists don’t try it. But the research supports it, and I’ve seen it transform treatment-resistant cases.

At WBMA, we sometimes use pharmacogenomic testing to guide medication selection. This genetic analysis shows how your body metabolizes different drugs – which ones you’ll process too quickly to get benefit from, which ones will build up and cause side effects. It doesn’t guarantee we’ll find the right medication faster, but it does reduce some trial and error. Insurance rarely covers it, so we discuss whether the cost provides enough value for your specific situation.

What I tell every patient starting OCD medication, and what I need you to hear – you will feel worse before you feel better. The first month brings side effects – nausea, headaches, fatigue, sometimes increased anxiety – without much symptom relief. Your brain is adjusting to altered serotonin levels. Push through to 10-12 weeks at therapeutic dose. That’s when real change happens. Stopping at week four or six, when you’re in the difficult middle phase, means you went through the hardest part for nothing.

Why Treating OCD Without Psychiatric Support

A therapist referred a patient to me last month with a note that said simply, “Can’t engage in exposures. Anxiety is too high. Need medical evaluation.” The patient had been trying exposure and response prevention for eight months. Their therapist was excellent – I know her, she specializes in OCD, and uses evidence-based protocols. But the patient’s baseline anxiety sat at an eight out of ten before even beginning an exposure. How do you sit with discomfort when you’re already drowning in it?

This happens more often than it should. Patients spend months in therapy making minimal progress, not because therapy doesn’t work, but because their neurochemistry won’t let them use it. It’s like trying to learn piano with broken fingers – the teaching is fine, but the physical foundation isn’t there.

The relationship between psychiatric care and therapy for OCD isn’t either/or – it’s both/and. When I manage someone’s medication, I’m creating neurological space for their therapy to work. When OCD symptoms are severe enough that exposure feels genuinely impossible, medication reduces the baseline anxiety enough that patients can actually practice sitting with discomfort. That practice, that gradual exposure work, is what creates lasting change. But you have to be able to do it first.

Here’s how integrated OCD treatment actually works at WBMA:

• Psychiatric evaluation first – I assess severity, rule out co-occurring conditions, determine if medication is indicated, and establish baseline symptoms to track improvement.
• Medication initiation if appropriate – Starting SSRIs at proper doses, educating about the timeline for improvement, monitoring for side effects, and adjusting as needed.
• Coordinated therapy referral – Connecting patients with therapists who specialize in exposure and response prevention, sharing relevant medical information with consent, and ensuring the behavioral work aligns with the medication timeline.
• Ongoing collaboration – Regular check-ins between me and the therapist about symptom changes, whether medication adjustments might help therapy progress, and coordinating the eventual medication taper as skills strengthen.
• Advanced options when needed – If standard approaches don’t provide enough relief, explore augmentation strategies, brain modulation therapies like TMS, or intensive treatment programs that combine multiple daily interventions.

Some patients need medication first to make therapy possible. Others start both simultaneously and progress faster because of the combined approach. And yes, a few people with mild OCD respond so well to exposure therapy alone that they never need psychiatric medication. My job is assessing which path makes sense for your specific presentation, not forcing everyone into the same treatment model.

When Standard OCD Treatment Isn’t Enough

What happens when you’ve tried multiple SSRIs at adequate doses for sufficient duration, worked with a skilled OCD therapist for months, and still wake up controlled by obsessions? This is treatment-resistant OCD, and it’s more common than people realize – about 40-60% of OCD patients don’t achieve full remission with first-line treatments.

Treatment resistance doesn’t mean hopeless. It means we need different interventions.

When I see treatment-resistant OCD, I’m thinking through several options systematically. Have we truly tried adequate medication doses for an adequate duration? Many patients are labeled treatment-resistant when actually they took 40mg of fluoxetine for six weeks – neither the dose nor duration was sufficient for OCD. So first, I verify we’ve exhausted standard approaches properly.

If we have, here’s where psychiatric expertise in OCD becomes critical:

• SSRI augmentation with low-dose antipsychotics – Adding 2-5mg of aripiprazole or 0.5-2mg of risperidone to your existing SSRI can improve response rates significantly. These aren’t high doses – we’re using the medications to modulate dopamine pathways that interact with serotonin systems. The combination often works when either medication alone doesn’t.
• Switching to clomipramine – If you haven’t tried this older tricyclic antidepressant, it should be next. Yes, it has more side effects and requires cardiac monitoring at higher doses. But it’s also the single most effective medication for OCD. I’ve seen people who failed four different SSRIs respond remarkably to clomipramine.
• Combination SSRI therapy – Sometimes combining two medications that work through different mechanisms produces better results than either alone. This isn’t standard practice, requires careful monitoring, but can be effective in resistant cases.
• High-dose SSRI trials – For some patients, going above standard maximum doses under close monitoring produces breakthrough responses. This requires experience with OCD specifically – most psychiatrists won’t try this.

Beyond medication, we have brain modulation options. At WBMA, we offer transcranial magnetic stimulation specifically for OCD. TMS uses targeted magnetic pulses to regulate the overactive brain circuits involved in OCD – primarily the connections between the prefrontal cortex and deeper structures. When medication and therapy haven’t provided adequate relief, TMS targets the problem at its neurological source. This isn’t first-line treatment, but for treatment-resistant OCD, it offers real hope. The FDA recently approved a specific TMS protocol for OCD, and research shows meaningful symptom reduction for many patients who’ve exhausted other options.

For severe, disabling OCD that hasn’t responded to outpatient treatment, intensive programs exist – residential treatment or partial hospitalization programs that provide multiple hours of exposure therapy daily combined with medication management, group support, and skills training. These programs aren’t appropriate for everyone, but when OCD has completely taken over someone’s life, the intensity of daily treatment can create breakthroughs that weekly therapy can’t.

What to Look for in an OCD Psychiatrist

Not all psychiatrists have equivalent OCD expertise. General psychiatry training covers OCD briefly, but treating it effectively requires specialized knowledge. When you’re looking for psychiatric care specifically for obsessive-compulsive disorder, ask these questions before committing:

• How many OCD patients are currently in your practice? – You want someone who treats OCD regularly, not someone who sees a case every few months. Regular exposure to OCD builds pattern recognition – I can often identify OCD subtypes and predict treatment response based on presentation because I see it constantly.
• What’s your approach to SSRI dosing for OCD? – The right answer mentions that OCD often requires higher doses than depression. If they talk about “starting low and going slow” without acknowledging OCD’s need for higher doses, they may not have specialized OCD knowledge.
• Do you work with therapists who specialize in exposure therapy? – Psychiatrists who collaborate with OCD-specialized therapists understand the condition deeply and coordinate care effectively. Integrated treatment produces better outcomes than fragmented care.
• What do you do when first-line medications fail? – Listen for mention of augmentation strategies, clomipramine, higher-dose trials, or brain modulation options. If they don’t have a clear answer beyond “try a different SSRI,” their OCD experience may be limited.
• How do you assess for co-occurring conditions? – OCD rarely exists in isolation. Your psychiatrist should routinely screen for depression, anxiety disorders, ADHD, autism spectrum conditions, and trauma – all of which affect treatment planning.

At Washington Behavioral Medicine Associates, OCD treatment happens within an integrated care model. When you see me or another psychiatrist on our team for medication management, you have access to specialized therapists trained in exposure and response prevention, comprehensive diagnostic testing including neuropsychological evaluation when indicated, and brain modulation therapies including TMS – all within the same practice. We coordinate your care instead of leaving you to manage communication between multiple disconnected providers.

This integration matters more for OCD than for many other conditions because effective treatment almost always requires both medical and behavioral interventions. When your psychiatrist and therapist communicate regularly about your progress, treatment adjustments happen faster and your care stays coordinated. We’re all working from the same understanding of your symptoms, your goals, and what’s helping versus what needs to change.

Your Next Step Toward OCD Relief

So here’s where we are. You’ve learned that OCD is a neurobiological condition requiring medical-level intervention, not just willpower or talk therapy. You understand that psychiatrists address the brain chemistry creating those relentless thought loops, while therapists teach you behavioral skills to respond differently. You know that medication for treating OCD requires higher doses than depression treatment, longer timelines for improvement, and often augmentation strategies when first-line approaches aren’t enough. And you’ve seen that treatment-resistant OCD has options – brain modulation, intensive programs, combination approaches that most general psychiatrists won’t try.

The question isn’t whether you need help. You already know you do. The question is whether you’re ready to pursue the right kind of help – integrated psychiatric and therapeutic care that addresses both the neurological roots and the behavioral patterns of OCD.

If you’re in the Chevy Chase, Bethesda, or greater Washington DC area and you’ve been struggling with OCD despite therapy, or if you’ve never had a proper psychiatric evaluation, that evaluation is your starting point. A psychiatrist trained specifically in OCD can assess whether medication would help, identify co-occurring conditions complicating your treatment, and create a medical plan that coordinates with your therapy work.

At WBMA, comprehensive OCD evaluation covers psychiatric assessment, medication management when indicated, therapy coordination with our specialized OCD therapists, and access to advanced options like TMS when standard approaches aren’t sufficient. We don’t just treat symptoms – we address the full picture of what’s keeping you stuck.

Your life beyond OCD is possible. Not the version where you white-knuckle your way through every day, fighting intrusive thoughts. The version where OCD becomes background noise instead of the loudest voice in your head. Where you can function, work, connect with people, and sleep without rituals consuming your evening. That life requires the right combination of medical and behavioral intervention, coordinated by providers who actually specialize in OCD treatment.

Contact Washington Behavioral Medicine Associates to schedule a psychiatric evaluation for OCD. We’ll assess your specific presentation, discuss treatment options that fit your situation, and create a coordinated plan between psychiatry and therapy. You’ve fought OCD alone long enough. Let’s fight it together with the full range of tools that actually work.