Case report : a multimodal treatment approach combining multi-target rTMS with a modified, largely self-administered, clinician-supervised exposure and response prevention protocol using a verbal termination cue in two patients with severe obsessive-compulsive disorder

Background/Objectives: Obsessive–compulsive disorder (OCD) is a chronic and disabling condition. Despite first-line treatment with cognitive behavioral therapy (CBT) including exposure and response prevention (ERP) and selective serotonin reuptake inhibitors (SSRIs), many patients remain severely symptomatic. This highlights the need for further research into innovative multimodal treatment strategies for OCD. We report two inpatients with severe OCD, comorbid depressive symptoms, and insufficient response to previous pharmacological and psychotherapeutic treatments. Methods: Both patients completed 30 multimodal treatment units over six weeks consisting of sequential multi-target repetitive transcranial magnetic stimulation (rTMS) targeting the left dorsolateral prefrontal cortex (DLPFC), right DLPFC, and supplementary motor area (SMA), combined with a modified, largely self-administered, clinician-supervised exposure and response prevention protocol. Results: Both patients demonstrated large observed reductions in OCD symptom severity. Y-BOCS total scores decreased from 29 to 11 in Patient 1 and from 29 to 10 in Patient 2, corresponding to reductions of 62.1% and 65.5%, respectively, with improvements apparent after approximately four weeks and largely maintained at follow-up. Depressive symptoms also improved, and no clinically relevant adverse effects were observed. Conclusions: These cases provide an initial description of the feasibility and tolerability of this specific protocol architecture but do not establish efficacy, long-term durability, or the contribution of individual components. The protocol-level novelty lies in integrating a repeated three-target TBS schedule with a response-limited, cue-terminated exposure procedure, a combination not previously described in the OCD neuromodulation literature.