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Revista Brasileira de Psiquiatria

versão impressa ISSN 1516-4446

Rev. Bras. Psiquiatr. vol.34 no.1 São Paulo mar. 2012 



Cognitive-Behavior Therapy-Online in OCD patient with hoarding symptoms



Helena da Silva PradoI; Eduardo Aliende PerinII

IBa, MSc, Universidade Ferderal do Paraná, Neuropediatria
IIMD, Universidade Federal de São Paulo; Brazilian Consortium of Research on Obsessive-compulsive Disorder and Spectrum (C-TOC)



Obsessive-Compulsive Disorder is known as a disorder that is frequently very incapacitating, which affects the social, familiar, professional, and affective aspects of daily life. The present letter concerns the successful Cognitive-Behavior Therapy-Online of an OCD patient with hoarding symptoms. The use of internet/computer and CBT is a feasible treatment for obsessive-compulsive disorder with a comparable outcome as f2f therapy when the therapist is specialized in CBT and OCD.1,2 There is suggestive evidence that online interventions3 have a powerful impact, similar to face-toface (f2f) therapy. Fenichel et al (2009)4 stated that the online principles are the same as offline principles, that is, 'people are people, whether talking f2f, on the telephone, or through Internet'. The patient-psychotherapist relationship in this context has some specific particularities that must be taken into account, such as the asynchronous versus synchronous time, the mix of several technologies and types of communication (voice, writings, e-mails, chat rooms, web-cams etc), and the psychotherapist ability to deal with such technology. Regarding phone therapy, Lovell et al (2006)1 pointed out that using the telephone as a tool for CBT-OL of OCD patients was quite similar to f2f or group therapy with comparable high levels of approval and success. A 32 years old female patient with Obsessive-Compulsive Disorder and hoarding symptoms was treated with CBT-OL and pharmacotherapy. She completed the Beck Depression Inventory, Beck Anxiety Inventory, Yale-Brown Obsessive-Compulsive Scale, and Dimensional Yale-Brown Obsessive-Compulsive Disorder at baseline and end point (Table 1). The therapy took nine months in weekly sessions of 40 minutes using internet tools - Skype, MSN, e-mails, and phone calls, plus four 60 minute f2f sessions. Whenever it was necessary, the patient could access the psychotherapist by phone call. The pharmacotherapy started with fluoxetine with doses gradually raised until 80 mg/day and zolpidem 5 mg/night because the patient also had insomnia. As the patient persisted having important anxiety symptoms and as it was impairing CBT, quetiapine 25 mg/night and clonazepam 0.5 mg/night were associated and anxiety decreased. Quetiapine dose was gradually raised to 100mg/night and clonazepam was suspended. Considering the hoarding symptoms, the patient stated: 'I don't have any kind of obsessions, thoughts, fears or images preceding my behaviors. Just an urging feeling. If I don't to do it, I feel an unbearable anxiety'. These urge feelings are known as mental sensory phenomena, and compulsions are performed to release these feelings (to know more about sensory phenomena see Prado et cols, 2008).5 The treatment was very successful. Patient stated that she was 98% better than in the beginning of the therapy. Nevertheless some limitations must be taken into account: patient and therapist have worked together in the past, possibly having caused some bias. The efficacy of this new approach should be tested by submitting OCD patients to new treatments with CBT-OL.

Acknowledgements: We thank the patient for consent and Mrs. Idalina Shimoda for her friendly support.



1. Lovell K, Cox D, Haddock G, Jones C, Raines D, Garvey R, Roberts C, Hadley S. Telephone administered cognitive behaviour therapy for treatment of obsessive compulsive disorder: randomized controlled non-inferiority trial. BMJ. 2006;333.         [ Links ]

2. Greist JH, Marks IM, Baer L, Parkin JR, Manzo PA, Mantle JM, Wenzel KW, Spierings CJ, Kobak KA, Dottl SL, Bailey TM, Forman L. Self-treatment for obsessive compulsive disorder using a manual and a computerized telephone interview: a US-UK study. MD Comput 1998;15:149-57.         [ Links ]

3. American Psychological Association: 118th Annual Convention - Online Psychological and Mental Health Interventions. 2010; San Diego, August 12-15.         [ Links ]

4. Fenichel M, Suler J, Barak A, Zelvin E, Gill Jones MA, Munro K, Meunier V, Walker-Schmucker W. Myths and Realities of Online Clinical Work: Observations on the phenomena of online behavior, experience and therapeutic relationships. A 3rd-year report from ISMHO's Clinical Case Study Group -Copyright © 2002-2009. [Access on Jan 02, 2009].

5. Prado HS, Rosário MC, Lee J, Hounie AG, Shavitt RG, Miguel EC. Sensory phenomena in obsessive-compulsive disorder and tic disorders: a review of the literature. CNS Spectr. 2008;13(5):425-32.         [ Links ]



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