**2. Etiology**

disorder. Janet handled this disorder under the title of psikasteni and exhibited that rituals could be improved by behavioral technics. S. Freud also stated the psychodynamic basis of

There are two basic classification systems in psychiatric disorders as the Diagnostic and Statistical Manual (DSM) and the International Classification of Diseases (ICD). Obsessivecompulsive disorder (OCD) has been included in ICD-5 first time among adult mental disorders in 1939, but for children OCD has been included in DSM-II among childhood mental disorders in 1968 and in ICD-9 in 1978 [2–4]. In DSM-IV, differences in childhood OCD patients "like they could not know their obsessions and compulsions" are extremely unreasonable were highlighted [5]. While obsessive-compulsive disorder (OCD) is present under the category of anxiety disorders in DSM-IV TR, it is classified under "Obsessive Compulsive Disorder and Related Disorders" in DSM 5 and hoarding compulsions separated from OCD in DSM 5 into a new disorder, as "Hoarding Disorder." But in the ICD 10 classification system, OCD is located under "neurotic, stress-related, and somatoform disorders" [6–8].

Obsessive compulsive disorder and related disorders include:

• Substance-/medication-induced obsessive-compulsive and related disorder

• Obsessive-compulsive and related disorder due to another medical condition

• Other specified obsessive-compulsive and related disorders and unspecified obsessive-

OCD is a disorder that is characterized by the presence of obsessions and/or compulsions [8]. Obsessions are intrusive and unwanted thoughts, urges, or images which are recurrent and persistently experienced and caused anxiety or distress. Patients usually try to ignore or suppress these thoughts, urges, or images or try to neutralize them. Compulsions are behaviors or mental acts which are repetitive and performed in response to an obsession or applied as rigid rules. These behaviors or mental acts are performed in order to prevent or reduce anxiety and distress or feared event or situations. These behaviors or mental acts are unrelated with feared events in reality. For this to be diagnosed, it should take a lot of time, for example, more than 1 h per day and cause clinically significant distress or impairment in functioning like social, occupational, or other important areas. Symptoms of OCD must not be related with any substance's physiological effects, medical conditions, or mental disorders. In DSM 5 diagnostic criteria, OCD could be specified as if with good or fair insight, with poor insight, and with absent insight/delusional beliefs or tic related [8]. Although there is no different diagnostic system for children and adolescents than the adults, it has been stated that young

• Obsessive-compulsive disorder (OCD)

28 Cognitive Behavioral Therapy and Clinical Applications

• Excoriation (skin-picking) disorder

compulsive and related disorders [8]

• Body dysmorphic disorder

• Hoarding disorder

• Trichotillomania

the disorder [1].

The etiology of OCD is certainly unknown, but multiple factors like genetic, biological, cognitive, and behavioral are found effective [10]. Also it involves interactions between genetic and environmental factors [11]. Environmental factors such as traumatic life events and stress were found to be effective in 50% of OCD cases [12, 13]. In a twin study, OCD concordance was found approximately 90% in identical twins and 47% in dizygotic twins [14]. And in a twin study, genetic factors were found related with OCD symptoms [15]. In early onset OCD patients, OCD may be almost twice as high through the relatives as late onset OCD patients. This shows that familiarity in early onset OCD patients is higher [16].

OCD is a neuropsychiatric disorder, and basal ganglia dysfunction has been associated with obsessive-compulsive symptoms. In literature there are some studies that found association between OCD and neurological disorders like epilepsy, brain injury, Tourette's syndrome, and Sydenham's chorea [16–19]. Repetitive behaviors in a patient with Sydenham cores were first described by Sir William Osler. During the course of Sydenham's chorea, usually obsessive-compulsive symptoms occur [18, 20]. In literature it was reported that immunologically based group A beta-hemolytic streptococcal infection is an another etiological factor. This disorder is called as Pediatric Autoimmune Neuropsychiatric Diseases Associated to Streptococcal Infections (PANDAS). This disorder leads to an autoimmune inflammation in the striatum and other brain areas and shows some neurologic symptoms like hyperactivity, choreiform movements, and tics. In addition to these, in a certain period, increase of obsessive-compulsive symptoms is observed. This makes researchers to think that Tourette's syndrome, Sydenham's chorea, and OCD have a common etiology [21]. OCD's neural basis is thought to include the circuits of the orbitofrontal cortex, striatum, and thalamus and the neurotransmitters as serotonin, dopamine, glutamate, and gammaamino-butyric acid [22, 23].

In recent neuroimaging studies, amygdala and prefrontal cortex's role has been found important in mechanism of regulating emotional responses like fear and anxiety [24]. Some evidences showed that there is a reward dysfunction in OCD [25]. Similar to addictive behaviors, compulsive behaviors that cause relief from anxiety and have a rewarding effect were hypothesized. Reward process has been associated with ventral striatal orbitofrontal circuitry and in neuroimaging studies; it was shown that OCD patients had an altered metabolism in this area frequently, and this results supported the hypothesis [26].

As psychoanalytic theory, unresolved oedipal complexes cause anxiety, and this takes place a factor in OCD etiology. According to this theory, as a result of encountering anxiety, people have a regression to anal period, and some defense mechanisms are commonly used like isolation, doing-undoing, reaction formation, and displacement [27].

Studies with adolescents showed that OCD development risk is higher at late adolescence than early adolescence [53]. It is very important to detect OCD at its early stage, because studies indicate that 50% of the adult patients develop the disease during childhood or ado-

Cognitive-Behavioral Therapy of Obsessive-Compulsive Disorder in Children and Adolescents

http://dx.doi.org/10.5772/intechopen.70612

31

It is generally considered that in children obsessive thoughts are less common compared to adults; solely compulsive behaviors in the absence of obsessive thoughts are more frequent, while solely obsessive thinking is less common [45]. However, there are studies in literature showing that all children with compulsive aspect of the disease also have accompanying obsessions [57]. Some studies have reported that unlike adults, children may add their families in their rituals, and they cannot describe triggering factors and stressors as well as

According to literature, the most common obsessions among children and adolescents include "fear of contamination, dirt, contracting disease"; "fear of aggressiveness, doing harm-receiving harm"; and "need for symmetry, order and precision", while the most common compulsions are "grooming," "repeating, and checking" [36, 37, 58, 59]. A study including 44 adolescents, 43 early onset adults, and 45 late onset adult OCD patients reported that religious and sexual obsessions are more common in adolescents than in adult patients, obsessions about contamination are more common in adolescents, and grooming compulsions are more frequent in early onset adults than adolescent patients [60]. Onset of OCD is rare before 6 years old. But in cases that began before 6 years old, symptoms usually began with rituals or hand washing and checking [27]. Childhood OCD in boys is 1.5–2 times more than girls [61]. In boys disorder is more severe, and neurological symptoms and comorbidi-

Studies that involved children and adolescents diagnosed with OCD reported the frequency of poor insight with the range of 20–45%. Poor insight in children and adolescents with OCD is associated with severity of symptoms and loss of functionality and has a great influence on duration and success of treatment [62, 63]. Poor insight in OCD causes patients not to recognize their symptoms as a problem and results in reduced treatment motivation and treatment success. Therefore OCD patients with poor insight may be misdiagnosed or may not seek

The Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) is mostly using tool and often referring as the "gold standard" measurement for assessment of pediatric OCD. It involves two subscales for Obsessions Severity and Compulsions Severity, and total score is estimating with these two subscales [65, 66]. Also there are some other assessment tools

lescence [47, 54–56].

**4. Clinical features**

ties are more common [27].

treatment [62, 64].

**5. Assessment**

adults [42].

There is a little evidence about the cognitive mechanisms of OCD; it is thought that these mechanisms are similar in adults and children. According to cognitive theory, the basis of obsessions is catastrophic interpretation of unwanted and distressing thoughts, impulses, and images. Obsessions are creating anxiety, and by rituals, ruminations, or avoidances, this anxiety is tried to be reduced. For obsession treatment these misinterpretations must be corrected. Also in a study, maternal cognitive biases are found more relevant with younger children's OCD severity; personal cognitive biases are more relevant in adolescents [28].
