**1. Introduction**

Obsessive thoughts and behaviors are mentioned since ancient times and mentioned on holy books. In Middle Ages, it was thought that people who have religious and sexual unwanted thoughts were taken over by the devil and to be punished by burning. In the seventeenth century, Shakespeare defined a character called Lady Macbeth; she had contamination obsession and hand washing compulsion. In the nineteenth century, Esquirol mentioned from a case report named Matmazel F. Matmazel F was rubbing her fingers and washing her hands constantly because she was thinking that she might be infected with something, and she could not stop herself. Morel used the term of "obsession" first time in 1866. In the twentieth century, Janet stated that the sense of incompleteness is the base of obsessive-compulsive

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 the disorder [1].

children may not be able to articulate the purposes of their compulsive behaviors or cognitive actions [8]. Children usually have less insight about the irrationality of their obsessions and compulsions. And at some developmental stages of children, it is hard to distinguish some normative behaviors from OCD. At this point, behavior's impact in child or adolescent's func-

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

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

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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.

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 gamma-

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

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

tioning is important; normative behaviors usually do not affect functioning [9].

This shows that familiarity in early onset OCD patients is higher [16].

**2. Etiology**

amino-butyric acid [22, 23].

frequently, and this results supported the hypothesis [26].

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:


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 children may not be able to articulate the purposes of their compulsive behaviors or cognitive actions [8]. Children usually have less insight about the irrationality of their obsessions and compulsions. And at some developmental stages of children, it is hard to distinguish some normative behaviors from OCD. At this point, behavior's impact in child or adolescent's functioning is important; normative behaviors usually do not affect functioning [9].
