**8.1. Cognitive behavioral therapy**

Cognitive behavioral therapy (CBT) is recommended for the first-line treatment in mild to moderate OCD, but in moderate to severe OCD cases, it is recommended to support CBT with medication [85].

CBT is a kind of psychotherapy which is developed on the basis of learning theories in psychology and the principles of cognitive psychology. The purpose of this therapy is to change emotions and incompatible behaviors by using psychotherapeutic methods based on these principles [86]. Behavioral therapies began to be used in the treatment of emotional and behavioral problems of young people in the 1950s. These behavioral approaches are based on the theories of Thorndike, Watson, and Bandura, and classical and operant conditioning have been used to treat behavioral disorders seen in infants and children. Cognitive therapies were developed by Aaron Beck in the 1970s and started to be used in the treatment of child and adolescent cases in the 1980s [87].

According to CBT, the mental condition of a person is the result of the mutual interaction of the environment, relationships, the biological structure, emotions, cognition, and behaviors. Psychotherapeutic methods can only be applied to cognition and behaviors of a person [86]. According to learning theory, compulsions reduce distress that triggered by obsession so that negative reinforcement occurs over time (**Figure 1**) [88].

**Figure 1.** The obsessive-compulsive cycle used by Piacentini et al. [89] to describe OCD's mechanism.

In the CBT, children and adolescents learn to confront with their fears step by step. By learning how to behave against what the OCD tells them, they would understand that their fears do not reflect reality [90]. According to cognitive theory, cognitive processes determine the feelings and behaviors of people. Cognitive processes provide one's interpretation of the external world, surrounding events, own life, and relations with other people. When the basic assumptions and beliefs involved in the cognitive structure that determines the person's view of the world and its interpretations are distorted or functionally improper, a person begins to experience problems [91]. Hence, problems that disturb the person are not due to the events and experiences themselves but due to perception and evaluation of the events and experiences [92]. Instead of these problematic forms of interpretation, cognitive therapy tries to reveal more compatible and appropriate perception and evaluation structures for a situation [93]. Additionally, cognitive therapy emphasizes that improper cognitive structures are an important factor in emerging and maintaining mental disorders. The basic cognitive features of OCD are an overestimation of thoughts and feelings, exaggerated sense of responsibility, perfectionism about controls of thoughts and behaviors, and catastrophic interpretation of possible outcomes of thoughts and impulses, and these features lead to misinterpretations [21]. Cognitive therapy firstly tries to establish connections among emotion, behavior, and thought [94]. According to the cognitive theory, cognition is examined in two sets: automatic thoughts and schemes (**Figure 2**) [86].

intermediate beliefs, rules, and assumptions regulating one's behavior underlying automatic thoughts. These are permanent rules and anticipations about the behavior of himself/herself and others, their life, and things that happened to them. Nonfunctional intermediate beliefs lead the therapist to core beliefs that are the deepest cognitive structures. Core beliefs consist of people's early life experiences and their identification with the people around them. These beliefs are reinforced by similar experiences and learnings by time [95]. According to Piaget, the child enters the concrete operational stage around the age of 7–8. Most of the children at the concrete operational stage have the logical processes to take advantage of the cognitive debate. There may be difficulties in cognitive therapy in children who have not reached the concrete operational stage [95]. Children and teenagers often apply to therapy by caregiver's decision. So the first thing to do by the therapists is to introduce themselves and to explain to

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The most effective behavioral techniques are a combination of exposure and response prevention. Exposure to anxiety-producing stimulus is advised to a person, and decrease of anxiety is expected after repeated practices. During exposure, the person must prevent rituals and avoidance behaviors. At this stage, response prevention is used. Practices can be in real or imaginary ways. A list should be made of the anxiety-inducing stimuli before practice. Practice starts with easy tasks in the list, and the difficulty of the tasks is increased step by

CBT session consists of symptom control, review, and getting feedback of homework done; determines the agenda items; configures session content; and determines the new homework, [97]. CBT usually continue 10–14 weeks, with weekly sessions taking 45–90 min [98]. Among the basic principles of the CBT, the first step is psychoeducation. In psychoeducation session, the incidence and prevalence of OCD, age-dependent normal obsessive-compulsive behaviors, OCD's symptoms and disorder's nature in child and adolescent age group, OCD's mechanism, and the impact of factors like developmental level and temperament are given. Also in this session, knowledge of underlying reasons of OCD and basis of cognitive and behavioral therapy, especially exposure and response prevention, and social learning theory, when the

The second step is the diagnostic assessment. There must be a detailed assessment of child's/ adolescent's problem and history of coping methods and medical, developmental, family, and school features. Social and cultural characteristics must be considered. Different sources of information such as the clinical interview, parents, questionnaires, and information from school must be integrated. Specific OCD symptoms and comorbidities should be asked. A formulation should be made including protective, precipitating, predisposing, and maintaining factors linked to child/adolescent's situation. The decision should be given about whether an additional medical treatment is necessary. A family assessment involving the capacity to support the child/adolescent of the family should be undertaken. Which family members have become involved in rituals, avoidance behaviors, and obsessions and family functioning must

In the third step, emotions, behaviors, and cognitions should be assessed. Anxiety should be explained and normalized in ordinary fear-inducing situations. Furthermore, thoughts,

the child who they are, what they do, and how they can help [93].

step [27, 96].

be questioned.

medical treatment is needed, are given.

Cognitive therapy deals with automatic thoughts. These thoughts are spontaneous and located in the stream of mind. Also, they are cognitions that are mostly specific to environment and situation that accompanied to moments of emotional distress. Contrary to emotions automatic thoughts are rarely noticed. These thoughts could be verbal or imaginary. There are unsaid

**Figure 2.** Cognition structure [86].

intermediate beliefs, rules, and assumptions regulating one's behavior underlying automatic thoughts. These are permanent rules and anticipations about the behavior of himself/herself and others, their life, and things that happened to them. Nonfunctional intermediate beliefs lead the therapist to core beliefs that are the deepest cognitive structures. Core beliefs consist of people's early life experiences and their identification with the people around them. These beliefs are reinforced by similar experiences and learnings by time [95]. According to Piaget, the child enters the concrete operational stage around the age of 7–8. Most of the children at the concrete operational stage have the logical processes to take advantage of the cognitive debate. There may be difficulties in cognitive therapy in children who have not reached the concrete operational stage [95]. Children and teenagers often apply to therapy by caregiver's decision. So the first thing to do by the therapists is to introduce themselves and to explain to the child who they are, what they do, and how they can help [93].

In the CBT, children and adolescents learn to confront with their fears step by step. By learning how to behave against what the OCD tells them, they would understand that their fears do not reflect reality [90]. According to cognitive theory, cognitive processes determine the feelings and behaviors of people. Cognitive processes provide one's interpretation of the external world, surrounding events, own life, and relations with other people. When the basic assumptions and beliefs involved in the cognitive structure that determines the person's view of the world and its interpretations are distorted or functionally improper, a person begins to experience problems [91]. Hence, problems that disturb the person are not due to the events and experiences themselves but due to perception and evaluation of the events and experiences [92]. Instead of these problematic forms of interpretation, cognitive therapy tries to reveal more compatible and appropriate perception and evaluation structures for a situation [93]. Additionally, cognitive therapy emphasizes that improper cognitive structures are an important factor in emerging and maintaining mental disorders. The basic cognitive features of OCD are an overestimation of thoughts and feelings, exaggerated sense of responsibility, perfectionism about controls of thoughts and behaviors, and catastrophic interpretation of possible outcomes of thoughts and impulses, and these features lead to misinterpretations [21]. Cognitive therapy firstly tries to establish connections among emotion, behavior, and thought [94]. According to the cognitive theory, cognition is examined in two sets: automatic

Cognitive therapy deals with automatic thoughts. These thoughts are spontaneous and located in the stream of mind. Also, they are cognitions that are mostly specific to environment and situation that accompanied to moments of emotional distress. Contrary to emotions automatic thoughts are rarely noticed. These thoughts could be verbal or imaginary. There are unsaid

thoughts and schemes (**Figure 2**) [86].

34 Cognitive Behavioral Therapy and Clinical Applications

**Figure 2.** Cognition structure [86].

The most effective behavioral techniques are a combination of exposure and response prevention. Exposure to anxiety-producing stimulus is advised to a person, and decrease of anxiety is expected after repeated practices. During exposure, the person must prevent rituals and avoidance behaviors. At this stage, response prevention is used. Practices can be in real or imaginary ways. A list should be made of the anxiety-inducing stimuli before practice. Practice starts with easy tasks in the list, and the difficulty of the tasks is increased step by step [27, 96].

CBT session consists of symptom control, review, and getting feedback of homework done; determines the agenda items; configures session content; and determines the new homework, [97]. CBT usually continue 10–14 weeks, with weekly sessions taking 45–90 min [98]. Among the basic principles of the CBT, the first step is psychoeducation. In psychoeducation session, the incidence and prevalence of OCD, age-dependent normal obsessive-compulsive behaviors, OCD's symptoms and disorder's nature in child and adolescent age group, OCD's mechanism, and the impact of factors like developmental level and temperament are given. Also in this session, knowledge of underlying reasons of OCD and basis of cognitive and behavioral therapy, especially exposure and response prevention, and social learning theory, when the medical treatment is needed, are given.

The second step is the diagnostic assessment. There must be a detailed assessment of child's/ adolescent's problem and history of coping methods and medical, developmental, family, and school features. Social and cultural characteristics must be considered. Different sources of information such as the clinical interview, parents, questionnaires, and information from school must be integrated. Specific OCD symptoms and comorbidities should be asked. A formulation should be made including protective, precipitating, predisposing, and maintaining factors linked to child/adolescent's situation. The decision should be given about whether an additional medical treatment is necessary. A family assessment involving the capacity to support the child/adolescent of the family should be undertaken. Which family members have become involved in rituals, avoidance behaviors, and obsessions and family functioning must be questioned.

In the third step, emotions, behaviors, and cognitions should be assessed. Anxiety should be explained and normalized in ordinary fear-inducing situations. Furthermore, thoughts, feelings, and behaviors should be assessed. Detailed list of obsessive ideas and rituals should be done by standardized instruments. Insight level should be questioned. A list of triggers to obsessional fears and compulsive behaviors/rituals and avoided situations should be generated. Cognitive and behavioral rituals used to reduce discomfort should be identified. By using scales appropriate for the age such as "fear thermometer" or "SUDS ratings" anxiety levels should be rated, and child/adolescent should rate how difficult to resist OCD symptoms. For exposure and response prevention, targets should be identified.

**8.2. Medical treatment**

quately delivered CBT [85].

in children [112].

out evidence-based results, have also been tried [109].

In OCD's pharmacological treatment, fluoxetine, sertraline, and fluvoxamine as selective serotonin reuptake inhibitor (SSRI) and clomipramine as nonselective serotonin reuptake inhibitor have the approval of US Food and Drug Administration for child and adolescents. Which serotonergic drug is the first choice is unknown. But clomipramine's effect was found superior than SSRIs [103]. Clomipramine is considered as the gold standard medication in pharmacological treatment of OCD; however, 46–74% of adolescent OCD patients have been reported to benefit from this drug [104]. Studies indicate that selective serotonin reuptake

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Some supportive strategies can be applied in case SSRI treatment is not adequate. These supportive methods include options like addition of CBT, risperidone, clonazepam, clomipramine, aripiprazole, or memantine to the treatment [105, 106]. Medication augmentation is recommended for cases which have moderate impairment persists in at least one functioning area despite adequate monotherapy. Treatment resistance can be described as failing ≥2 adequate SSRI monotherapy treatment, 1 SSRI and a clomipramine trial, and failure of ade-

In augmentation strategy especially clomipramine and the atypical antipsychotics are commonly used [107, 108]. And also some other drugs like stimulants, gabapentin, sumatriptan, pindolol, inositol, opiates, St. John's wort, N-acetyl cysteine, memantine, and riluzole, with-

Adding clomipramine to an SSRI (often fluvoxamine at low doses like 25–75 mg/day) could be a useful augmentation strategy. But practitioner must be careful about adding clomipramine to fluvoxamine or to other CYP-450 2D6 inhibitors like fluoxetine or paroxetine to prevent potentially toxic serum clomipramine levels which would cause cardiological side effects and must follow up with electrocardiography. In augmentation therapy, mostly atypical antipsychotics are chosen. This strategy can improve oppositional behaviors which are caused by increased anxiety level [85]. Riluzole is a "glutamatergic modulator" which effects on glutamate release and increases the level of α-amino-3- hydroxy-5-methyl-4-isoxazolepropionic acid trafficking and amino acid transporters that stimulates neuroglia [110]. Riluzole has FDA indication only in amyotrophic lateral sclerosis, but there are no indications for childhood conditions. Recently, riluzole was studied in a few open-label trials for generalized anxiety disorder, major depressive disorder, bipolar depression, and OCD in adults, and these results showed riluzole's beneficial effects, and it was well tolerated [111]. In an openlabel trial of riluzole of childhood OCD, four of six patients' OCD symptoms had improved significantly. In this study riluzole was well tolerated, and there were no any side effects seen

In a study that includes 17 children and adolescents between aged 8 and 18 years with a primary diagnosis of OCD, effectiveness of D-cycloserine (DCS)-augmented CBT for children and adolescents was investigated. Results of this study showed DCS-augmented exposure, and response prevention produced significant improvements in OCD severity relative to a

inhibitors (SSRIs) are superior to placebo for treatment of childhood OCD [103].

The next step is intervention stage. At this step, OCD and intervention rationale should be explained. OCD could be explained by age-appropriate metaphors. With positive reinforcement like praise, awards, and "certificates of achievement," engagement to therapy should be increased. OCD symptoms are tried to be externalized by giving a nickname to OCD, using "boss back OCD" strategy, being child/adolescent's ally in fighting OCD and figuring out strategies for fighting OCD. Constructive self-talk might be helpful for coping, and cognitive reconstruction would be useful for unhelpful assumptions underlying the obsessions. In the exposure trials, a child/an adolescent creates a hierarchic list of anxiety situations. Mutually agreed targets are chosen from the list, and those targets are worked together. A direct exposure method is implemented on the agreed targets, and enough exposure time is allowed for habituation. In this process, anxiety levels are rated. Graded exposure including imaginal exposure, exposure to cartoons or images of the feared trigger, is used in the session [99]. The exposure trial is continued until distress ratings decrease by 50% [100]. By agreeing on realizable daily homework tasks, chances of success are maximized.

For ritual prevention, a plan will be made as delaying, shortening, doing differently or performing the ritual slowly. Also, self-monitoring and recording rituals are a part of the exposure process. During response prevention, child's/adolescent's anxiety is measured by the fear thermometer. Then relapse prevention is used. The distinction between "lapse" and "relapse" is explained to child/adolescent and parents. For any future OCD symptoms, a rehearsal is made for remembering and using CBT techniques. Family members are included in the intervention as "coaches" for supporting children during exercises, and it is important to work with the school [99]. When CBT is implemented, escape, avoidance, and security search behaviors must be considered because these behaviors are the factors leading to anxiety [101].

Child/adolescent is trained for some anxiety management strategies like breathing and relaxation techniques [102]. CBT could be implemented in groups. Studies show that group CBT programs are more comfortable for patient children because of seeing other children with the same problem [90]. The developmental characteristics as a level of autonomy and dependence of the child should also be considered when CBT is applied [101]. The level of language development during therapy can cause problems. They may not express their feelings verbally. For this reason, first of all, emotional words and concepts should be studied with comics, pictures, heroes, and narratives [93]. And cognitive behavioral play therapy can be applied while working with very young children [101].
