**8.2. Medical treatment**

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 symp-

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

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 lead-

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

toms. For exposure and response prevention, targets should be identified.

success are maximized.

36 Cognitive Behavioral Therapy and Clinical Applications

ing to anxiety [101].

while working with very young children [101].

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

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 adequately delivered CBT [85].

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, without evidence-based results, have also been tried [109].

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 children [112].

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 placebo control in severe and difficult-to-treat pediatric OCD [113]. Lamotrigine is an antiepileptic drug and also a mood stabilizer that decreases extreme glutamate release [114, 115]. Thus Lamotrigine could be a good augmentation agent in refractory OCD cases. Except those studies, there is a case report that aripiprazole was used with clomipramine, which showed remarkable improvement [116].

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