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Executive and Attention Functioning Among Children in the PANDAS Subgroup
Matthew E. Hirschtritt, Christopher J. Hammond, David Luckenbaugh, Jason Buhle, Audrey E. Thurm, B. J. Casey & Susan E. Swedo (2009) Executive and Attention Functioning Among Children in the PANDAS Subgroup, Child Neuropsychology, 15:2, 179-194, DOI: 10.1080/09297040802186899

Evidence from past studies indicates that adults and children with Obsessive-Compulsive Disorder (OCD) and Tourette syndrome (TS) experience subtle neuropsychological deficits. Less is known about neuropsychological functioning of children and adolescents with a symptom course consistent with the PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection) subgroup of OCD and tics. T

  • Administered three tests of attention control and two of executive function to 67 children and adolescents (ages 5–16) diagnosed with OCD and/or tics and a symptom course consistent with the PANDAS subgroup and 98 healthy volunteers (HV) matched by age, sex, and IQ.
  • The PANDAS subjects were less accurate than HV in a test of response suppression.
  • In a two-step linear regression analysis of the PANDAS group in which clinical variables were added stepwise into the model and in the second step matching variables (age, sex, and IQ) were added, IQ emerged as a predictor of performance on this task.
  • ADHD diagnosis and age emerged as predictors of response time in a continuous performance task.
  • Subdividing the PANDAS group by primary psychiatric diagnosis revealed that subjects with TS or OCD with tics exhibited a longer response time compared to controls than subjects with OCD only
  • Children with PANDAS exhibit neuropsychological profiles similar to those of their primary psychiatric diagnosis.
Cognitive-Behavioral Therapy for PANDAS-Related Obsessive-Compulsive Disorder: Findings From a Preliminary Waitlist Controlled Open Trial
Storch EA, Murphy TK, Geffken GR, Mann G, Adkins J, Merlo LJ, Duke D, Munson M, Swaine Z, Goodman WK. Cognitive-behavioral therapy for PANDAS-related obsessive-compulsive disorder: findings from a preliminary waitlist controlled open trial. J Am Acad Child Adolesc Psychiatry. 2006 Oct;45(10):1171-8. doi: 10.1097/01.chi.0000231973.43966.a0. PMID: 17003662.

  • Six of seven children with PANDAS-related OCD improved after CBT; half maintained gains at follow-up.

  • Clinician-rated OCD and anxiety severity dropped significantly (large effect sizes: 3.38 and 2.29).

  • Self-reported anxiety and depression did not show significant changes.

  • Findings suggest CBT is a promising, safe, and minimally invasive treatment for PANDAS-related OCD.

Selective serotonin reuptake inhibitor-induced behavioral activation in the PANDAS subtype

Murphy, Tanya & Storch, Eric & Strawser, Melissa & Ba,. (2006). Selective serotonin reuptake inhibitor-induced behavioral activation in the PANDAS subtype. Primary Psychiatry. 13.

Although selective serotonin reuptake inhibitors (SSRI) are an effective and commonly used treatment for pediatric obsessive-compulsive disorder (OCD), their use has come under close scrutiny following reports of adverse reactions. The authors of this case report believe that children with the OCD subtype, pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS), may have increased vulnerability. The following report provides initial data on behavioral activation following SSRI use in 38 children with OCD of the PANDAS subtype. The authors use a particular case to highlight this issue and discuss treatment implications.

 

PANDAS With Catatonia: A Case Report. Therapeutic Response to Lorazepam and Plasmapheresis
Elia J, Dell ML, Friedman DF, Zimmerman RA, Balamuth N, Ahmed AA, Pati S. PANDAS with catatonia: a case report. Therapeutic response to lorazepam and plasmapheresis. J Am Acad Child Adolesc Psychiatry. 2005 Nov;44(11):1145-50. doi: 10.1097/01.chi.0000179056.54419.5e. PMID: 16239863.
  • Patient: 11-year-old boy with sudden urinary urgency, OCD, severe mood swings, inattention, impulsivity, hyperactivity, and intermittent immobilization.
  • Preceding Illness: Fever, cough, ear infection, sinusitis.
  • Findings: Elevated ASO & DNAse B titers; MRI showed caudate nuclei swelling.
  • Treatment & Outcome: Plasmapheresis rapidly improved OCD and reduced basal ganglia swelling, suggesting an immune-mediated process linked to strep.
  • Additional Note: ADHD-like symptoms improved with lorazepam, indicating possible catatonia.
Paediatric autoimmune neuropsychiatric disorders (PANDAS): A case report

Sankaranarayanan, Anoop & John, J. (2003). Paediatric autoimmune neuropsychiatric disorders (PANDAS): A case report. The National medical journal of India. 16. 22-3. Read report

In view of the early onset of obsessive symptoms with periodic sudden exacerbations interspersed with periods of partial remissions, and the past history of streptococcal throat infection, the possibility of PANDAS was considered (Table I). However, he did not exhibit any abnormal movement, although he seemed fidgety and restless (Swedo2 has described ‘squirminess’ in some patients). In addition, the ASO titre done at our hospital was negative. It is, however, well accepted that not all exacerbations are preceded by group A beta-haemolytic streptococci (GABHS) infections and a prospective follow up is required to establish this association.

Note: Neither tics nor abnormal movements are required for a PANS diagnosis.

The question of PANDAS in adults

Sara M Bodner, Syed A Morshed, Bradley S Peterson, The question of PANDAS in adults, Biological Psychiatry, Volume 49, Issue 9, 2001, Pages 807-810, ISSN 0006-3223, https://doi.org/10.1016/S0006-3223(00)01127-6.

We describe an adult with onset of obsessive–compulsive disorder at 25 years of age after a severe antibiotic-responsive pharyngitis. He was evaluated with multiple psychiatric rating scales for obsessive–compulsive disorder and Tourette’s syndrome, as well as with serologic assays and radiologic studies.

Results: In all respects except age our patient fulfilled established criteria for PANDAS. Assays for antibodies to group A β-hematolytic streptococci, serum D8,17 lymphocytes, antistriatal (neuronal) antibodies, and anticytoskeletal antibodies all supported the hypothesis that a poststreptococcal process was active. Magnetic resonance imaging was abnormal and is described.

Case Study: A New Infection-Triggered, Autoimmune Subtype of Pediatric OCD and Tourette’s Syndrome
Allen AJ, Leonard HL, Swedo SE. Case study: a new infection-triggered, autoimmune subtype of pediatric OCD and Tourette’s syndrome. J Am Acad Child Adolesc Psychiatry. 1995 Mar;34(3):307-11. doi: 10.1097/00004583-199503000-00015. PMID: 7896671.

A review of clinical observations and literature reports leads to the hypothesis that, via a process analogous to Sydenham’s chorea, infections with group A β-hemolytic streptococci, among others, may trigger autoimmune responses that cause or exacerbate some cases of childhood-onset obsessive-compulsive disorder (OCD) or tic disorders (including Tourette’s syndrome).

The neuropsychiatric manifestations of Lyme borreliosis
Fallon BA, Nields JA, Burrascano JJ, Liegner K, DelBene D, Liebowitz MR. The neuropsychiatric manifestations of Lyme borreliosis. Psychiatr Q. 1992 Spring;63(1):95-117. doi: 10.1007/BF01064684. PMID: 1438607.
  • Lyme disease is a growing tick-borne illness affecting multiple systems.
  • While its neurological effects are well documented, its psychiatric symptoms are less recognized. This paper reviews Lyme’s neuropsychiatric impact and key research.
  • It also explores common psychiatric symptoms, patient challenges, and clinical guidance.
Borrelia burgdorferi in the nervous system: the new “great imitator”

Pachner AR. Borrelia burgdorferi in the nervous system: the new “great imitator”. Ann N Y Acad Sci. 1988;539:56-64. doi: 10.1111/j.1749-6632.1988.tb31838.x. PMID: 3190104.

Patient Vignette – Bicycle Boy
The patient was bitten by a tic. Weeks later he presented with neuropsychiatric symptoms. Was given IV antibiotics and all symptoms resolved.

  • Lyme disease shares key similarities with syphilis: spirochetal etiology, extended tissue survival, staged clinical manifestations, and antibiotic susceptibility. Lessons from syphilis, particularly regarding spirochetal brain disease mimicking other neurological conditions, apply to Lyme disease.
  • Clinicians should consider Lyme disease early due to its effective response to antibiotics.
  • Lyme meningitis in the second stage is recognizable, but milder cases often go undiagnosed.
  • Progression to third-stage disease, as in Lyme arthritis, may occur, highlighting the importance of serologic tests.
  • Serology is crucial for diagnosing later stages of Lyme disease, paralleling the situation in neurosyphilis where cultures and antigen tests are less useful.
  • Antibody titers vary in different manifestations, with Lyme arthritis and acrodermatitis atrophicans showing high titers.
  • Recognition challenges exist for CNS Lyme disease without prior stages, emphasizing the significance of serological diagnosis in later stages.
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases
Swedo SE, Leonard HL, Garvey M, Mittleman B, Allen AJ, Perlmutter S, Lougee L, Dow S, Zamkoff J, Dubbert BK. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. Am J Psychiatry. 1998 Feb;155(2):264-71. doi: 10.1176/ajp.155.2.264. Erratum in: Am J Psychiatry 1998 Apr;155(4):578. PMID: 9464208.

Results: The children’s symptom onset was acute and dramatic, typically triggered by GABHS infections at a very early age (mean = 6.3 years, SD = 2.7, for tics; mean = 7.4 years, SD = 2.7, for OCD). The PANDAS clinical course was characterized by a relapsing-remitting symptom pattern with significant psychiatric comorbidity accompanying the exacerbations; emotional lability, separation anxiety, nighttime fears and bedtime rituals, cognitive deficits, oppositional behaviors, and motoric hyperactivity were particularly common. Symptom onset was triggered by GABHS infection for 22 (44%) of the children and by pharyngitis (no throat culture obtained) for 14 others (28%). Among the 50 children; there were 144 separate episodes of symptom exacerbation; 45 (31%) were associated with documented GABHS infection, 60 (42%) with symptoms of pharyngitis or upper respiratory infection (no throat culture obtained), and six (4%) with GABHS exposure.

Conclusions: The working diagnostic criteria appear to accurately characterize a homogeneous patient group in which symptom exacerbations are triggered by GABHS infections. The identification of such a subgroup will allow for testing of models of pathogenesis, as well as the development of novel treatment and prevention strategies.