Obsessive compulsive disorder (OCD) is a neuropsychiatric condition that affects 1-3% of the Australian population and recognised as the fourth most prevalent psychiatric disease. OCD tends to commence in late childhood to early adolescence and, whilst not yet proven, it is believed that genetic susceptibility may play a role in its development.[1,2]
A literature review found several studies indicating that a subset of children who present with sudden onset OCD may in fact be experiencing an autoimmune response after having a group-A beta-haemolytic streptococcus (GABHS) infection. This OCD subtype has been named paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and currently its prevalence is unknown.
PANDAS has all the hallmark signs and symptoms of OCD (invasive recurrent thoughts, repetitive behaviours, reduced ability to function, increased anxiety) although it may present as a tic disorder (sudden, violent movements or sounds) or both.[2,3]
PANDAS also shares similar signs and symptoms to Sydenham’s chorea (SC), another childhood onset OCD resulting from GABHS infection. However, SC is a known manifestation of rheumatic fever and has its own distinct characteristics and treatment regime. As such, it is important to distinguish between the two conditions for successful treatment outcomes.
The pathogenesis of PANDAS is thought to be associated with basal ganglia dysfunction and susceptibility to the condition may be genetic and involve elevated levels of D8/D17 -specific monoclonal antibody binding to B-lymphocytes - though further studies are needed to confirm this.
The diagnosis of PANDAS requires five distinct criteria be met:
- The presence of OCD and/or tics.
- Symptoms arising between the ages of three and puberty.
- Sudden onset of symptoms with an episodic course.
- Symptoms occurring in conjunction with, or post, a recent streptococcus infection.
- Relapsing/remitting symptoms.
There are several options available for the treatment of PANDAS and appropriate selection depends on severity of the condition. Given a growing body of evidence now suggests PANDAS is an autoimmune subtype of OCD associated with GABHS, treatment aims to address the infectious trigger and/or the autoimmune response.
Treatments range from the minimally invasive such as the use of therapeutic doses of antibiotics (often penicillin), oral courses of steroids, SSRIs, cognitive behavioural therapy and education therapy for the parents through to the extremely invasive plasmapheresis (replacement of diseased plasma with healthy donor plasma) and intravenous immunoglobulin (IVIG).
The latter invasive treatments tend to deliver the most successful long-term outcomes, but they are expensive, require hospital admission and carry significant risk so should be reserved for those patients who have a more severe case and do not respond to antibiotics or other non-invasive treatments. For patients who experience persistent symptoms, prophylactic use of antibiotics may also be considered an effective treatment option.[2,5]
Naturopathic, nutritional and homeopathic therapies for PANDAS are emerging and involve addressing the infection along with supporting the immune system and the gut. However first line treatment remains medical management given the response is often rapid.[5,6]
To date, no long-term studies of PANDAS patients have been completed, and a better understanding of this debilitating condition is needed to aid in its early identification, along with increasing the effectiveness of non-invasive treatments with minimal side-effects in both the allopathic and complementary medicine fields.
- Obsessive compulsive disorder (OCD). Anxiety Recovery Centre Victoria. Viewed 23 May 2017, www.arcvic.org.au/anxiety-disorders/obsessive-compulsive-disorder
- Arnold P, Richter M. Is obsessive-compulsive disorder an autoimmune disease? CMAJ 2001;165(10):1353-1358. [Full text]
- Lack CW. Obsessive-compulsive disorder: evidence-based treatments and future directions for research. World J Psychiatr 2012;2(6):86-90. [Full text]
- PANDAS: PPN diagnostic guidelines. PANDAS Physicians Network 2017. Viewed 22 May 2017, www.pandasppn.org/ppn-pandas-diagnostic-guidelines/
- General overview and historical context. PANDAS Physicians Network 2017. Viewed 25 May 2017, www.pandasppn.org/therapeutic-options-for-pandas-and-pans/
- Cosford RE. PANDAS (pediatric autoimmune neuropsychiatric disease associated with streptococcus) in autism?: a case history. Electronic J Appl Psychol: Innovations Autism 2009;5(1):9-48. [Full text]