Tourette Syndrome Plus - Conditions - PANDAS - Overview of P.A.N.D.A.S. (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections)

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Information Section: Conditions
Condition: PANDAS
Article: What is "PANDAS?"
Source: Leslie E. Packer, PhD
This Files Last Updated: December 2004

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WHAT IS 'PANDAS?"

"PANDAS" is an acronym for "Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections." Another acronym that appears less frequently in the literature is PITANDS (Pediatric Infection-Triggered Autoimmune Neuropsychiatric Disorders). The terms "PANDAS" and "PITANDS" may not be not wholly interchangeable. A. J. Allen, MD, distinguishes between PANDAS and PITANDS, where PITANDS includes triggering by bacterial or viral infection. In his usage, PANDAS would be a subset of PITANDS [personal communication, November 25, 2000]. While research has focused on bacterial infections, there are clinical reports of viral infections also being associated with acute onset or dramatic exacerbation of OCD or Tourette's Syndrome [see, for example, Budman et al., 1997].
The term PANDAS is generally used to describe a subgroup of children who have either a tic disorder (such as Tourette's Syndrome) or Obsessive-Compulsive Disorder and whose tics, obsessions, and/or compulsions typically worsen dramatically following streptococcal infections or children who have no prior history or tics, obsessions, and compulsions but who suddenly "explode" in symptoms following a Group A ß-hemolytic streptococcal (GABHS) infection. What parents refer to as "strep throat" is one form of streptococcal infection. In some cases, parents may be aware that their child had a strep throat in the recent past, but in other cases, the child may have (or have had) a strep infection without it being detected.

DIAGNOSING PANDAS

The National Institute of Health researchers use the following five criteria to diagnose PANDAS (all five criteria must be met):

Presence of a tic disorder and/or OCD;
Pediatric onset of symptoms (age 3 years to puberty);
Episodic course of symptom severity with sudden onset or acute exacerbations that are in:
Temporal association with group A Beta-hemolytic streptococcal infection (indicated by a positive throat culture for strep and/or elevated anti-streptococcal antibody titer); and
Association with neurological abnormalities (hyperactivity/fidgetiness/restlessness, or adventitious movements such as the choreiform movements of Sydenham).

Although not necessary for diagnosis, parents may also observe a significant deterioration in the child's handwriting during these acute exacerbations. Some investigators have suggested that it's not just tics and OCD symptoms that may worse or emerge explosively and that some children may suddenly develop severe separation anxiety disorder or a mood disorder, but for now, we will focus on the tics and obsessive-compulsive symptoms, because even that literature is somewhat controversial.

Note that the first two diagnostic criteria above do not distinguish PANDAS cases from childhood-onset TS or OCD cases, and the last diagnostic criterion does not really distinguish PANDAS cases from children with TS-OCD-ADHD who tend to display a waxing and waning cycle in their symptoms anyway (i.e., when tics are waxing, OCD symptoms also worsen, and ADHD symptoms also appear to be clinically worse). In their clinical publications, the NIMH researchers have provided more detail about the topography of the symptoms that make it clear to them that these are not just typical "waxing" and "waning" patterns. For example, tic disorders tend to emerge gradually, with the child exhibiting one simple motor tic that may increase in frequency over weeks and then subside. Subsequent waxing cycles also begin somewhat gradually and increase in frequency and severity before subsiding. In contrast, children who may represent a PANDAS cohort either have "explosive" onset of their tics where they display multiple tics that emerge simultaneously and at high frequency. Over time, these children reportedly display a "saw-tooth" pattern to their symptom frequency and severity instead of the more gradual waxing cycles.

Perhaps the most crucial part of the diagnostic criteria is that there must be some temporal (time) association between having a confirmed GABHS infection and the sudden onset or acute exacerbations in tic and/or OCD symptoms.

In their article, Arnold and Richter (2001) note the following guidelines for the temporal relationship between GABHS infection and acute onset or acute worsening:

Generally requires more than one exacerbation of symptoms associated with elevated titres of anti-GABHS antibodies (ASO or anti-DNAse B) and either a positive throat culture or a recent history of pharyngitis
Latency between infection and neuropsychiatric symptoms may be longer with the first exacerbation (up to 9 mo) than with later exacerbations (days to weeks)
Fever and other nonspecific illness stressors may increase symptom severity, therefore the exacerbations should not occur exclusively during periods of acute physical illness

Since that time, the NIMH researchers have revised their statements to suggest that the temporal relationship between GABHS infection and onset or acute exacerbation is generally 1 - 2 weeks.

It is important to keep in mind that criteria for diagnosing PANDAS are somewhat irrelevant if there is no distinct condition to diagnosis and that the above discussion addresses the issue of how do we even determine if there is a relationship between GABHS and clinical symptoms. At the present time, professionals still disagree sharply about whether there is sufficient evidence to support the notion of a unique condition. The commentary by Dr. Roger Kurlan in April 2004 and the reply by Dr. Swedo almost immediately afterwards demonstrate the contentiousness of the hypothesis.

COMMENTS

The research on PANDAS is considered controversial or contentious, but from a clinical standpoint, parents can take heart. If you think your child has a strep infection, you should be taking your child to the doctor anyway, right? Standard medical practice is to treat an active strep infection with antibiotics, and if your child seems to get acute worsening of tics or OCD symptoms whenever they have an infection or shortly after an infection, it just makes good sense for you to get them to the doctor and see if an antibiotic is needed. At the present time there is no evidence that putting children on antibiotics to prevent infections works, and even if the PANDAS hypothesis is correct and your child does have a PANDAS-type condition, the treatment for the tics and OCD symptoms would be the usual treatments for tics and OCD. Perhaps the only time the PANDAS hypothesis might have important clinical implications for parents is if their child's symptoms are so severe that some second-line treatment is needed because the usual treatments do not help.

From a practical standpoint, parents whose children seem to show a temporal relationship between infections and symptom severity can also use that knowledge to plan for their child and to take preventive measures. It's one thing to caution your child not to go near a friend who's infectious or who might be infectious, but if you know that whenever your child has an infection, they pay for it dearly in terms of their tics or OCD symptoms, then your cautions -- and precautions -- need to be increased.

Information Section: Conditions
Condition: PANDAS
Article: What is "PANDAS?"
Source: Leslie E. Packer, PhD
This Files Last Updated: December 2004

Page 1 of 1

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