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PANDAS: when strep throat brings on OCD
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A child develops a sore throat and a fever and within the week develops very unusual and concerning behaviors. Perhaps he washes his hands until they are raw or counts every windowpane he sees. Maybe she wipes over and over after going to bathroom because she can’t seem to feel dry. The child might even become unusually obsessed by a philosophical question (such as “is the world really real?”) or develop a new motor tic.
What is going on?
An unusual, and somewhat controversial, disorder called PANDAS may be to blame. PANDAS stands for pediatric neuropsychiatric disorder associated with strep and it is thought to affect a subset of children who exhibit features of obsessive-compulsive disorder. It is caused by a Group A strep infection – the kind of bacteria that causes “strep throat.”
Children with PANDAS develop sudden and often explosive OCD symptoms whenever they are infected by strep. Their clinical course is episodic. That is, when their strep is treated the OCD symptoms improve markedly and do not reoccur until the next infection. People with ‘regular’ OCD tend to show a more consistently progressive course.
The diagnostic criteria for PANDAS are:
- obsessive-compulsive disorder and/or tic disorder
- Onset between 3 years of age and puberty
- Abrupt onset and episodic course of symptoms
- Temporal relationship between strep infection and OCD symptoms
- Tic or other neurologic abnormality during exacerbations.
There is some controversy regarding this diagnosis, with some experts arguing that the relationship between the strep and the OCD is coincidental. However studies in both humans and animals have shown a correlation between strep infection and OCD in a subset of individuals. It is thought that an abnormal immune response to strep directly affects the brain, leading to obsessive and compulsive symptoms. Episodes are often described as “explosive” and the parents may not initially connect the antecedent infection with the current unusual symptoms. Occasionally the infection is mild enough that it does not cause a sore throat or fever and may therefore be hard to recognize.
Treatment involves treating the strep infection with antibiotics and employing medications and cognitive behavioral therapy as needed for the residual OCD symptoms. Some children with PANDAS are maintained on daily antibiotics to prevent strep infections, however this approach is controversial.
Many doctors are not familiar with PANDAS and thus some children are never properly diagnosed. I propose that any child with explosive OCD symptoms should be tested for strep. If the test is negative or inconclusive, consideration could be given to a presumptive 10 day trial of antibiotics.
If you know someone whose child is suffering from OCD, please pass this article along.
Be well.
Dr. Chiaramonte
www.insightmedicalconsultants.com
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