Understanding Pans And Pandas: A Baffling Brain Disease

PANS and PANDAS are neuropsychiatric conditions that affect the brain. They are characterised by a variety of symptoms, including mental health issues, behavioural changes, and difficulties with movement. PANS stands for Paediatric Acute-onset Neuropsychiatric Syndrome, while PANDAS stands for Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections. PANDAS is a subset of PANS. Both conditions can have a sudden onset, with symptoms that may come and go over time.

PANS diagnostic criteria

PANS, or Pediatric Acute-onset Neuropsychiatric Syndrome, is a clinically defined disorder characterised by the abrupt onset of obsessive-compulsive symptoms (OCS) or eating restrictions, along with acute behavioural deterioration in at least two designated domains. PANS diagnostic criteria are as follows:

• Abrupt, acute, dramatic onset of obsessive-compulsive disorder or severely restricted food intake.
• Concurrent presence of additional neuropsychiatric symptoms with a similarly severe and acute onset from at least two of the following categories: anxiety; emotional lability and/or depression; irritability, aggression, and/or severe oppositional behaviours; behavioural (developmental) regression; sudden deterioration in school performance; motor or sensory abnormalities; somatic signs and symptoms, including sleep disturbances, enuresis, or urinary frequency.
• Symptoms are not better explained by a known neurological or medical disorder.
• There is no age requirement.

PANS symptoms typically begin during the grade-school years, but there is no age limitation. The rapid change in a child's symptoms can make it harder for the patient and their parents to cope.

PANDAS, or Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, is a subset of PANS. PANDAS diagnostic criteria are as follows:

• Abrupt, dramatic onset of OCD or disabling tics.
• Relapsing-remitting, episodic symptom course.
• Young age of onset (average of 6-7 years).
• Presence of neurological abnormalities.
• Temporal association between symptom onset and Group A strep (GAS) infection.

PANDAS diagnostic criteria

PANDAS, or Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections, is a subset of PANS (Pediatric Acute-onset Neuropsychiatric Syndrome). PANDAS was first reported by a team at the National Institute of Mental Health in 1998.

PANDAS is characterised by the following diagnostic criteria:

• The presence of OCD, a tic disorder, or both. This is a key differentiator between PANDAS and PANS, as PANS can be diagnosed without the presence of OCD or tics. The symptoms must be severe enough to meet the criteria for OCD or a tic disorder and interfere with the patient's ability to function.
• Pediatric onset of symptoms, typically between the ages of 3 and puberty, though it is possible for PANDAS to present in adolescence.
• An episodic course of symptom severity, with abrupt, dramatic, debilitating exacerbations of existing symptoms.
• Association with Group A Streptococcal (GAS) infection. This is a key differentiator between PANDAS and PANS, as PANDAS requires the presence of GAS infection, while PANS can be triggered by other infectious agents.
• Association with neurological abnormalities, such as physical hyperactivity or unusual, jerky movements that are beyond the patient's control.

PANDAS is a clinical diagnosis, meaning there are no lab tests that can be used to diagnose the disorder. Instead, healthcare providers rely on the above diagnostic criteria.

PANS and PANDAS symptoms

PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) is a clinically defined disorder characterised by the sudden onset of obsessive-compulsive symptoms (OCD) or eating restrictions, along with acute behavioural deterioration in at least two designated domains. PANS symptoms may include anxiety, sensory amplification, motor abnormalities, behavioural regression, deterioration in school performance, mood disorders, urinary symptoms, and/or sleep disturbances.

PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) is a subset of PANS. PANDAS patients experience a similar set of symptoms, but they test positive for a recent streptococcal infection, such as strep throat, perianal strep, or scarlet fever. PANDAS has five distinct criteria for diagnosis: abrupt OCD or dramatic, disabling tics; a relapsing-remitting, episodic symptom course; young age at onset (6-7 years on average); presence of neurologic abnormalities; and a temporal association between symptom onset and Group A strep infection.

The symptoms of PANS and PANDAS usually present suddenly and intensely, and can get better and then worse again. The severity of symptoms and the onset can vary from patient to patient.

PANS and PANDAS can cause a range of behavioural changes in children, including:

• Obsessions: intense fears or concerns about things being even, clean, dirty, or a certain way. These thoughts can be so strong that the child may be hard to comfort.
• Compulsions (rituals): the child may feel compelled to wash, touch, do, or repeat things, and be unable to stop.
• Tics or jerky movements
• Anxiety, depression, or mood swings
• Aggressive or "hyper" behaviour
• Using baby talk, acting clingy, or having new bedtime fears
• Trouble with handwriting or other fine motor skills
• Memory, reading, or math difficulties
• Bedwetting or not sleeping
• Fears about food, eating, or choking; not eating
• Sensitivity to noise, touch, clothes, or light

PANS and PANDAS are not contagious and are considered rare disorders.

PANS and PANDAS treatments

PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) and PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections) are severe forms of obsessive-compulsive disorder (OCD) that appear suddenly in young children, accompanied by other symptoms such as restricted eating, anger, irritability, anxiety, and depression. PANDAS is a subset of PANS, with the same symptoms but specifically triggered by streptococcal infections.

The treatment approach for PANS and PANDAS depends on the specific symptoms and their severity, as well as the underlying cause. Here are some common treatments:

• Antibiotics: If a streptococcal infection is detected, a course of antibiotics is usually prescribed to treat the infection and alleviate the PANDAS symptoms. Antibiotics may also be used for PANS if a bacterial infection is identified.
• Cognitive Behavioural Therapy (CBT): CBT is often recommended to help manage the obsessive-compulsive symptoms, anxiety, and other neuropsychiatric symptoms associated with PANS and PANDAS.
• Medications: Selective Serotonin Reuptake Inhibitors (SSRIs) or other anti-depressants may be prescribed to treat OCD symptoms and severe anxiety. It is important to closely monitor medication dosages and side effects, especially in children with PANS and PANDAS, who may be more sensitive to these medications.
• Plasma Exchange or Immunoglobulin (IVIG) Therapy: For severe cases of PANDAS, plasma exchange or IVIG therapy may be considered. These treatments can improve global functioning, depression, emotional instability, and obsessive-compulsive symptoms. However, they carry a risk of side effects and infection, so they should only be administered by qualified healthcare professionals.
• Plasmapheresis: If IVIG therapy is unsuccessful, plasmapheresis (the removal, filtering, and return of blood plasma) may be used as a treatment option. This treatment has shown significant improvement in patients with PANDAS.
• Long-term Antibiotics for PANDAS: To prevent recurring streptococcal infections, children with PANDAS may be prescribed long-term antibiotics as a form of prophylaxis. This approach can reduce the number of PANDAS symptom exacerbations.
• Other Treatments: In some cases, additional treatments such as anti-inflammatory drugs, steroids, or psychiatric interventions (medications and/or psychotherapy) may be explored if patients do not respond to the initial treatments.

It is important to note that the treatment approach may vary depending on the individual case, and a comprehensive evaluation by a qualified healthcare professional is necessary to determine the most appropriate treatment plan.

PANS and PANDAS causes

PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) is a clinically defined disorder characterised by the sudden onset of obsessive-compulsive symptoms (OCD) or eating restrictions, along with acute behavioural deterioration in at least two designated domains. PANS does not require a known trigger, but it is believed to be triggered by one or more pathogens, including infectious agents such as influenza, varicella, and mycoplasma pneumoniae. Lyme disease has also been proposed as a trigger.

PANDAS (Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) is a subset of PANS. PANDAS was first reported by a team at the National Institute of Mental Health in 1998. PANDAS occurs after a streptococcal infection, most commonly strep throat or scarlet fever. The symptoms of OCD or tics (involuntary, purposeless movements) suddenly become worse following a strep infection. The symptoms are usually dramatic and can happen "overnight and out of the blue". In addition to these symptoms, children may become moody or irritable, experience anxiety attacks, or show concerns about separating from parents or loved ones.

Strep bacteria are ancient organisms that survive in the human body by hiding from the immune system. They do this by putting molecules on their cell walls so that they look almost identical to molecules found in the child's heart, joints, skin, and brain tissues. This hiding strategy is called "molecular mimicry" and it allows the strep bacteria to evade detection for a long time. Eventually, the molecules on the strep bacteria are recognised as foreign to the body, and the child's immune system reacts by producing antibodies. Because of the molecular mimicry, the immune system reacts not only to the strep molecules but also to the human host molecules that were mimicked. These antibodies that react to both the molecules on the strep bacteria and the human host molecules are called "cross-reactive" antibodies. Studies have shown that some cross-reactive antibodies target the brain, causing OCD, tics, and other neuropsychiatric symptoms of PANDAS.

PANDAS is considered a paediatric disorder and typically first appears in childhood, from age 3 to puberty. Reactions to strep infections are rare after age 12, but researchers acknowledge that PANDAS could occur, although rarely, in adolescents. It is highly unlikely that someone would experience these post-strep neuropsychiatric symptoms for the first time as an adult.

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