Source: Pathdoc/Shutterstock
Obsessive-compulsive disorder (OCD) is associated with unwanted recurring thoughts or images (obsessions), and repetitive behaviors (compulsions) intended to relieve the obsessive thoughts. OCD has been estimated to affect 0.75% to 2.5% of the general population. Both genetic and environmental factors appear to contribute to the risk of developing OCD (Mahjani, 2020).
Children who present with sudden-onset OCD before puberty, sometimes associated with tics, restricted food intake, anxiety, or other behavioral changes, may be suffering from pediatric acute-onset neuropsychiatric syndrome (PANS) or pediatric autoimmune neuropsychiatric syndrome associated with streptococcal infection (PANDAS) (Leonardi, 2024).
It is important that therapists who are referred children with such symptoms be aware of PANS and PANDAS, and ensure that such children are evaluated concurrently by physicians who are experts in the treatment of these illnesses. In rare cases, the onset of PANS/PANDAS-like symptoms may also occur in adolescents and adults.
In PANS/PANDAS, it is thought that antibodies formed against a bacterial or viral infection cross the blood-brain barrier because of genetic and environmental factors, and attack the basal ganglia and perhaps other regions in the brain. These abnormalities in the immune system cause inflammation in the brain that is thought to cause the associated clinical symptoms.
During and soon after bacterial and possibly viral infections PANS/PANDAS, patients can improve with use of antibiotics, including azithromycin, which can act both as an antibiotic and an anti-inflammatory agent. Other treatments aimed at changing the body’s immune response include steroids, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous immunoglobulin (IVIG), and plasmapheresis (removing blood plasma from the body, and washing antibodies out of it before replacing it into the patient) (Gagliano, et al., 2023).
Treatments for PANS/PANDAS-related psychiatric symptoms include addressing OCD that usually occurs in these conditions. Patients have been provided with cognitive behavioral therapy (CBT) including exposure response prevention (in which patients are encouraged to avoid responding to repeated exposures to triggers of their OCD), and family systems therapy. I have used therapy with hypnosis regularly with such patients with good success. Psychiatric medications such as SSRIs, antipsychotics, anxiolytics, and mood stabilizers have also been used.
The following two brief case descriptions illustrate how PANS/PANDAS may present:
A Patient With Long-Standing Illness
An 11-year-old boy presented with abdominal discomfort and emetophobia (fear of throwing up). At that time, he began developing rituals to prevent people from becoming sick around him, which could lead to throwing up. He became confused regarding the types of foods he could eat after doctors told him to avoid certain foods because of his stomachaches, which led to decreased caloric intake, weight loss, and associated anemia.
The patient then was misdiagnosed with an eating disorder and was hospitalized on three occasions for treatment of this condition, suicidal thoughts, and OCD symptoms. He was treated with selective serotonin reuptake inhibitors (SSRIs) and CBT, with little relief. However, his OCD improved when he was treated with an antibiotic for sinusitis. The improvement following antibiotic therapy led to his diagnosis of PANDAS. He was treated with IVIG to help improve his immune response, but this did not help improve his OCD.
His OCD-related obsessive thoughts and compulsive rituals made it difficult to leave his bedroom and interact with other people. He ended up restricting himself to his room for four years, during which time he did not attend school.
Five years after onset of his illness, I had the opportunity to meet this patient and treated him using hypnosis. I taught him how to calm himself by using imagery of a safe place, and how to interact with his subconscious through hypnosis. Within a month of calming himself and receiving guidance from his subconscious, the patient was able to leave his room. A month later, he began to be more social with his family. Two months later, he started attending school. His OCD improved slowly over the subsequent four years.
A Patient With Early PANS/PANDAS
A 7-year-old girl developed sudden-onset tics including eye blinking, extending her arms, and flexing her abdomen when sitting or standing. Over the subsequent year, use of guanfacine did not reduce her tic frequency. Additionally, the patient developed symptoms suggestive of OCD including a desire to keep things orderly and even. She wanted to eat the same foods every day and to put her water bottle in the same place. When she was not allowed to do so, she became agitated. Her mother reported that when the patient was treated with an antibiotic for an ear infection, her tics and OCD symptoms improved.
Given the rapid onset of her tics and OCD, as well as reported improvement of these symptoms with antibiotic therapy, in addition to teaching her how to utilize hypnosis techniques, I referred the patient back to her pediatrician who prescribed a six-week course of azithromycin. With this therapy, her tics and OCD nearly resolved. With further application of hypnotic imagery, the patient reported resolution of her symptoms.
Takeaway
Early recognition of PANS/PANDAS induced psychiatric symptoms can lead to initiation of effective medical and psychological therapy, which may reduce long-term complications from these conditions.
To find a therapist, please visit the Psychology Today Therapy Directory.