Expert Panel Publishes Comprehensive Guidelines for Treating PANS/PANDAS

An expert panel of clinicians and researchers has published comprehensive guidelines for treatment of Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS) and Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS).

PANS/PANDAS is characterized by an unusually abrupt onset of obsessive-compulsive disorder (OCD) symptoms and/or severe eating restrictions in children, along with secondary behavioral, cognitive, and/or neurological symptoms. This syndrome is believed to result from a range of triggers, though studies have shown that autoimmune problems and/or neuroinflammation drive the illness in most cases.

Accordingly, the treatment guidelines, published in the Journal of Child and Adolescent Psychopharmacology, are divided into three clinical focus areas:

1. Psychiatric and behavioral interventions to address obsessive-compulsive symptoms, eating restrictions, anxiety, irritability, and more.
2. Immunomodulatory therapies that target the neuroinflammation and post-infectious autoimmunity commonly seen in PANS/PANDAS.
3. Treatment and prevention of the streptococcal and other infections that underlie these neuropsychiatric conditions.

“While underlying infectious and inflammatory processes in PANS and PANDAS patients are treated, psychiatric and behavioral symptoms need simultaneous treatment to decrease suffering and improve adherence to therapeutic intervention,” Margo Thienemann, M.D., of Stanford University, Susan Swedo, M.D., of the National Institutes of Mental Health, and colleagues wrote. “Psychological, behavioral, and psychopharmacologic interventions tailored to each child's presentation can provide symptom improvement and improve functioning during both the acute and chronic stages of illness.”

Clinical evidence suggests that depression, anxiety, OCD, and other behavioral symptoms of PANS/PANDAS respond to the same medications used to treat these disorders in the general population. However, some reports also suggest that PANS/PANDAS patients may be more sensitive to adverse effects of psychotropic medications such as agitation or dystonia, the authors noted in the psychiatric guidelines (part I).

Therefore, clinicians are advised to initiate with dosages no more than one-quarter the normal amount and slowly titer upwards. Benzodiazepines are also considered first-line treatments for PANS/PANDAS as anxiety, agitation, aggression, and insomnia are common symptoms, but clinicians and parents should be aware of the risk of disinhibition following benzodiazepine treatment in pediatric patients.

For related information, see the Psychiatric News article “Experts at BIO Convention Discuss Link Between Infection, Psychiatric Disorders.”

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