PANS and PANDAS

Definition

Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is identified in children who experience a sudden, often overnight, emergence of neuropsychiatric behaviors such as intense obsessions/compulsions or extreme food restriction. While these children might initially be thought to have obsessive-compulsive disorder (OCD) or an eating disorder, the rapid appearance of symptoms distinguishes PANS from these conditions. Children with PANS might also show signs of depression, irritability, anxiety, and struggle academically. The origins of PANS remain largely unknown, though it’s believed to be linked to various triggers like infectious diseases (e.g., influenza, chickenpox, Lyme disease, mold exposure), metabolic issues, and inflammatory responses.
Similarly, Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections (PANDAS) manifests as a swift onset of neuropsychiatric symptoms such as OCD or tics, occurring within a few days. The defining characteristic of PANDAS is a positive test for a recent streptococcal infection, like strep throat or scarlet fever. Children with PANDAS can also experience dramatic emotional shifts, irritability, anxiety, and a noticeable decline in school performance and handwriting. Although PANDAS was recognized as a distinct syndrome earlier than PANS, it is now considered a specific instance of PANS. PANDAS remains the only explicitly identified subset of PANS thus far, with the potential for identifying additional subsets in the future.

Causes/ Risk Factors of Anxiety Disorder

Research suggests that PANS and PANDAS are caused by an unusual response of the immune system. It’s believed that when infections like strep throat or the flu enter the body, the immune system mistakenly attacks cells in the brain and nervous system instead of the infection. In the case of PANDAS, this misdirected immune response involves a process called molecular mimicry, where antibodies produced to fight Group A Streptococcal infection mistakenly target brain tissues. This mistaken attack leads to inflammation in the basal ganglia, a brain region involved in regulating emotions, behavior, cognition, sensory processing, learning, and motor skills. This mechanism explains the abrupt behavioral and psychological changes observed in children diagnosed with PANS/PANDAS.

Signs and Symptoms

• Acute-onset OCD
• Severe separation anxiety
• Panic attacks
• Behavioral regression, suddenly acting much younger than they should for their age (e.g. reverting to baby talk)
• Suicidal thoughts
• Depression
• Anxiety
• Mood or personality changes (Irritability, emotionally erratic and/or severely oppositional behavior)
• Aggression
• Sudden decline in school performance (math and reading competence, memory and concentration)
• ADHD symptoms, including fidgeting
• Obsessive-compulsive like behavior
• Tics and/or jerky movements
• Increase in hyperactivity
• Motor or sensory abnormalities (handwriting suddenly becomes unrecognizable, drawings look like scribbles)
• Distressed by light or noise
• Disinterest in food / trouble eating
• Bed wetting, or other changes in urinary frequency or intensity 
• Bedtime fears (new onset)
• Sleep disturbances

Diet and Lifestyle Considerations for PANS and PANDAS:

• Focus on Nutrition
• Therapeutic Diets
• Utilize Antimicrobials and Herbs
• Reduce Inflammation
• Behavioral Therapy
• Mind-Body Therapies

Integrative Treatments Overview:

Quickly evaluating a child who shows sudden signs of OCD, restrictive eating, and other neuropsychiatric issues is crucial for recovery. Investigating children’s vulnerability to pathogenic microbes could effectively identify those at higher risk for these conditions. Although there’s still much to learn about treating PANS/PANDAS, and treatment will vary depending on the severity of symptoms, combining traditional medical treatments, functional medicine assessments, and holistic therapies can offer the most favorable results for a child. Specifically, one should aim to remove the sources of inflammation, treat immune disturbances with immunomodulators and anti-inflammatories, and address individual symptoms.

Nutritional & Environmental Medicine Overview:

It is recommended that a patient consult a certified practitioner to assess their symptoms and case history and explore their individual needs. 

Diagnosis

PANS/PANDAS diagnosis requires clinical assessment focused on abrupt behavioral changes, including restrictive eating or OCD, alongside at least two neuropsychiatric symptoms (e.g., anxiety, mood disorders, sleep disturbances) not explained by other conditions. For PANDAS, evidence of prior group A Beta-hemolytic strep infection is necessary, confirmed through swab tests or elevated strep antibodies (ASO or anti-DNase B).

Supportive lab tests, though not definitive for PANS/PANDAS, help identify underlying infections or dysfunctions: Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) for overall health; CRP and ESR for inflammation; Streptococcus Antibodies Profile to detect strep infections; Comprehensive Stool Analysis for gut health. A rapid strep test may further support PANDAS diagnosis.

Treatment

Treatment for PANS and PANDAS varies depending on the severity of the symptoms and often involves a combination of conventional as well as integrative approaches. Conventional approaches include treatments like antibiotics, corticosteroids, behavioral therapy, anti-inflammatories, low-dose SSRIs, Intravenous Immunoglobulins (IVIG) and Plasmapheresis. For more severe cases, treatment may include all of the previously mentioned therapies as well as Rituximab (a monoclonal antibody) and DMARDS (Disease-Modifying Antirheumatic Drugs). 

Integrative Treatments

• • Antimicrobials: The type of antimicrobial needed is specific to the individual patient, however a combination of prescription antibiotics early in treatment and antimicrobial herbs later in treatment tend to yield the best results.
  • Reduce Inflammation: Reducing inflammation, which is again case specific, may include the use of antihistamines as well as nutritional interventions like Essential Fatty Acids (EFAs), specialized pro-resolving mediators (SPMs), Aloe, Curcumin, Flavonoids (quercetin, luteolin, rutin), CBD Oil, Turmeric, Gabapentin, and Amantadine. Introducing more antioxidants into the patient is also key, these include vitamin A, vitamin C, vitamin D, zinc, resveratrol, melatonin, glutathione, antioxidant rich food (spinach, avocados, ginger, garlic, turmeric, nuts, green tea). 
  • Nutrition: Nutrition plays a crucial role in managing PANS/PANDAS, especially since these conditions often lead to restrictive eating patterns. In addition to focusing on anti-inflammatory foods, diets should include foods that decrease anxiety and OCD such as those high in zinc, magnesium, iron, and omega 3s (which are especially important for cellular health and neurocognitive function). An organic, fresh, “real food” diet with a good mix of herbs and species and that avoids colors, additives and preservatives is also recommended. 
  • Therapeutic Diets; Certain specific dietary protocols can be effective at reducing infections and inflammation, balancing the microbiome and supporting the immune and nervous systems. It is recommended that you work with a Functional Practitioner to identify the appropriate protocol. Diets to consider for PANS/PANDAS include; Gluten-Free/Dairy-Free, Gut And Psychology Syndrome (GAPS), SCD (Specific Carbohydrate Diet), Auto-Immune Paleo (AI-Paleo) and, depending on testing, a low oxalate, salicylate histamine and/or glutamate approach.
  • Herbs: Depending on the infectious agent – Streptococcus, Mycoplasma, Viruses, Yeast, or Parasites – different herbal treatments may be helpful. (Refer to Demystifying PANS/PANDAS: A Functional Medicine Desktop Reference on Basal Ganglia Encephalitis by Dr. Nancy O’Hara for a full breakdown).
  • CBT: Cognitive Behavioral Therapy (CBT), particularly with exposure and response prevention (ERP), is a cornerstone therapy for managing OCD symptoms in PANS/PANDAS. By helping children develop coping skills and modify intrusive thoughts, CBT effectively retrains the brain to process obsessions differently.
  • Mind-Body Therapies: Mind-body therapies, such as Equine Therapy and mindfulness meditation, offer support for anxiety, depression, and ADHD symptoms in children with PANS/PANDAS. These therapies promote relaxation and emotional well-being, helping to manage stress and improve quality of life.
  • Acupuncture with Moxibustion: Acupuncture, particularly when combined with moxibustion, has been effective in treating tic symptoms associated with PANS/PANDAS. This traditional Chinese medicine approach can help reduce muscle twitching and support overall healing, offering an effective complement to Western medicine treatments.

Resources

• PANS/PANDAS Field Guide – a FREE e-book by Dr Nancy O’Hara https://www.drohara.com/field-guide  
• Demystifying PANS/PANDAS https://www.amazon.com/Demystifying-PANS-PANDAS-Functional-Encephalitis/dp/1939794269/ref=sr_1_1?dib=eyJ2IjoiMSJ9.BMZ2EqfzI2j08QhGCnS9DXT8eTfSPkjhZ0wIQzhU4vrGjHj071QN20LucGBJIEps.KdniG2WLL3aZUF7aMU6VxuR0ZMCx-hvvLJPLBnDeL4M&dib_tag=se&hvadid=617565188321&hvdev=c&hvlocphy=9067609&hvnetw=g&hvqmt=e&hvrand=2886540301668362747&hvtargid=kwd-1730143943920&hydadcr=7884_13469609&keywords=demystifying+pans+pandas&qid=1712582726&sr=8-1
• Choosing the Right Healing Diet https://old.mindd.org/diet/choosing-right-healing-diet/