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Bhatt S, Anitha K, Chellappan DK, Mukherjee D, Shilpi S, Suttee A, Gupta G, Singh TG, Dua K. Targeting inflammatory signaling in obsessive compulsive disorder: a promising approach. Metab Brain Dis 2024; 39:335-346. [PMID: 37950815 DOI: 10.1007/s11011-023-01314-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/23/2023] [Indexed: 11/13/2023]
Abstract
Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder. Approximately, around 2% to 3% percent of the general population experience symptoms of OCD over the course of their lifetime. OCD can lead to economic burden, poor quality of life, and disability. The characteristic features exhibited generally in OCD are continuous intrusive thoughts and periodic ritualized behaviours. Variations in genes, pathological function of Cortico-Striato-Thalamo-Cortical (CSTC) circuits and dysregulation in the synaptic conduction have been the major factors involved in the pathological progression of OCD. However, the basic mechanisms still largely unknown. Current therapies for OCD largely target monoaminergic neurotransmitters (NTs) in specific dopaminergic and serotonergic circuits. However, such therapies have limited efficacy and tolerability. Drug resistance has been one of the important reasons reported to critically influence the effectiveness of the available drugs. Inflammation has been a crucial factor which is believed to have a significant importance in OCD progression. A significant number of proinflammatory cytokines have been reportedly amplified in patients with OCD. Mechanisms of drug treatment involve attenuation of the symptoms via modulation of inflammatory signalling pathways, modification in brain structure, and synaptic plasticity. Hence, targeting inflammatory signaling may be considered as a suitable approach in the treatment of OCD. The present review focuses mainly on the significant findings from the animal and human studies conducted in this area, that targets inflammatory signaling in neurological conditions. In addition, it also focusses on the therapeutic approaches that target OCD via modification of the inflammatory signaling pathways.
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Affiliation(s)
- Shvetank Bhatt
- School of Health Sciences and Technology, Dr. Vishwanath Karad MIT World Peace University, Pune, Maharashtra, 411038, India.
| | - Kuttiappan Anitha
- Department of Pharmacology, School of Pharmacy & Technology Management (SPTM), SVKM's Narsee Monjee Institute of Management Studies (NMIMS), Shirpur, 425405, Maharashtra, India
| | - Dinesh Kumar Chellappan
- Department of Life Sciences, School of Pharmacy, International Medical University, 57000, Bukit Jalil, Kuala Lumpur, Malaysia
| | - Dhrubojyoti Mukherjee
- Department of Pharmaceutics, School of Pharmacy & Technology Management (SPTM), SVKM's Narsee Monjee Institute of Management Studies (NMIMS), Shirpur, Maharashtra, 425405, India
| | - Satish Shilpi
- Faculty of Pharmacy, DIT University, Dehradun, Uttarakhand, 248009, India
| | - Ashish Suttee
- School of Pharmaceutical Sciences, Lovely Professional University, Jalandhar-Delhi G.T Road, Phagwara, Punjab, India
| | - Gaurav Gupta
- Centre for Global Health Research, Saveetha Medical College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Saveetha Nagar, Thandalam, Kanchipuram - Chennai Rd, Chennai, India
- School of Pharmacy, Graphic Era Hill University, Dehradun, 248007, India
- School of Pharmacy, Suresh Gyan Vihar University, Jagatpura, Mahal Road, Jaipur, 302017, India
| | | | - Kamal Dua
- Discipline of Pharmacy, Graduate School of Health, University of Technology Sydney, Ultimo, NSW, 2007, Australia
- Faculty of Health, Australian Research Centre in Complementary & Integrative Medicine, University of Technology Sydney, Ultimo, NSW, 2007, Australia
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La Bella S, Scorrano G, Rinaldi M, Di Ludovico A, Mainieri F, Attanasi M, Spalice A, Chiarelli F, Breda L. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): Myth or Reality? The State of the Art on a Controversial Disease. Microorganisms 2023; 11:2549. [PMID: 37894207 PMCID: PMC10609001 DOI: 10.3390/microorganisms11102549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/04/2023] [Accepted: 10/10/2023] [Indexed: 10/29/2023] Open
Abstract
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) syndrome is one of the most controversial diseases in pediatric rheumatology. Despite first being described more than 25 years ago as the sudden and rapid onset of obsessive-compulsive disorder (OCD) and/or tic disorder symptoms as complications of a Group A beta-hemolytic Streptococcus (GAS) infection, precise epidemiological data are still lacking, and there are no strong recommendations for its treatment. Recent advances in the comprehension of PANDAS pathophysiology are largely attributable to animal model studies and the understanding of the roles of Ca++/calmodulin-dependent protein kinase (CaM kinase) II, disrupted dopamine release in the basal ganglia, and striatal cholinergic interneurons. The diagnosis of PANDAS should be made after an exclusion process and should include prepubescent children with a sudden onset of OCD and/or a tic disorder, with a relapsing/remitting disease course, a clear temporal association between GAS infection and onset or exacerbation of symptoms, and the association with other neurological abnormalities such as motoric hyperactivity and choreiform movements. Antibiotic medications are the primary therapeutic modality. Nonetheless, there is a paucity of randomized studies and validated data, resulting in a scarcity of solid recommendations.
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Affiliation(s)
- Saverio La Bella
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Giovanna Scorrano
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Marta Rinaldi
- Department of Pediatrics, Buckinghamshire Healthcare NHS Trust, Aylesbury-Thames Valley Deanery, Aylesbury HP21 8AL, UK
| | - Armando Di Ludovico
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Francesca Mainieri
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Marina Attanasi
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Alberto Spalice
- Child Neurology Division, Department of Pediatrics, “Sapienza” University of Rome, 00185 Rome, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
| | - Luciana Breda
- Department of Pediatrics, “G. D’Annunzio” University of Chieti-Pescara, 66100 Chieti, Italy
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Gagliano A, Carta A, Tanca MG, Sotgiu S. Pediatric Acute-Onset Neuropsychiatric Syndrome: Current Perspectives. Neuropsychiatr Dis Treat 2023; 19:1221-1250. [PMID: 37251418 PMCID: PMC10225150 DOI: 10.2147/ndt.s362202] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 05/03/2023] [Indexed: 05/31/2023] Open
Abstract
Pediatric acute-onset neuropsychiatric syndrome (PANS) features a heterogeneous constellation of acute obsessive-compulsive disorder (OCD), eating restriction, cognitive, behavioral and/or affective symptoms, often followed by a chronic course with cognitive deterioration. An immune-mediated etiology is advocated in which the CNS is hit by different pathogen-driven (auto)immune responses. This narrative review focused on recent clinical (ie, diagnostic criteria, pre-existing neurodevelopmental disorders, neuroimaging) and pathophysiological (ie, CSF, serum, genetic and autoimmune findings) aspects of PANS. We also summarized recent points to facilitate practitioners with the disease management. Relevant literature was obtained from PubMed database which included only English-written, full-text clinical studies, case reports, and reviews. Among a total of 1005 articles, 205 were pertinent to study inclusion. Expert opinions are converging on PANS as the effect of post-infectious events or stressors leading to "brain inflammation", as it is well-established for anti-neuronal psychosis. Interestingly, differentiating PANS from either autoimmune encephalitides and Sydenham's chorea or from alleged "pure" psychiatric disorders (OCD, tics, Tourette's syndrome), reveals several overlaps and more analogies than differences. Our review highlights the need for a comprehensive algorithm to help both patients during their acute distressing phase and physicians during their treatment decision. A full agreement on the hierarchy of each therapeutical intervention is missing owing to the limited number of randomized controlled trials. The current approach to PANS treatment emphasizes immunomodulation/anti-inflammatory treatments in association with both psychotropic and cognitive-behavioral therapies, while antibiotics are suggested when an active bacterial infection is established. A dimensional view, taking into account the multifactorial origin of psychiatric disorders, should suggest neuro-inflammation as a possible shared substrate of different psychiatric phenotypes. Hence, PANS and PANS-related disorders should be considered as a conceptual framework describing the etiological and phenotypical complexity of many psychiatric disorders.
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Affiliation(s)
- Antonella Gagliano
- Department of Health Science, "Magna Graecia" University of Catanzaro, Catanzaro, Italy
- Department of Biomedical Sciences, University of Cagliari & "A. Cao" Paediatric Hospital, Child & Adolescent Neuropsychiatry Unit, Cagliari, Italy
| | - Alessandra Carta
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Unit of Child Neuropsychiatry, Sassari, Italy
| | - Marcello G Tanca
- Department of Biomedical Sciences, University of Cagliari & "A. Cao" Paediatric Hospital, Child & Adolescent Neuropsychiatry Unit, Cagliari, Italy
| | - Stefano Sotgiu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Unit of Child Neuropsychiatry, Sassari, Italy
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Blum K, Dennen CA, Braverman ER, Gupta A, Baron D, Downs BW, Bagchi D, Thanos P, Pollock M, Khalsa J, Elman I, Bowirrat A, Badgaiyan RA. Hypothesizing That Pediatric Autoimmune Neuropsychiatric Associated Streptococcal (PANDAS) Causes Rapid Onset of Reward Deficiency Syndrome (RDS) Behaviors and May Require Induction of "Dopamine Homeostasis". OPEN JOURNAL OF IMMUNOLOGY 2022; 12:65-75. [PMID: 36407790 PMCID: PMC9670240 DOI: 10.4236/oji.2022.123004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with group A streptococcal infections (PANDAS) is a concept that is used to characterize a subset of children with neuropsychiatric symptoms, tic disorders, or obsessive-compulsive disorder (OCD), whose symptoms are exacerbated by group A streptococcal (GAS) infection. PANDAS has been known to cause a sudden onset of reward deficiency syndrome (RDS). RDS includes multiple disorders that are characterized by dopaminergic signaling dysfunction in the brain reward cascade (BRC), which may result in addiction, depression, avoidant behaviors, anxiety, tic disorders, and/or OCD. According to research by Blum et al., the dopamine receptor D2 (DRD2) gene polymorphisms are important prevalent genetic determinants of RDS. The literature demonstrates that infections like Borrelia and Lyme, as well as other infections like group A beta-hemolytic streptococcal (GABHS), can cause an autoimmune reaction and associated antibodies target dopaminergic loci in the mesolimbic region of the brain, which interferes with brain function and potentially causes RDS-like symptoms/behaviors. The treatment of PANDAS remains controversial, especially since there have been limited efficacy studies to date. We propose an innovative potential treatment for PANDAS based on previous clinical trials using a pro-dopamine regulator known as KB220 variants. Our ongoing research suggests that achieving "dopamine homeostasis" by precision-guided DNA testing and pro-dopamine modulation could result in improved therapeutic outcomes.
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Affiliation(s)
- Kenneth Blum
- Center for Mental Health and Sports, Psychiatry, Western University Health Sciences, Pomona, USA
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, USA
- Department Psychiatry, Boonshoff School of Medicine, Wright University, Dayton, USA
- Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary
- Department of Psychiatry, School of Medicine, University of Vermont, Burlington, USA
- Division of Nutrigenomics, Victory Nutrition International Inc., Bonita Springs, USA
- Department of Molecular Biology, Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Catherine A. Dennen
- Department of Family Medicine, Jefferson Health Northeast, Philadelphia, USA
| | | | | | - David Baron
- Center for Mental Health and Sports, Psychiatry, Western University Health Sciences, Pomona, USA
| | - Bernard William Downs
- Division of Nutrigenomics, Victory Nutrition International Inc., Bonita Springs, USA
| | - Debasis Bagchi
- Division of Nutrigenomics, Victory Nutrition International Inc., Bonita Springs, USA
- Department of Pharmaceutical Sciences, Texas Southern University, Houston, USA
| | - Panayotis Thanos
- Department of Psychology & Behavioral Neuropharmacology and Neuroimaging Laboratory on Addictions (BNNLA), Research Institute on Addictions, University at Buffalo, Buffalo, USA
| | - Maureen Pollock
- The Kenneth Blum Behavioral & Neurogenetic Institute, Austin, USA
| | - Jag Khalsa
- Department of Microbiology, Immunology, and Tropical Medicine, School of Medicine, George Washington University, Washington DC, USA
| | - Igor Elman
- Cambridge Health Alliance, Harvard Medical School, Cambridge, USA
| | - Abdalla Bowirrat
- Department of Molecular Biology, Adelson School of Medicine, Ariel University, Ariel, Israel
| | - Rajendra A. Badgaiyan
- Department of Psychiatry, Ichan School of Medicine at Mount Sinai, New York, USA
- Department of Psychiatry, South Texas Veteran Health Care System, Audie L. Murphy Memorial VA Hospital, Long School of Medicine, University of Texas Health Science Center, San Antonio, USA
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Pfeiffer HCV, Wickstrom R, Skov L, Sørensen CB, Sandvig I, Gjone IH, Ygberg S, Visscher C, Idring Nordstrom S, Herner LB, Hesselmark E, Hedderly T, Lim M, Debes NM. Clinical guidance for diagnosis and management of suspected Pediatric Acute-onset Neuropsychiatric Syndrome in the Nordic countries. Acta Paediatr 2021; 110:3153-3160. [PMID: 33848371 DOI: 10.1111/apa.15875] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/16/2021] [Accepted: 03/19/2021] [Indexed: 12/13/2022]
Abstract
Pediatric acute-onset neuropsychiatric syndrome is a clinical concept used to describe a subgroup of children with sudden onset of psychiatric and somatic symptoms. The diagnostic term and especially management of children differs depending on the clinical setting to which they present, and the diagnosis and management is controversial. The aim of this paper is to propose a clinical guidance including homogenous diagnostic work-up and management of paediatric acute onset neuropsychiatric syndrome within the Nordic countries. The guidance is authored by a Nordic-UK working group consisting of paediatric neurologist, child psychiatrists and psychologists from Denmark, Norway, Sweden and Great Britain, and is the result of broad consensus. CONCLUSION: Consensus was achieved in the collaboration on work-up and treatment of patients with paediatric acute-onset neuropsychiatric syndrome, which we hope will improve and homogenise patient care and enable future collaborative research in the field.
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Affiliation(s)
- Helle Cecilie Viekilde Pfeiffer
- Department of Child Neurology Oslo University Hospital Oslo Norway
- Department of Pediatrics and Adolescence Medicine Copenhagen University Hospital Hvidovre Copenhagen Denmark
| | - Ronny Wickstrom
- Department of Women´s and Children's Health Neuropediatric Unit Karolinska Institutet Stockholm Sweden
| | - Liselotte Skov
- Department of Pediatrics and Adolescence Medicin Copenhagen University Hospital Herlev Copenhagen Denmark
| | - Camilla Birgitte Sørensen
- Department of Pediatrics and Adolescence Medicin Copenhagen University Hospital Herlev Copenhagen Denmark
| | - Inger Sandvig
- Department of Child Neurology Oslo University Hospital Oslo Norway
| | - Inger Helene Gjone
- Division of Pediatric and Adolescent Medicine Department of Child and Adolescent Mental Health in Hospitals Oslo University Hospital Oslo Norway
| | - Sofia Ygberg
- Department of Women´s and Children's Health Neuropediatric Unit Karolinska Institutet Stockholm Sweden
| | - Caroline Visscher
- Centre for Psychiatry Research Department of Clinical Neuroscience Region Stockholm, Child and Adolescent Psychiatry Research Center Karolinska Institutet & Stockholm Healthcare Services Stockholm Sweden
| | - Selma Idring Nordstrom
- Centre for Psychiatry Research Department of Clinical Neuroscience Region Stockholm, Child and Adolescent Psychiatry Research Center Karolinska Institutet & Stockholm Healthcare Services Stockholm Sweden
| | - Linn Breen Herner
- Division of Pediatric and Adolescent Medicine Department of Child and Adolescent Mental Health in Hospitals Oslo University Hospital Oslo Norway
| | - Eva Hesselmark
- Centre for Psychiatry Research Department of Clinical Neuroscience Region Stockholm, Child and Adolescent Psychiatry Research Center Karolinska Institutet & Stockholm Healthcare Services Stockholm Sweden
| | - Tammy Hedderly
- Tic and Neurodevelopmental Movements Service (TANDeM) Children's Neurosciences Centre Evelina London Children's Hospital, Guys and St Thomas NHS Foundation Trust London UK
| | - Ming Lim
- Children's Neurosciences Evelina London Children's Hospital at Guy's and St Thomas’ NHS Foundation Trust King's Health Partners Academic Health Science Centre London UK
| | - Nanette Marinette Debes
- Department of Pediatrics and Adolescence Medicin Copenhagen University Hospital Herlev Copenhagen Denmark
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Johnson M, Ehlers S, Fernell E, Hajjari P, Wartenberg C, Wallerstedt SM. Anti-inflammatory, antibacterial and immunomodulatory treatment in children with symptoms corresponding to the research condition PANS (Pediatric Acute-onset Neuropsychiatric Syndrome): A systematic review. PLoS One 2021; 16:e0253844. [PMID: 34197525 PMCID: PMC8248649 DOI: 10.1371/journal.pone.0253844] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 06/15/2021] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE To assess effects of treatment against a hypothesized neuroinflammation in children with symptoms corresponding to the research condition Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) which is not included in current diagnostic systems. METHODS Systematic literature searches were performed (1998 to June 2020) in PubMed, Embase, the Cochrane Library, CINAHL, PsycInfo, and HTA databases. Inclusion criteria: patients (P) were children (<18 years) with PANS; intervention (I)/comparison (C) was use of, versus no use of, anti-inflammatory, antibacterial or immunomodulating treatments; outcomes (O) were health-related quality of life (HRQL), level of functioning, symptom change, and complications. RESULTS Four randomised controlled trials (RCTs) and three non-RCTs, including 23 to 98 patients, fulfilled the PICO. HRQL was not investigated in any study. Regarding level of functioning, two RCTs investigated antibiotics (penicillin V, azithromycin) and one RCT investigated immunomodulating treatments (intravenous immunoglobulins (IVIG), plasma exchange). Regarding symptoms, two non-RCTs investigated anti-inflammatory treatment (cyclooxygenase (COX) inhibitors, corticosteroids), two RCTs and one non-RCT investigated antibiotics (penicillin V, azithromycin), and two RCTs investigated immunomodulating treatments (IVIG, plasma exchange). Complications, reported in five studies, were consistent with those listed in the summary of products characteristics (SPC). All studies were assessed to have some or major problems regarding directness, the absence of an established diagnosis contributing to clinical diversity in the studied populations. All studies were assessed to have major risk of bias, including selection and detection biases. Due to clinical and methodological diversity, meta-analyses were not performed. CONCLUSION This systematic review reveals very low certainty of evidence of beneficial effects, and moderate certainty of evidence of adverse effects, of anti-inflammatory, antibacterial or immunomodulating treatments in patients with symptoms corresponding to the research condition PANS. Available evidence neither supports nor excludes potential beneficial effects, but supports that such treatment can result in adverse effects. REGISTRATION PROSPERO (CRD42020155714).
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Affiliation(s)
- Mats Johnson
- Child Neuropsychiatry Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stephan Ehlers
- Regional Knowledge Center for Mental Health, Gothenburg, Sweden
| | - Elisabeth Fernell
- Child Neuropsychiatry Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
- Gillberg Neuropsychiatry Centre, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Constanze Wartenberg
- HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
| | - Susanna M. Wallerstedt
- HTA-Centrum, Sahlgrenska University Hospital, Gothenburg, Region Västra Götaland, Sweden
- Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Geller DA, Homayoun S, Johnson G. Developmental Considerations in Obsessive Compulsive Disorder: Comparing Pediatric and Adult-Onset Cases. Front Psychiatry 2021; 12:678538. [PMID: 34248714 PMCID: PMC8269156 DOI: 10.3389/fpsyt.2021.678538] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/17/2021] [Indexed: 12/12/2022] Open
Abstract
There appear to be two peaks of incidence of Obsessive Compulsive Disorder (OCD), one with a pre-adolescent onset and another in early adulthood. As new cases are added, the cumulative prevalence of OCD increases, but the great majority of cases have an onset in youth. The notion that early onset OCD represents a unique developmental subtype of the disorder has been considered by many researchers based on several specific age-related factors. Ascertainment and early intervention in affected youth is critical to abbreviate the functional impairments associated with untreated illness. In this paper we review the clinical, familial and translational biomarker correlates seen in early onset OCD that support the notion of a developmental subtype and discuss implications for research and treatment aimed at this cohort. The importance of cognitive, academic and social development tasks of childhood and adolescence, illness-specific and familial factors, and immune-mediated inflammatory factors are discussed, with their implications for management.
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Affiliation(s)
- Daniel A. Geller
- Pediatric OCD and Tic Disorder Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Saffron Homayoun
- Harvard Medical School, Boston, MA, United States
- Psychiatry and Neuroimmunology Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Gabrielle Johnson
- Pediatric OCD and Tic Disorder Program, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
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8
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Xu J, Liu RJ, Fahey S, Frick L, Leckman J, Vaccarino F, Duman RS, Williams K, Swedo S, Pittenger C. Antibodies From Children With PANDAS Bind Specifically to Striatal Cholinergic Interneurons and Alter Their Activity. Am J Psychiatry 2021; 178:48-64. [PMID: 32539528 PMCID: PMC8573771 DOI: 10.1176/appi.ajp.2020.19070698] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Pediatric obsessive-compulsive disorder (OCD) sometimes appears rapidly, even overnight, often after an infection. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections, or PANDAS, describes such a situation after infection with Streptococcus pyogenes. PANDAS may result from induced autoimmunity against brain antigens, although this remains unproven. Pilot work suggests that IgG antibodies from children with PANDAS bind to cholinergic interneurons (CINs) in the striatum. CIN deficiency has been independently associated with tics in humans and with repetitive behavioral pathology in mice, making it a plausible locus of pathology. The authors sought to replicate and extend earlier work and to investigate the cellular effects of PANDAS antibodies on cholinergic interneurons. METHODS Binding of IgG to specific neurons in human and mouse brain slices was evaluated ex vivo after incubation with serum from 27 children with rigorously characterized PANDAS, both at baseline and after intravenous immunoglobulin (IVIG) treatment, and 23 matched control subjects. Binding was correlated with symptom measures. Neural activity after serum incubation was assessed in mouse slices using molecular markers and electrophysiological recording. RESULTS IgG from children with PANDAS bound to CINs, but not to several other neuron types, more than IgG from control subjects, in three independent cohorts of patients. Post-IVIG serum had reduced IgG binding to CINs, and this reduction correlated with symptom improvement. Baseline PANDAS sera decreased activity of striatal CINs, but not of parvalbumin-expressing GABAergic interneurons, and altered their electrophysiological responses, in acute mouse brain slices. Post-IVIG PANDAS sera and IgG-depleted baseline sera did not alter the activity of striatal CINs. CONCLUSIONS These findings provide strong evidence for striatal CINs as a critical cellular target that may contribute to pathophysiology in children with rapid-onset OCD symptoms, and perhaps in other conditions.
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Affiliation(s)
- Jian Xu
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519
| | - Rong-Jian Liu
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519
| | - Shaylyn Fahey
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519
| | - Luciana Frick
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519,Current address: Hunter James Kelly Research Institute,
University at Buffalo
| | - James Leckman
- Child Study Center, Yale University School of
Medicine,Department of Pediatrics, Yale University School of
Medicine
| | - Flora Vaccarino
- Child Study Center, Yale University School of
Medicine,Department of Neuroscience, Yale University School of
Medicine
| | - Ronald S. Duman
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519
| | - Kyle Williams
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519,Current address: Department of Psychiatry, Massachusetts
General Hospital and Harvard Medical School
| | - Susan Swedo
- Pediatrics and Developmental Neuroscience Branch, National
Institute of Mental Health,PANDAS Physicians Network
| | - Christopher Pittenger
- Department of Psychiatry, Yale University School of
Medicine, 34 Park Street, New Haven, CT 06519,Child Study Center, Yale University School of
Medicine,Interdepartmental Neuroscience Program, Yale
University,Address correspondence to: Christopher Pittenger,
Yale University School of Medicine, 34 Park Street 333b, New Haven, CT 06519.
Phone: 203-974-7675.
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9
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Shimasaki C, Frye RE, Trifiletti R, Cooperstock M, Kaplan G, Melamed I, Greenberg R, Katz A, Fier E, Kem D, Traver D, Dempsey T, Latimer ME, Cross A, Dunn JP, Bentley R, Alvarez K, Reim S, Appleman J. Evaluation of the Cunningham Panel™ in pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS) and pediatric acute-onset neuropsychiatric syndrome (PANS): Changes in antineuronal antibody titers parallel changes in patient symptoms. J Neuroimmunol 2019; 339:577138. [PMID: 31884258 DOI: 10.1016/j.jneuroim.2019.577138] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/28/2019] [Accepted: 12/12/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVE This retrospective study examined whether changes in patient pre- and post-treatment symptoms correlated with changes in anti-neuronal autoantibody titers and the neuronal cell stimulation assay in the Cunningham Panel in patients with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection (PANDAS), and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). METHODS In an analysis of all tests consecutively performed in Moleculera Labs' clinical laboratory from April 22, 2013 to December 31, 2016, we identified 206 patients who were prescribed at least one panel prior to and following treatment, and who met the PANDAS/PANS diagnostic criteria. Patient follow-up was performed to collect symptoms and treatment or medical intervention. Of the 206 patients, 58 met the inclusion criteria of providing informed consent/assent and documented pre- and post-treatment symptoms. Clinician and parent-reported symptoms after treatment or medical intervention were categorized as "Improved/Resolved" (n = 34) or "Not-Improved/Worsened" (n = 24). These were analyzed for any association between changes in clinical status and changes in Cunningham panel test results. Clinical assay performance was also evaluated for reproducibility and reliability. RESULTS Comparison of pre- and post-treatment status revealed that the Cunningham Panel results correlated with changes in patient's neuropsychiatric symptoms. Based upon the change in the number of positive tests, the overall accuracy was 86%, the sensitivity and specificity were 88% and 83% respectively, and the Area Under the Curve (AUC) was 93.4%. When evaluated by changes in autoantibody levels, we observed an overall accuracy of 90%, a sensitivity of 88%, a specificity of 92% and an AUC of 95.7%. Assay reproducibility for the calcium/calmodulin-dependent protein kinase II (CaMKII) revealed a correlation coefficient of 0.90 (p < 1.67 × 10-6) and the ELISA assays demonstrated test-retest reproducibility comparable with other ELISA assays. CONCLUSION This study revealed a strong positive association between changes in neuropsychiatric symptoms and changes in the level of anti-neuronal antibodies and antibody-mediated CaMKII human neuronal cell activation. These results suggest there may be clinical utility in monitoring autoantibody levels and stimulatory activity against these five neuronal antigen targets as an aid in the diagnosis and treatment of infection-triggered autoimmune neuropsychiatric disorders. Future prospective studies should examine the feasibility of predicting antimicrobial and immunotherapy responses with the Cunningham Panel.
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Affiliation(s)
- Craig Shimasaki
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America.
| | - Richard E Frye
- Barrow Neurological Institute, Phoenix Children's Hospital, 1919 East Thomas Rd, Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States of America
| | - Rosario Trifiletti
- The PANS/PANDAS Institute, 545 Island Road, Suite 1D, Ramsey, NJ 07446, United States of America
| | - Michael Cooperstock
- Division of Infectious Diseases, University of Missouri School of Medicine, Columbia, MO, United States of America
| | - Gary Kaplan
- The Kaplan Center for Integrative Medicine, 6828 Elm Street, Suite 300, McLean, VA 22101, United States of America
| | - Isaac Melamed
- IMMUNOe Health and Research Centers, 6801 South Yosemite Street, Centennial, CO 80112, United States of America
| | - Rosalie Greenberg
- Medical Arts Psychotherapy Associates, P.A., 33 Overlook Road, Suite 406, Summit, NJ 07901, United States of America
| | - Amiram Katz
- Private Practice Neurology, 325 Boston Post Rd., Suite 1D, Orange, CT 06477, United States of America
| | - Eric Fier
- TherapyWorks ATL, 621 North Avenue NE, Atlanta, GA 30308, United States of America
| | - David Kem
- Section of Endocrinology and Diabetes, University of Oklahoma Department of Medicine, 1000 N Lincoln Blvd., Oklahoma City, OK 73104, United States of America
| | - David Traver
- 1261 E. Hillsdale Blvd., Foster City, CA 94404, United States of America
| | - Tania Dempsey
- Armonk Integrative Medicine, Private Practice, Pediatrics, 99 Business Park Drive, Armonk, NY 10504, United States of America
| | - M Elizabeth Latimer
- Latimer Neurology Center, 1101 30th Street NW Suite #320, Washington, DC 20007, United States of America
| | - Amy Cross
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
| | - Joshua P Dunn
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
| | - Rebecca Bentley
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
| | - Kathy Alvarez
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America; The University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, United States of America
| | - Sean Reim
- The University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, United States of America
| | - James Appleman
- Moleculera Labs, Inc., 755 Research Parkway, Suite 410, Oklahoma City, OK 73104, United States of America
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10
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McManus KR, Garber MD, Chen KY. It's Okay to Blink and Miss It. Hosp Pediatr 2019; 9:736-738. [PMID: 31391214 DOI: 10.1542/hpeds.2019-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Kayla Ryan McManus
- Wolfson Children's Hospital, Jacksonville, Florida; and
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Matthew David Garber
- Wolfson Children's Hospital, Jacksonville, Florida; and
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
| | - Kuo Yun Chen
- Wolfson Children's Hospital, Jacksonville, Florida; and
- University of Florida College of Medicine-Jacksonville, Jacksonville, Florida
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11
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Gerentes M, Pelissolo A, Rajagopal K, Tamouza R, Hamdani N. Obsessive-Compulsive Disorder: Autoimmunity and Neuroinflammation. Curr Psychiatry Rep 2019; 21:78. [PMID: 31367805 DOI: 10.1007/s11920-019-1062-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Here, we propose to review the immuno-inflammatory hypothesis in OCD given the concurrent incidence of autoimmune comorbidities, infectious stigma, and raised levels of inflammatory markers in a significant subset of patients. A better understanding of the immune dysfunction in OCD may allow stratifying the patients in order to design personalized pharmaco/psychotherapeutic strategies. RECENT FINDINGS A persistent low-grade inflammation involving both innate and adaptive immune system with coexisting autoimmune morbidities and stigma of infectious events has been prominently observed in OCD. Hence, specific treatments targeting inflammation/infection are a feasible alternative in OCD. This review highlights that OCD is associated with low-grade inflammation, neural antibodies, and neuro-inflammatory and auto-immune disorders. In some subset of OCD patients, autoimmunity is likely triggered by specific bacterial, viral, or parasitic agents with overlapping surface epitopes in CNS. Hence, subset-profiling in OCD is warranted to benefit from distinct immune-targeted treatment modalities.
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Affiliation(s)
- Mona Gerentes
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France
| | - Antoine Pelissolo
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France.,Faculté de médecine, UPEC, Université Paris-Est, 94000, Créteil, France
| | | | - Ryad Tamouza
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France.,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France
| | - Nora Hamdani
- Inserm U955, Team 15, Genetic Psychiatry, 94000, Creteil, France. .,AP-HP, DHU Pe-PSY, Henri Mondor - Albert Chenevier, group, Psychiatry, 94000, Creteil, France.
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12
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Abstract
BACKGROUND The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) hypothesis suggests an association between group A beta-hemolytic streptococcus (GABHS) infections and subsequent onset or exacerbation of neuropsychiatric symptoms, such as obsessive-compulsive disorder or tic disorders. METHODS We performed a systematic review and meta-analysis including longitudinal, prospective studies on exacerbations of neuropsychiatric symptoms associated with GABHS infections in children with PANDAS. We searched PubMed and EMBASE through August 14, 2017. Two independent reviewers extracted data and we used random-effects analysis to calculate rate ratios (RR). RESULTS Three studies were included with a total of 82 PANDAS cases and 127 control children with obsessive-compulsive disorder or chronic tic disorder. PANDAS cases had a nonsignificantly increased RR of 2.33 [95% confidence interval [CI]: 0.63-8.70, P = 0.21, I = 28.3%] for exacerbations of neuropsychiatric symptoms in temporal proximity to a GABHS infection and no increased risk of GABHS infections (RR = 0.99, 95% CI: 0.56-1.73, P = 0.97, I = 45%) compared with the control children. However, PANDAS cases had an increased risk of neuropsychiatric exacerbations in general with a RR of 1.54 (95% CI: 1.12-2.11, P = 0.008, I = 0%) compared with the control children. The studies had methodologic heterogeneity, high risk of selection bias and differed concerning case definition and infection measures. CONCLUSIONS Our findings did not show significant evidence concerning higher rates of temporally associated GABHS infections and exacerbations of neuropsychiatric symptoms in children with PANDAS. The included studies were small and limited by low GABHS rates and exacerbations. Future studies with large population sizes and routine evaluations are needed to thoroughly examine the PANDAS hypothesis.
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13
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Wilbur C, Bitnun A, Kronenberg S, Laxer RM, Levy DM, Logan WJ, Shouldice M, Yeh EA. PANDAS/PANS in childhood: Controversies and evidence. Paediatr Child Health 2018; 24:85-91. [PMID: 30996598 DOI: 10.1093/pch/pxy145] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/13/2018] [Indexed: 12/12/2022] Open
Abstract
Since first defined in 1998, paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and its later, broader iteration, paediatric acute-onset neuropsychiatric syndrome (PANS), have garnered significant attention and controversy. The role of streptococcal infection in children with explosive onset obsessive-compulsive disorder and new onset tics, the natural history of this entity, and the role of symptomatic and disease-modifying therapies, including antibiotics, immunotherapy, and psychoactive drugs, are all issues that have yet to be definitively addressed. While definitive proof of the autoimmune hypothesis of PANDAS is lacking, given the heightened attention to this entity and apparent rise in use of this diagnostic category, addressing questions around diagnosis, treatment, and etiology is imperative. In this paper, we review current working definitions of PANDAS/PANS, discuss published evidence for interventions related to this entity, and propose a clinical approach to children presenting with acute symptoms satisfying criteria for PANDAS/PANS.
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Affiliation(s)
- Colin Wilbur
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Ari Bitnun
- Division of Infectious Diseases, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Sefi Kronenberg
- Department of Psychiatry, The Hospital for Sick Children, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Ronald M Laxer
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Deborah M Levy
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Rheumatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - William J Logan
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Shouldice
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - E Ann Yeh
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Neuroscience and Mental Health, The Hospital for Sick Children Research Institute, Toronto, Ontario, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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14
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Cancilliere MK, Freeman J, Garcia A, Benito K, Sapyta J, Franklin M. Assessing Acute Secondary Treatment Outcomes in Early-Onset Obsessive-Compulsive Disorder. Child Psychiatry Hum Dev 2018; 49:718-729. [PMID: 29435695 DOI: 10.1007/s10578-018-0786-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Obsessive-compulsive disorder (OCD) in children under 8 years of age, referred to as early-onset OCD, has similar features to OCD in older children, including moderate to severe symptoms, impairment, and significant comorbidity. Family-based cognitive behavioral therapy (FB-CBT) has been found efficacious in reducing OCD symptoms and functional impairment in children ages 5-8 years with OCD; however, its effectiveness on reducing comorbid psychiatric symptoms in this same population has yet to be demonstrated. This study examined the acute effects of FB-CBT vs. family-based relaxation treatment over 14 weeks on measures of secondary treatment outcomes (non-OCD) in children with early-onset OCD. Children in the FB-CBT condition showed significant improvements from pre- to post-treatment on secondary outcomes, with a decrease in overall behavioral and emotional problems, internalizing symptoms, as well as overall anxiety symptom severity. Neither condition yielded significant change in externalizing symptoms. Clinical implications of these findings are considered.
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Affiliation(s)
- Mary Kathryn Cancilliere
- Department of Psychology, University of Rhode Island, 10 Chafee Road, Suite 8, Kingston, RI, 02881, USA.
| | - Jennifer Freeman
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI, USA.,Bradley-Hasbro Children's Research Center, Emma Pendleton Bradley Hospital, East Providence, RI, USA
| | - Abbe Garcia
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI, USA.,Bradley-Hasbro Children's Research Center, Emma Pendleton Bradley Hospital, East Providence, RI, USA
| | - Kristen Benito
- Department of Psychiatry and Human Behavior, Brown University Medical School, Providence, RI, USA.,Bradley-Hasbro Children's Research Center, Emma Pendleton Bradley Hospital, East Providence, RI, USA
| | - Jeffrey Sapyta
- Duke Child and Family Study Center, Duke University School of Medicine, Durham, NC, USA
| | - Martin Franklin
- Child and Adolescent OCD, Tic, Trich, and Anxiety Group, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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15
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Lamothe H, Baleyte JM, Smith P, Pelissolo A, Mallet L. Individualized Immunological Data for Precise Classification of OCD Patients. Brain Sci 2018; 8:E149. [PMID: 30096863 PMCID: PMC6119917 DOI: 10.3390/brainsci8080149] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/01/2018] [Accepted: 08/03/2018] [Indexed: 12/11/2022] Open
Abstract
Obsessive⁻compulsive disorder (OCD) affects about 2% of the general population, for which several etiological factors were identified. Important among these is immunological dysfunction. This review aims to show how immunology can inform specific etiological factors, and how distinguishing between these etiologies is important from a personalized treatment perspective. We found discrepancies concerning cytokines, raising the hypothesis of specific immunological etiological factors. Antibody studies support the existence of a potential autoimmune etiological factor. Infections may also provoke OCD symptoms, and therefore, could be considered as specific etiological factors with specific immunological impairments. Finally, we underline the importance of distinguishing between different etiological factors since some specific treatments already exist in the context of immunological factors for the improvement of classic treatments.
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Affiliation(s)
- Hugues Lamothe
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Jean-Marc Baleyte
- Centre Hospitalier Intercommunal de Créteil, 94000 Créteil, France.
- Fondation FondaMental, 94000 Créteil, France.
| | - Pauline Smith
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
| | - Antoine Pelissolo
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- INSERM, U955, Team 15, 94000 Créteil, France.
| | - Luc Mallet
- Institut du Cerveau et de la Moelle Epinière, Sorbonne Universités, UPMC Univ Paris 06, CNRS, INSERM, 75013 Paris, France.
- Fondation FondaMental, 94000 Créteil, France.
- Assistance Publique-Hôpitaux de Paris, Pôle de Psychiatrie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Université Paris-Est Créteil, 94000 Créteil, France.
- Department of Mental Health and Psychiatry, Global Health Institute, University of Geneva, 1202 Geneva, Switzerland.
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16
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A Pediatric Neurology Perspective on Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection and Pediatric Acute-Onset Neuropsychiatric Syndrome. J Pediatr 2018; 199:243-251. [PMID: 29793872 DOI: 10.1016/j.jpeds.2018.04.035] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/25/2018] [Accepted: 04/17/2018] [Indexed: 12/21/2022]
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17
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Abstract
Tics are the most common movement disorder in childhood and are a frequent reason for referral to child neurology clinics. The purpose of this review is to examine the phenomenology of tics, discuss what is known regarding their genetic and pathophysiological causes and to evaluate current treatment options. The evidence for the evaluation and treatment of the controversial diagnosis of pediatric autoimmune neuropsychiatric disorders associated with group A streptococci (PANDAS) will also be reviewed. With improved understanding of tic disorders, their etiology and response to current treatment options, we may be able to more effectively diagnose them and identify novel treatment strategies.
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Affiliation(s)
- Joanna S Blackburn
- Division of Child Neurology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, IL.
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18
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Treatment of PANDAS and PANS: a systematic review. Neurosci Biobehav Rev 2018; 86:51-65. [DOI: 10.1016/j.neubiorev.2018.01.001] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/10/2017] [Accepted: 01/01/2018] [Indexed: 12/25/2022]
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19
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Calaprice D, Tona J, Murphy TK. Treatment of Pediatric Acute-Onset Neuropsychiatric Disorder in a Large Survey Population. J Child Adolesc Psychopharmacol 2018; 28:92-103. [PMID: 28832181 PMCID: PMC5826468 DOI: 10.1089/cap.2017.0101] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The goal of this study was to investigate treatment histories and outcomes in a large community sample of youth with Pediatric Acute-onset Neuropsychiatric Syndrome (PANS), and, where appropriate, to examine the impact of immune deficiency on treatment outcomes. METHODS A comprehensive internet-based survey was completed by parents or guardians of youth who had received physician diagnoses of PANS, or by young adults (age 18+) who had themselves been diagnosed by a physician (N = 698). Data regarding the treatment histories of these patients, including the variety of medical and psychological treatments employed and the caregiver- or self-reported response to each, are presented. RESULTS The PANS patients in this study had commonly been treated with antibiotic (N = 675), anti-inflammatory (N = 437), and/or psychotropic therapy (N = 378). Response to antibiotic treatment was best when treatment was relatively aggressive, with broad-spectrum antibiotics and courses of >30 days generally producing the best results (i.e., up to 52% of patients achieving a "very effective" response). For immune-deficient patients (caregiver-reported laboratory studies below normal limits; N = 108), use of broad-spectrum antibiotics appeared to be particularly desirable. Anti-inflammatory therapies, including over-the-counter medications such as ibuprofen, were at least "somewhat effective" for most patients. Intravenous immunoglobulin (IVIG) had been used to treat PANS in 193 (28%) of the patients and was at least "somewhat effective" for 89%, although for 18% of these, the effect was not sustained. The highest rate of sustained response to IVIG treatment was seen in immune-deficient patients who received doses of at least 0.8 g/kg IVIG on a regular basis. Psychotropic medications, most commonly SSRIs (38% reported a trial), were commonly employed, but were often ineffective (e.g., 44% found SSRIs "somewhat" to "very effective"). Many patients (N = 473) had received some form of psychotherapy with some benefit, with cognitive behavioral therapy found to be at least somewhat effective in a majority of those treated with this modality. CONCLUSION Among the PANS patients represented in this study, relatively aggressive treatment courses targeted at eradicating infection and modulating the inflammatory response appeared to provide the best caregiver-reported therapeutic results, and to be generally well tolerated. Given its relative efficacy and tolerability, treatment targeting the inflammatory response may represent an underutilized approach in this population. The results of this study should be considered in light of the limitations inherent in a self-selected and administered online survey.
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Affiliation(s)
| | - Janice Tona
- Department of Rehabilitation Science, University at Buffalo, Buffalo, New York
| | - Tanya K. Murphy
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychiatry, University of South Florida, St. Petersburg, Florida
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20
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Cooperstock MS, Swedo SE, Pasternack MS, Murphy TK. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part III-Treatment and Prevention of Infections. J Child Adolesc Psychopharmacol 2017; 27:594-606. [PMID: 36358106 PMCID: PMC9836684 DOI: 10.1089/cap.2016.0151] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Objectives: Pediatric acute-onset neuropsychiatric syndrome (PANS) and its subset, pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection (PANDAS), are emerging autoimmune encephalopathies of childhood. Management guidelines are needed. This article, from the PANS/PANDAS Consortium, presents a consensus management guideline for the infection components. Accompanying papers from the Consortium discuss psychiatric and immunomodulatory management. Methods: Literature was reviewed and integrated with the clinical experience of the authors to provide a set of practical guidelines. This article was submitted to all members of the PANS/PANDAS Consortium, and their additional comments were added. Results: The relationships between PANS and infections are reviewed. An approach to the retrospective diagnosis of group A streptococcal infection for an operational definition of PANDAS is proposed. An initial course of anti-streptococcal treatment is proposed for all newly diagnosed PANS cases. Chronic secondary antimicrobial prophylaxis is suggested for children with PANDAS who have severe neuropsychiatric symptoms or recurrent group A Streptococcus-associated exacerbations. Guidelines for children with non-streptococcal PANS include vigilance for streptococcal pharyngitis or dermatitis in the patient and close contacts. All patients with PANS or PANDAS should also be closely monitored for other intercurrent infections, including sinusitis and influenza. Intercurrent infections should be diagnosed and treated promptly according to current standard guidelines. A guideline for the assessment of infection at initial onset or during neuropsychiatric exacerbations is also presented. Standard immunizations and attention to vitamin D are encouraged. Data indicating limited utility of adenotonsillectomy and probiotics are presented. Conclusion: A working guideline for the management of infection issues in PANS and PANDAS, based on literature and expert opinion, is provided.
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Affiliation(s)
- Michael S Cooperstock
- Division of Infectious Diseases, University of Missouri School of Medicine, Columbia, Missouri
| | - Susan E Swedo
- Department of Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health (NIMH), Rockville, Maryland
| | - Mark S Pasternack
- Department of Pediatric Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts
| | - Tanya K Murphy
- Director and Professor of Pediatric Neuropsychiatry, Pediatrics and Psychiatry, University of South Florida, St. Petersburg, Florida
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21
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Murphy TK, Brennan EM, Johnco C, Parker-Athill EC, Miladinovic B, Storch EA, Lewin AB. A Double-Blind Randomized Placebo-Controlled Pilot Study of Azithromycin in Youth with Acute-Onset Obsessive-Compulsive Disorder. J Child Adolesc Psychopharmacol 2017; 27:640-651. [PMID: 28358599 DOI: 10.1089/cap.2016.0190] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Sudden and severe onset of obsessive-compulsive disorder (OCD) may present secondary to infectious and/or immune-mediated triggers. We assessed the preliminary efficacy, tolerability, and safety of azithromycin compared with placebo in the treatment of OCD and associated symptoms in children with pediatric acute-onset neuropsychiatric syndrome (PANS). METHODS Thirty-one youth aged 4-14 years (M = 8.26 ± 2.78 years, 62.5% male) were randomized to receive either placebo or azithromycin for 4 weeks (10 mg/kg up to 500 mg per day). Both groups were administered twice daily probiotics. The primary outcome, obsessive-compulsive symptom severity, was assessed using the OCD Clinical Global Impressions Severity (CGI-S OCD) and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). RESULTS Participants in the azithromycin group (n = 17) showed significantly greater reductions in OCD severity on the CGI-S OCD than the placebo group (n = 14) posttreatment (p = 0.003), although there were no significant differences on the CY-BOCS. Significantly more participants in the azithromycin condition met treatment responder criteria on the CGI-I OCD at the end of week 4 (41.2%, n = 7) in comparison to the placebo group (7.1%, n = 1; p = 0.045). Tic severity moderated treatment response, with greater tic severity being associated with enhanced treatment response on the CGI-S OCD. Azithromycin was well tolerated with minimal adverse effects and no study dropouts due to side effects. However, the azithromycin group showed a trend toward significantly greater electrocardiography QTc (p = 0.060) at the end of week 4, and significantly more reports of loose or abnormal stools (p = 0.009). CONCLUSION This double blind pilot study suggests that azithromycin may be helpful in treating youth meeting the PANS diagnosis, especially those with elevated levels of both OCD and tic symptoms. Azithromycin was well tolerated, but the potential for cardiac risks suggests that additional monitoring may be needed to ensure safety.
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Affiliation(s)
- Tanya K Murphy
- 1 Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida , St. Petersburg, Florida.,2 Department of Psychiatry & Behavioral Sciences, University of South Florida , St. Petersburg, Florida.,3 All Children's Hospital-Johns Hopkins Medicine , St. Petersburg, Florida
| | - Erin M Brennan
- 1 Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida , St. Petersburg, Florida
| | - Carly Johnco
- 4 Department of Psychology-Macquarie University , Sydney, New South Wales
| | - Ellisa Carla Parker-Athill
- 1 Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida , St. Petersburg, Florida
| | - Branko Miladinovic
- 5 Department of Internal Medicine, Center for Comparative Effectiveness Research, University of South Florida Morsani College of Medicine , Tampa, Florida
| | - Eric A Storch
- 1 Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida , St. Petersburg, Florida.,2 Department of Psychiatry & Behavioral Sciences, University of South Florida , St. Petersburg, Florida.,3 All Children's Hospital-Johns Hopkins Medicine , St. Petersburg, Florida.,6 Department of Health Policy and Management, University of South Florida , St. Petersburg, Florida.,7 Rogers Memorial Hospital , Tampa, Florida
| | - Adam B Lewin
- 1 Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida , St. Petersburg, Florida.,2 Department of Psychiatry & Behavioral Sciences, University of South Florida , St. Petersburg, Florida
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22
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Affiliation(s)
- Harvey S Singer
- Professor of Neurology and Pediatric, Johns Hopkins University School of Medicine, Rubenstein Child Health Building, Baltimore, Maryland.
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23
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Singer HS. Autoantibody-Associated Movement Disorders in Children: Proven and Proposed. Semin Pediatr Neurol 2017; 24:168-179. [PMID: 29103424 DOI: 10.1016/j.spen.2017.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Movement disorders secondary to autoantibodies in children represent a rapidly expanding group of conditions. Once considered to be limited to poststreptococcal Sydenham's chorea or rare cases of childhood systemic lupus erythematosus, a variety of antibody-related movement abnormalities are now seen as part of noninfectious autoimmune encephalitis or within an expanding list of postinfectious disorders. In this article, several proposed autoantibody-mediated movement disorders in children are reviewed. In each one, there is a hypothesized antibody biomarker that is believed to be pathogenic and cause the clinical symptoms. As will be discussed, in some, such as anti-NMDA receptor encephalitis, the strength of supporting evidence is strong. In others, antibodies have been identified, but their role as the pathophysiological mechanism remains undetermined. Lastly, there are proposed disorders, such as PANDAS, that are controversial on both a clinical and autoimmune basis.
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Affiliation(s)
- Harvey S Singer
- Departments of Neurology and Pediatrics, Johns Hopkins University, Baltimore MD.
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24
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Abstract
Among the critically ill, infectious diseases can play a significant role in the etiology of neuropsychiatric disturbances. All critical care physicians are familiar with delirium as a secondary complication of systemic infection. This article focuses on key infectious diseases that commonly and directly produce neuropsychiatric symptoms, including direct infection of the central nervous system, human immunodeficiency virus infection, and AIDS.
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Affiliation(s)
- Sahil Munjal
- Department of Psychiatry, Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA
| | - Stephen J Ferrando
- Department of Psychiatry, Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA.
| | - Zachary Freyberg
- Department of Psychiatry, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA; Department of Cell Biology, University of Pittsburgh, 3811 O'Hara Street, Pittsburgh, PA 15213, USA
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25
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Bandelow B, Baldwin D, Abelli M, Bolea-Alamanac B, Bourin M, Chamberlain SR, Cinosi E, Davies S, Domschke K, Fineberg N, Grünblatt E, Jarema M, Kim YK, Maron E, Masdrakis V, Mikova O, Nutt D, Pallanti S, Pini S, Ströhle A, Thibaut F, Vaghix MM, Won E, Wedekind D, Wichniak A, Woolley J, Zwanzger P, Riederer P. Biological markers for anxiety disorders, OCD and PTSD: A consensus statement. Part II: Neurochemistry, neurophysiology and neurocognition. World J Biol Psychiatry 2017; 18:162-214. [PMID: 27419272 PMCID: PMC5341771 DOI: 10.1080/15622975.2016.1190867] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 05/03/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Biomarkers are defined as anatomical, biochemical or physiological traits that are specific to certain disorders or syndromes. The objective of this paper is to summarise the current knowledge of biomarkers for anxiety disorders, obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD). METHODS Findings in biomarker research were reviewed by a task force of international experts in the field, consisting of members of the World Federation of Societies for Biological Psychiatry Task Force on Biological Markers and of the European College of Neuropsychopharmacology Anxiety Disorders Research Network. RESULTS The present article (Part II) summarises findings on potential biomarkers in neurochemistry (neurotransmitters such as serotonin, norepinephrine, dopamine or GABA, neuropeptides such as cholecystokinin, neurokinins, atrial natriuretic peptide, or oxytocin, the HPA axis, neurotrophic factors such as NGF and BDNF, immunology and CO2 hypersensitivity), neurophysiology (EEG, heart rate variability) and neurocognition. The accompanying paper (Part I) focuses on neuroimaging and genetics. CONCLUSIONS Although at present, none of the putative biomarkers is sufficient and specific as a diagnostic tool, an abundance of high quality research has accumulated that should improve our understanding of the neurobiological causes of anxiety disorders, OCD and PTSD.
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Affiliation(s)
- Borwin Bandelow
- Department of Psychiatry and Psychotherapy, University of Göttingen, Germany
| | - David Baldwin
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Marianna Abelli
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Blanca Bolea-Alamanac
- School of Social and Community Medicine, Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - Michel Bourin
- Neurobiology of Anxiety and Mood Disorders, University of Nantes, Nantes, France
| | - Samuel R. Chamberlain
- Hertfordshire Partnership University NHS Foundation Trust and University of Hertfordshire, Parkway, UK
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Eduardo Cinosi
- Department of Neuroscience Imaging and Clinical Sciences, Gabriele D’Annunzio University, Chieti, Italy
| | - Simon Davies
- Centre for Addiction and Mental Health, Geriatric Psychiatry Division, University of Toronto, Toronto, Canada
- School of Social and Community Medicine, Academic Unit of Psychiatry, University of Bristol, Bristol, UK
| | - Katharina Domschke
- Department of Psychiatry Psychosomatics and Psychotherapy, University of Wuerzburg, Wuerzburg, Germany
| | - Naomi Fineberg
- Hertfordshire Partnership University NHS Foundation Trust and University of Hertfordshire, Parkway, UK
| | - Edna Grünblatt
- Department of Psychiatry Psychosomatics and Psychotherapy, University of Wuerzburg, Wuerzburg, Germany
- Department of Child and Adolescent Psychiatry and Psychotherapy, Psychiatric Hospital, University of Zurich, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and the ETH Zurich, Zurich, Switzerland
- Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Marek Jarema
- Third Department of Psychiatry, Institute of Psychiatry and Neurology, Warszawa, Poland
| | - Yong-Ku Kim
- Department of Psychiatry College of Medicine, Korea University, Seoul, Republic of Korea
| | - Eduard Maron
- Department of Psychiatry, North Estonia Medical Centre, Tallinn, Estonia
- Department of Psychiatry, University of Tartu, Estonia
- Faculty of Medicine Department of Medicine, Centre for Neuropsychopharmacology, Division of Brain Sciences, Imperial College London, UK
| | - Vasileios Masdrakis
- Athens University Medical School, First Department of Psychiatry, Eginition Hospital, Athens, Greece
| | - Olya Mikova
- Foundation Biological Psychiatry, Sofia, Bulgaria
| | - David Nutt
- Faculty of Medicine Department of Medicine, Centre for Neuropsychopharmacology, Division of Brain Sciences, Imperial College London, UK
| | - Stefano Pallanti
- UC Davis Department of Psychiatry and Behavioural Sciences, Sacramento, CA, USA
| | - Stefano Pini
- Department of Clinical and Experimental Medicine, Section of Psychiatry, University of Pisa, Pisa, Italy
| | - Andreas Ströhle
- Department of Psychiatry and Psychotherapy, Campus Charité Mitte, Charité – University Medica Center Berlin, Berlin, Germany
| | - Florence Thibaut
- Faculty of Medicine Paris Descartes, University Hospital Cochin, Paris, France
| | - Matilde M. Vaghix
- Department of Psychology and Behavioural and Clinical Neuroscience Institute, University of Cambridge, UK
| | - Eunsoo Won
- Department of Psychiatry College of Medicine, Korea University, Seoul, Republic of Korea
| | - Dirk Wedekind
- Department of Psychiatry and Psychotherapy, University of Göttingen, Germany
| | - Adam Wichniak
- Third Department of Psychiatry, Institute of Psychiatry and Neurology, Warszawa, Poland
| | - Jade Woolley
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Peter Zwanzger
- kbo-Inn-Salzach-Klinikum Wasserburg am Inn, Germany
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University Munich, Munich, Germany
| | - Peter Riederer
- Department of Psychiatry Psychosomatics and Psychotherapy, University of Wuerzburg, Wuerzburg, Germany
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26
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Defining cognitive-behavior therapy response and remission in pediatric OCD: a signal detection analysis of the Children's Yale-Brown Obsessive Compulsive Scale. Eur Child Adolesc Psychiatry 2017; 26:47-55. [PMID: 27209422 PMCID: PMC6167060 DOI: 10.1007/s00787-016-0863-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 05/04/2016] [Indexed: 12/25/2022]
Abstract
The objective of the study was to examine the optimal Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) percent reduction and raw cutoffs for predicting cognitive-behavioral treatment (CBT) response among children and adolescents with obsessive-compulsive disorder (OCD). The sample consisted of children and adolescents with OCD (N = 241) participating in the first step of the Nordic long-term OCD treatment study and receiving 14 weekly sessions of CBT in the form of exposure and response prevention. Evaluations were conducted pre- and post-treatment, included the CY-BOCS, Clinical Global Impressions-severity/improvement. The results showed that the most efficient CY-BOCS cutoffs were 35 % reduction for treatment response, 55 % reduction for remission, and a post-treatment CY-BOCS raw total score of 11 for treatment remission. Overall, our results diverge from previous research on pediatric OCD with more conservative cutoffs (higher cutoff reduction for response and remission, and lower raw score for remission). Further research on optimal cutoffs is needed.
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27
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Windfuhr JP. Tonsillectomy remains a questionable option for pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2016; 15:Doc07. [PMID: 28025607 PMCID: PMC5169080 DOI: 10.3205/cto000134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is a disease attributed to children with obsessive compulsive disorders (OCD) or tic disorders associated with streptococcal infections. Because otolaryngologists examine a large number of pediatric patients with recurrent streptococcal infections, tonsillectomy (TE) is a common option of therapy. This study was conducted to evaluate the efficacy of TE in patients presenting with verified PANDAS. Material and methods: A PubMed review was performed using search terms "tonsillectomy" and "PANDAS", "OCD", "compulsive" "pediatric autoimmune", "chorea" and "tic" limited by publication date of January 1, 1995, to July 31, 2015. Reviews without patients were not included in the review. Results: Nine papers matched our search criteria, including 6 case reports with 8 patients and 3 case series. Most case reports were in favor of TE, but this was by far not supported by the findings in the case series. The follow-up ranged from 2 to 36 months in case reports and from 24 to 36 in case series. Conclusion: Establishing the diagnosis of PANDAS is complicated because of underlying comorbidities in the field of neurology-psychiatry and the lack of a reliable biomarker. The positive outcome after TE as reported in case studies may be influenced by the postoperative medication and is not supported by the results of large-scale studies. In the light of the considerable postoperative morbidity rate, it appears wise to indicate TE for PANDAS only in supervised clinical studies.
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Affiliation(s)
- Jochen P Windfuhr
- Department of Otolaryngology, Head & Neck Surgery, Allergology, Kliniken Maria Hilf, Mönchengladbach, Germany
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28
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Hollis C, Pennant M, Cuenca J, Glazebrook C, Kendall T, Whittington C, Stockton S, Larsson L, Bunton P, Dobson S, Groom M, Hedderly T, Heyman I, Jackson GM, Jackson S, Murphy T, Rickards H, Robertson M, Stern J. Clinical effectiveness and patient perspectives of different treatment strategies for tics in children and adolescents with Tourette syndrome: a systematic review and qualitative analysis. Health Technol Assess 2016; 20:1-450, vii-viii. [PMID: 26786936 DOI: 10.3310/hta20040] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Tourette syndrome (TS) is a neurodevelopmental condition characterised by chronic motor and vocal tics affecting up to 1% of school-age children and young people and is associated with significant distress and psychosocial impairment. OBJECTIVE To conduct a systematic review of the benefits and risks of pharmacological, behavioural and physical interventions for tics in children and young people with TS (part 1) and to explore the experience of treatment and services from the perspective of young people with TS and their parents (part 2). DATA SOURCES For the systematic reviews (parts 1 and 2), mainstream bibliographic databases, The Cochrane Library, education, social care and grey literature databases were searched using subject headings and text words for tic* and Tourette* from database inception to January 2013. REVIEW/RESEARCH METHODS For part 1, randomised controlled trials and controlled before-and-after studies of pharmacological, behavioural or physical interventions in children or young people (aged < 18 years) with TS or chronic tic disorder were included. Mixed studies and studies in adults were considered as supporting evidence. Risk of bias associated with each study was evaluated using the Cochrane tool. When there was sufficient data, random-effects meta-analysis was used to synthesize the evidence and the quality of evidence for each outcome was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. For part 2, qualitative studies and survey literature conducted in populations of children/young people with TS or their carers or in health professionals with experience of treating TS were included in the qualitative review. Results were synthesized narratively. In addition, a national parent/carer survey was conducted via the Tourettes Action website. Participants included parents of children and young people with TS aged under 18 years. Participants (young people with TS aged 10-17 years) for the in-depth interviews were recruited via a national survey and specialist Tourettes clinics in the UK. RESULTS For part 1, 70 studies were included in the quantitative systematic review. The evidence suggested that for treating tics in children and young people with TS, antipsychotic drugs [standardised mean difference (SMD) -0.74, 95% confidence interval (CI) -1.08 to -0.41; n = 75] and noradrenergic agents [clonidine (Dixarit(®), Boehringer Ingelheim) and guanfacine: SMD -0.72, 95% CI -1.03 to -0.40; n = 164] are effective in the short term. There was little difference among antipsychotics in terms of benefits, but adverse effect profiles do differ. Habit reversal training (HRT)/comprehensive behavioural intervention for tics (CBIT) was also shown to be effective (SMD -0.64, 95% CI -0.99 to -0.29; n = 133). For part 2, 295 parents/carers of children and young people with TS contributed useable survey data. Forty young people with TS participated in in-depth interviews. Four studies were in the qualitative review. Key themes were difficulties in accessing specialist care and behavioural interventions, delay in diagnosis, importance of anxiety and emotional symptoms, lack of provision of information to schools and inadequate information regarding medication and adverse effects. LIMITATIONS The number and quality of clinical trials is low and this downgrades the strength of the evidence and conclusions. CONCLUSIONS Antipsychotics, noradrenergic agents and HRT/CBIT are effective in reducing tics in children and young people with TS. The balance of benefits and harms favours the most commonly used medications: risperidone (Risperdal(®), Janssen), clonidine and aripiprazole (Abilify(®), Otsuka). Larger and better-conducted trials addressing important clinical uncertainties are required. Further research is needed into widening access to behavioural interventions through use of technology including mobile applications ('apps') and video consultation. STUDY REGISTRATION This study is registered as PROSPERO CRD42012002059. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Chris Hollis
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK
| | - Mary Pennant
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
| | - José Cuenca
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK
| | - Cris Glazebrook
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK
| | - Tim Kendall
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
| | - Craig Whittington
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
| | - Sarah Stockton
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
| | - Linnéa Larsson
- National Collaborating Centre for Mental Health, Royal College of Psychiatrists, London, UK
| | - Penny Bunton
- School of Psychological Sciences, University of Manchester, Manchester, UK
| | - Suzanne Dobson
- Tourettes Action, The Meads Business Centre, Farnborough, Hampshire, UK
| | - Madeleine Groom
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK
| | - Tammy Hedderly
- Paediatric Neurology Department, Kings College Hospital NHS Foundation Trust, London, UK
| | - Isobel Heyman
- Department of Child and Adolescent Mental Health, Great Ormond Street Hospital for Children, London, UK
| | - Georgina M Jackson
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, University of Nottingham Innovation Park, University of Nottingham, Nottingham, UK
| | - Stephen Jackson
- School of Psychology, University of Nottingham, Nottingham, UK
| | - Tara Murphy
- Institute of Neurology, University College London, London, UK
| | | | - Mary Robertson
- Department of Neurology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jeremy Stern
- Tourettes Action, The Meads Business Centre, Farnborough, Hampshire, UK
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PANDAS: A systematic review of treatment options. Int J Pediatr Otorhinolaryngol 2016; 89:149-53. [PMID: 27619047 DOI: 10.1016/j.ijporl.2016.08.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 08/09/2016] [Accepted: 08/10/2016] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS) is a rare but important condition for pediatric otolaryngologists to recognize. Several treatment options exist including tonsillectomy, antibiotic treatment/prophylaxis, intravenous immunoglobulin (IVIG), and psychiatric medications/therapy. METHODS A systematic review of the PubMed, EMBASE, and Scopus databases was performed searching for articles that focused exclusively on the aforementioned treatment modalities in the PANDAS population. Review articles, single patient case reports, and studies examining the natural history or diagnostic strategies were excluded. RESULTS Five articles regarding tonsillectomy treatments with level of evidence (LOE) 4 were found but no clear benefit could be determined. Three articles were selected involving the use of antibiotic therapy. One prospective study and one double-blind randomized control trial (DB RCT) supported the use of antibiotics but a separate DB RCT showed no benefit. Two selected articles described the use of IVIG: one unblinded RCT and one retrospective study. One prospective study on cognitive-behavioral therapy (CBT) showed benefit in PANDAS. CONCLUSION There is a paucity of high-level studies regarding this rare disorder and no hard treatment recommendations can be made. Tonsillectomy should only be performed in those who are surgical candidates based on current published guidelines. Antibiotics are an option but provide uncertain benefit. CBT remains a low-risk option. Studies support the use of IVIG, however more investigation is needed prior to widespread adoption of this treatment given its potential risks.
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30
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Skriner LC, Freeman J, Garcia A, Benito K, Sapyta J, Franklin M. Characteristics of Young Children with Obsessive-Compulsive Disorder: Baseline Features from the POTS Jr. Sample. Child Psychiatry Hum Dev 2016; 47:83-93. [PMID: 25820921 DOI: 10.1007/s10578-015-0546-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pediatric obsessive-compulsive disorder (OCD) is a chronic and impairing condition that can emerge early in childhood and persist into adulthood. The primary aim of this paper is to examine the characteristics of a large sample of young children with OCD (age range from 5 to 8). The sample will be described with regard to: demographics, OCD symptoms/severity, family history and parental psychopathology, comorbidity, and global and family functioning. The sample includes 127 youth with a primary diagnosis of OCD who participated in a multi-site, randomized control clinical trial of family-based exposure with response prevention. Key findings include moderate to severe OCD symptoms, high rates of impairment, and significant comorbidity, despite the participants' young age. Discussion focuses on how the characteristics of young children compare with older youth and with the few other samples of young children with OCD. Considerations regarding generalizability of the sample and limitations of the study are discussed.
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Affiliation(s)
- L C Skriner
- Department of Psychiatry and Human Behavior, Bradley/Hasbro Children's Research Center, Alpert Medical School of Brown University, Providence, RI, USA.
| | - J Freeman
- Department of Psychiatry and Human Behavior, Bradley/Hasbro Children's Research Center, Alpert Medical School of Brown University, Providence, RI, USA
| | - A Garcia
- Department of Psychiatry and Human Behavior, Bradley/Hasbro Children's Research Center, Alpert Medical School of Brown University, Providence, RI, USA
| | - K Benito
- Department of Psychiatry and Human Behavior, Bradley/Hasbro Children's Research Center, Alpert Medical School of Brown University, Providence, RI, USA
| | - J Sapyta
- Duke Child and Family Study Center, Duke University School of Medicine, Durham, NC, USA
| | - M Franklin
- Child & Adolescent OCD, Tic, Trich & Anxiety Group, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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31
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Mullen S. Review of pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections. Ment Health Clin 2015. [DOI: 10.9740/mhc.2015.07.184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
During the past decade, pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS) has become the topic of numerous debates, sparking research on its presentation, existence, and treatment. As the awareness of PANDAS has increased among the general community, health care providers have been forced to increase their knowledge of this controversial disease state. This article will review the background information, diagnostic criteria, treatment, and contentious issues related to PANDAS.
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Affiliation(s)
- Sandy Mullen
- (Corresponding author) Clinical Pharmacist, Psychiatry, Clinical Assistant Professor, Pharmacy, Clinical Assistant Professor, Psychiatry, Virginia Commonwealth University Health System, Richmond, Virginia,
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32
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Walker KG, de Vries PJ, Stein DJ, Wilmshurst JM. Sydenham Chorea and PANDAS in South Africa: Review of Evidence and Recommendations for Management in Resource-Poor Countries. J Child Neurol 2015; 30:850-9. [PMID: 25227516 DOI: 10.1177/0883073814544704] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/28/2014] [Indexed: 11/15/2022]
Abstract
In South Africa, and worldwide, rheumatic fever represents a public health problem. Improved diagnosis and management of Sydenham chorea, a major manifestation of acute rheumatic fever is key to prevention of rheumatic heart disease. This article reviews Sydenham chorea from its original description to current opinions. Recommendations are founded on expert opinion as class 1 data is lacking. This South African perspective is relevant to resource-poor settings globally insofar as it provides diagnosis and management recommendations for primary- and secondary-level healthcare professionals who care for patients in such environments. Four basic tenets of care are recommended, namely, elimination of the streptococcal infection, symptomatic treatment, immunological treatment, and nonpharmacologic interventions. A user-friendly outcome measurement tool, viable for use in low-resource settings is presented. Introduction of this tool may lead to increased awareness of the neuropsychiatric manifestations of poststreptococcal movement disorders in Africa, where reports are limited.
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Affiliation(s)
- Kathleen G Walker
- Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa Rheumatic Fever Clinic, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Petrus J de Vries
- Division of Child & Adolescent Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Dan J Stein
- MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Cape Town, Cape Town, South Africa
| | - Jo M Wilmshurst
- Department of Pediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
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33
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Nadeau JM, Jordan C, Selles RR, Wu MS, King MA, Patel PD, Hanks CE, Arnold EB, Lewin AB, Murphy TK, Storch EA. A pilot trial of cognitive-behavioral therapy augmentation of antibiotic treatment in youth with pediatric acute-onset neuropsychiatric syndrome-related obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 2015; 25:337-43. [PMID: 25978743 PMCID: PMC4442557 DOI: 10.1089/cap.2014.0149] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND This study reports an open trial of family-based cognitive-behavioral therapy (CBT) in children and adolescents with obsessive-compulsive disorder (OCD) exhibiting an onset pattern consistent with pediatric acute-onset neuropsychiatric syndrome (PANS). METHODS Eleven primarily Caucasian youth with PANS-related OCD (range=4-14 years; 6 boys) who were incomplete responders to antibiotic treatment, received family-based CBT delivered either face-to-face or via web camera. RESULTS All participants completing treatment (8 of 8) were considered improved at posttreatment, and average obsessive-compulsive symptom severity was reduced by 49%. Significant reductions in obsessive-compulsive symptom severity and in clinician- and parent-rated OCD-related impairment were noted. Reductions in parent- and child-rated anxiety, child-rated OCD-related impairment, and comorbid neuropsychiatric symptoms were not statistically significant. CONCLUSIONS Gains were maintained at follow-up, with 100% (6 of 6) of those assessed remaining improved. Implications for treatment and further research are discussed.
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Affiliation(s)
- Joshua M. Nadeau
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Rogers Behavioral Health, Tampa Bay, Florida
| | - Cary Jordan
- Department of Disability and Psychoeducational Studies, University of Arizona, Tucson, Arizona
| | - Robert R. Selles
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychology, University of South Florida, Tampa, Florida
| | - Monica S. Wu
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychology, University of South Florida, Tampa, Florida
| | - Morgan A. King
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Priyal D. Patel
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Camille E. Hanks
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida
| | - Elysse B. Arnold
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychology, University of South Florida, Tampa, Florida
| | - Adam B. Lewin
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychiatry and Neuroscience, University of South Florida, St. Petersburg, Florida
| | - Tanya K. Murphy
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Department of Psychiatry and Neuroscience, University of South Florida, St. Petersburg, Florida.,All Children's Hospital – Johns Hopkins Medicine, Baltimore, Maryland
| | - Eric A. Storch
- Department of Pediatrics, University of South Florida, St. Petersburg, Florida.,Rogers Behavioral Health, Tampa Bay, Florida.,Department of Psychology, University of South Florida, Tampa, Florida.,Department of Psychiatry and Neuroscience, University of South Florida, St. Petersburg, Florida.,All Children's Hospital – Johns Hopkins Medicine, Baltimore, Maryland
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Martin WJ, Steer AC, Smeesters PR, Keeble J, Inouye M, Carapetis J, Wicks IP. Post-infectious group A streptococcal autoimmune syndromes and the heart. Autoimmun Rev 2015; 14:710-25. [PMID: 25891492 DOI: 10.1016/j.autrev.2015.04.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 04/10/2015] [Indexed: 12/16/2022]
Abstract
There is a pressing need to reduce the high global disease burden of rheumatic heart disease (RHD) and its harbinger, acute rheumatic fever (ARF). ARF is a classical example of an autoimmune syndrome and is of particular immunological interest because it follows a known antecedent infection with group A streptococcus (GAS). However, the poorly understood immunopathology of these post-infectious diseases means that, compared to much progress in other immune-mediated diseases, we still lack useful biomarkers, new therapies or an effective vaccine in ARF and RHD. Here, we summarise recent literature on the complex interaction between GAS and the human host that culminates in ARF and the subsequent development of RHD. We contrast ARF with other post-infectious streptococcal immune syndromes - post-streptococcal glomerulonephritis (PSGN) and the still controversial paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), in order to highlight the potential significance of variations in the host immune response to GAS. We discuss a model for the pathogenesis of ARF and RHD in terms of current immunological concepts and the potential for application of in depth "omics" technologies to these ancient scourges.
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Affiliation(s)
- William John Martin
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia.
| | - Andrew C Steer
- Centre for International Child Health, Department of Pediatrics, University of Melbourne and Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia; Group A Streptococcus Laboratory, Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia
| | - Pierre Robert Smeesters
- Centre for International Child Health, Department of Pediatrics, University of Melbourne and Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia; Group A Streptococcus Laboratory, Murdoch Childrens Research Institute, Parkville, VIC 3052, Australia
| | - Joanne Keeble
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia
| | - Michael Inouye
- Medical Systems Biology, Department of Pathology and Department of Microbiology and Immunology, University of Melbourne, VIC 3010, Australia
| | | | - Ian P Wicks
- Inflammation Division, Water and Eliza Hall Institute of Medical Research, Parkville, VIC 3052, Australia; Department of Medical Biology, University of Melbourne, Parkville, VIC 3052, Australia; Rheumatology Unit, Royal Melbourne Hospital, Parkville, VIC 3052, Australia.
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Swedo SE, Seidlitz J, Kovacevic M, Latimer ME, Hommer R, Lougee L, Grant P. Clinical presentation of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections in research and community settings. J Child Adolesc Psychopharmacol 2015; 25:26-30. [PMID: 25695941 PMCID: PMC4340334 DOI: 10.1089/cap.2014.0073] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The first cases of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) were described >15 years ago. Since that time, the literature has been divided between studies that successfully demonstrate an etiologic relationship between Group A streptococcal (GAS) infections and childhood-onset obsessive-compulsive disorder (OCD), and those that fail to find an association. One possible explanation for the conflicting reports is that the diagnostic criteria proposed for PANDAS are not specific enough to describe a unique and homogeneous cohort of patients. To evaluate the validity of the PANDAS criteria, we compared clinical characteristics of PANDAS patients identified in two community practices with a sample of children meeting full research criteria for PANDAS. METHODS A systematic review of clinical records was used to identify the presence or absence of selected symptoms in children evaluated for PANDAS by physicians in Hinsdale, Illinois (n=52) and Bethesda, Maryland (n=40). RESULTS were compared against data from participants in National Institute of Mental Health (NIMH) research investigations of PANDAS (n=48). RESULTS As described in the original PANDAS cohort, males outnumbered females (95:45) by ∼ 2:1, and symptoms began in early childhood (7.3±2.7 years). Clinical presentations were remarkably similar across sites, with all children reporting acute onset of OCD symptoms and multiple comorbidities, including separation anxiety (86-92%), school issues (75-81%), sleep disruptions (71%), tics (60-65%), urinary symptoms (42-81%), and others. Twenty of the community cases (22%) failed to meet PANDAS criteria because of an absence of documentation of GAS infections. CONCLUSIONS The diagnostic criteria for PANDAS can be used by clinicians to accurately identify patients with common clinical features and shared etiology of symptoms. Although difficulties in documenting an association between GAS infection and symptom onset/exacerbations may preclude a diagnosis of PANDAS in some children with acute-onset OCD, they do appear to meet criteria for pediatric acute-onset neuropsychiatric syndrome (PANS).
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Affiliation(s)
- Susan E. Swedo
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
| | - Jakob Seidlitz
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
| | - Miro Kovacevic
- Loyola University School of Medicine, Department of Pediatrics, Hinsdale, Illinois.,Drs. Kovacevic and Latimer are in private practice in pediatrics and child neurology, respectively
| | - M. Elizabeth Latimer
- Pediatrics and Neurology, Georgetown University School of Medicine, Washington, DC.,Drs. Kovacevic and Latimer are in private practice in pediatrics and child neurology, respectively
| | - Rebecca Hommer
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
| | - Lorraine Lougee
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
| | - Paul Grant
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
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Latimer ME, L'Etoile N, Seidlitz J, Swedo SE. Therapeutic plasma apheresis as a treatment for 35 severely ill children and adolescents with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections. J Child Adolesc Psychopharmacol 2015; 25:70-5. [PMID: 25658452 PMCID: PMC4340509 DOI: 10.1089/cap.2014.0080] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Because of its reported similarities to Sydenham chorea, therapeutic plasma apheresis (TPA) has been proposed as a potential treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). To date, support for the use of TPA has been limited to a few anecdotal reports and a small placebo-controlled trial demonstrating dramatic symptom improvements at 1 month and 1 year follow-up. To evaluate the safety and efficacy of TPA further, we undertook a retrospective review of all PANDAS patients treated with TPA at Georgetown University Hospital between August 2009 and October 2013. METHODS Forty patients were identified, and sufficient information was available from medical records and telephone interview for 35 cases (88%). All 35 (23 boys; 12 girls) met diagnostic criteria for PANDAS (Swedo et al. 1998 ) and had severe symptoms. The TPA procedures were performed at Georgetown University Hospital using a protocol that processes a total of 4.5 blood volumes over 3-5 days (three treatments of 1.5 volumes each). Overall symptom improvements at 6 months post-TPA and long-term follow-up were estimated by parents, who also rated changes in individual symptoms to provide information about patterns of improvement. RESULTS All patients were reported to have received at least some benefit from TPA, with average improvement of 65% at 6 months post-TPA and 78% at longer-term follow-up. A decrease in the number of reported symptoms also occurred, with particular improvements in obsessive-compulsive disorder (OCD), anxiety, tics, and somatic symptoms, including dysgraphia, sleep difficulties, and urinary urgency or frequency. Contrary to expectations, preceding duration of illness was not correlated with degree of improvement following TPA, suggesting that acuity of illness is not a factor affecting response. Only two adverse events were reported: both involved reopening of the site where the central line had been placed and resolved immediately following application of pressure and re-dressing of the puncture site. CONCLUSIONS Therapeutic plasma apheresis is an invasive medical intervention that should be reserved for treatment of children and adolescents who are severely affected by PANDAS. In such patients, it appears to be a safe, well-tolerated, and beneficial treatment option.
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Affiliation(s)
- M. Elizabeth Latimer
- Pediatric Neurology Practice, Washington, DC.,Georgetown University School of Medicine, Washington, DC
| | | | - Jakob Seidlitz
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
| | - Susan E. Swedo
- Pediatrics & Developmental Neuroscience Branch, National Institute of Mental Health, Bethesda Maryland
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Frankovich J, Thienemann M, Pearlstein J, Crable A, Brown K, Chang K. Multidisciplinary clinic dedicated to treating youth with pediatric acute-onset neuropsychiatric syndrome: presenting characteristics of the first 47 consecutive patients. J Child Adolesc Psychopharmacol 2015; 25:38-47. [PMID: 25695943 PMCID: PMC4340335 DOI: 10.1089/cap.2014.0081] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Abrupt, dramatic onset obsessive-compulsive disorder (OCD) and/or eating restriction with at least two coinciding symptoms (anxiety, mood dysregulation, irritability/aggression/oppositionality, behavioral regression, cognitive deterioration, sensory or motor abnormalities, or somatic symptoms) defines pediatric acute-onset neuropsychiatric syndrome (PANS). Descriptions of clinical data in such youth are limited. METHODS We reviewed charts of 53 consecutive patients evaluated in our PANS Clinic; 47 met PANS symptom criteria but not all met the requirement for "acute onset." Patients meeting full criteria for PANS were compared with patients who had a subacute/insidious onset of symptoms. RESULTS Nineteen of 47 (40%) patients in the study had acute onset of symptoms. In these patients, autoimmune/inflammatory diseases and psychiatric disorders were common in first-degree family members (71% and 78%, respectively). Most acute-onset patients had a relapsing/remitting course (84%), prominent sleep disturbances (84%), urinary issues (58%), sensory amplification (66%), gastrointestinal symptoms (42%), and generalized pain (68%). Inflammatory back pain (21%) and other arthritis conditions (28%) were also common. Suicidal and homicidal thoughts and gestures were common (44% and 17%, respectively) as were violent outbursts (61%). Group A streptococcus (GAS) was the most commonly identified infection at onset (21%) and during flares (74%). Rates of the above-mentioned characteristics did not differ between the acute-onset group and the subacute/insidious-onset groups. Low levels of immunoglobulins were more common in the subacute/insidious-onset group (75%) compared with the acute-onset group (22%), but this was not statistically significant (p=0.06). CONCLUSIONS In our PANS clinic, 40% of patients had acute onset of symptoms. However, those with and without acute onset of symptoms had similar symptom presentation, rates of inflammatory conditions, somatic symptoms, and violent thoughts and behaviors. GAS infections were the most commonly identified infection at onset and at symptom flares. Because of the wide variety of medical and psychiatric symptoms, youth with PANS may require a multidisciplinary team for adequate care management.
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Affiliation(s)
- Jennifer Frankovich
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Margo Thienemann
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Jennifer Pearlstein
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Amber Crable
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Kayla Brown
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
| | - Kiki Chang
- Stanford PANS Clinic and Research Program at Lucille Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California
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Williams KA, Swedo SE. Post-infectious autoimmune disorders: Sydenham's chorea, PANDAS and beyond. Brain Res 2014; 1617:144-54. [PMID: 25301689 DOI: 10.1016/j.brainres.2014.09.071] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 12/29/2022]
Abstract
Infections, and the resulting immune response to these infections, have recently received increased recognition as pathogenic mechanisms for neuropsychiatric disorders. Sydenham's chorea (SC), a widely recognized post-streptococcal autoimmune disorder, represents a model for this proposed pathogenesis. In SC, a dysregulated immune response to a streptococcal infection is hypothesized to result in inflammation of neuronal networks, particularly the basal ganglia nuclei. The resulting dysfunction in the basal ganglia nuclei are hypothesized to lead to a constellation of adventitious movements and psychiatric symptoms, which investigations have shown are amenable to immunomodulatory therapies. PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections) has been proposed as a variant of SC, and is hypothesized to share a pathogenic mechanism, despite a unique symptom profile of predominantly psychiatric symptoms. In this review, we present the clinical aspects of both disorders, the data for potential shared etiopathogenesis between them, and the evidence for the therapeutic use of immunomodulatory therapies for the symptoms of SC and PANDAS. This article is part of a Special Issue entitled SI: Neuroimmunology in Health And Disease.
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Affiliation(s)
- Kyle A Williams
- Pediatric Neuropsychiatry and Immunology Clinic, Department of Psychiatry, Massachusetts General Hospital, MA, United States; Department of Psychiatry, Harvard Medical School, MA 02114, United States.
| | - Susan E Swedo
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, National Institutes of Health, MA, United States
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Abstract
Whether some instances of obsessive-compulsive disorder are secondary to infectious and/or autoimmune processes is still under scientific debate. The nosology has undergone an iterative process of criteria and acronyms from PITANDS to PANDAS to PANS (or CANS for neurology). This review focuses on the clinical presentation, assessment, proposed pathophysiology, and treatment of pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS), and the newest iteration, pediatric acute-onset neuropsychiatric syndrome (PANS). Children who have these symptoms, which have become known as PANS, have been described by their parents as "changed children."
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Affiliation(s)
- Tanya K Murphy
- Rothman Center for Pediatric Neuropsychiatry, USF Pediatrics, 880 6th Street South, Suite 460, Box 7523, St Petersburg, FL 33701, USA.
| | - Diana M Gerardi
- Rothman Center for Pediatric Neuropsychiatry, USF Pediatrics, 880 6th Street South, Suite 460, Box 7523, St Petersburg, FL 33701, USA
| | - James F Leckman
- Child Study Center, Yale University School of Medicine, 230 S Frontage Road, New Haven, CT 06520, USA
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Murphy TK, Gerardi DM, Parker-Athill EC. The PANDAS Controversy: Why (and How) Is It Still Unsettled? CURRENT DEVELOPMENTAL DISORDERS REPORTS 2014. [DOI: 10.1007/s40474-014-0025-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Hartmann A. Clinical pharmacology of nondopaminergic drugs in Tourette syndrome. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2014; 112:351-72. [PMID: 24295626 DOI: 10.1016/b978-0-12-411546-0.00011-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Treatment of tics and Gilles de la Tourette syndrome (GTS) by nondopaminergic drugs was initiated more than three decades ago. These approaches were driven by the wish to circumvent antipsychotic-related side effects (metabolic disturbances, parkinsonian syndromes, tardive dyskinesia) or to use these treatments as a valuable add-on therapy in patients at least partially refractory to antipsychotics. In this review, we will therefore discuss the potential value of treating tics with alpha2 receptor agonists, nicotine, tetrabenazine, GABA agonists, botulinum toxin, cannabinoids, and immune modulators (plasmapheresis, intravenous immunoglobulins, antibiotic prophylaxis). Future directions for clinical trials based on our expanding understanding of the pathophysiology of GTS with regard to cholinergic, glutamatergic, and histaminergic neurotransmission will also be briefly outlined.
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Affiliation(s)
- Andreas Hartmann
- Centre de Référence National Maladie Rare: 'Syndrome Gilles de la Tourette', Département de Neurologie, Pôle des Maladies du Système Nerveux, Paris, France; Centre de Recherche de l'Institut du Cerveau et de la Moelle Epinière, UPMC/INSERM UMR_S975; CNRS UMR 7225, Paris, France.
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Esposito S, Bianchini S, Baggi E, Fattizzo M, Rigante D. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: an overview. Eur J Clin Microbiol Infect Dis 2014; 33:2105-9. [PMID: 24953744 DOI: 10.1007/s10096-014-2185-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 06/09/2014] [Indexed: 11/28/2022]
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Freeman J, Sapyta J, Garcia A, Compton S, Khanna M, Flessner C, FitzGerald DP, Mauro C, Dingfelder R, Benito K, Harrison J, Curry J, Foa E, March J, Moore P, Franklin M. Family-based treatment of early childhood obsessive-compulsive disorder: the Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children (POTS Jr)--a randomized clinical trial. JAMA Psychiatry 2014; 71:689-98. [PMID: 24759852 PMCID: PMC4511269 DOI: 10.1001/jamapsychiatry.2014.170] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
IMPORTANCE Cognitive behavior therapy (CBT) has been established as efficacious for obsessive-compulsive disorder (OCD) among older children and adolescents, yet its effect on young children has not been evaluated sufficiently. OBJECTIVE To examine the relative efficacy of family-based CBT (FB-CBT) involving exposure plus response prevention vs an FB relaxation treatment (FB-RT) control condition for children 5 to 8 years of age. DESIGN, SETTING, AND PARTICIPANTS A 14-week randomized clinical trial (Pediatric Obsessive-Compulsive Disorder Treatment Study for Young Children [POTS Jr]) conducted at 3 academic medical centers between 2006 and 2011, involving 127 pediatric outpatients 5 to 8 years of age who received a primary diagnosis of OCD and a Children's Yale-Brown Obsessive Compulsive Scale total score of 16 or higher. INTERVENTIONS Participants were randomly assigned to 14 weeks of (1) FB-CBT, including exposure plus response prevention, or (2) FB-RT. MAIN OUTCOMES AND MEASURES Responder status defined as an independent evaluator-rated Clinical Global Impression-Improvement scale score of 1 (very much improved) or 2 (much improved) and change in independent evaluator-rated continuous Children's Yale-Brown Obsessive Compulsive Scale total score. RESULTS Family-based CBT was superior to FB-RT on both primary outcome measures. The percentages of children who were rated as 1 (very much improved) or 2 (much improved) on the Clinical Global Impression-Improvement scale at 14 weeks were 72% for FB-CBT and 41% for FB-RT. The effect size difference between FB-CBT and FB-RT on the Clinical Global Impression-Improvement scale was 0.31 (95% CI, 0.17-0.45). The number needed to treat (NNT) with FB-CBT vs FB-RT was estimated as 3.2 (95% CI, 2.2-5.8). The effect size difference between FB-CBT and FB-RT on the Children's Yale-Brown Obsessive Compulsive Scale at week 14 was 0.84 (95% CI, 0.62-1.06). CONCLUSIONS AND RELEVANCE A comprehensive FB-CBT program was superior to a relaxation program with a similar format in reducing OCD symptoms and functional impairment in young children (5-8 years of age) with OCD. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00533806.
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Affiliation(s)
- Jennifer Freeman
- Alpert Medical School of Brown University; Bradley-Hasbro Children’s Research Center
| | | | - Abbe Garcia
- Alpert Medical School of Brown University; Bradley-Hasbro Children’s Research Center
| | | | | | - Chris Flessner
- Alpert Medical School of Brown University; Bradley-Hasbro Children’s Research Center
| | | | | | | | - Kristen Benito
- Alpert Medical School of Brown University; Bradley-Hasbro Children’s Research Center
| | | | | | - Edna Foa
- University of Pennsylvania School of Medicine
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Thomsen PH, Torp NC, Dahl K, Christensen K, Englyst I, Melin KH, Nissen JB, Hybel KA, Valderhaug R, Weidle B, Skarphedinsson G, von Bahr PL, Ivarsson T. The Nordic long-term OCD treatment study (NordLOTS): rationale, design, and methods. Child Adolesc Psychiatry Ment Health 2013; 7:41. [PMID: 24354717 PMCID: PMC3878347 DOI: 10.1186/1753-2000-7-41] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 12/11/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This paper describes and discusses the methodology of the Nordic long-term OCD-treatment study (NordLOTS). The purpose of this effectiveness study was to study treatment outcome of CBT, to identify CBT non- or partial responders and to investigate whether an increased number of CBT-sessions or sertraline treatment gives the best outcome; to identify treatment refractory patients and to investigate the outcome of aripiprazole augmentation; to study the outcome over a three year period for each responder including the risk of relapse, and finally to study predictors, moderators and mediators of treatment response. METHODS Step 1 was an open and uncontrolled clinical trial with CBT, step 2 was a controlled, randomised non-blinded study of CBT non-responders from step 1. Patients were randomized to receive either sertraline plus CBT-support or continued and modified CBT. In step 3 patients who did not respond to either CBT or sertraline were treated with aripiprazole augmentation to sertraline. CONCLUSIONS This multicenter trial covering three Scandinavian countries is going to be the largest CBT-study for paediatric OCD to date. It is not funded by industry and tries in the short and long-term to answer the question whether further CBT or SSRI is better in CBT non-responders.
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Affiliation(s)
- Per Hove Thomsen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Risskov, Risskov, Denmark.
| | - Nor C Torp
- Centre for Child and Adolescent Mental Health, Eastern and Southern Norway (R-BUP), Oslo, Norway
| | - Kitty Dahl
- Centre for Child and Adolescent Mental Health, Eastern and Southern Norway (R-BUP), Oslo, Norway
| | - Karin Christensen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Risskov, Risskov, Denmark
| | - Inger Englyst
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Risskov, Risskov, Denmark
| | - Karin H Melin
- Department of Child and Adolescent Psychiatry, Queen Silvia’s Children’s Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Judith B Nissen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Risskov, Risskov, Denmark
| | - Katja A Hybel
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital Risskov, Risskov, Denmark
| | - Robert Valderhaug
- Regional Centre for Child and Youth Mental Health and Child Welfare, Central Norway, Klostergata 46, 3rd floor, Trondheim 4391, Norway
| | - Bernhard Weidle
- St. Olavs Hospital, BUP Klinik, Klostergate 44/46, Trondheim, Norway
| | - Gudmundur Skarphedinsson
- Centre for Child and Adolescent Mental Health, Eastern and Southern Norway (R-BUP), Oslo, Norway
| | | | - Tord Ivarsson
- Centre for Child and Adolescent Mental Health, Eastern and Southern Norway (R-BUP), Oslo, Norway
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Macerollo A, Martino D. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): An Evolving Concept. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2013; 3. [PMID: 24106651 PMCID: PMC3783973 DOI: 10.7916/d8zc81m1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 07/13/2013] [Indexed: 12/14/2022]
Abstract
Pediatric autoimmune neuropsychiatric disorders associated with streptococcus infections (PANDAS) originated from the observational work of Swedo and collaborators, who formalized their definition in 1998 in a set of operational criteria. The application of these criteria, which focuses on tics and obsessive-compulsive symptoms as core symptoms, has encountered difficulties, eventually leading to a high rate of misdiagnosis. In particular, the core feature represented by the association between newly diagnosed infections and neuropsychiatric symptom relapses in youths with this diagnosis could not be demonstrated by longitudinal studies. Exploratory studies aiming to identify clinical or cognitive features that could discriminate PANDAS from other pediatric obsessive-compulsive and tic disorders present methodological limitations, and therefore are not conclusive. Other behavioral features, in addition to obsessive-compulsive symptoms and tics, have been included in pediatric acute-onset neuropsychiatric syndromes (PANS) and childhood acute neuropsychiatric syndromes (CANS), two new concepts recently proposed in order to define a much broader clinical spectrum encompassing etiologically diverse entities. Given the uncertainties on the clinical definition of PANDAS, it is not surprising that evidence in support of a post-infectious, immune-mediated pathophysiology is also insufficient. Anti-dopamine receptor antibodies might be relevant to both Sydenham's chorea (SC)-the prototypical post-streptococcal neuropsychiatric disorder-and some rare forms of encephalitis targeting the basal ganglia specifically, but studies exploring their association with children fulfilling Swedo's criteria for PANDAS have been inconclusive. Moreover, we lack evidence in favor of the efficacy of antibiotic prophylaxis or tonsillectomy in patients fulfilling Swedo's criteria for PANDAS, whereas a response to immune-mediated treatments like intravenous immunoglobulins has been documented by one study, but needs replication in larger trials. Overall, the available evidence does not convincingly support the concept that PANDAS are a well-defined, isolated clinical entity subdued by definite pathophysiological mechanisms; larger, prospective studies are necessary to reshape the nosography and disease mechanisms of post-streptococcal acute neuropsychiatric disorders other than SC. Research is also under way to shed further light on a possible relationship between streptococcal infections, other biological and psychosocial stressors, and the complex pathobiology of chronic tic disorders.
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Affiliation(s)
- Antonella Macerollo
- Sobell Department of Motor Neuroscience and Movement Disorders, National Hospital of Neurology and Neurosurgery, Institute of Neurology, University College London, London, United Kingdom
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Hoekstra PJ, Dietrich A, Edwards MJ, Elamin I, Martino D. Environmental factors in Tourette syndrome. Neurosci Biobehav Rev 2013; 37:1040-9. [DOI: 10.1016/j.neubiorev.2012.10.010] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Revised: 10/08/2012] [Accepted: 10/15/2012] [Indexed: 01/29/2023]
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Abstract
OBJECTIVE This study aimed to improve understanding and treatment of psychiatric symptoms in antiphospholipid syndrome (APS) and to present an approach to the medical management of patients presenting with obsessive-compulsive disorder (OCD) with suspected neurovascular pathology. METHOD A 15-year-old boy presented with severe OCD of recent onset. An infarct of the caudate nucleus was identified as the initial presentation of primary APS. This case report includes a selective literature review of the neuropsychiatric correlates of APS. RESULTS The patient had OCD for 3 months with increasing symptoms resulting in admission for psychiatric reasons. After referral to the emergency department 3 weeks later, an infarct of the caudate nucleus was documented using magnetic resonance images of the brain, and APS was diagnosed based on additional laboratory findings. Anticoagulant treatment (enoxaparin and phenprocoumon) in this patient was effective in reducing obsessive-compulsive symptom severity. CONCLUSION OCD may present as a neuropsychiatric manifestation of APS. The present observations are consistent with a thrombotic mechanism for neurologic or psychiatric symptoms in APS. In general, routine medical workup for childhood OCD is not indicated, but a comprehensive psychiatric, medical, and family history taking and physical examination are essential, particularly if OCD is of recent onset. The role of anticoagulant therapy in neuropsychiatric manifestations of APS without the presence of a cerebral infarct requires further research.
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Dale RC. Immune-mediated extrapyramidal movement disorders, including Sydenham chorea. HANDBOOK OF CLINICAL NEUROLOGY 2013; 112:1235-41. [DOI: 10.1016/b978-0-444-52910-7.00046-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Abstract
The basal ganglia are deep nuclei in the brain that include the caudate, putamen, globus pallidus, and substantia nigra. Pathological processes involving the basal ganglia often result in disorders of movement and behavior. A number of different autoimmune disorders predominantly involve the basal ganglia and can result in movement and psychiatric disorders. The classic basal ganglia autoimmune disorder is Sydenham chorea, a poststreptococcal neuropsychiatric disorder. Resurgence in the interest in Sydenham chorea is the result of the descriptions of other poststreptococcal neuropsychiatric disorders including tics and obsessive-compulsive disorder, broadly termed pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection. Encephalitic processes affecting the basal ganglia are also described including the syndromes basal ganglia encephalitis, encephalitis lethargica, and bilateral striatal necrosis. Last, systemic autoimmune disorders such as systemic lupus erythematosus and antiphospholipid syndrome can result in chorea or parkinsonism. Using paradigms learned from other autoantibody associated disorders, the authors discuss the autoantibody hypothesis and the role of systemic inflammation in autoimmune basal ganglia disorders. Identification of these entities is important as the clinician has an increasing therapeutic repertoire to modulate or suppress the aberrant immune system.
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Affiliation(s)
- Russell C Dale
- Neuroimmunology Group, Institute for Neuroscience and Muscle Research, Children's Hospital at Westmead, University of Sydney, Sydney, Australia.
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Freeman J, Garcia A, Benito K, Conelea C, Sapyta J, Khanna M, March J, Franklin M. The Pediatric Obsessive Compulsive Disorder Treatment Study for Young Children (POTS jr): Developmental Considerations in the Rationale, Design, and Methods. J Obsessive Compuls Relat Disord 2012; 1:294-300. [PMID: 23181244 PMCID: PMC3501965 DOI: 10.1016/j.jocrd.2012.07.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This paper presents the rationale, design, and methods of the Pediatric Obsessive Compulsive Disorder (OCD) Treatment Study for young children (POTS Jr). The study is a multi-site randomized controlled trial (RCT) of family-based Cognitive Behavioral Treatment (CBT) vs. family-based Relaxation Therapy (RT) for young children (ages 5-8) with OCD, which examines the effect of treatment on symptom reduction, functional impairment, and quality of life. Secondary aims evaluate: potential moderators and mediators of treatment response, differences in time course of response, retention rates, and maintenance of treatment gains over one year post-treatment. The sample included 127 children (53% female) and their parents. With regard to ethnicity, 89% of the sample described themselves as non-Hispanic, 5% Hispanic/Latino, and 6% did not endorse a category. In terms of race, the sample was predominantly (91%) White. Because the rationale and methods of the multi-site RCT have been well established, we emphasize here the methodological aspects of the study that were tailored to meet the developmental needs of young children with OCD. Aspects that are highlighted include: choice of control group, inclusion/exclusion criteria, assessment/measurement issues, treatment adaptations, training, and recruitment.
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Affiliation(s)
- Jennifer Freeman
- Alpert Medical School of Brown University, Bradley/Hasbro Children’s Research Center, CORO West Building, Suite 204, 1 Hoppin St., Providence, RI, 02903, USA
| | - Abbe Garcia
- Alpert Medical School of Brown University, Bradley/Hasbro Children’s Research Center, CORO West Building, Suite 204, 1 Hoppin St., Providence, RI, 02903, USA
| | - Kristen Benito
- Alpert Medical School of Brown University, Bradley/Hasbro Children’s Research Center, CORO West Building, Suite 204, 1 Hoppin St., Providence, RI, 02903, USA
| | - Christine Conelea
- Alpert Medical School of Brown University, Bradley/Hasbro Children’s Research Center, CORO West Building, Suite 204, 1 Hoppin St., Providence, RI, 02903, USA
| | - Jeffrey Sapyta
- Duke University School of Medicine, Duke Child and Family Study Center, 2608 Erwin Road, Suite 300, Durham, NC, 27705, USA
| | - Muniya Khanna
- University of Pennsylvania School of Medicine, Child & Adolescent OCD, Tic, Trich & Anxiety Group, University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA
| | - John March
- Duke University School of Medicine, Duke Child and Family Study Center, 2608 Erwin Road, Suite 300, Durham, NC, 27705, USA
| | - Martin Franklin
- University of Pennsylvania School of Medicine, Child & Adolescent OCD, Tic, Trich & Anxiety Group, University of Pennsylvania, 3535 Market Street, Suite 600, Philadelphia, PA 19104, USA
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