More threads by Daniel E.

Daniel E.
Can Strep Bring On an Anxiety Disorder?

New York Times
Published: December 14, 2004

Looking back, Denise Watkins is convinced a sore throat disabled her son one year ago. His bizarre obsessions emerged not long after, first the constant nightmares about snakes and alligators, then the relentless hand washing that left his skin raw and chapped.

Mrs. Watkins, who lives in Lakeland, Fla., was told that her son, Will, had obsessive-compulsive disorder. But it seemed odd, Ms. Watkins thought. Will was only 5 years old, and his illness seemed to burst out of nowhere.

"In a matter of weeks," she said, "this was a totally different child."

Then one day, buried on a Web site about mental illness, her husband noticed a small "blip" on children who develop a sudden, severe form of obsessive-compulsive disorder after a bout of strep throat.

Mrs. Watkins read the description, decided that Will fit the pattern, and thus became part of a small but growing number of parents who blame a common bacterial infection for the psychiatric illness of a son or daughter.

About one child in 1,000 may be afflicted, but some experts say the number is higher if milder cases that escape notice are included. The condition is known as Pandas, or pediatric autoimmune neuropsychiatric disorder associated with streptococcal infection, and scientists know so little about it that some question whether it even exists.

Frustrated parents, many of whom describe watching helplessly as their children unravel overnight, are waiting on a handful of studies now under way to yield some answers. Meanwhile, many have sought out drugs and complicated medical procedures that may be unnecessary, and in some cases dangerous.

"With Pandas you get a very desperate situation," said Dr. Tanya Murphy, director of the child anxiety and tic disorder clinic at the University of Florida. "It's amazing how quickly the kids go from functioning pretty well to being devastated with motor tics and symptoms of O.C.D. Then you see parents wanting to do anything to get their kids back to the way they used to be. I can understand where they're coming from."

There are no nationwide statistics on how many children may have the disorder. But Dr. Murphy said that in the last three years, in Florida alone, she had enrolled in her studies at least 100 children who fit the pattern.

"I'm also aware of at least three times that many children from phone calls and parents of clinic patients who do not want their children enrolled in research," she added.

First described by scientists at the National Institutes of Health in the mid-1990's, Pandas is still relatively new. There is no surefire way to detect it, and few doctors have even heard of it. But the signs are often unmistakable.

Children, sometimes as young as 2 or 3, develop odd verbal and motor tics. They feel compelled to engage in repetitive behaviors. They develop irrational fears of germs, bugs, intruders, almost everything around them. Separation anxiety is another hallmark. Even getting them to perform routine activities like going to school becomes a struggle. Many of the symptoms - ritualistic behaviors and disturbing thoughts, for example - mirror those of obsessive-compulsive disorder.

But unlike O.C.D., Pandas crops up almost overnight, its onset coinciding with a streptococcus infection or immediately after it. And the symptoms wax and wane. They flare up, anecdotal evidence suggests, whenever the child has contracted a new strep infection, leading some scientists to suspect a causal link.

"This is not what we're used to seeing," said Dr. Paul Lombroso, a professor of child psychiatry at the Yale Child Study Center who is also involved in studies of the disorder. "Normally, the onset of a tic disorder is a much more slow, insidious process."

Dr. Susan Swedo, a researcher at the National Institute of Mental Health who first described Pandas, believes the disorder is caused by a severe immune reaction that leads to brain damage. The mechanism may be similar to what is seen in some other diseases. In rheumatic fever, for example, antibodies produced against an untreated strep infection mistakenly attack the heart valves.

Dr. Swedo, after finding that children with Pandas had abnormally high levels of antibodies, theorized that their immune systems had also gone haywire. In this case, she suspects, it is the basal ganglia, a clump of nerve clusters in the brain that helps sequence movements, that is damaged.

"The hypothesis is that there is a similarity between proteins found in strep bacteria and proteins in the brain," said Dr. James Leckman, a professor of child psychiatry at the Yale Child Study Center.

At least two recent studies have shown that antibiotics can reduce symptoms. Only small samples of children were involved, however, and the studies were not long term. For some researchers, that is not enough evidence to conclude that a strep infection can set off brain damage or that children thought to have Pandas should be given antibiotics. Strep infections are so widespread, they argue, that a child who develops tics and obsessive-compulsive behaviors might also test positive for the bacteria purely by chance.

Dr. Roger Kurlan, a neurologist at the University of Rochester School of Medicine and Dentistry, said in some parts of the country up to half the students in any given grade school will test positive for strep, depending on the time of the year. He believes that in most children with a tic disorder, like Tourette's syndrome, strep infections may be just one of thousands of things that can provoke symptoms without actually causing the underlying illness.

"It's been known forever that almost anything can act as a trigger - a viral infection, a death in the family, allergies, anything that causes anxiety," he said. "The question now is whether an infection with strep is just another one of these nonspecific triggers."

The answer may have farreaching effects. Studies show that antibiotics are widely overused, and some experts worry that doctors are prescribing the drugs for children with tics or obsessive-compulsive disorder who do not need them.

Other doctors and parents may be going to greater lengths. Dr. Kurlan said some children had been treated with costly medical procedures that could have serious side effects. One is plasma exchange, a modern form of bloodletting. The technique involves removing a patient's blood and purging it of antibodies. In some cases it can lead to infection and blood clots.

"It's expensive and potentially dangerous," he said. "I know some parents have asked for it. Most doctors who know the facts will not use plasma exchange, but there are places in the country that have made it available to parents."

Experts say that cognitive behavioral therapy may be one helpful option. There is no solid evidence backing any drug treatments, but several large-scale studies could soon change that. Dr. Murphy and scientists at the National Institutes of Health are following dozens of children thought to have Pandas to determine whether antibiotics can prevent symptoms from flaring. One group will receive penicillin, the other a placebo. Dr. Murphy expects to have the answer early next year.

Other studies, at multiple sites, are following children month by month with tests for antibodies and strep to determine how tightly infections and symptoms are linked, if at all. Dr. Kurlan, who is leading one of the studies, said results might be ready by next summer.

In the meantime, parents like Mrs. Watkins wait. Mrs. Watkins said her son's most destructive symptoms - the hand washing, separation anxiety and night terrors - slowly disappeared when he began taking antibiotics for his sore throat a year ago. He often repeats his sentences now and displays tics and quirky behaviors. Mrs. Watkins enrolled him in the penicillin study at Florida, which he is scheduled to begin this month.

"I really hope he's not in the placebo group," she said.


Related Link:
Official P.A.N.D.A.S Web Page - NIMH
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