Fwd: Possible causes of sudden onset obsessive compulsive disorder in kids broadened

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> Children with PANS and PANDAS sometimes experience sudden loss of fine motor

skills. Source: Swedo, M.D., NIMH Pediatric and Developmental Neuroscience

Branch

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> Criteria for a broadened syndrome of acute onset obsessive compulsive disorder

(OCD) have been proposed by a National Institutes of Health scientist and her

colleagues. The syndrome, Pediatric Acute-onset Neuropsychiatric Syndrome

(PANS), includes children and teens that suddenly develop on-again/off-again OCD

symptoms or abnormal eating behaviors, along with other psychiatric symptoms

without any known cause.

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> PANS expands on Pediatric Autoimmune Neuropsychiatric Disorder Associated with

Streptococcus (PANDAS), which is limited to a subset of cases traceable to an

autoimmune process triggered by a strep infection. A clinical trial testing an

immune-based treatment for PANDAS is currently underway at NIH and Yale

University (see below).

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> " Parents will describe children with PANS as overcome by a 'ferocious' onset

of obsessive thoughts, compulsive rituals and overwhelming fears, " said

Swedo, M.D., of the NIH’s National Institute of Mental Health (NIMH), who first

characterized PANDAS two decades ago. “Clinicians should consider PANS when

children or adolescents present with such acute-onset of OCD or eating

restrictions in the absence of a clear link to strep.”

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> Swedo, Leckman, M.D., of Yale University, and Noel Rose, M.D., Ph.D. of

s Hopkins University, propose working criteria for PANS in February 2012 in

the open source journal Pediatrics & Therapeutics.

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> " As the field moves toward agreement on this broadened syndrome, affected

youth will be more likely to receive appropriate care, regardless of whether

they are seen by a neurologist, pediatrician or child psychiatrist, " said NIMH

Director R. Insel, M.D.

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> Differing causes sharing a " common presentation " The PANS criteria grew out of

a PANDAS workshop convened at NIH in July 2010, by the NIMH Pediatric and

Developmental Neuroscience Branch, which Swedo heads. It brought together a

broad range of researchers, clinicians and advocates. The participants

considered all cases of acute-onset OCD, regardless of potential cause.

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> Clinicians reported that evaluations of more than 400 youth diagnosed with

PANDAS confirmed that affected boys outnumbered girls 2:1, with psychiatric

symptoms, always including OCD, usually beginning before 8 years.

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> Although debate continues about the fine points, the field is now of one mind

on the core concept of " acute and dramatic " onset of a constellation of

psychiatric symptoms. There is also broad agreement on the need for a

" centralized registry " that will enable the research community to analyze

evidence from studies that will eventually pinpoint causes and treatments. Such

a registry is currently under development by members of the International

Obsessive Compulsive Foundation (IOCDF).

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> Since a diagnosis of PANS implies no specific cause, clinicians will have to

evaluate and treat each affected youth on a case-by-case basis.

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> " PANS will likely turn out to include a number of related disorders with

different causes that share a common presentation, " explained Swedo.

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> The authors propose that a patient must meet 3 diagnostic criteria for a

diagnosis of PANS:

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> 1. Abrupt, dramatic onset of OCD or anorexia.

> 2. Concurrent presence of at least two additional neuropsychiatric symptoms

with similarly severe and acute onset. These include: anxiety; mood swings and

depression; aggression, irritability and oppositional behaviors; developmental

regression; sudden deterioration in school performance or learning abilities;

sensory and motor abnormalities; somatic signs and symptoms.

> 3. Symptoms are unexplainable by a known neurologic or medical disorder.

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> Among the wide range of accompanying symptoms, children may appear terror

stricken or suffer extreme separation anxiety, shift from laughter to tears for

no apparent reason, or regress to temper tantrums, baby talk or bedwetting. In

some cases, their handwriting and other fine motor skills worsen dramatically.

Leckman's team at the Yale Child Study Center is in the process of developing

assessment tools for diagnosing the syndrome.

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> PANDAS treatment study targets errant antibodies

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> Meanwhile, Swedo, Leckman, and Madeleine Cunningham of the University of

Oklahoma, and colleagues, are collaborating on a new, multi-site

placebo-controlled study, testing the effectiveness of intravenous

immunoglobulin (IVIG) for reducing OCD symptoms in children with PANDAS.

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> Previous human and animal research suggested mechanisms by which

strep-triggered antibodies mistakenly attack specific brain circuitry, resulting

in obsessional thoughts and compulsive behaviors.

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> " Strep bacteria has evolved a kind of camouflage to evade detection by the

immune system, " Swedo explained. " It does this by displaying molecules on its

cell wall that look nearly identical to molecules found in different tissues of

the body, including the brain. Eventually, the immune system gets wise to this

'molecular mimicry,' recognizes strep as foreign, and produces antibodies

against it; but because of the similarities, the antibodies sometimes react not

only with the strep, but also with the mimicked molecules in the human host.

Such cross-reactive ‘anti-brain’ antibodies can cause OCD, tics, and the other

neuropsychiatric symptoms of PANDAS. "

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> IVIG, a medication derived from normal antibodies, neutralizes such harmful

antibodies, restoring normal immune function. It is used to treat other

autoimmune illnesses and showed promise in a pilot study with PANDAS patients.

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> " We predict that IVIG will have striking benefits for OCD and other

psychiatric symptoms, and will prove most effective for children who show high

levels of anti-brain antibodies when they enter the study, " said Swedo.

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> Prospective study participants are first screened by phone by investigators at

the NIH or the Yale Child Study Center. Those who meet eligibility requirements

are then randomized to receive either active IVIG or a placebo procedure during

a brief inpatient stay at the NIH Clinical Center. The researchers remain blind

to which children received the active medication; after 6 weeks of placebo

control, they give any children whose symptoms fail to improve the option to

receive open-label active treatment.

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> In addition to assaying for antibodies that attack brain cells, the

researchers use magnetic resonance imaging to see if the treatment reduces

inflammation in an area of the brain known as the basal ganglia, which is

thought to be the target of the errant antibodies. They also analyze levels of

immune system chemical messengers (cytokines) in cerebrospinal fluid and blood

with an eye to identifying biomarkers of disease activity and potential

predictors of treatment response.

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> The study was launched with support from the NIH Clinical Center's Bench to

Bedside program, which encourages such intramural-extramural collaborations in

translational science.

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> Provided by National Institutes of Health

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> Source:

http://medicalxpress.com/news/2012-03-sudden-onset-obsessive-compulsive-disorder\

..html

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