Streptococcal Infection and Obsessive Compulsive Disorders
A personal experience with the condition known as PANDAS (https://www.nimh.nih.gov/health/publications/pandas/index.shtml)
For most preschoolers, going to the doctor’s office meant a general check-up, the occasional “I don’t want a shot” tantrum, and a few free stickers and a lollipop after the visit. When I went to the doctor’s office in preschool, it usually meant throat cultures, blood draws and another antibiotic prescription. At around age 4, I began contracting strep throat at least twice per year even with minimal exposure.. When I contracted my first streptococcal infection, I presented with normal symptoms--sore/irritated throat, nausea, and a fever. However, as I continued to contract this bacterial infection repeatedly, I began to show uncommon strep symptoms that presented more like the common cold. Due to this, it became increasingly difficult for my parents and caretakers to recognize the infection. It was perplexing for my family and doctors. They monitored my symptoms closely each time I became sick and I was tested multiple times to determine if I was a carrier for the streptococcal bacteria. However, even with the close monitoring of infections I developed, it was sometimes impossible to tell.
When I was 6 years-old, almost through my kindergarten year, I began presenting with somewhat strep-like symptoms. It was very well known in my family that a sore throat was not an anomaly for me and my parents waited, as they were instructed, to see if I developed further symptoms. To this day, I remember waking up suddenly in the early morning panicked and delirious from a terrifying fever dream. My parents rushed me to my pediatrician’s office with an 104 degree fever, nausea and an off-putting rash. They quickly determined that I had contracted strep and that I had developed scarlet fever because I had not been treated. After a month of illness and doctor’s office visits, I began to recover and was able to return to school for a few weeks before the start of summer.
Over the summer, my parents did not notice any lingering symptoms (likely due to my comfort level at home with them) but when I started first grade, I seemed to have developed a bit of a personality shift. My once outgoing, brave personality had become more nervous and I seemed more attached to being with my mom and dad at all times. Because this behavior is so typical of a young child, they were concerned but did not consider anything drastic. However, over the summer, after 1st grade, my nervousness seemed to worsen and at the beginning of 2nd grade, I began to have full-blown panic attacks, separation anxiety, tics and fears of even leaving my house due to an odd fear of being attacked by a wild animal in my front-yard. My parents took me to a psychiatrist who diagnosed me with Obsessive Compulsive Disorder.
Though anxiety disorders are not necessarily curable, my family made sure that from a young age, I received the proper treatments and developed proper tools to live a happy, fulfilling life with this disorder--but they were still perplexed by how their outgoing, brave, totally anxiety free child had changed so drastically and so quickly. When they learned about the phenomena of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) they felt that ( though there are some arguments that OCD is not developed solely due to streptococcus infection) this is what had happened to me.
PANDAS is a disorder that has been observed in children who develop OCD/anxiety disorder-like behaviors with a sudden onset after streptococcal infection. Though OCD like behaviors don’t completely go away, it is common, especially in children with this disorder, to have anxietal episodes when they are infected with strep.
The disorder is not believed to be directly caused by the infection but more so the body’s immune response to the infection. Strep bacteria functions by hiding from its’ host for as long as possible. It mimics nearby molecules such as those found on a child’s heart, joints, skin and brain. Because the body’s immune system does not immediately recognize these cells as out of the ordinary, there isn’t an immediate immune response. Once the bacteria is recognized, antibodies are produced. However, due to the mimicry of other molecules, the antibodies attack molecules that are and aren’t strep.
It is believed that because the strep virus mimics molecules in the brain, that the antibodies cross a barrier that normally functions to protect the brain from what is circulating in the human bloodstream. Once the antibodies have crossed this barrier, they inflame the basal ganglia which controls motor movements like handwriting, thinking, emotion, and learning routine behaviors or habits. The basal ganglia is currently suspected to play a role in the Obsessive Compulsive Disorder. However, though there has been multiple cases of children with chronic strep developing OCD like symptoms there is also a lot of controversy surrounding PANDAS.1,2
The term was coined by Doctor Susan Swedo in 1998. Swedo studied pediatric OCD and knew that the streptococcus bacteria can cause complications in the heart, brain and kidneys. She noticed a pattern in children having a sudden onset of OCD symptoms, specifically tic disorders, after bouts of strep throat. However, doctor’s such as Stanford Shulman, an infectious disease specialist at Lurie Children’s Hospital, somewhat disagreed with the diagnosis. He stated that: “What’s unclear is whether there are any specific infectious triggers that are responsible for that — either strep or some other kinds of infections.”5
Since this time, there are many doctors who fully believe there is a relationship between the sudden onset of OCD and many that believe there is not enough scientific evidence to make a clinical diagnosis--though no one denies the obvious correlation between the two. There is a PANDAS network of parents who have watched their children deal with multiple strep infections causing the disease are advocates for making it a clinical diagnosis and having more funded research on the subject. The international OCD Foundation has also supported the idea that there is, in fact, the scientific evidence to at least warn families of the streptococcal infections affect on the brain. They discuss taking handwriting samples from children before infection, after the development of PANDAS, and post-treatment. 4 They believe this is due to the studied swelling of the basal ganglia and how it affects fine motor skills (I personally had the experience of losing my handwriting skills and have difficulty improving my handwriting skills--but I am unsure if it is related.)
Though there is still debate on why the streptococcal infection may be causing sudden onset of OCD in children, it is beginning to be the general consensus that treatment for these early OCD symptoms should not just be meetings with a psychiatrist/psychologist but should also include more antibiotics, plasma exchange or immunoglobulin treatment used to treat any underlying infection and immune response. Dr. Kyle Williams, the director of pediatric neuropsychiatry and immunology at Massachusetts General Hospital stated that “We don’t have a biomarker or an identifying antibody that we can use to separate this population out yet. We think we’re beginning to identify one.” Williams and coauthors also found that an antibody found in children with PANDAS binds to specific neurons that are found basal ganglia of mice. These neurons have also shown abnormalities in adults with Tourette syndrome which the doctors think may be closely related to the tic disorder that develops in the children with OCD.3
It is difficult, even for me, to know if the streptococcal virus is what caused my sudden onset of this anxiety disorder. Because of the early onset, there could be other factors at play. Children may be developing more extreme anxiety symptoms that were underlying due to the continuous development of their brains and awareness of their surroundings. Many children get strep throat so it could be that the two are unrelated and the age of OCD onset is just in early childhood when strep throat is common in kids.
However, not only my parents, but I remember the extreme neurological change I experienced after developing scarlet fever. The panic attacks are some of my most vivid early childhood experiences because I had never experienced fear that way prior. I had no symptoms of anxiety, OCD, or tics leading up to the sudden change in personality. Though I was lucky enough to have a family that got me the help I needed as a child, the research doctors, psychologists and others are doing on this topic intrigues me. If there is a direct correlation, it would not only be helpful for those who have dealt with it to understand, but it will help children currently suffering find an optimal treatment and avoid years of panic and confusion due to sudden anxiety.
Nimh.nih.gov. NIMH » PANDAS—Questions and Answers. [online]
https://www.nimh.nih.gov/health/publications/pandas/index.shtml [Accessed 12 Dec. 2018].
Vogel, L. Growing consensus on link between strep and obsessive–compulsive disorder. NCBI.
April 17th, 2015
Quandt, K. PANDAS: A Rare Disease? Or Not a Disease at All?. [online] Undark.
March 22, 2017
https://undark.org/article/doctors-divide-on-pandas/ [Accessed 12 Dec. 2018].
Szymanski, J. Can an infection suddenly cause OCD? - Harvard Health Blog. [online] Harvard Health Blog.
July 27, 2012
https://www.health.harvard.edu/blog/can-an-infection-suddenly-cause-ocd-201202274417 [Accessed 12 Dec. 2018].
Antonella Macerollo, D. Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS): An Evolving Concept. [online] PubMed Central (PMC).
September 25, 2013
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783973/ [Accessed 12 Dec. 2018].