OCD/PANDAS and PANS Flashcards
What is the main diagnostic criteria for obsessions?
▪️Recurrent and persistent thoughts/impulses/images
▪️Cause marked anxiety or distress
▪️Not simply excessive worries about real-life problems
▪️Attempts to suppress
▪️Recognises their a product of their own mind
What are the four components of the OCD cycle?
▪️Obsession
▪️Anxiety
▪️Compulsion
▪️Temporary relief
Gets stronger with time!
How common is OCD?
1-3%
What is the main demographic of OCD?
Two peaks:
▪️Childhood/adolescence - more males, symmetry and checking
▪️20-29 - more females, washing
What are the four main types of OCD?
▪️Contamination/washing (more common in older & religious groups
▪️Obsessions/checking
▪️Hoarding/saving
▪️Symmetry/order
What are the most common obsessional symptoms?
▪️Aggression
▪️Contamination
▪️Symmetry
▪️Somatic
What are the most common compulsive symptoms?
▪️Checking
▪️Cleaning
▪️Repeating
What psychiatric condition occurs lost commonly with OCD?
Depression (50-60%)
What evidence points towards a biological model of OCD?
▪️Familial prevalence
▪️Response to serotonergic drugs
▪️OCD symptoms in neurological conditions (e.g. Sydenham’s chorea)
▪️Acquired symptoms after BI
▪️Hyperactivity in front-subcortical circuits
▪️PANS/PANDAS
What has been found with twin studies of OCD?
▪️Highly genetic, particularly in children (45-65%)
▪️Unique environmental effects are equally important (e.g. trauma)
, ▪️Shared environmental effects are negligible
What targets for candidate genes have been proposed for the genetic basis of OCD?
▪️Serotonin
▪️Glutamate
▪️Dopamine
▪️GABA
▪️Neurodevelopmental factors (e.g. BDNF)
▪️Peptides (e.g. oxytocin
▪️SAPAP3
What environmental factors may contribute to the development of the OCD?
▪️Perinatal insults
▪️Childhood stressors
▪️Autoimmune factors (e.g. streptococcal infection)?
Do different subtypes of OCD have distinct neural correlates?
Yes!
Which brain regions have been implicated in OCD?
Frontostriarothalamic circuits implicated in cognitive and emotional processing
▪️VMPFC
▪️OFC
▪️Caudate nucleus
▪️Putamen/GP/thalamus
▪️Precentral gyrus
Can brain abnormalities seen in OCD be reversed with treatment?
Yes!
What do the NICE guidelines for treatment of OCD with mild functional impairment in children?
▪️Self help support
▪️Information for family
What do the NICE guidelines for treatment of OCD with moderate/severe functional impairment in children?
▪️CBT
▪️ERP
What can you consider for children with OCD if CBT and ERP have not been effective?
SSRIs (in combination!)
What techniques can be used in CBT for OCD?
▪️Functional analysis (formulation)
▪️Psychoeducation
▪️Goal setting
▪️Hierarchy of situations
▪️(Self) exposure and ritual prevention (ERP)
What rating scales can be used to assess OCD symptoms?
▪️Children’s Tale-Brown Obsessive Compulsive Scale (clinician administered)
▪️Obsessive Compulsive Inventory (self-administered)
What is the goal of ERP?
▪️To incrementally expose self to avoided and anxiety provoking situations
▪️Learn to sit with the distress/urge and delay/prevent the ritual or strategy normally used to neutralise anxiety
When would you consider medication for OCD?
▪️If psychological treatments haven’t worked
▪️If ERP not possible
▪️If comorbidities present
What medications can be used for OCD?
SSRIs
▪️Sertraline or fluvoxamine for children
▪️Citalopram for severe cases
What could be considered in cases of SSRI-refractory OCD?
Antipsychotic augmentation
(1/3 show meaningful response)
What patients may benefit from antipsychotic augmentation?
▪️Those treated with maximal-tolerated SSRI dose for at least 3 months
▪️Patients with comorbid tics
Symptoms tend to relapse when drug discontinued!
What other somatic treatments may be considered in severe, treatment resistant cases?
▪️Psychosurgery (e.g. cingulotomy, capsulotomy, ~50% responsive)
▪️TMS
▪️DBS
What structures could you target with DBS for OCD?
▪️Anterior limb of internal capsule
▪️Nucleus accukvens
What is PANDAS?
Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections
▪️OCD/tics suddenly following strep (e.g. strep throat, scarlet fever)
▪️OCD/tics suddenly worse following strep
What is the main diagnostic criteria for PANDAS?
▪️Presence of OCD/tic disorder
▪️Paediatric onset (age 3-puberty)
▪️Episodic course
▪️Association with group A beta-hemolytic streptococcal infection
▪️Association with neurological abnormalities (e.g. jerky movements)
▪️Abrupt onset or worsening
What are the two main types of immunity?
▪️Innate immunity
▪️Adaptive immunity (T-cells, B-cells)
What is the theory behind PANDAS?
▪️Strep infection leads to B-cells producing antibodies
▪️Antibodies cross BBB and bind to dopamine receptors
▪️Triggers inflammatory response that irritates cells
▪️Cells release dopamine particularly in basal ganglia resulting in OCD symptoms and tics
What are the Koch postulates required to conclude a micro-organisms has caused disorder?
▪️Organism present in all cases
▪️Organisms can be extracted and cultured
▪️Transferring organism into healthy subjects would cause disorder
▪️Organisms can be re-isolated from infected party
What are the main problems with studying PANDAS?
▪️Strep is so common making it difficult to prove
▪️Not all children with strep develop an infection
▪️Not all children with PANDAS features have positive throat swabs
▪️Recent trial found little association
Why might antibiotics show an improvement in OCD/tic symptoms?
▪️Inflammation?
▪️Placebo?
Does NOT prove PANDAS as only treats the infection, does not get rid of the antibodies
What are the criteria for establishing whether something is an autoimmune disorder?
- There is a self-reactive antibody
- A particularly target for the antibody is identified
- Disorder can be caused in animals
- Transferring antibodies from one animal to another triggers the disorder
What antibodies has been associated in relation to PANDAS?
ASO - Anti-streotolysin-O
Cunningham anti-body panel
What are the challenges of associating ASO with PANDAS?
▪️ASO titres often remains high after infection, even with negative swabs
▪️Some children with PANDAS and positive swab, have low ASO levels
(Similar problems with Cunningham antibody panel)
What relationship has been found between strep infection and exacerbation of childhood tics and OCD symptoms?
Some worsening but most have no correlation
Conclude no relationship between levels of antistreptococcal antibody titers and occurrence of exacerbations
What other factors may explain the relationship between OCD and autoimmunity?
Shared genetics between OCD and autoimmune disorders
When could you consider strong immune treatments (e.g. steroids, immunosuppressants, IgGs) for OCD symptoms?
ONLY in cases where clear indications of different immune system on blood test
What is PANS?
Paediatric Acute-Onset Neuropsychiatric Symptoms
How does PANS differ from PANDAS?
▪️Not specific to strep, can be any infection
▪️Not necessarily Autoimmune
▪️OCD or food restriction plus 2 other neuropsychiatric symptoms (e.g. anxiety, depression, sensory abnormalities etc)
What is the current state of the PANDAS/PANS debate?
▪️There is a subset of children with OCD who have unusually Abrupt onset, acute neuropsychtric symptoms
▪️Although not many
▪️PANS is a better term
▪️Little focus in familial anxiety, health anxiety, and treating OCD
Common things are common!
What is the treatment approach recommended by the PANS consortium?
- Treat symptoms (psychoactive meds, CBT, support etc)
- Remove source of inflammation with antimicrobial
- Treat disturbances of immune system (immunomodulatory/anti inflammatory)
What is the main diagnostic criteria for compulsions?
▪️Repetitive behaviours or mental acts
▪️Feels driven in response to obsession or rules
▪️Aimed at reducing distress or preventing dreaded event but not connected in a realistic way/are excessive
