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Management of Disorders > OCD/PANDAS and PANS > Flashcards

OCD/PANDAS and PANS Flashcards

1
Q

What is the main diagnostic criteria for obsessions?

A

▪️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

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2
Q

What are the four components of the OCD cycle?

A

▪️Obsession
▪️Anxiety
▪️Compulsion
▪️Temporary relief

Gets stronger with time!

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3
Q

How common is OCD?

A

1-3%

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4
Q

What is the main demographic of OCD?

A

Two peaks:

▪️Childhood/adolescence - more males, symmetry and checking
▪️20-29 - more females, washing

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5
Q

What are the four main types of OCD?

A

▪️Contamination/washing (more common in older & religious groups
▪️Obsessions/checking
▪️Hoarding/saving
▪️Symmetry/order

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6
Q

What are the most common obsessional symptoms?

A

▪️Aggression
▪️Contamination
▪️Symmetry
▪️Somatic

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7
Q

What are the most common compulsive symptoms?

A

▪️Checking
▪️Cleaning
▪️Repeating

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8
Q

What psychiatric condition occurs lost commonly with OCD?

A

Depression (50-60%)

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9
Q

What evidence points towards a biological model of OCD?

A

▪️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

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10
Q

What has been found with twin studies of OCD?

A

▪️Highly genetic, particularly in children (45-65%)
▪️Unique environmental effects are equally important (e.g. trauma)
, ▪️Shared environmental effects are negligible

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11
Q

What targets for candidate genes have been proposed for the genetic basis of OCD?

A

▪️Serotonin
▪️Glutamate
▪️Dopamine
▪️GABA
▪️Neurodevelopmental factors (e.g. BDNF)
▪️Peptides (e.g. oxytocin
▪️SAPAP3

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12
Q

What environmental factors may contribute to the development of the OCD?

A

▪️Perinatal insults
▪️Childhood stressors
▪️Autoimmune factors (e.g. streptococcal infection)?

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13
Q

Do different subtypes of OCD have distinct neural correlates?

A

Yes!

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14
Q

Which brain regions have been implicated in OCD?

A

Frontostriarothalamic circuits implicated in cognitive and emotional processing

▪️VMPFC
▪️OFC
▪️Caudate nucleus
▪️Putamen/GP/thalamus
▪️Precentral gyrus

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15
Q

Can brain abnormalities seen in OCD be reversed with treatment?

A

Yes!

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16
Q

What do the NICE guidelines for treatment of OCD with mild functional impairment in children?

A

▪️Self help support
▪️Information for family

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17
Q

What do the NICE guidelines for treatment of OCD with moderate/severe functional impairment in children?

A

▪️CBT
▪️ERP

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18
Q

What can you consider for children with OCD if CBT and ERP have not been effective?

A

SSRIs (in combination!)

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19
Q

What techniques can be used in CBT for OCD?

A

▪️Functional analysis (formulation)
▪️Psychoeducation
▪️Goal setting
▪️Hierarchy of situations
▪️(Self) exposure and ritual prevention (ERP)

20
Q

What rating scales can be used to assess OCD symptoms?

A

▪️Children’s Tale-Brown Obsessive Compulsive Scale (clinician administered)
▪️Obsessive Compulsive Inventory (self-administered)

21
Q

What is the goal of ERP?

A

▪️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

22
Q

When would you consider medication for OCD?

A

▪️If psychological treatments haven’t worked
▪️If ERP not possible
▪️If comorbidities present

23
Q

What medications can be used for OCD?

A

SSRIs

▪️Sertraline or fluvoxamine for children
▪️Citalopram for severe cases

24
Q

What could be considered in cases of SSRI-refractory OCD?

A

Antipsychotic augmentation

(1/3 show meaningful response)

25
Q

What patients may benefit from antipsychotic augmentation?

A

▪️Those treated with maximal-tolerated SSRI dose for at least 3 months
▪️Patients with comorbid tics

Symptoms tend to relapse when drug discontinued!

26
Q

What other somatic treatments may be considered in severe, treatment resistant cases?

A

▪️Psychosurgery (e.g. cingulotomy, capsulotomy, ~50% responsive)
▪️TMS
▪️DBS

27
Q

What structures could you target with DBS for OCD?

A

▪️Anterior limb of internal capsule
▪️Nucleus accukvens

28
Q

What is PANDAS?

A

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

29
Q

What is the main diagnostic criteria for PANDAS?

A

▪️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

30
Q

What are the two main types of immunity?

A

▪️Innate immunity
▪️Adaptive immunity (T-cells, B-cells)

31
Q

What is the theory behind PANDAS?

A

▪️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

32
Q

What are the Koch postulates required to conclude a micro-organisms has caused disorder?

A

▪️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

33
Q

What are the main problems with studying PANDAS?

A

▪️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

34
Q

Why might antibiotics show an improvement in OCD/tic symptoms?

A

▪️Inflammation?
▪️Placebo?

Does NOT prove PANDAS as only treats the infection, does not get rid of the antibodies

35
Q

What are the criteria for establishing whether something is an autoimmune disorder?

A
  1. There is a self-reactive antibody
  2. A particularly target for the antibody is identified
  3. Disorder can be caused in animals
  4. Transferring antibodies from one animal to another triggers the disorder
36
Q

What antibodies has been associated in relation to PANDAS?

A

ASO - Anti-streotolysin-O

Cunningham anti-body panel

37
Q

What are the challenges of associating ASO with PANDAS?

A

▪️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)

38
Q

What relationship has been found between strep infection and exacerbation of childhood tics and OCD symptoms?

A

Some worsening but most have no correlation

Conclude no relationship between levels of antistreptococcal antibody titers and occurrence of exacerbations

39
Q

What other factors may explain the relationship between OCD and autoimmunity?

A

Shared genetics between OCD and autoimmune disorders

40
Q

When could you consider strong immune treatments (e.g. steroids, immunosuppressants, IgGs) for OCD symptoms?

A

ONLY in cases where clear indications of different immune system on blood test

41
Q

What is PANS?

A

Paediatric Acute-Onset Neuropsychiatric Symptoms

42
Q

How does PANS differ from PANDAS?

A

▪️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)

43
Q

What is the current state of the PANDAS/PANS debate?

A

▪️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!

44
Q

What is the treatment approach recommended by the PANS consortium?

A
  1. Treat symptoms (psychoactive meds, CBT, support etc)
  2. Remove source of inflammation with antimicrobial
  3. Treat disturbances of immune system (immunomodulatory/anti inflammatory)
45
Q

What is the main diagnostic criteria for compulsions?

A

▪️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

Management of Disorders (28 decks)

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