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Evil P.A.N.D.A.S., Part II: Adult Affliction & Treatment

Evil P.A.N.D.A.S. Attacks adults, too!

In a previous post I have written about P.A.N.D.A.S. The last post generated some interesting and useful comments. The most important message inferred from the correspondence is the unfortunate lack of understanding of this problem coupled with a lack of effective treatment. I don't want to rewrite that post so I encourage you to review it and the comments if you need further background.

There is virtually no literature on adult P.A.N.D.A.S. Below I shall present the data of my evidence-based clinical research over the past couple of years in which I was ably assisted by ENT surgeon Dr. Robert Ruder. There is no bibliography at this point nor is there room for spread sheets of a variety of laboratory data pre-and postoperatively. I shall give a brief description of each patient, premorbid diagnoses, my diagnoses, and postoperative outcome. It is my hope that those of you to follow this important topic can use these data to foster better understanding, education and treatment in your communities.

Patient 1: 23-year-old Caucasian female presented with the diagnoses of; severe Asperger's syndrome versus pervasive developmental disorder NOS, bipolar disorder, multiple learning disabilities, and severe impulse control problems consistent with possible intermittent explosive disorder. Patient had been in special education and special schools her entire life.

My diagnoses were: ADHD, periodic limb movement disorder, Tourette's syndrome, tics, narcolepsy, learning disabilities, panic disorder, obsessive-compulsive disorder, dysthymic disorder, mixed character pathology, symbiotic relationship with mother and P.A.N.D.A.S. Elevated Anti-DNAaseB antibody.

Patient underwent Sleep Study with Multiple Sleep Latency Test as well as removal of tonsils and adenoids (T&A). Patient's narcolepsy, ADHD and periodic limb movement disorder were readily stabilized with a combination of Adderall XR and Neurontin. There was complete resolution of her OCD, Tourette's syndrome (her impulse/explosive problems) and panic disorder. Mood improved. Attitude and behavior issues were referred to a psychotherapist. Patient is in school, has a job and lives independently.

Patient 2: 32 year-old Caucasian male previously diagnosed with; OCD, chronic insomnia, severe GAD (disabling), TMJ, hypochondriasis v. somatization v. body dysmorphic disorder. Poor response to SSRIs.

My diagnoses were: Major Depression, GAD, OCD and P.A.N.D.A.S. Elevated antibody titre.

Patient underwent T&A. Rapid and complete resolution of OCD, GAD and somatic complaints. Mood issues resolved with Wellbutrin. Back to full-time professional career.

Patient 3: 64-year-old Caucasian female with long history of fibromyalgia, depression, hypothyroidism, poor quality sleep, multiple treatment failures.

My diagnoses were: Depressive disorder NOS, ADHD, PLMD, OSA (obstructive sleep apnea), PLMD, hypothyroidism and "fibromyalgia. Positive ANA and elevated antibody titer.

Patient underwent sleep study with CPAP titration. This resolved sleep apnea. Patient underwent T&A. ANA now negative. PLMD improved with Neurontin. Mood improved with Wellbutrin and achievement of euthyroid state. Gradual if erratic diminution and aches pains and other symptoms of fibromyalgia. Mood and attention improved with Wellbutrin.

Patient 4: 32-year-old Caucasian male diagnosed with severe OCD, severe GAD, and multiple facial, head and neck tics.

My diagnoses concurred with those above. Patient had marked elevation of antibody.

Patient underwent T&A. Complete resolution of all symptoms. Asymptomatic, gratefully relieved and back to full time employment.

Above is but a brief summary of adult patients who have been treated very successfully for P.A.N.D.A.S. with T&A. Clarification of corollary diagnoses and treatment thereof obviously is quite important. In the same timeframe I have had several children and adolescents successfully treated for P.A.N.D.A.S.

All of the patient's are educated about the diagnosis. It is made clear that they are genetically predisposed and that they are very likely to experience flares of their symptoms if they are exposed to strep, have a strep infection or possible exposure to other bacteria or viruses. Mild flares generally are ignored and more severe flares are treated with corticosteroid boluses.

There is much more to be said about this and Dr. Ruder and I will address it in a forthcoming paper. However, given the degree of pain and suffering so many people experience as a result of undiagnosed and or untreated P.A.N.D.A.S. I believe it is important to publish this information now. I will point out that not all patients with P.A.N.D.A.S. Have elevated antibody titers and this probably relates to different strains of streptococci. Also, T&A is not always the definitive procedure for every patient. Foci of chronic/subacute infection may be in the sinuses, ears, mastoids, abscesses and other places. And no, not every patient with tics, Tourette's, GAD, OCD, anorexia nervosa, and a plethora of other neuropsychiatric symptoms as P.A.N.D.A.S. But, as we are told at the beginning of medical school, if one does not consider a diagnosis one does not look for the diagnosis and if one does not look for the diagnosis one does not make the diagnosis. Good luck out there.

Jory F. Goodman, M.D., is a practicing psychiatrist in Beverly Hills, with more than thirty years of clinical experience.

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