[psychiatry-research] Treatments reduce strep-triggered symptoms of OCD and tics in some children
- FOR RELEASE: 30 SEPTEMBER 1999 AT 18:00 ET US
NIH-National Institute of Mental Health
Treatments reduce strep-triggered symptoms of OCD and tics in some children
National Institute of Mental Health (NIMH) researchers report that some
children whose symptoms of obsessive-compulsive disorder (OCD) and tic
disorders were worsened by a common strep infection have been successfully
treated with plasma exchange (PEX) and intravenous immunoglobulin (IVIG). Dr.
Susan Swedo and colleagues at the National Institutes of Health reported their
findings in the October 2 issue of Lancet.
In previous studies, Dr. Swedo and others observed that in a small number of
children suffering from the obsessional thoughts and compulsive behaviors
typical of OCD and tic disorders, symptoms suddenly became worse following
infection with Group A beta hemolytic streptococci. Evidence pointed to an
autoimmune response to the infection, in which antibodies attack healthy as
well as infected cells, leading to inflammation in the brain's basal ganglia,
an area involving movement and motor control. The syndrome, known as PANDAS, or
Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal
Infections, typically occurs in young children and is noted for its dramatic,
sudden onset or exacerbation of symptoms and episodic course, in which periods
of symptom worsening follow strep infections.
"The investigation shows that plasma exchange and IVIG relieve neuropsychiatric
symptoms in this subgroup of children with tics and obsessive-compulsive
disorder. A few children were even able to discontinue all psychotropic
medications after treatment," Dr. Swedo said. "The study does not, however,
support using PEX and IVIG for all cases of tics or OCD. Nor does it suggest
that all children with untreated strep infections will get OCD, tics, or
Tourette syndrome. In fact, strep infections are very common and
strep-triggered neuropsychiatric disorders are quite rare, so the vast majority
of children with strep infections are not going to develop these disorders,
particularly with prompt attention and treatment," according to Dr. Swedo.
Although the cause of obsessions, compulsions, and tics is unknown, evidence
suggests a common origin for all of these symptoms, with genetic and nongenetic
factors playing a role. Symptoms affect 1-2% of children, but the number
involving PANDAS is unknown. The antistreptococcal antibodies reported in
children with OCD and tic disorders are considered part of the unique syndrome
of the subgroup PANDAS.
Thirty children ages 9 to 15 with severe, infection-induced worsening of OCD or
tic disorders, including Tourette syndrome, participated in the double blind,
placebo-controlled study at NIH. After medical, neurological, and psychiatric
assessments, the children were randomly assigned to plasma exchange, IVIG, or
placebo (saline solution). PEX and IVIG were chosen as active treatments
because of their safety and effectiveness in a variety of childhood and adult
immune-related diseases. Researchers rated symptom severity at baseline and at
one month and twelve months after treatment, using standardized assessments for
OCD, tics, anxiety, depression, and normal behavior.
Of the 29 children who completed the trial (19 boys, 10 girls), 10 received
PEX, 9 IVIG, and 10 placebo. Both PEX and IVIG produced substantial improvement
in obsessive-compulsive symptoms, anxiety, and overall functioning; PEX also
improved tic symptoms. Ratings done one month after treatment revealed that
patients in both the PEX and IVIG groups were much improved. In contrast,
symptoms changed little in children who received placebo. The treatment gains
of PEX and IVIG remained at one-year follow-up, with 14 of 17 subjects "much"
or "very much" improved over baseline.
The one-month follow-up consisted of a neurological examination to rate symptom
severity. After that evaluation, if a child taking placebo had no symptom
improvement, IVIG or PEX was offered, so one-year ratings are not available for
the placebo group. At the one-year assessment, obsessive-compulsive symptoms,
tic severity, psychosocial functioning, and symptom severity remained improved.
Among subjects who received IVIG, there was a 58% improvement in OCD symptoms;
with those who received PEX, a 70% improvement; 82% of the children had symptom
reductions of at least 50%. On average, children now had good functioning in
all social areas. Parents and children often reported, "My child's back to his
old self again" or "Things are a lot easier now."
Susan J. Perlmutter, M.D., Marjorie A. Garvey, M.D., Susan Hamburger, M.S.,
M.A., Elad Feldman, B.S., and Henrietta L. Leonard, M.D., NIMH, and Susan F.
Leitman, M.D., NIH Clinical Center, also participated in the study. Dr. Leonard
is now affiliated with Rhode Island Hospital and Brown University.
The National Institute of Mental Health is part of the National Institutes of
Health (NIH), the Federal Government's primary agency for biomedical and
behavioral research. NIH is a component of the U.S. Department of Health and