Quick Guide to PANS and PANDAS (Acute-Onset OCD)

PANS and PANDAS are two names for a set of disturbing symptoms that are often linked to a bacterial infection.  The primary symptom is acute-onset OCD (obsessive-compulsive disorder). Normally, kids with OCD develop the disorder slowly. But in acute-onset OCD, severe symptoms show up suddenly.  Parents often say that the child changes “overnight” or  symptoms arise “out of the blue.” 

Children with PANS or PANDAS also develop other distressing and confusing symptoms that include restricted eating, tics, regression, rage, depression and even suicidality. These symptoms can show up in children as young as three or four. 

PANS and PANDAS are called autoimmune neuropsychiatric disorders because the symptoms are thought to be caused by the body’s immune system mistakenly attacking healthy brain cells.

The symptoms of PANS and PANDAS are the same. The only difference is whether they are linked to a known strep infection (PANDAS) or not (PANS).

Some cases of PANS are linked to a bacterial infection other than strep, such as mononucleosis, walking pneumonia, or the flu. Some have no known cause. There have been reports of PANS cases associated with Lyme disease and COVID-19, but the evidence so far is not strong enough to include these infections as possible causes.

PANS and PANDAS are episodic disorders, which means they come and go. Symptoms may disappear for extended periods then reappear, triggered by a later exposure to strep or some other bacteria or virus. Symptoms may get increasingly severe with later recurrences. 

PANDAS (which stands for pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections) was first identified more than three decades ago, when strep was identified in connection with these acute-onset symptoms.  But many in the medical community were skeptical about the link to infection, which made it very difficult for parents to get effective diagnosis or treatment.

After years of controversy, experts finally agreed on adding a broader category called PANS (pediatric acute-onset neuropsychiatric syndrome) that does not indicate causation. Today PANS is used for cases linked to a bacteria other than strep, or which have no identified cause. PANDAS is a subset of PANS

In January 2025, the American Academy of Pediatrics issued a clinical report on PANS that acknowledged PANS as a legitimate diagnosis but remained skeptical about the link to infection. The AAP described PANS as “a condition that involves a constellation of psychiatric and neurologic symptoms that present simultaneously and in rapid onset, the cause or causes of which are unknown. Although the cause is still under investigation, the manifestations may follow a recent infection.”

PANDAS and PANS are more common in boys than in girls and usually show up in younger children. 

A consortium of experts called the PANDAS Physicians Network (PPN) has developed what are considered a “working draft” of diagnostic criteria for PANS, which have been mirrored by the AAP.

The criteria for PANS are the abrupt onset or recurrence of OCD or severely restricted food intake, along with abrupt onset at least two of the following seven categories:

• Anxiety
• Emotional dysregulation
• Irritability, aggression, and/or oppositional behaviors
• Behavioral regression
• Academic deterioration
• Motor/sensory abnormalities (including heightened sensitivity to sensory stimuli, hallucinations, dysgraphia, and complex motor and/or vocal tics)
• Somatic abnormalities (including sleep disturbances, enuresis, or urinary frequency)

A diagnosis of PANDAS requires the symptoms to be associated with a recent untreated strep infection. The criteria for PANDAS are:

• Abrupt onset of OCD and/or tics
• A relapsing-remitting, episodic symptom course
• Symptom onset prior to puberty (average of 6–7 years)
• Presence of neurologic abnormalities (such as tics, fidgeting, or involuntary “piano playing” finger movements)
• Symptoms started soon after a group A streptococcus infection

Unlike regular OCD, symptoms of PANDAS and PANS start all at once. Parents often say that the child changes “overnight” or “out of the blue.” 

The treatment for PANS and PANDAS outlined by the PPN starts with targeting the inciting infection with antibiotics. The OCD symptoms should be treated, as they would be in other cases of OCD, with behavior therapy (specifically exposure with response prevention) and, if necessary, antidepressant medication, including SSRIs. Anti-inflammatories, including NSAIDs and corticosteroid bursts, can be added to hasten recovery and minimize residual symptoms.

The PPN advises that severe and recurring cases can be treated with long-term antibiotics. The autoimmune response can be treated with IVIG (intravenous immunoglobin) or plasmapheresis (the exchange of blood plasma).

The AAP does not support the use in treatment of long-term antibiotics, plasmapheresis, or IVIG, on the grounds that there is insufficient evidence of their effectiveness.