BPNA Consensus Statement, The Nordic Guidelines & PANS PANDAS

It’s been a busy week or two in the world of PANDAS with the publication of the Nordic guidelines (1) together with the release of the “Consensus statement on childhood neuropsychiatric presentations, with a focus on PANDAS/PANS” by the British Paediatric Neurology Association (BPNA) (2). This was preceded by the EMTICS paper by Martino et al (3) whose authors included UK representation from authors who have had additional publications in this field very recently (4). Interestingly, the “Nordic” guidelines had UK input from authors who have also been involved in either the UK PANS PANDAS guidelines (published by the UK PANS PANDAS Physicians Network in 2018) or the EMTICS study (3). The recognition of PANS PANDAS as disease entities that need further research has got to be welcomed and, in this respect, I welcome this recent flurry of publications. I do have a concern that the different publications give a confusing message and we do need to address this. There is a suggestion from some psychiatrists that the recent increase in tic disorders is due to a functional disease process rather than a post-infectious process related to COVID-19. I do not think the evidence for such a position exists, but it is certainly something that should be explored through robust research. Calling the BPNA statement a “consensus” statement I think will also be explored in the very near future. Professor Forsyth presents an interesting discussion of the potential “mind versus cytokine” debate and how we need to avoid negative frameworks on both sides of the debate (5). Forsythe says a key question for Heyman and others to address is “why, specifically, tics?”(5). An obvious question which will need answering with strong independent research.

This is a good time for PANS PANDAS. The disease is firmly in the limelight and accepted. The opportunity to move forward with research to clarify the disease processes and treatments that should be used is now with us.

In 1896 Sir William Osler was at odds with Charcot and Gilles de la Tourette over the mechanisms behind tic disorders. Osler favoured the idea that tics were the manifestation of a physical process whilst Charcot and Tourette promoted the idea of a psychiatric basis for these symptoms. The parallels with the discussions taking place today are uncanny, hopefully we can all widen our lens to see if we can answer the question of whether inflammation of the brain can cause psychiatric phenomenon and more importantly, whether this can be effectively treated.

References

1. Pfeiffer H, Wickstrom R, Skov L, Sørensen CB, Sandvig I, Gjone H, et al. Clinical guidance for diagnosis and management of suspected Pediatric Acute-onset Neuropsychiatric Syndrome in the Nordic countries. Acta Paediatr. 2021 Apr.
2. British Paediatric Neurology Association. Consensus statement on chidhood neuropsychiatric presentations, with a focus on PANDAS/PANS. Statement from the BPNA [serial on the Internet]. 2021: Available from: Click to download
3. Martino D, Schrag A, Anastasiou Z, Apter A, Benaroya-Milstein N, Buttiglione M, et al. Association of Group A Streptococcus Exposure and Exacerbations of Chronic Tic Disorders: A Multinational Prospective Cohort Study. Neurology. 2021 Feb 10.
4. Heyman I, Liang H, Hedderly T. COVID-19 related increase in childhood tics and tic-like attacks. Arch Dis Child. 2021 Mar.
5. Forsyth RJ. Tics, TikTok and COVID-19. Arch Dis Child. [editorial]. 2021;106:417.