Cognitive behavioral therapy and acceptance and commitment therapy as augmentation treatment for paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS): A case report

Introduction Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) are a subgroup of conditions including obsessive-compulsive disorder (OCD), tic disorders, pre-pubertal and sudden onset, temporal association between streptococcal infections and associated neurological abnormalities. Some strategies were developed, including the use of antibiotic prophylaxis to prevent streptococcal-triggered exacerbations, and immunomodulatory interventions for the management of acute symptoms. Cognitive-behavioral therapy (CBT), which has been demonstrated to be the first-line treatment for OCD, can be a valid adjuvant during the difficult course of PANDAS to target acute symptoms and prevent exacerbations. Objectives The study presented a case of a patient with PANDAS treated with antibiotic medication and CBT as augmentation. Methods The 11-year-old patient (Y-BOCS pre-test score = 32), had been hospitalized for three weeks for acute onset of PANDAS. The clinical picture consisted of asthenia, contamination fears and washing compulsions, separation anxiety, severe depression and anxiety. Pharmacotherapy involved risperidone 2 mg/die and sertraline 250 mg/die for five months combined with antibiotic prophylaxis for two years. The CBT intervention started at discharge from hospital and included psycho-education on anxiety, intensive exposure and response prevention (2 hour sessions three times a week) for twelve months, cognitive restructuring, diffusion and mindfulness for the subsequent twelve months. Results Anxiety and OCD symptoms substantially improved. The patient gradually started school again. Post-test score was 11 on the Y-BOCS. Conclusions Along with psychiatric and antibiotic medications, CBT may be a valid augmentation strategy for PANDAS to reduce risk of exacerbations and enhance symptom improvement. Limitations are discussed.