You know, I've talked to Sue Sweeto a lot, we're on several boards together, and she wishes she had never called it Pandas because it became a very kitschy name.

She wished that they still called it autoimmune encephalitis of the basal ganglia associated with streptococcal infection. I wish they had called it the Swede disease.

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Let's get started. Hi, everybody. Welcome to another episode of the Recharged Bowel Medical Podcast. I'm your host, Dr. Ed Park, and today we're very happy to be joined by Nancy O'Hara.

How are you, Nancy? I'm good, Ed, and thanks so much for inviting me. Absolutely. So we met almost two years ago at Lisa Song's A4M Peets conference. It really opened my eyes to a lot of the chronic diseases of childhood.

And of course, everyone knows autism and gut dysbiosis, but they don't necessarily know or have heard of PANS-PANDAS. And so that's really your area of expertise.

So for those that don't know, Nancy wrote a great book called PANS-PANDAS, right? Demystifying PANS-PANDAS, yep. Yeah, so I've read that a couple times.

It's really quite interesting. So for those that don't know, what do the acronyms stand for? Right, well, PANDAS was coined by Sue Suito in the 1990s, and it stands for Pediatric Autoimmune Neuropsychiatric Disorder Associated with Strep.

So after a child got a strep infection, rather than just having a strep throat or whatever, they got neuropsychiatric symptoms, OCD, restrictive eating disorder, tics, anxiety, et cetera.

after the strep infection because of a misdirected immune response so it's an autoimmune disease and then in 2012 about 30 clinicians researchers got together because pandas was a very controversial diagnosis they were trying to make it less controversial So, recoined the phrase PANS, which stood for pediatric abrupt onset neuropsychiatric syndrome.

And that was to include things like mycoplasma, tick-borne diseases, in my opinion, mold, yeast, but also viruses. And we've seen a lot of it post-COVID.

So if you see a child, for example, with COVID, and they don't get very sick with the illness, but they get neuropsychiatric symptoms abruptly after a COVID infection, that fits into that pan's umbrella.

I gotcha. Okay, so PAN does, or pediatric disorder associated with strep, is a subset of PANS in a way. Correct. Okay, so how would this typically, in the past when people got strep though, and I'm sure this used to happen for decades, was it part of just the odd complications of a strep infection, or is this kind of emerged as a separate syndrome?

It has emerged as a separate syndrome. The prototype is Sydenham's Korea. You know, when there was rheumatic fever after a strep infection, there were a group of children and young adults who got choreic movements, involuntary large movements after rheumatic fever.

And that looks exactly similar to pandas in the brain. It's in the basal ganglia where that inflammation from the strep antibodies attacks the brain and causes the symptoms.

Interesting. So now it's somewhat controversial, whether it's a thing, but I think it's like, you know, phenomenologically speaking, if you're a pediatrician or parent, and so typically walk us through the typical presentation of how the kid changed suddenly and what those changes looked like.

So there'll be people will be aware. Right. A typical example is Johnny comes home with strep throat and Johnny's brother, George, doesn't have any symptoms of strep throat, doesn't have a sore throat, doesn't have a fever, but all of a sudden starts having looping intrusive thoughts or starts being very anxious, can't separate from mom, can't go to bed at night.

or develop somatic symptoms. And when you have that OCD, that looping thought or the recurrent patterns of obsessions, together with a somatic symptom, like an abrupt onset of urinary frequency or bedwetting when they were previously dry or an abrupt onset of very restless sleep, that REM disinhibition together with OCD or an abrupt onset of restrictive eating disorder.

That is classic for pandas. And what I recommend doing is going to the pediatrician, getting Johnny treated for strep, but also checking George for strep, doing that throat culture, even if the throat looks pristine.

Because remember, what's happening in the throat is they get the the fatigue, the eye, the inflammation due to the antibody response in the throat. But what's happening instead is those antibodies are attacking the basal ganglia in the brain and causing these neuropsych symptoms.

All right. Fascinating. So just to restate, it's a disease of childhood, above three and not in adults typically. And it manifests as sudden onset of behavioral changes, obsessive-compulsive, tics, social phobia, being very clingy, being very kinetic sometimes.

So you're saying it's almost a complete overlap with these choreographic movements that people used to get after rheumatic fever. Okay. Now, I just treated a kid with autism.

With some exosomes and I have a practitioner who trained in my course and she treats a lot of autistic kids and she feels like it helps a lot with neuro inflammation.

And I'm just wondering this kid had something else going on with. uh extra cerebral cortical stuff that needed surgery and there was a lot of epileptic stuff but when you see a kid that has the self-soothing like they're so they're moving and they they have the echolalia they repeat themselves and so can it look like the sudden onset of like this uh profound autism if you get pandas It can.

And I have seen that. There are some kids that have been mislabeled as autism that actually had an abrupt onset after a viral infection or a strep infection or something like that.

And in treating that with a three-pronged approach, their autism symptoms definitely get better. And one of it is, of course, the exosomes or other anti-inflammatory immune modulating agents.

We'll talk about treatment. Obviously, Johnny's brother brought the strap. He was carrying it in his throat. And then so anybody else have a role to play?

Certainly, if you're having acute strep or carriage among the family. But if we think broadly about pants, like, you know, you said bold, maybe COVID, maybe lime.

What is it about the neuroinflammation? Is it always antibody mediated? Is it somehow always in the basal ganglia? Or is it more of a broad neuroinflammatory sort of pathology?

In this strict diagnosis, it should be in the basal ganglia, but there certainly can be overall autoimmune encephalitis, especially when it's vector-borne disease or virally mediated with COVID or mold-mediated.

And in those cases, although I would not call it Pan's Pandas, it certainly is autoimmune encephalitis and can be treated from a neuroinflammation standpoint very similarly.

I see. But now we have a problem in like epistemologically speaking, a lot of pediatricians don't even consider a real disease. Why is that do you think?

You know, I've talked to Sue Sweeto a lot, we're on several boards together, and she wishes she had never called it Pandas because it became a very kitschy name.

She wished that they still called it autoimmune encephalitis of the basal ganglia associated with streptococcal infection. I wish they had called it the Swede disease.

So that's number one. Number two is it is a known fact that if a child comes in with an ear infection, a sinus infection, as well as a sore throat, the pediatrician may well treat them with antibiotics without ever doing a strep culture.

And then three weeks later, they come down with the behavioral manifestations because it may not be right at the time of the strep infection. It may be several days up to several weeks after.

And so there's no documentation of a strep throat and there's no association in the pediatrician's mind or the parent's mind. Right. So it's a delayed sort of thing.

Right. But once you get the disease, is it relapsing or remaining or is it just a one-off, generally speaking? If it's caught early and treated appropriately, it can be a one-off.

Certainly in my practice, where they've been dealing with it for several years, it's obviously relapsing and remitting. And I think one of the things is to remember that it's an autoimmune disease.

It's not an infectious disease. So unless you're treating the neuroinflammation and only using an antibiotic, it's going to keep coming back. So autoimmune meaning it's like cell mediated or mostly antibody mediated or it could be both?

It could be both. And there's certainly, depending on the triggers, and if it's COVID or mold, the cytokine inflammation, the mast cell inflammation is much greater than the antibody inflammation in those cases.

So basically, it's just a neuro-inflammatory autoimmune response attacking the motor coordinating centers of basal ganglia. And how does that result in this sort of mood and affect changes of the sort of compulsivity and the anxiety?

Well, certainly it also affects the amygdala, which is our anxiety center and where we're really seeing those non-motor OCD looping thoughts, et cetera.

So it's anywhere in that hippocampal, amygdala, basal ganglia, you know, chordae plexus kind of area. So, but so treatment wise, I guess, if you look it up, that you could do IV IG, obviously, anybody to treat and the underlying this strap is pretty susceptible in most cases to anybody treatment.

But what do you, where do you come down on like anti-inflammatories, like NSAIDs, steroids, or even immune modulators? Are those helpful generally, or it's a crapshoot?

I think they're very helpful and there are several articles that have been written on the use of NSAIDs at appropriate dosages as a frontline immune modulator.

I also find there are several oral immune modulators like turmeric, for example, like specialized pro-resolving mediators, phospholipids, peptides, and in your experience, I'm sure exosomes also, and many that we can use long before we get to IVIG.

The general rule of thumb in conventional practices that treat pans and pandas is that 60% of children need to go on to IVIG. In our practice, it's only 20%. Is it quite effective?

It is quite effective. So for people that don't know, IVIG is just pooled immunoglobulin. So I guess the theory is it just kind of introduces a bunch of immune noise, I guess.

It kind of blocks whatever the immune system is trying to focus on. Exactly. And resets the immune tolerance. So if you're a parent and all of a sudden you get your kid acting super freaky, and then you think, oh God, I remember that podcast with Dr.

O'Hara, maybe it's Pan's Pandas, how do you present that to your clinician who may be less than sanguine about the idea of such a disease even being real?

How do you get the help you might need from somebody who may be agnostic? I think, first of all, there are a couple of good books, mine, and there's also one by Scott Antoine that is also very well referenced and a very good book on Pan's Pandas.

I think there are multiple articles. There's a whole section of the Journal of Child and Adolescent Psychopharmacology that was dedicated to Pan's Pandas.

If you can take that one of the books or that whole journal to your pediatrician and say, look, this exists and this is my child. Why I wrote so many case studies in the book is so they can say it looks just like this kid.

The American Academy of Pediatrics came out in December and said, Pandas exists. We agree that it exists. It's been like a little bit of a sea change over the last year or two.

Well, unfortunately, Lo, they said there's nothing you can do about it because the research that they were basing it on was back in 2017. They were about to put out the statement in the end of 2019 COVID hit, you know, everything gets delayed a little bit.

COVID hit, it got delayed, and then they didn't base their findings on any of the new research since 2017. Since 2017, there have been over 200 articles written about not just the rat models, mice models, but the real brain biopsy models of the inflammation and what to do about it.

So I wonder if they know what about the strep antigens or epitopes is cross reacting with the nervous system, but maybe the science there. Dritan, the basic science is there, and Dritan Aguali wrote some excellent papers recently on that, looking at specific strep Th17 cells, not just the antibodies.

And I think the big problem is that in conventional medicine, we are so test-oriented, and parents say, well, check for strep. And what they go to are what are called streptiters, ASO and anti-DNAHB.

As Sue said, and I agree, I wish those didn't exist because 40% of children in addition to the neuroinflammation will have concomitant immunodeficiency and will have no rise in serologic titers.

And so getting that test means nothing. It may be elevated just because you had a strep infection. It may be normal because you have immune dysregulation and it's not showing the positivity.

That's the problem because doctors are reductionists and we like to have one test and one treatment and so it falls into a gray area where you have to be a clinician.

and have a high index of suspicion. Right, because this really is a clinical diagnosis. So it's the history of an infection, strep, mycoplasma. I see it a lot.

Grandpa was in the hospital with walking pneumonia. They diagnosed him with mycoplasma. The kid comes down with separation anxiety, hoarding, you know, restrictive eating disorder.

They don't even look for mycoplasma. And yet, If you looked for it, the titers for that are through the roof in the child, and treating it could successfully decrease the symptoms.

So just to wrap up, the big ones are like ticks, obsessive-compulsive behavior, eating disorders, anorexia, and then also urinary stuff. They can go into bedwetting.

But usually it's a disease of younger age, not teenagers as much. The classic is 3 to 13. Certainly with tick-borne infections, mold, COVID, it can happen at any age, and we've seen that in the literature as well as in children and young adults we take care of.

But classically for pandas, it's 3 to 13. Okay. Let's shift a little bit to this really unfortunate experiment done by Project Warp Speed and Pfizer and Moderna.

I've seen in a few of my interviewees, we've talked about the downstream inadvertent effects of COVID. I think a lot of people that expressed the spike protein ended up having small vessel disease, which caused neurologic sequelae, but also immune derangement, which may have set them up for higher rates of cancer and autoimmune and neurologic stuff generally.

I think if you take the pre and post rates of Alzheimer's and ALS and Parkinson's, they're probably going to show a significant bump in future retrospective studies.

I heard a patient who had long COVID and really bad symptoms and his idea was to take another COVID shot while he was currently battling active COVID infection.

What is it about people's susceptibility to nonsense? Why would you take COVID spike protein if your body's swimming in it? What's wrong with people? Do you not understand or it's just fear-based motivation?

From my perspective, in my opinion, it's fear-based. And I think there's been so much misinformation and isolationism that has led people to believe that the injection, the COVID injection, is the only way to treat the disease.

But we know that with the micro clotting, with the inflammation, with the spike protein, that in fact, there are many other ways to treat that. And in children, at least, it's now well known that the injection is more likely to cause a negative response than any positives, not just myocarditis, but also other autoimmune and inflammatory conditions.

Yeah, no, it's really odd that it got so universally accepted and I would say the vast majority of doctors were just so concerned with toeing the line.

They didn't even look at the safety or animal studies. Exactly. Horrific. Exactly. That's a topic for another thing. But so I think that, you know, my son had a lot of anxiety four years ago.

He got an exosome shot and it kind of shifted him that along with some plant medicine, but it kind of became a different person. So it kind of raised the question in me, how much of anxiety, depression until illness or dis-ease is just some sort of low level inflammation.

Do you have thoughts? I agree. I think a lot of it is. And I think even if a child presents with anxiety, OCD, et cetera, and does not classically fit the Pan's Pandas diagnosis, there definitely can still be neuroinflammation.

And I think anything we can do to decrease that rather than just putting them on an SSRI or an antipsychotic can really provide much more benefit. And I think research is more and more showing that we're seeing that.

The other thing I see a lot of is cerebral folate deficiency. Dr. Wells and I wrote an article on that last year in a small group of children with pans-pandas and concomitant cerebral folate deficiency.

So I think that's another avenue of depression, anxiety, OCD that should be looked at and possibly treated both the neuroinflammation and the cerebral folate deficiency before considering other more traditional psychiatric medications.

Yeah. And I think there's a lot, it's a great point about supplements. Sometimes people who have odd diets, like, you know, they only pop tarts or chicken nuggets, right?

They're not getting enough of the B vitamins. And, you know, there was that great presentation about suicide rates in places where there's low and high lithium.

Um, you know, there's a lot that goes in, you know, obviously with the screen time and the dopamine addiction of the devices. But I think that the one lecture I liked was to the woman who took her kid to Disneyland they had like funnel cakes and hot dogs and Coke and and the kid developed a tick disorder like severe ticks to rest really and she said that by training these kids and then even um, athletes, teenage athletes, they, there's self-regulation, breathing, mindfulness, meditation, exercise.

There's so much you can do to modulate the way that your body is diseased that that was really interesting. Like, you know, but in school, they don't really teach you about health and wellness and breathing and time management and sleep hygiene.

I just feel like we're not really equipping these humans for self care and self You know? Right. So much of it is abnormal vagal nerve. And if we appropriately stimulate the vagal nerve through breathing, through good sleep, through good diet, through being outside playing in the dirt, all the things our kids really need, we can decrease a lot of that negative brain stimulation that they're getting from the screen time and from their awful diets.

I mean, you know, the gut isn't the second brain. It's the first brain. And so much of our neurotransmitters are coming from the gut. So much of our inflammation comes from eating carbs, sugars, processed grains, things like that.

And if we ate more proteins, more real food, more vegetables, more good fiber, we would have a much healthier brain, a much healthier system, not just a healthier gut.

I think that's a great message. You know, it's interesting. My son is in Denmark. And Denmark in the last month just outlawed social media for children under 15 following with Australia did the same thing for about the same age.

And I just, I was thinking back to a patient of mine whose brother kids grew up in America with the devices and everything. And they just moved back to Ecuador and the kids are just totally different people there.

They don't play on their devices, they're out in the nature, they're socializing with friends, but they're on that path to becoming these sort of transhumanist zombie kids that we see now.

I think it's very important, and it's also to your point about COVID and the isolationism and all of that, Social media tends to bring you that which you look at over and over again.

So it's sort of that self-fulfilling prophecy. If you look that this is going to be good, you're going to keep getting the algorithm, right? Yeah, exactly.

And I was blessed. I complained to the headmaster at my son's private school in Honolulu, and Ithaca was very isolated, so they thought they were safe.

So my two sons never had remote learning. They were actually in person, although very restricted. But think about that year or two where people were at home and just the social maturation skills just went to kaput and that term doom scrolling was invented, right?

So why is it doom scrolling? It's because you're scrolling and algo is feeding you stuff, tickling your amygdala, like we're in danger. Danger, danger, yep, exactly.

We kind of had an inflection point in human evolution, don't you think? Absolutely. One of our colleagues, Dr. Elizabeth Mumper, wrote a great book called Kids and COVID, talking about not just COVID and the vaccine, but also about the isolation, the masking, all of the negative effects that that had on our children and the long lasting effects, I think.

Your sons, like you said, were very lucky that they were not as isolated as many others were. Yeah, no, I could see it. Okay, so you have a practice and then so somebody is unfortunately in the remitting relapsing like it came and it sometimes come back.

They can connect with your practice how. Yes, my website is drohara.com. All the information is there. I do a lot of training of other practitioners. I'm happy to talk to any practitioner about this disease or the possibilities that a child may be going through.

I also have a membership where we do monthly teachings, live and recorded, trying to train more educated parents and practitioners about this disease.

I think your point is well taken. I mean, what's good for the goose is good for the gander. If you're eating healthy, if you have good hygiene, exercise, whatever, mental health, sleep, you're going to have less severe and less frequent outbreaks because you're just not in that inflamed state.

You're more vagal. So even if people want to pick up the book, Demystifying Pan's Pandas, there's a lot of stuff you can do for free that will help your child and your lifestyle in general without having to just put out fires, so to speak, in retrospect.

Yeah. And I did record an audiobook version that I included five new chapters, one on COVID, because that was since the book was written, as well as Bartonella, Babesia, cerebral folate deficiency, and mold.

Because those are ones that are often forgotten. I had this consult with this young girl. She was an influencer and she was dealing with Bartonella and Babesia.

And it's interesting when you start to see the patterns, like this immune dysregulation is a common denominator, isn't it? There's many ways to get to it.

But you have these co-infections with Lyme or Bartonella, Babesia and mold. And it's really sad because she was trying to get exosomes to help. And she said her doctor recommended one brand, which I didn't know.

And I said, oh, do you know your doctor's on the board of directors of this brand? She's like, I don't know. So anyway, so she went with that, and she got much worse.

Like her immune suppression, I don't know what happened, but it got to the point where she took her own life at like 23. And she was in such pain. The fear, she was like, oh, I got to get the vaccine.

I got to get the booster. I got to get the third one. And then she just kept having her immune system just kept going down and down and down and then chronic pain.

I mean, not really sad to be so afraid. I mean, she wouldn't even consult with me outside because I was unvaccinated. I mean, that's why they really got her was just this fear, you know?

Yeah. And unfortunately, there are many of our young people who have died by suicide. There's a lot of foundations like the Manful Foundation that are really working to both prevent that, but also study those young people.

And what they found is that tremendous neuroinflammation. in their brains on biopsy. So even when we don't find it in our autoimmune encephalitis panels, we don't find it on regular blood work or any of the other blood work.

The microglial, the microinflammation that's going on in the brain is definitely present. Well, you know, I just feel that there's just so many inadvertent consequences of modern life, you know, and it expands the generations, just the angst about being able to survive and create meaning and not be totally subjugated to this system, let alone like the sort of the several sub messages.

The world is not a safe place. Yeah. And why would you bring children into it? And it's, everything's going to hell in a hand basket. So all these integrated consequences of making pay out of, you know, climate change or, you know, COVID or, you know, politics, it really, the kids are not okay.

The kids are not all right. Cause all they get fed by the algorithm in their peer groups is this incredibly doomsday scenarios. I just feel bad. Like where's the voices trying to make everything more affordable.

You know, trying to do self care, I feel like just the leverage of social media. And tech has made everyone feel a little despondent about their life.

Like, I don't know. It's very sad. Like, the boomers are all set. They got the 401k and their properties, but. I feel like every generation after is just like, how are we going to make it?

It's kind of an existential question. Well, that's why we talk a lot in our practice about the lifestyle changes and about the being outside, about the getting good sleep, about breathing, you know, the old adage of put your own oxygen mask on, you know, before you get your child's.

It's also about the parental stress, the parental anxiety that has to be addressed to help decrease our children's anxiety too. Yeah, no, I just, you know, I just wish they would make it more affordable for people to have children instead of just, you know, having to elect like people like Zoran Vandani who could promise all this stuff, but can he deliver?

I don't think so. So it's, I think that there are a lot of generations that are feeling the stress of not being able to just be like it's survival out there.

They got two, three gig jobs. They're not happy. And so you just project that up and down the generations. It's like, man, who is benefiting from all this scarcity?

People just live, you know? I mean, do your kids worry about being able to make ends meet and buy a house and have a family? I mean, is that a conversation?

Absolutely, absolutely. But also, you know, making positive steps to, you know, live their lives fully. You know, I think it's really important to not lose hope.

And one of the things that can also help is having some type of spiritual practice outside yourself, some type of belief like that. And I think that's helped our kids a lot too.

Yeah. The one good like sort of silver lining is that they're very interdependent in terms of community and supporting each other. And I think that's really great.

Absolutely. Yeah. Well, okay. So the book is Demystifying Pan's Pandas and Dr. Nancy O'Hare at DrO'Hare.com, right? Yes. and a lot of good stuff you can learn for free, and you can also connect if you're a provider, so she's there for you.

All right, well, Nancy, thanks for doing this. Finally, we got it done. Thank you, Ed. I really appreciate it, and good to see you again. Well, I don't want people to leave thinking there's no hope.

There definitely is hope, and I think the most important thing is to take one step you know, remove the social media for one day, get a slightly better diet, a little bit more protein or fiber on another day and get outside.

And there are people that are there to listen and that can help. And I'm training a lot of them. So contact us to get all the people in your area. So.

I love it. Okay, Dr. Herd, thanks so much for joining us. Appreciate it. Thank you. Have a great day. Thanks for tuning into the Recharged Biomedical Podcast.

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Is Your Child’s Sudden OCD or Anxiety Linked to PANS/PANDAS?

Ed Park, MD

Nancy O’Hara, MD, MPH, FAAP

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