As nurse educators and mental health advocates, we believe it is essential to spotlight misunderstood conditions that often straddle the line between medical and psychiatric care or lesser-known medical conditions that can easily be misdiagnosed, especially in children. One such condition is PANS/PANDAS, where infections can trigger sudden neuropsychiatric symptoms that mimic mental illness. This article examines the growing body of evidence surrounding this syndrome and the crucial role nurses play in recognizing early signs and advocating for appropriate care.
In 1998, Dr. Susan Swedo and colleagues described an unsettling cluster of 50 children whose lives unraveled after a common infection. Among them was a teenage boy, ”now referred to as “Patient Zero”, who, just days after recovering from strep throat, suddenly spiralled into a world of fear, food refusal, and obsessive rituals. One week, he was playing soccer; the next, he was scrubbing his hands raw and screaming that his food was poisoned.
After antibiotic treatment, his symptoms dramatically improved, only to return during his next strep infection. This waxing and waning cycle revealed a powerful truth: the infection had likely triggered the immune system to attack his basal ganglia, a region of the brain involved in emotion and movement.
The condition was coined PANDAS: Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections.
The Shift to PANS: Beyond Strep
As awareness grew, researchers began noticing similar symptoms in children without strep infections. Some were triggered by Lyme disease, mycoplasma, influenza, or even environmental exposures. This led to a broader diagnosis: PANS (Pediatric Acute-onset Neuropsychiatric Syndrome) a clinical condition where sudden neuropsychiatric symptoms emerge from various non-streptococcal sources.
A once cheerful girl in Illinois began hitting herself and repeating phrases for hours after a common cold. In Maryland, a boy started hoarding garbage, terrified his thoughts might harm his parents. Neither had strep. Both had PANS.
A Misunderstood Crisis
Many doctors were and still are skeptical. Without clear diagnostic tests and with overlapping psychiatric symptoms, children were misdiagnosed with OCD, bipolar disorder, autism, or psychosis. They were often medicated, hospitalized, or even institutionalized.
Parents were dismissed. One mother was reported for Munchausen syndrome by proxy after asking about IVIG treatment for her daughter’s sudden regression.
Yet, immune-based treatments such as intravenous immunoglobulin (IVIG), plasmapheresis, and steroids have shown dramatic results in documented cases. One child regained speech after a single round of steroids. Another stopped self-harming within days of IVIG therapy.
The Nursing and Cultural Implications
For nurses, the challenge lies in recognising subtle neuropsychiatric shifts, advocating for the child’s voice, and navigating between psychiatric care and medical investigation. Nursing is often the first discipline to observe when “something just doesn’t feel right,” and in PANS/PANDAS cases, that intuition may be life-changing.
These syndromes force us to rethink mental illness not as a standalone entity, but potentially as a misdirected immune event. As autoimmune conditions like lupus and multiple sclerosis are understood and accepted, so too must we embrace the possibility that psychiatric symptoms can have immunological roots.
NCLEX-Style Question
A 23-year-old client newly diagnosed with schizophrenia is admitted to the psychiatric unit after being found wandering and responding to unseen stimuli. The client is disoriented, appears fearful, and repeatedly states, “They’re coming to take me.” The nurse’s initial priority should be:
A) Establish a trusting therapeutic relationship by offering frequent, brief interactions.
B) Reorient the client to reality and provide structured activities during the day.
C) Assess the client’s level of risk for harm to self or others.
D) Administer prescribed antipsychotic medication to manage psychotic symptoms.
Correct Answer: C) Assess the client’s level of risk for harm to self or others.
Rationale:
While all of the listed interventions are appropriate in psychiatric nursing care, assessing for risk of harm is always the highest priority. The client is exhibiting active psychosis (responding to hallucinations and expressing paranoia), which places them at risk of self-harm, harm to others, or elopement. According to Maslow’s hierarchy and safety principles, physiological and safety needs must be addressed before therapeutic relationships or medications.
- Option A is therapeutic and important, but not the immediate priority until safety is confirmed.
- Option B assists with disorientation and cognitive support, but reality orientation can exacerbate agitation if not administered correctly.
- Option D is an appropriate intervention after a full assessment, but giving medication without ruling out acute risk or medical contraindications first is not safe nursing practice.
Swedo, S. E., Leonard, H. L., Garvey, M., Mittleman, B., Allen, A. J., Perlmutter, S., Dow, S., Zamkoff, J., Dubbert, B. K., & Lougee, L. (1998). Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections: Clinical Description of the First 50 Cases. The American Journal of Psychiatry, 155(2), 264–271. https://doi.org/10.1176/ajp.155.2.264
Chang, K., Frankovich, J., Cooperstock, M., Cunningham, M. W., Latimer, M. E., Murphy, T. K., Pasternack, M., Thienemann, M., Williams, K., Walter, J., & Swedo, S. E. (2015). Clinical Evaluation of Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Recommendations from the 2013 PANS Consensus Conference. Journal of Child and Adolescent Psychopharmacology, 25(1), 3–13. https://doi.org/10.1089/cap.2014.0084