By Daniel A. Kinderlehrer MD

Last month I posted an article on this website describing Diane, a teen-age girl suffering from anorexia nervosa.¹ As it turned out, she had Lyme disease and was co-infected with Babesia, Bartonella and Mycoplasma. She responded well to antibiotics and three years later she still has no evidence of an eating disorder.

Dr. Nancy Brown, a colleague, was in my office during one of Diane’s appointments, and I commented to Nancy, “Wouldn’t it be great if we could test a group of people who suffer from anorexia nervosa for tick-borne infections?”

“Well,” she told me, “I’m the medical consultant at a residential treatment center for adolescents with mental health issues. Let’s see if I can get permission to do this.”

We did receive cooperation from the residential center. In addition, IGeneX Laboratory agreed to test a dozen patients free of charge for Lyme, Bartonella, and tick-borne relapsing fever (TBRF). Moleculera Labs also generously agreed to test our patients with the Cunningham Panel. (The Cunningham Panel is a blood test which measures the levels of circulating autoantibodies associated with certain neurologic and psychiatric symptoms.)

Testing depressed adolescents

It was not difficult to get 10 volunteers at the residential center. None had eating disorders, since the center was not equipped to deal with that, but all 10 were diagnosed with DSM-5 Major Depressive Disorder, seven were additionally diagnosed with Generalized Anxiety Disorder, and three had made serious suicide attempts.

With the exception of one subject previously diagnosed with celiac disease, none had a known physical disorder. All of these teens had severe psychological dysfunction requiring intensive residential treatment—they could not hack it at home or go to school.

Here is what we found²:

• Lyme disease immunoblot was positive by IGeneX criteria for three teens.
• A more liberal interpretation of the test results consistent with analysis by most Lyme docs, indicated nine had antibodies to Lyme.
• Antibodies to Bartonella were detected in three, and borderline positive in a fourth.
• Antibodies to TBRF were detected in four subjects, and borderline positive in another two.
• Antibodies to Streptococcus were detected in three subjects, and borderline positive in a fourth.
• The Cunningham Panel was positive in nine of the 10 teens.

In all likelihood, nine of 10 had antibodies to tick-borne infections. And nine of 10 had evidence of autoimmune encephalitis.

Autoimmune encephalitis is the medical term for ‘Brain on Fire’: inflammation in the brain that can result in serious mood, behavioral and cognitive disorders.

PANS/PANDAS

Susan Swedo at the National Institute of Mental Health first described this condition in children who developed neuropsychiatric symptoms shortly after a strep infection. She termed it Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infections—PANDAS.^3,4

Not long afterwards, it became clear that other microbes besides Streptococcus can trigger autoimmune encephalitis. Hence, the name was broadened to Pediatric Acute-Onset Neuropsychiatric Disorder—PANS.

The microbes that thus far have been shown to trigger PANS include several viruses including Epstein-Barr, the common cold, influenza, and chicken pox as well as Bartonella, Mycoplasma and mold.^5-7

There was a recent report out of Italy describing two boys in whom SARS-CoV-2, the virus that causes Covid-19, triggered PANS.⁸ It is likely, but not definitive at this time, that Borrelia burgdorferi, the Lyme pathogen, also triggers PANS.

In 2013, the PANS collaborative consortium published criteria for the diagnosis of PANS.⁹ These include the sudden onset of obsessive-compulsive disorder (OCD) or severely restricted food intake, without a known medical disorder that would account for these symptoms. In addition, the case definition requires two of the following seven criteria to make the diagnosis:

• Anxiety
• Emotional lability (mood swings) or depression
• Irritability, aggression and/or oppositional behavior
• Behavioral (developmental) regression
• Sudden deterioration in school performance
• Motor or sensory abnormalities including tics and involuntary movements
• Somatic signs and symptoms—like sleep disturbances and bed-wetting

It is important to have clear diagnostic criteria so that researchers studying this condition are always studying the same population of subjects, but not all kids with autoimmune encephalitis will fulfill these criteria. In particular, most of my patients do not have an acute—i.e, sudden—onset of their symptoms. Instead, the onset may be stuttering or slow.

An epidemic of mental illness in adolescents?

According to the National Institutes of Mental Health, nearly one-third of all adolescents ages 13 to 18 will experience an anxiety disorder, and 8% of those will become severely impaired.¹⁰

The NIMH also reported that the prevalence of major depressive disorder in adolescents in 2017 was 13.3%, with nearly three-quarters of those becoming severely impaired.¹¹ Suicide has replaced homicide as the second most common cause of death for teenagers ages 10 to 19 in the United States.¹²

In other words, we have an epidemic of mental illness in adolescents.

Our investigation was small. Ten adolescents picked at random with mental illness severe enough that they required institutionalization—nine of them had evidence of tick-borne infections and nine had evidence of autoimmune encephalitis.

Clearly there is a need for more investigation, but I suspect that many of the teens afflicted with mental illness in the U.S. are suffering from brains on fire. Their illness may present as emotional, but the cause may be organic. In the next installment I will discuss the diagnosis and treatment of PANS.

Dr. Daniel Kinderlehrer is an internal medicine physician with a private practice in Denver, Colorado, devoted to treating patients with tick-borne illness. He is the author of  Recovery From Lyme Disease: The Integrative Medicine Guide to the Diagnosis and Treatment of Tick-Borne Illness.

References

1. https://www.lymedisease.org/lyme-bartonella-eating-disorders/#:~:text=An%20infection%20can%20cause%20an,but%20also%20trigger%20anorexia%20nervosa.
2. Kinderlehrer DA, Brown N. Microbial Induced Autoimmune Inflammation as a Cause of Mental Illness in Adolescents. Global J Med Res. 2021;21(1):1-13.
3. Swedo SE, Leonard HL, Kiessling LS. Speculations on Antineuronal Antibody-Mediated Neuropsychiatric Disorders of Childhood. Pediatrics. 1994Feb1; 93(2):323–6. 39.
4. Swedo SE, Seidlitz J, Kovacevic M, Latimer ME, Hommer R, Lougee L, Grant P. Clinical presentation of pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections in research and community settings. J Child Adolesc Psychopharmacol. 2015 Feb; 25(1):26-30.
5. Breitschwerdt EB, Greenberg R, Maggi RG, Mozayeni BR, Lewis A, Bradley JM. Bartonella henselae Bloodstream Infection in a Boy With Pediatric Acute-Onset Neuropsychiatric Syndrome. J Cent Nerv Syst Dis. 2019Mar18; 11. DOI: 10.1177/1179573519832014.
6. Frankovich J, Thienemann M, Rana S, Chang K. Five Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome of Differing Etiologies. J Child Adolesc Psychopharmacol. 2015; 25(1):31–7. DOI: 10.1089/cap.2014.0056.
7. Tisi G, Marzolini M, Biffi G. Pediatric acute onset neuropsychiatric syndrome associated with Epstein–Barr infection in child with Noonan syndrome. Europ Psychiatry. 2017; 41(Supplement): S456. DOI: 10.1016/j.eurpsy.2017. 01.492.
8. Pavone P, Ceccarelli M, Marino S. SARS-CoV-2 related paediatric acute-onset neuropsychiatric syndrome. Lancet. 2021;5:e19-21.
9. Chang K, Frankovich J, Cooperstock M, Cunningham MW, Latimer ME, Murphy TK, Pasternack M, Thienemann M, Williams K, Walter J, Swedo SE, and from the PANS collaborative consortium. Clinical Evaluation of Youth with Pediatric Acute-Onset Neuropsychiatric Syndrome (PANS): Recommendations from the 2013 PANS Consensus Conference. J Child Adolesc Psychopharmacol. 2015; 25(1):3–13.
10. https://www.nimh.nih.gov/health/statistics/any-anxiety-disorder#:~:text=An%20estimated%2031.9%25%20of%20adolescents,than%20for%20males%20(26.1%25).
11. https://www.nimh.nih.gov/health/statistics/major-depression
12. Curtin SC, Heron M. Death rates due to suicide and homicide among persons aged 10–24: United States, 2000–2017. NCHS Data Brief. 2019Oct;352.