What are the symptoms associated with Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS)?

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Last updated: November 8, 2026 • View editorial policy

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PANDAS Symptom Profile

PANDAS presents with abrupt-onset obsessive-compulsive disorder (OCD) or severe eating restriction following group A streptococcal infection, accompanied by at least two additional neuropsychiatric symptoms including tics, anxiety, behavioral regression, hyperactivity, or motor abnormalities. 1, 2

Core Diagnostic Features

The cardinal symptoms that define PANDAS include:

  • Sudden onset of OCD symptoms: Obsessive thoughts and compulsive behaviors that appear dramatically and acutely 1, 3
  • Tics or choreiform movements: Motor tics or mild choreiform (dance-like) movements 1, 2
  • Severe eating restrictions: Acute food refusal or restrictive eating patterns 4, 5

These core symptoms must appear abruptly—not gradually—though only 22% of reported cases actually demonstrate truly sudden onset 6, highlighting diagnostic challenges in real-world practice.

Associated Neuropsychiatric Symptoms

The majority of PANDAS patients (95%) exhibit two or more concomitant neuropsychiatric features 6:

Behavioral and Emotional Symptoms

  • Anxiety and panic attacks (extremely common) 3, 2
  • Depression and emotional lability 3, 7
  • Irritability and aggressive behavior (particularly prominent in PANS subtype) 2
  • Separation anxiety and behavioral regression 7, 5

Cognitive and Attention Symptoms

  • Inattention and hyperactivity 1, 3
  • Difficulties with executive function: Problems with inhibitory control, attentional regulation, and processing speed 3
  • Reduced cognitive efficiency despite average intellectual functioning 3

Motor and Neurological Symptoms

  • Hyperactivity and restlessness 1, 2
  • Graphomotor difficulties: Reduced handwriting skills despite normal dexterity 3
  • Mild choreiform movements affecting coordination 1

Academic and Functional Impact

  • Reading and math fluency deficits despite intact core academic skills 3
  • Significant school difficulties: The majority require special education services or accommodations 3
  • Social skills impairment with ongoing psychosocial challenges 3

Important Clinical Caveats

A critical pitfall: Core diagnostic criteria (OCD, tics, or acute food refusal) were absent in 12% of cases receiving the PANDAS label 6, indicating diagnostic overuse. The temporal association with streptococcal infection is inconsistent—infection was linked to symptom onset or exacerbation in less than one-third of cases 6.

The relationship between neuropsychiatric symptoms in Sydenham chorea and PANS/PANDAS requires further exploration 8, as these conditions share overlapping features but distinct pathophysiology. When evaluating suspected PANDAS, maintain a broad differential including autoimmune encephalitis (anti-NMDAR, anti-D2R), tic disorders, Tourette syndrome, systemic lupus erythematosus, and functional neurological disorders 8.

Symptoms persist beyond acute episodes, with ongoing anxiety, depression, inattention, and social difficulties requiring long-term clinical intervention 3. The significant health care utilization and symptom burden, combined with diagnostic uncertainty between physicians and families 6, underscores the complexity of managing these patients.

References

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