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Case Study: Mack, an 18-Year-Old Male, with Sudden Onset Psychosis, Depression and Suicidal Ideation

While all case studies are based on actual patients, significant aspects of the case have been changed to conceal the patient’s original identity.

Initial Presentation

Mack was an 18-year-old college student who enjoyed sports and was doing well in his classes. He was socially engaged with no previous history of mental illness. Yet two months prior, things rapidly changed when he awoke with feelings of being persecuted and delusions about being under attack. He became convinced that the government was beaming microwaves into his body and was afraid he was going to be thrown in jail for inexplicable reasons.

With the onset of his symptoms, Mack also became severely depressed. His affect flattened and his responses became stiff and wooden. Of even more concern, his mind repeatedly returned to thoughts of suicide.

Due to the severity of his symptoms, Mack had been hospitalized. Several medications were administered without benefit. After three weeks, he was finally discharged with very modest improvements from the antipsychotic medication, risperidone. Yet due to lingering concerns, Mack’s family brought him to their family doctor who ran some additional blood work.

Upon questioning, one of Mack’s close friends had a case of strep throat one week prior to Mack’s symptom onset. The previous summer, Mack had also been bitten by a tick without medical follow-up. There was no history of drug use.

He tested positive for Lyme disease and was started on doxycycline. With the complexity of the case, the family doctor referred Mack for a more thorough integrative medicine workup to help identify other potential causes or underlying factors contributing to his symptoms.

Upon exam, Mack had involuntary muscle movements and muscle weakness. His left arm and hand twitched repeatedly. His left fingers would grasp and release without conscious control. His thyroid was mildly tender to palpation.

Initial Relevant Labs

The following were results from Mack’s hospital stay:

  • TSH was elevated at 5.2
  • Anti-thyroglobulin antibodies were elevated at 173
  • Anti-thyroid peroxidase antibodies were elevated at 182
  • Low vitamin D at 17.5

Additional labs

  • Antistreptolysin O titers were negative
  • Throat culture was attempted, but patient was not compliant with the sample collection procedure

Working Diagnosis

Post-infectious autoimmune encephalitis/pediatric acute-onset neuropsychiatric disorders associated with streptococcus (PANDAS)

Initial Treatment

  • Amoxicillin, 500 mg every 12 hours for suspected strep
  • Ibuprofen, 600 mg three times daily with food
  • Vitamin C, 1000 mg three times daily
  • Curcumin, 500 mg three times daily
  • Probiotic, 1 cap twice per day
  • Vitamin D, 5000 IU daily
  • Continue doxycycline and risperidone


Due to the sudden onset of symptoms without a prior history of mental illness, the likelihood of an underlying biochemical or physiological cause of Mack’s symptoms was quite high. With a positive Lyme disease test and recent exposure to strep, addressing the potentially infectious nature of his condition was paramount. Immune activation is a known component of schizophrenia and was a likely contributing factor to Mack’s sudden onset of symptoms (Mora 2020).

While Mack’s ASO titers—a test for strep exposure—were negative, up to 40% of children with strep infection may test negative (PANDAS 2024). A negative ASO test does not rule out the possibility of a strep infection. Due to the difficulty in getting a throat swab, and the severity of Mack’s symptoms, empiric treatment for strep was prescribed.

Amoxicillin is an effective choice to treat streptococcus, and antibiotics are generally recommended to treat PANDAS (Cooperstock 2017). Non-steroidal anti-inflammatory medications are also known to shorten the acute mental-emotional symptoms associated with the condition (Brown 2017). Rapid treatment targeting the infectious cause and underlying inflammation in cases of PANDAS can decrease the likelihood of chronic, disabling neurological symptoms (Lepri 2019).

Curcumin, probiotics, and vitamin C have well-documented immune-regulating and anti-inflammatory effects (Peng 2021, Maldonado Galdeano 2019, Jafari 2019). The supplements were included to further support Mack’s immune system, decrease inflammation, and improve the chances of recovery.

Hashimoto’s thyroiditis, with elevations of thyroid antibodies, can contribute to psychosis (Gondwal 2021). The condition can also originate from an infectious origin (Shah 2000).

Low vitamin D is commonly associated with psychosis. And while trials of vitamin D in schizophrenia have been mixed, evidence suggests the potential for improvements in symptoms with supplementation (Neriman 2021).

Follow-up Presentation

Follow-up one week later was marked by startling improvements. All psychotic symptoms, depression, and suicidal ideation were gone. Mack’s effect had returned to normal: he smiled and made jokes throughout the medical visit. While the patient’s insight about the severity of his experience was low, he understood that he had experienced a psychotic episode. Mack was adamant that he did not want to re-experience symptoms and was willing to continue treatment.

Upon physical exam, thyroid tenderness had resolved. All signs of uncontrolled twitching and weakness were dramatically improved with just a small hand tremor remaining.

Follow-up Testing

  • Thyroid labs had fully normalized

Follow-up Treatment

  • Continue previous treatments
  • Fish oil, 1 gram daily


Evidence for fish oil in the treatment of psychosis and schizophrenia is somewhat mixed. However, a meta-analysis from 2021 found significant benefits with fish oil supplementation (Goh 2021). In addition, a recent analysis found that fish oil may prevent the transition to psychosis in high-risk individuals (Chen 2024).

Case Summary

While PANDAS is usually thought to occur in children before puberty, case reports in adults exist (Deshmukh 2022, Jory 2024). In addition, psychosis due to Lyme disease with a delayed onset has also been reported (Peixoto 2020). Psychiatric symptoms as a consequence of an infection should be on any differential diagnosis, especially in cases with a rapid onset without a prior history of mental illness. Infections that contribute to a psychiatric condition can be “occult” or hidden (Mufaddel 2014). As a consequence, underlying infections can not be ruled out due to a lack of infectious-type symptoms.

Mack’s case highlights the complexity of mental health diagnoses, their relationship to physiological factors, and the resilience of the brain to recover when those underlying components are addressed properly. Evaluating and treating a patient’s unique biochemistry can yield powerful results. Symptom resolution is more often achievable through this type of comprehensive, whole-person approach. While Mack will need to be followed carefully to prevent relapse, his quick recovery bodes well. Rapid treatment likely prevented a lifetime of neurological problems and mental illness.

Learn more about PANS/PANDAS

If you are interested in learning more about PANS/PANDAS, join us for our virtual conference Psychiatry Reimagined, a Functional and Integrative Medicine event for mental health on June 22-23. Dr. Nancy O’Hara, MD, MPH, FAAP will be a keynote speaker.

She has dedicated her functional medicine practice to the integrative and holistic care of children with chronic illness and neurodevelopmental disorders such as ADHD, PANDAS/PANS, OCD, Lyme, and ASD.

She is also a leader in the training of clinicians in the United States and abroad. Dr. O’Hara has written a comprehensive guidebook, “Demystifying PANS/PANDAS: A Functional Medicine Desktop Reference on Basal Ganglia Encephalitis”

Click here to register for the conference.

Want to learn new interventions like these to help your patients? Don’t miss our 2024 virtual conference on functional medicine for mental health!

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Brown KD, Farmer C, Freeman GM Jr, et al. Effect of Early and Prophylactic Nonsteroidal Anti-Inflammatory Drugs on Flare Duration in Pediatric Acute-Onset Neuropsychiatric Syndrome: An Observational Study of Patients Followed by an Academic Community-Based Pediatric Acute-Onset Neuropsychiatric Syndrome Clinic. J Child Adolesc Psychopharmacol. 2017;27(7):619-628. doi:10.1089/cap.2016.0193

Chen C, Deng Y, Li Y, et al. Network meta-analysis indicates superior effects of omega-3 polyunsaturated fatty acids in preventing the transition to psychosis in individuals at clinical high-risk. Int J Neuropsychopharmacol. Published online February 26, 2024. doi:10.1093/ijnp/pyae014

Cooperstock MS, Swedo SE, Pasternack MS, Murphy TK. Clinical Management of Pediatric Acute-Onset Neuropsychiatric Syndrome: Part III-Treatment and Prevention of Infections. J Child Adolesc Psychopharmacol. 2017;27(7):594-606. doi:10.1089/cap.2016.0151

Deshmukh RP, Mane AB, Singh S. PANDAS in an Adult? A Case Report. Ind J Priv Psychiatry 2022;16(1):44–45.

Goh KK, Chen CY, Chen CH, Lu ML. Effects of omega-3 polyunsaturated fatty acids supplements on psychopathology and metabolic parameters in schizophrenia: A meta-analysis of randomized controlled trials. J Psychopharmacol. 2021;35(3):221-235. doi:10.1177/0269881120981392

Gondwal R, Avinash PR, Pal A, Modi S. Psychosis as acute presentation in Hashimoto’s thyroiditis. Indian J Psychiatry. 2021;63(3):302-304. doi:10.4103/psychiatry.IndianJPsychiatry_232_20

Jafari D, Esmaeilzadeh A, Mohammadi-Kordkhayli M, Rezaei N. Vitamin C and the Immune System. In: Mahmoudi M, Rezaei N. eds Nutrition and Immunity. Springer, Cham. 2019. https://doi.org/10.1007/978-3-030-16073-9_5

Jory J, Handelman K. Sudden-Onset Acute Obsessive-Compulsive Disorder Associated with Streptococcus and Brain MRI Hyperintensity in a Young Adult. Healthcare (Basel). 2024;12(2):226. Published 2024 Jan 16. doi:10.3390/healthcare12020226

Lepri G, Rigante D, Bellando Randone S, et al. Clinical-Serological Characterization and Treatment Outcome of a Large Cohort of Italian Children with Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection and Pediatric Acute Neuropsychiatric Syndrome. J Child Adolesc Psychopharmacol. 2019;29(8):608-614. doi:10.1089/cap.2018.0151

Maldonado Galdeano C, Cazorla SI, Lemme Dumit JM, Vélez E, Perdigón G. Beneficial Effects of Probiotic Consumption on the Immune System. Ann Nutr Metab. 2019;74(2):115-124. doi:10.1159/000496426

Mora S, Martín-González E, Flores P, Moreno M. Neuropsychiatric consequences of childhood group A streptococcal infection: A systematic review of preclinical models. Brain Behav Immun. 2020;86:53-62. doi:10.1016/j.bbi.2019.02.027

Mufaddel A, Omer AA, Salem MO.. Psychiatric Aspects of Infectious Diseases. OJPsych. 2014;4(3). doi:10.4236/ojpsych.2014.43027

Neriman A, Hakan Y, Ozge U. The psychotropic effect of vitamin D supplementation on schizophrenia symptoms. BMC Psychiatry. 2021;21(1):309. Published 2021 Jun 15. doi:10.1186/s12888-021-03308-w

PANDAS Physician Network. PANDAS Diagnostic Guidelines. Accessed March 8, 2024. https://www.pandasppn.org/pandas/

Peixoto MJ, Timóteo S, Moreira I, et al. Psychosis and/or Lyme disease: There is more than meets the eye. European Psychiatry. 2017;41(S1):S698-S699. doi:10.1016/j.eurpsy.2017.01.1234

Peng Y, Ao M, Dong B, et al. Anti-Inflammatory Effects of Curcumin in the Inflammatory Diseases: Status, Limitations and Countermeasures. Drug Des Devel Ther. 2021;15:4503-4525. Published 2021 Nov 2. doi:10.2147/DDDT.S327378

Shah SS, Baum SG. Diagnosis and Management of Infectious Thyroiditis. Curr Infect Dis Rep. 2000;2(2):147-153. doi:10.1007/s11908-000-0027-7

Nancy O’Hara, MD, MPH, FAAP

If you are interested in learning more about PANS/PANDAS, join us for our Psychiatry Reimagined virtual conference, a Functional and Integrative Medicine event for mental health on June 22-23. Dr. Nancy O’Hara, MD, MPH, FAAP will be a keynote speaker.

Since 1999 Dr. O’Hara has dedicated her functional medicine practice to the integrative and holistic care of children with chronic illness and neurodevelopmental disorders such as ADHD, PANDAS/PANS, OCD, Lyme and ASD. She is also a leader in the training of clinicians, both in the United States and abroad. Dr. O’Hara has written a comprehensive guidebook, “Demystifying PANS / PANDAS: A Functional Medicine Desktop Reference on Basal Ganglia Encephalitis”, which is available on Amazon in e-book or soft-cover formats. For more information on her membership and mentoring program, visit www.drohara.com.