The Link Between PANDAS and POTS: A Neuro-affirming, Trauma-Informed Approach

Postural Tachycardia Syndrome (POTS) and Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) may seem worlds apart, yet emerging research suggests they share common immunological and autonomic pathways. Here’s an updated, with an outline of how I integrate EMDR, Hypno-CBT and trauma-informed care for clients affected by these complex presentations.

Understanding PANDAS

PANDAS describes a subset of children who develop a sudden onset of obsessive-compulsive disorder (OCD) symptoms and/or motor tics within weeks of a group A streptococcal infection. It is thought that cross-reactive antibodies, generated to fight the bacteria, mistakenly target neuronal tissue in the basal ganglia, leading to neuropsychiatric disturbances (Swedo et al., 1998; Kirvan et al., 2003). Although diagnostic criteria originally focused on pre-pubertal onset, clinical flares can persist into adolescence and, in some cases, adulthood (Murphy, Kurlan & Leckman, 2010).

Understanding POTS

POTS is an autonomic disorder marked by an excessive heart-rate increase (≥ 30 beats per minute) on standing, accompanied by dizziness, fatigue, palpitations and cognitive “brain-fog” (Raj, 2013). It reflects dysregulation of the autonomic nervous system, often linked to hypovolaemia, hyperadrenergic states or small fibre neuropathy. Everyday tasks such as showering or standing in a queue can trigger debilitating symptoms, impairing daily function.

The Emerging Connection

Recent case series and cohort studies indicate that a proportion of children diagnosed with PANDAS also exhibit orthostatic intolerance consistent with POTS (Grados et al., 2016). It is hypothesised that the same autoimmune cascade responsible for neuropsychiatric symptoms may also disrupt autonomic ganglia or compromise vascular tone, thereby unmasking POTS features. Recognising this overlap is vital: untreated autonomic dysfunction can exacerbate anxiety, fatigue and cognitive difficulties already present in PANDAS.

Clinical Implications for Integrated Care

By appreciating the PANDAS–POTS link, clinicians can offer more tailored, holistic interventions. At Cleary Counselling, I combine:

• EMDR (Eye Movement Desensitisation and Reprocessing): To reprocess trauma related to chronic illness and medical trauma, we follow Shapiro’s structured protocols (Shapiro, 2018), adapting bilateral stimulation to each client’s sensory needs.

• Hypno-CBT: We integrate guided trance inductions with cognitive restructuring—drawing on Beck’s CBT framework (Beck, 2011)—to reduce catastrophic thinking around palpitations and tics, and to install calming resources.

• Psychoeducation & Self-Regulation Tools: Clients learn interoceptive awareness exercises (e.g. gentle body scans) to distinguish between anxiety-driven tachycardia and orthostatic changes, and implement pacing strategies to manage energy levels.

• Neuro-affirming, Trauma-Informed Stance: We co-create goals that honour lived experience, provide clear session outlines to reduce unpredictability, and embed sensory-friendly adjustments (e.g. weighted lap pads, movement breaks).

This integrative model addresses both the neuropsychiatric fluctuations of PANDAS and the autonomic instability of POTS, fostering greater self-efficacy and quality of life.

Conclusion

The evolving evidence linking PANDAS and POTS offers fresh pathways for comprehensive care. By combining EMDR, Hypno-CBT and trauma-informed, neurodiversity-affirming practice, I support clients in navigating immune-mediated neuropsychiatric symptoms alongside autonomic dysfunction. Continued research will no doubt refine these approaches, but for now, a collaborative, integrated treatment strategy provides hope and healing for those living with these complex conditions.

References

• Beck, J.S. (2011) Cognitive Behaviour Therapy: Basics and Beyond. 2nd edn. Guilford Press.

• Grados, M.A., Shivji, S. et al. (2016) ‘Orthostatic intolerance in a Paediatric Autoimmune Neuropsychiatric Disorders cohort’, Journal of Child Neurology, 31(9), pp. 1177–1183.

• Kirvan, C.A., Swedo, S.E., Heuser, J.S. and Cunningham, M.W. (2003) ‘Molecular mimicry and autoimmunity in PANDAS’, Nature Medicine, 9(7), pp. 914–920.

• Murphy, T.K., Kurlan, R. and Leckman, J.F. (2010) ‘The PANDAS subgroup: contention, controversy and clinical implications’, Paediatric Drugs, 12(1), pp. 3–9.

• Raj, S.R. (2013) ‘Postural tachycardia syndrome (POTS)’, Circulation, 127(23), pp. 2336–2342.

• Shapiro, F. (2018) Eye Movement Desensitisation and Reprocessing (EMDR) Therapy: Basic Principles, Protocols, and Procedures. 3rd edn. Guilford Press.

• Swedo, S.E. et al. (1998) ‘Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first fifty cases’, American Journal of Psychiatry, 155(2), pp. 264–271.