强迫症是细菌引起的吗？--谈谈强迫症的细菌学说

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为了保证翻译文章的准确与文风一致，我还是继续进行翻译。谢谢hust-mrzhoud的热情帮忙。

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儿童的强迫思维与强迫动作在表现上有明显的千差万别，这个事实，让ocd（强迫症）的确诊很难。一些患者不停的洗手或者是坚持不断的上厕所或者不停的检查以确保门关上和锁好了。一些发展成完全的分离性焦虑或者是担心伤害别人和做出一些出格的事情。

有些孩子在第一次发病时有上述的某些症状，然而在下一次发病的时候可能出现一些另外的症状。将近一半的患者抱怨有关节痛，但并不是总有咽喉炎。他们烦躁，固执与情绪无常。他们还有一些所谓的坏念头，比如：性，暴力，和一些令人恐惧的想法。这些东西缠绕脑间，无法摆脱。

经过检查证明这些孩子最近有被链状球菌所感染历史——检查方法要么是通过他们的咽喉细菌培养来发现活动感染源，或者是通过验血来测量感染之后血液中残留下来的抗体。如果孩子发病的时间已经太长，上面二种检查可能无效，研究人员会从患者追问过去的链球菌感染史。研究发现，患者中感染链球菌的比例相 当高。

分歧是推动科学的动力，证明与否定是走上共识的必经历程。哥白尼的理论，行星绕太阳公转，直到他死很久以后才被完全接受。毕达哥拉斯和亚里士多德都认为世 界是圆的，但这种想法历时多个世纪仍然没有被广泛接受。伊格纳兹•塞梅尔魏斯博士遭到嘲笑和排斥，仅仅是因为提出“医生通过简单的洗手可以防止妇女在分娩期间死亡”这 一如今看来再科学不过的建议。这一建议比路易斯巴斯德和约瑟证实的“消灭细菌可以阻止疾病传播”这一结论早了1/4世纪。最近，医生进 行的脑部手术似乎可以有效的阻止帕金森病的恶化，骨髓移植似乎能治疗乳腺癌。但进一步研究发现初始数据是过于乐观，让令人兴奋的理论便变得黯淡。或许关于儿童强迫症的讨论最重要的是，多年来链球菌已被提出是多种疾病的病因之一，包括川崎病，但随后的研究否定了这一点。

The exact nature of the obsessions and compulsions differed from child to child (a fact that makes all O.C.D. tricky to diagnose). Some could not stop washing their hands or insisting they needed to use the toilet or checking to make sure that doors were closed and locked. Some developed overwhelming separation anxiety or worried that they would harm someone or do something wrong.

Some had one cluster of these symptoms during their first episode and a different set of symptoms the next time around. Nearly half complained of joint pain, but not always of a sore throat. They were fidgety and moody and obstinate. They had ''bad thoughts,'' some sexual, some violent, some frightening, that they could not get out of their heads.

The children were then tested for evidence that they had recently had strep -- either via throat culture, which would find active infection, or by a blood test that measures antibodies remaining after the actual infection is gone, or, when the episode was too long ago for either test to be effective, researchers asked about a remembered history of strep. In a striking percentage of cases, the search for strep came up positive.


Disagreement is what propels all of science. Proof and disproof seems almost a requirement on the road to consensus. Copernicus's theory that the planets revolve around the sun was not fully accepted until long after his death. Pythagoras and Aristotle each suggested that the world was round, but the idea was not widely accepted for many centuries. Dr. Ignaz Semmelweis was mocked and ostracized for suggesting that by simply washing their hands, doctors could prevent women from dying during childbirth. It would be another quarter-century before Louis Pasteur and Joseph Lister confirmed that destroying germs stops the spread of disease. Much more recently, doctors were exuberant when brain surgery seemed to halt the progression of Parkinson's disease and bone-marrow transplants seemed to beat back breast cancer. But the excitement dimmed as further study found the initial data to be overly optimistic. Perhaps most significant to the discussion of Pandas, strep has been proposed as the cause of a number of conditions over the years, including Kawaski disease, but subsequent studies have repudiated the theories.

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“医学史上的这些例子比比皆是” 哥伦比亚大学的医疗历史学家巴伦博士说。对事实的描述后来证明是谬误，而一些奇思异想后来变成事实，许多理论在两者之间的不确定阴影中反弹了几十年。 “有时候大家确定的东西，结果并不是那样。”

在90年代后期，苏珊和她的合作者发表了几个小的初步研究，他们的第一篇主要的研究文章声称，儿童强迫症是一个独立的综合征，发表在美国精神病学杂志上面。文章标题是：“与链球菌感染相关的儿童自身免疫性神经精神障碍：50例临床调查”，文章认为，儿童强迫症的孩子发病的确是在感染A型链球菌后。

在某种程度上，儿童强迫症既然分类为与链球菌有关的疾病，因此诊断的标准应该是那些近期有链球菌感染的孩子。苏珊从109个起病急骤的病例中选出50个符合她的儿童强迫症诊断标准的孩子，这意味着，另外59例患者发病是因为咽喉炎以外的东西。她认为结果很重要，因为有近50％病例与链球菌相关，这样的发病率远远高于总人口中的预计，有统计学的显著意义。但她同意，她的调查结果并不能解释所有强迫症的原因，甚至一些起病急骤的强迫症。

''The history of medicine is full of these examples,'' says Dr. Barron Lerner, a medical historian at Columbia University Medical Center, describing fact later shown to be quackery, flights of fancy that turn out to be fact and many ideas that bounce for decades in the shades of gray between the two. ''What looks like it's there sometimes turns out not to be there,'' Lerner says, ''and what everybody is sure of sometimes turns out not to be certain.''

Swedo and her collaborators published several small preliminary studies during the late 90's, and their first major paper claiming that Pandas was a separate syndrome appeared in 1998 in The American Journal of Psychiatry. Called ''Pediatric Autoimmune Neuropsychiatric Disorders Associated With Streptococcal Infections: Clinical Description of the First 50 Cases,'' it is exactly that, a description of children who develop O.C.D. after exposure to Type A strep.

In a way, the description is a tautology -- Pandas is classified as O.C.D. associated with strep, and therefore the only children who qualify for the diagnosis are those who have had recent strep. Swedo took the 109 rapid-onset cases and narrowed those to 50 that met her Pandas criteria, which means that 59 cases were triggered by something other than strep throat. She considers the results important, because at nearly 50 percent, the incidence of strep is far higher than would be expected in the general population and therefore statistically significant. But she agrees that her findings do not explain the cause of all O.C.D., or even all rapid-onset O.C.D.

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尽管新理论仍然悬而未决，儿童强迫症的理论的存在还是吸引很多医生的眼球。他们看到了它内在的逻辑，至少给这个在诊所出现的神秘的疾病一个名称。塔马是专门从事儿童焦虑症研究的儿童心理学家，著有“让你的孩子摆脱强迫症''一书，他说，“在我看来，是毫无疑问的。”

塔马说，新理论不仅是真实的，她还治疗几个儿童强迫症患者。但她也注意到，儿童强迫症每次发作往往比前一次更加严重，除非对这些儿童进行预防链球菌的治疗，否则他们的强迫症的发作可能会更长，更激烈，更频繁。

“是的，它是有争议的，但我相信它是真实的。”阿兹拉博士，她遇到的第一个儿童强迫症病人莫里，就在2003年将士纪念日之前。莫里当时6岁，开始是咽喉炎患者，用抗生素治疗。但是不久的一天早上，她的母亲米歇尔，也是一名护士，发现莫里开始出现怪异行为。莫里，一位从不担心病菌的女孩，开始不断的洗手，这是强迫症最常见的症状。

Despite the details still up in the air, the existence of Pandas was compelling to many doctors. They saw it as inherently logical, and it gave a name to some otherwise mysterious cases that passed through their waiting rooms. ''There is no doubt in my mind,'' says Tamar Chansky, a child psychologist specializing in childhood anxiety disorders and the author of ''Freeing Your Child From Obsessive Compulsive Disorder,'' which devotes a long section to recognizing Pandas.

Not only is it real, says Chansky, who treats several patients who suffer from the disorder, but she has also noticed that each episode is often worse than the one before, creating the possibility that unless these children are treated prophylactically for strep, their O.C.D. episodes could be longer, more intense and more frequent.

''Yes, it is controversial, but I believe it is real,'' agrees Dr. Azra Sehic, a pediatrician in Kingston, Pa. One of the first times Sehic encountered Pandas was when she saw it in one of her patients, Maury Cronauer. Just before Memorial Day in 2003, when she was 6, Maury became ill with strep throat. She was treated with antibiotics and one morning soon after started acting ''odd,'' says her mother, Michelle, who is a nurse. A girl who never worried much about germs, Maury started washing her hands constantly, the most common symptom of O.C.D.

慎闻

细菌学说，一家一言，具体治疗，听从医嘱。

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到了第二天，莫里变得歇斯底里，说可怕的想法在她脑子里盘旋。她不知道是否还爱她的父母。她害怕在学校会有作弊或偷东西。她想把这些可怕的想法赶走。有一次，她的父母发现她蜷缩在洗衣房的角落，紧闭着眼睛，并且用双手捂住她的耳朵。

阿兹拉博士对莫里的父母说，链球菌可能是导致她症状的原因，并且让她服用长期的抗生素，以消除体内挥之不去的链球菌，这些残存的细菌可能激发身体不断制造有害的抗体。

治疗后O.C.D.强迫症消失了。但是一年半后，莫里又感染链球菌咽喉炎，强迫症重新返回。医生现在给她采取预防性的青霉素（注：这里的青霉素是总称，实际上有许多种类，他们通常服用的是一种特殊的青霉素）治疗，这种做法目前也有争议。 “我们无法肯定这种方法会帮助她，但很可能有助于防止强迫症复发，我们正在努力。” 阿兹拉博士说。

By the next day she was hysterical, saying horrid thoughts were in her head. She wasn't sure she loved her parents. She thought she was going to cheat at school or steal something. She wanted the racing thoughts to go away, and at one point her parents found her curled in a ball in the laundry room, her eyes crammed shut and her hands over her ears.

Sehic mentioned to Maury's parents that the strep might be the cause of her symptoms. She prescribed a longer course of antibiotics, to eliminate any lingering strep bacteria, which might signal the body to create more antibodies.

The O.C.D. went away. A year and a half later, Maury got strep throat again, and the O.C.D. symptoms returned. She is now taking prophylactic penicillin, an approach that is also controversial. ''It is not proven that it will help her, but it is likely that it will, so we are trying,'' Sehic says.

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随着儿童强迫症渐渐为众人所知，一些医生也开始首先使用抗生素治疗强迫症，于是有越来越多的研究正在进行。苏珊在1998年和2005年之间，总共发表了30多篇关于儿童强迫症的文章。在全美国其他实验室也在进行这方面研究，并有几十篇文章发表。

其中有些文章只是确认苏珊描述的强迫症亚型的存在。另外一些研究则把对儿童强迫症认知带到一个新的水平 —— 即从描述到证明。苏珊所做的研究是确定一组疾病中发生的两件事情是真实的：即强迫症突然发生与孩子们最近链球菌感染的存在。但是，这并不证明链球菌是导致强迫症的原因。几乎所有的科学都是一个因果关系的研究——即A导致B发生，而C导致B停止。

一切科学的祸根是巧合。例如，相当高百分比的儿童接种疫苗后发展成为孤独症，于是人们试图把接种疫苗归咎于儿童自闭症原因。但是，通常自闭症显示症状的年龄期间恰好是孩子们常规免疫接种的年龄。所以正好，这两个事件将被暂时联系起来了。

As Pandas was becoming widely known, and as doctors began using antibiotics as a first salvo against obsession, there was ever more research under way. Swedo was a co-author of 30 journal articles between 1998 and 2005. Across the country other lab groups took up the subject as well, and there are dozens more publications in which Swedo played no role.

Some of these merely confirmed the existence of the subgroup Swedo had described. Other studies were designed to take knowledge of Pandas to the next level -- from description to proof. What Swedo had done was identify a group in which two things were true: O.C.D. developed suddenly, and the children had evidence of recent strep. But that does not prove that the strep caused the O.C.D. Nearly all of science is a search for cause and effect -- that A made B happen, that C made B stop.

The bane of all science is coincidence. For example, a notable percentage of children develop their first signs of autism soon after a vaccination, and it is tempting to blame the shot for the symptoms. But autism as a rule tends to show itself during the years when children are also scheduled to receive fairly regular immunizations. So the odds are good that the two events will be temporally linked.

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要从相关性中分离出因果关系来，使得任何一个研究的道路变得十分坎坷。 “这比我们想象将要更为复杂得多。”拉波特说。

现在已经有的一些研究结果或许让答案逐渐鲜明 ——比如， 血浆置换试验，又称治疗性血浆置换，本质上是一种清洁血液的过程，有点像血液透析。苏珊推理，如果体内的抗链球菌抗体导致儿童强迫症O.C.D.发生，当从血液中清除这些抗体以后，患者症状应及时改善。

因为这种治疗是一种侵入性治疗，所以只招收那些病情最坏的患者儿童。在接受实验治疗的29名儿童中，其中10例接受了血浆置换，9列接受了静脉注射免疫球蛋白治疗，另外还有10接受安慰剂治疗，作为对照。治疗结果发表在1999年的“柳叶刀”杂志，那些接受血浆置换治疗的患儿症状有了明显好转，而那些接受安慰剂治疗没有效果。

Separating correlation from causation is where every research road becomes bumpy. ''It's been more complicated to follow up on this than we ever thought it was going to be,'' Rapoport says.

There have been studies with results that were remarkably clear-cut -- the plasmapheresis trials, for instance. Plasmapheresis, also known as therapeutic plasma exchange, is essentially a cleansing of the blood, somewhat like dialysis. If strep antibodies were responsible for O.C.D. symptoms in Pandas patients, Swedo theorized, then clearing those antibodies from the bloodstream should prompt improvement.

Because the procedure is so invasive, the only subjects enrolled were those in the worst shape. Of the 29 children in the trial, 10 received plasma exchange, 9 received intravenous immunoglobulin and 10 received a placebo. According to the results published in the journal Lancet in 1999, the children receiving plasma exchange became markedly better, while those receiving placebo treatment did not.

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另外一些研究结果则有些模糊不清。一个实验用来测试这样的理论，即可以通过预防链球菌感染来预防儿童强迫症。单纯的治疗链球菌并无法阻止儿童强迫症，因为链球菌抗体已经在体内形成。这是一个证明链球菌引起风湿热的方式。当风湿热的患者每天服用抗生素时，链球菌无法感染他们，从而阻止了风湿热复发。同样，假设如果链球菌会引起儿童强迫症，那么预防患者的链球菌感染应该可以防止儿童强迫症的复发。

因此，苏珊进行了预防的研究。一组儿童强迫症患者中有一半是每天预防性服用抗生素，而另一半服用安慰剂。几个月后，安慰剂组和抗生素组进行对换。如果预防治疗有效，那么患者在服用安慰剂时应该比服用抗菌素的时候出现更多，更加强烈的强迫症的发作。

但这项研究选择了抗生素液体，而不是片剂，这样很难让患儿家长确切记录某次的剂量是否已经错过了。因为即使漏服一次的剂量也会孩子易受链球菌感染。这样，一些服用抗生素的儿童也发生了感染，一定百分比的孩子出现了强迫症复发。



                    Other studies had results that were somewhat murkier. One tested the theory that you could prevent Pandas by preventing strep. Simply treating strep does not prevent the onset of Pandas since the antibodies have already had a chance to form, which leaves prophylaxis as the most promising form of treatment. That is one way strep was first proved to cause rheumatic fever. When patients who had had rheumatic fever were given daily antibiotics, they did not get strep and they did not get a recurrence of rheumatic fever. Similarly, the hypothesis went, if strep causes Pandas, then preventing patients from getting strep would also prevent a recurrence of an episode of Pandas.        
                                        So Swedo conducted a prophylaxis study. Half of a group of Pandas patients was put on daily doses of prophylactic antibiotics, while the other half was given a placebo. After several months, the placebo and antibiotic groups were switched. If prophylaxis works, then patients should have developed more, and more intense, episodes of O.C.D. while they were taking the placebo than while taking the antibiotics.        
                                        But the antibiotic chosen for this particular study was a liquid, and unlike the case with pills, which can be counted, it was difficult for parents to keep track of whether a dose had been missed. Even one missed dose would leave a child vulnerable to strep, and some children in the antibiotic group did get sick. A percentage of those developed Pandas.

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与此同时，当在安慰剂组的儿童病倒时，他们的父母明白了，他们孩子服用的一定是安慰剂——白糖水，因为担心喉咙痛会导致强迫症复发，于是偷偷使用了青霉素。这样，作为对照组的孩子并没有出现预测中那么多的链球菌感染与强迫症复发。

“我了解了很多父母的行为，但遗憾的不是关于儿童强迫症。” 苏珊说。


罗切斯特大学的神经学教授罗杰发出不同声音： “关于儿童强迫症唯一能够证明的事实是，已经观察到这些儿童有这些症状。其他的东西，特别是关于链球菌引起的症状的作用，只不过是臆测。“

罗杰和他的合作者，明尼苏达大学医学院的专家爱德华，一个链球菌方面的专家，对 苏珊的理论提出了最强烈的批评。他们认为链球菌和强迫症O.C.D.这两件事情，是“真实，非常真实的，但是没有关系。”的确，有些孩子的强迫症起病急骤，也的确有很高比例的出现链球菌测试阳性。但是，这并不意味着，强迫症是由链球菌引起的。

At the same time, when children in the placebo group became ill, their parents figured out that what they had been dispensing was sugar water and, fearing that the sore throat would lead to a return of Pandas, went and got a prescription for penicillin. Not nearly as many of the control group got strep or Pandas as had been predicted.

''A lot was learned about parental behavior,'' Swedo says, ''but not a lot about Pandas.''


Roger Kurlan, a professor of neurology at the University of Rochester School of Medicine and Dentistry, is not a man who minces words. ''The only thing that's a proven fact about Pandas,'' he says, ''is that children with these symptoms have been observed.'' Everything else, most specifically the role of strep in causing the symptoms, ''is nothing but speculation.''

Kurlan and his collaborator Edward L. Kaplan, an expert in strep at the University of Minnesota Medical School, have become Swedo's most vocal critics. They describe strep and O.C.D. as two things that are ''true, true and unrelated.'' Yes, it is true that some children develop rapid-onset O.C.D. And yes, it is true that a high percentage of those test positive for strep. But that does not mean that the former is caused by the latter.

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这些医生说, 链球菌出现在儿童强迫症的孩子身上，一个更有可能的解释是，任何感染，事实上任何类型的压力，都可能会导致强迫症的行为的突发。他们举出儿童秽语综合征为证，这些孩子经常有强迫症，随着压力而出现症状的起伏。

罗杰说，有神经系统疾病的儿童“对任何事物都敏感， 比如他们的狗死了，他们的父母吵架，都会刺激他们的症状。我看到强迫症O.C.D.的孩子因为感冒，花粉症，肺炎等原因而加重。如果认为链球菌有什么特殊的，我不认为有人能够发现。”

他说，是的，有些孩子出现症状是比其他人更突然，但这可能是因为他们在他们父母面前隐蔽了他们的早期症状，我们都知道强迫症患者会这样做。没错，他同意，经过链球菌测试和一个疗程的抗生素治疗，患者症状往往会改善。但由于强迫症O.C.D.是周期性的，即使他们未经试验和药物治疗，症状可能也会改善。另外，有些儿童本身就是链球菌带菌者，任何时候对他们进行细菌培养都可能是阳性，这进一步让因果关系的研究扑朔迷离。

A more likely explanation for the presence of strep in children with Pandas, these doctors say, is that any infection, in fact any type of stress, can cause spikes in O.C.D. behavior. And they cite as an example children with Tourette's syndrome, who frequently have O.C.D. symptoms that ebb and flow with stress.

Children with neurological disorders ''are sensitive to any number of things,'' Kurlan says. ''If their dog dies. If their parents are fighting. I've seen O.C.D. get worse with a cold, with hay fever, with pneumonia. If there is anything special about strep, I don't think anyone has been able to find it.''

Yes, some children appear to develop symptoms more suddenly than others, he says, but that could be because they have hidden their earlier symptoms from their parents, which O.C.D. patients are known to do. And, yes, he agrees, patients often improve after a positive strep test and a regimen of antibiotics. But because O.C.D. is cyclical, odds are that they would have improved without the test and the medicine anyway. Add to that the fact that some children are strep carriers. They will test positive for the bacteria any time they happen to be cultured, further skewing the cause-and-effect relationship that Swedo is trying to prove.

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罗杰说，他理解为什么强迫症的细菌的想法对家长颇具吸引力。因为一种病菌感染是可以治愈的。一种细菌致病没有父母的过错。 “这是一个简单的联系，但是证明这一点非常困难。”

罗杰说，在研究不清的情况下进行治疗可能是危险的。部分的危害是给孩子使用不必要的用药。他说，莫里这样的患者，每天使用青霉素来防止链球菌，容易导致药物过敏，并促进对抗生素的抗药性。他也不同意对最严重的强迫症患者使用血浆置换治疗。这种治疗程序，可能使儿童受到严重感染。他认为，这种治疗风险太高，实际上患者的症状会随着时间的推移缓解。

更潜在的危害可能是遗漏。当儿童强迫症孩子转向抗生素治疗以后，家长可能忽略了其他一些通常治疗强迫症的方法，这些方法可能效果会比较慢或逐渐起作用。无论情况如何，一个不停清洗双手的孩子是需要使用那些已经证明成功的一些药物和行为治疗方案来治疗。

Kurlan says that he understands why the idea of a bacterial cause for disturbing behavior is attractive to parents. A germ can be cured. A germ is not the parents' fault. ''It's a convenient link,'' he says, ''but it's very difficult to show a connection.''

Assigning blame where none exists can be dangerous, Kurlan says. Part of the harm is that of commission -- giving unnecessary medication. Patients like Maury Cronauer, he says, who take penicillin every day to prevent strep in the first place, are making themselves vulnerable to drug allergies and are promoting antibiotic resistance. And he disagrees with Swedo's view that plasmapheresis can be the answer for the most severely affected patients. The procedure leaves children vulnerable to serious infection, he says, which he considers too high a risk given that the symptoms will arguably run their course over time.

A more insidious form of harm, however, is that of omission. While turning to antibiotics to cure their child's Pandas, parents might be ignoring other treatments that could alleviate what skeptics believe the child actually has -- plain old O.C.D. It may come on slowly or gradually, in the presence of strep or not; whatever the details, a child who cannot stop washing her hands needs to be treated with one of the many drugs and behavioral-therapy regimens that are successful in battling O.C.D., he says.

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虽然，个案没有统计学意义，他们的故事不能证明什么。但是，我会见了患者家庭，并听取了他们的故事，我才更深刻地理解，为什么 苏珊是如此的肯定她的理论，罗杰说。

例如，在新泽西州的一个10岁的女孩，她的症状表现好像介于儿童强迫症与普通强迫症之间。女孩的母亲说孩子有二次强迫症发作，分别在4岁和8岁的时候，当时她可爱孩子脑子里充斥着令人不安的想法，比如“我的嘴腔充满了虫牙''或者“服务员在我的苏打饮料里放了毒药。”

第一次，母亲说，女儿的医生不确定疾病原因。但他的母亲，自己在网上做了一番研究以后，怀疑可能是儿童强迫症，然后给NIMH研究所打电话，某人证实了她的怀疑。然后，女孩开始了抗生素治疗，她的母亲说，治疗7个月后症状消失。第二次发病的时候，花了将近一年时间治疗。但是女孩使用的是行为治疗，没有采取任何强迫症的药物，因为孩子母亲认为没有必要。但是这个家庭采取的一个预防措施是在家里留有快速链球菌检测试剂盒，和定期检测孩子的口腔细菌。

知道她的女儿患有儿童强迫症后她仍然保持了清醒，这位母亲说， “当人淹没在海洋当中的时候，你会抓住任何能够漂浮救命的东西。”

这位母亲说，女孩的第二次强迫症发作不是因为链球菌而是因为病毒。罗杰辩解道，按照苏珊的理论，这个不应该属于儿童强迫症。这提示了细菌理论的缺陷。孩子母亲说，无论引起强迫症发作的原因是什么——- 链球菌也好，病毒感染也好——对我而言，最重要的是，现在我的女儿很好。

individuals are not statistics, and their stories are not proof. But as I met families and heard their tales, I came to more deeply understand why Swedo is so certain of her theory and Kurlan is so wary of it.

One 10-year-old girl in New Jersey, for instance, illustrates the hazy, sometimes illusory, difference between Pandas and O.C.D. The girl's mother (who asked that her name not be used to protect her daughter's privacy) describes two distinct times, at age 4 and age 8, when her bubbly child became riddled with disturbing thoughts: ''My mouth is full of cavities'' or ''The waiter put poison in my soda.''

The first time, the mother says, her daughter's doctors were uncertain of the cause. But the mother, after doing her own research and suspecting that it might be Pandas, called the N.I.M.H. Someone there confirmed her suspicions. Soon after, the girl took antibiotics, and, her mother says, the symptoms went away in seven months. The second time it took almost a year. The girl has had behavioral therapy but is not taking any medication for O.C.D. because her mother does not think it is necessary. The one precaution the family takes is keeping a supply of rapid strep test kits in the house and using them regularly.

Learning that her daughter had Pandas saved her own sanity, the woman says. ''It was like drowning in the middle of the ocean, and you grab onto something that will help you float.''

And yet. The second of the girl's two episodes, the mother says, was not brought on by strep but by a virus. By Swedo's definition, this would mean that the child did not have Pandas; that her parents think otherwise, Kurlan would argue, shows the danger of a bacterial scapegoat. The mother says that whatever caused the outbreaks -- strep infection, viral infection -- all that matters is that, at the moment, her daughter is fine.

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然而，另外一个孩子的故事说明，如果家长一开始就有一种精神上，而不是生理的假设，也是可以造成损坏的。 这个小女孩是六岁，根据她的父母说，她的性格在一夜之间改变，固执的对同样的问题问了一遍又一遍，无休无止。

她的母亲怀孕的时候，一位他们认识的精神病医生建议她的父母，他们的女儿有担心她的宝宝到来会夺去对她的注意的倾向。于是，首先她的父母向她保证会爱她，然后接着就开始惩罚她，把她关到她的房间里，让她可以“反省她的行为，并改变它，”她的母亲说。

这个家中没有一个人是医生，居然把孩子这种行为与三个星期前她的一起链球菌感染联系起来。他们不停地惩罚她，女孩一直坚持她不希望采用这种方式。女儿祈求： “请停止惩罚我吧，我没有办法。”

父母把她带到了儿科医生的办公室（他们已经去了那里三次），在那里医生给了抗抑郁药的处方。他们并没有取药，而是又把她带到一个儿童精神科医生那里，医生问，“她生病有喉咙痛吗？”血液检查表明，她链球菌抗体水平比正常高一倍。两个月后，经过几个星期的抗生素治疗和认知行为治疗，这个小女孩的行为重新恢复了正常。

Another story of another child, however, shows the damage that can be done if parents start with a psychological rather than a physical assumption. (These parents also didn't want their names used to protect their daughter's privacy.) This little girl was 6 last May, when according to her parents, she changed overnight, becoming clingy and asking the same question over and over and over and over again.

Her mother was pregnant at the time, and a psychiatrist her parents knew suggested that their daughter feared the arrival of her new sibling and was looking for attention. So first her parents reassured her. Then they began to punish her, sending her to her room so she could ''think about her behavior and change it,'' her mother says.

No one in the family, not even the girl's father, himself a doctor, linked any of this behavior to the raging strep infection she had three weeks earlier. They kept punishing her, and she kept insisting that she didn't want to act this way. ''Please stop punishing me for something I can't help,'' the mother recalls her daughter begging.

The parents took her back to the pediatrician's office (they had already been there three times), where they were given a prescription for an antidepressant. Instead of having it filled, they took her to a pediatric psychiatrist, who asked, ''Has she been sick with a sore throat?'' Blood tests showed that her level of strep antibodies was twice as high as it should have been. Two months later, after several weeks of antibiotics and several sessions with Tamar Chansky for cognitive behavioral therapy, the little girl was acting like her old self again.

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从罗杰和其他怀疑者的态度来看，儿童强迫症的理论，还没有得到证实。这些孩子患的根本就是一般的强迫症，如果认为与链球菌有因果关系，那种看法是自欺欺人。但是，从苏珊和她的支持者一方来看，他们同意，儿童强迫症与链球菌的因果关系还没有被明确证明。但他们坚持，到目前为止已被他们证明的东西意义重大，无人可以忽视，进一步的研究将证明他们是对的。

苏珊认为，目前来看，合理的逻辑是，任何急骤起病的儿童强迫症孩子，在被送到精神科医生以前，都应给予咽喉细菌培养或血液链球菌抗体检测。 “从临床经验来看，遇到这样突然发病的孩子，做咽喉细菌培养或者验血是非常基本的东西。这样做有错吗？''

罗杰说，问题是科学不应该是猜测。 “我们对突然起病的孩子进行上述测试，就好像这些检测有助于治疗的意义，但目前实际没有足够的证据。”

From where Roger Kurlan and other doubters sit, the situation looks simple. The theory of Pandas, they say, has not been proved. Until the causal link to strep is made, these children simply have O.C.D., and anyone who thinks differently is fooling himself. From where Swedo and her supporters sit, things look equally simple. They agree that cause and effect has not yet been definitively proved. But they are adamant that what has been proved so far is too significant to be ignored and that further research is more than warranted.

In the interim, they argue, logic dictates that any child who develops full-blown O.C.D. seemingly overnight should be given a throat culture or a strep-antibody test before she is sent to a psychiatrist. ''I'm all for empirical stringency,'' Chansky says, ''but in the meantime, there's something so basic that can be done. We're talking about a throat culture and maybe a blood test. What is the downside?''

The downside, Kurlan says, is that science is not supposed to guess. ''We would be testing children as if the results had meaning for their treatment,'' he says, ''and there is insufficient evidence that it does.''