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Non-genetic, environmental, post-infectious, or psychosocial factors—while not causing Tourette's—can influence its severity. [26] Autoimmune processes may affect tic onset and exacerbation in some cases. In 1998, a team at the US National Institute of Mental Health proposed a hypothesis based on observation of 50 children that both obsessive–compulsive disorder (OCD) and tic disorders may arise in a subset of children as a result of a poststreptococcal autoimmune process. [3] Children who meet five diagnostic criteria are classified, according to the hypothesis, as having Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections ( PANDAS ). [41] This contentious hypothesis is the focus of clinical and laboratory research, but remains unproven. [2] [3] [42]

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