Rosalie Greenberg Medical Arts Psychotherapy Associates PA, Summit, NJ, USAI read with great interest the article by Bransfield,1 wherein the author reviewed potential contributors to and manifestations of heightened loss of control in Lyme disease patients. As a child psychiatrist living in a Lyme-endemic state, New Jersey, in the USA, I have seen a number of children and adolescents who exhibit significant acute or gradual onset of highly oppositional behaviors often both at home and at school. Refusal to do classwork or homework, heightened paranoia or feeling rejected by others is often present. In addition, they often demonstrate increased irritability, extreme temper tantrums, problems concentrating, elevated impulsivity, sensory hypersensitivity (sound, touch, smell, taste and/or light) and intense emotional lability. Parents describe these behaviors as either a sudden change or a period of worsening of a previous condition, such as attention-deficit hyperactivity disorder or mood disorder. During periods of intense anger over minimal issues, they can appear menacing and threaten to kill a sibling, parent or a friend or state that they want to die themselves. In a recent record review of 69 youth evaluated in my private psychopharmacology practice, 49 of these new patients, without a known history of Lyme disease or other tick-borne disorders, demonstrated evidence of exposure to one or more of the pathogens Borrelia burgdorferi, Bartonella, Babesia, Ehrlichia and Anaplasma on serologic testing performed by multiple laboratories. In addition, 6 of the 69 patients were initially referred because of psychiatric difficulties observed by other physicians during the active treatment of tick-borne infections. Supporting this connection of childhood neuropsychiatric symptoms and tick-borne illness is a recent article looking at 27 youth diagnosed with bipolar disorder I or II, which found that 74% or 20/27 were diagnosed with at least one tick-borne illness based on serologic testing and clinician evaluation.2 Of note, bipolar disorder is a psychiatric illness that carries a high risk of suicide. There appears to be no question that exploration of the association of Lyme disease and tick-borne illnesses with neuropsychiatric symptoms both in children and adults requires more extensive study.View the original paper by Bransfield