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Broomfield NM, Blake J, Gracey F, Steverson T. Post-stroke emotionalism: Diagnosis, pathophysiology, and treatment. Int J Stroke 2024:17474930241242952. [PMID: 38503711 DOI: 10.1177/17474930241242952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Post-stroke emotionalism affects one in five stroke sufferers 6 months after their stroke, but despite its frequency remains a poorly understood stroke symptom. The literature is limited, especially compared to other frequently observed neurological conditions such as aphasia and visual neglect. AIM AND METHODS This narrative review presents a summary of the post-stroke emotionalism literature, to inform clinical practice and future research. We cover discussion of definitions, prevalence, neurobiology, predisposing and precipitating factors, and treatment. RESULTS Increasing evidence suggests that damage to specific areas functionally linked to emotion expression or regulation processes, disruption to structural pathways and those related to serotonin production and modulation individually or in concert give rise to emotionalism-type presentations. A range of emotionalism measurement tools have been used in research contexts making between study comparisons difficult. Testing for Emotionalism after Recent Stroke-Questionnaire (TEARS-Q) has recently been developed to allow standardized assessment. Treatment options are limited, and there have been few adequately powered treatment trials. Antidepressants may reduce severity, but more trial data are required. There have been no randomized-controlled trials of non-pharmacological interventions. CONCLUSIONS More research is needed to improve recognition and treatment of this common and disabling symptom. We conclude with research priorities and recommendations for the field.
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Affiliation(s)
- Niall M Broomfield
- Department of Clinical Psychology and Psychological Therapies (CPPT), Norwich Medical School, University of East Anglia, Norwich, UK
| | - Joshua Blake
- Department of Clinical Psychology and Psychological Therapies (CPPT), Norwich Medical School, University of East Anglia, Norwich, UK
| | - Fergus Gracey
- Department of Clinical Psychology and Psychological Therapies (CPPT), Norwich Medical School, University of East Anglia, Norwich, UK
| | - Tom Steverson
- Department of Clinical Psychology and Psychological Therapies (CPPT), Norwich Medical School, University of East Anglia, Norwich, UK
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Trojsi F, Di Nardo F, D’Alvano G, Caiazzo G, Passaniti C, Mangione A, Sharbafshaaer M, Russo A, Silvestro M, Siciliano M, Cirillo M, Tedeschi G, Esposito F. Resting state fMRI analysis of pseudobulbar affect in Amyotrophic Lateral Sclerosis (ALS): motor dysfunction of emotional expression. Brain Imaging Behav 2023; 17:77-89. [PMID: 36370302 PMCID: PMC9922228 DOI: 10.1007/s11682-022-00744-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 11/13/2022]
Abstract
Pseudobulbar affect (PBA), referring to exaggerated or inappropriate episodes of laughing and/or crying without an apparent motivating stimulus, has been mainly attributed to bilateral degeneration of corticobulbar tracts. We aimed at exploring brain functional connectivity (FC) correlates of PBA in patients with amyotrophic lateral sclerosis (ALS), the most common motor neuron disease, frequently associated with PBA. Resting state functional MRI (RS-fMRI) independent component (ICA) and seed-based analyses and voxel-based morphometry (VBM) whole-brain analysis were performed on 27 ALS patients (13 with PBA; 14 without PBA) and 26 healthy controls (HC), for investigating functional and structural abnormalities in ALS patients compared to HC and in patients with PBA compared to patients without PBA. Between-patient analysis revealed different FC patterns, especially regarding decreased FC in several areas of cognitive (default mode, frontoparietal, salience) and sensory-motor networks in patients with PBA compared to those without PBA. However, no significant differences were found in gray matter atrophy. Seed-based analysis showed increased FC between middle cerebellar peduncles and posterior cingulate cortex and decreased FC between middle cerebellar peduncles and left middle frontal gyrus in patients with PBA compared to patients without PBA. Our findings suggest that some alterations of fronto-tempo-parietal-cerebellar circuits could be related to PBA in ALS. In particular, the abnormal FC between cerebellum and posterior cingulate cortex and left middle frontal gyrus in patients with PBA compared to patients without PBA highlights a crucial role of the cerebellum in regulating emotion expression in patients with ALS.
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Affiliation(s)
- Francesca Trojsi
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania "Luigi Vanvitelli", P.Zza Miraglia 2, 80138, Naples, Italy.
| | - Federica Di Nardo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Giulia D’Alvano
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Giuseppina Caiazzo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Carla Passaniti
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Antonella Mangione
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Minoo Sharbafshaaer
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Antonio Russo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Marcello Silvestro
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Mattia Siciliano
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Mario Cirillo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Gioacchino Tedeschi
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Fabrizio Esposito
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
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Gillespie DC, Halai AD, West RM, Dickie DA, Walters M, Broomfield NM. Demographic, clinical and neuroimaging markers of post-stroke emotionalism: A preliminary investigation. J Neurol Sci 2022; 436:120229. [PMID: 35378397 DOI: 10.1016/j.jns.2022.120229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 02/15/2022] [Accepted: 03/11/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Post stroke emotionalism (PSE) is a common but poorly understood condition. The value of altered brain structure as a putative risk factor for PSE alongside routinely available demographic and clinical variables has yet to be elucidated. METHODS 85 patients were recruited from acute inpatient settings within 2 weeks of stroke. PSE was diagnosed using a validated semi-structured interview and standardised measures of stroke severity, functional ability, cognition, mood and quality of life were obtained. Neuroimaging variables (intracranial volume and volumes of cortical grey matter, subcortical grey matter, normal appearing white matter, cerebrum, cerebrospinal fluid and stroke; white matter hyperintensities; and mean cortical thickness) were derived using standardised methods from Magnetic Resonance Imaging (MRI) studies. The relationships between PSE diagnosis, brain structure, demographic and clinical variables were investigated using machine learning algorithms to determine how well different sets of predictors could classify PSE. RESULTS The model with the best performance was derived from neuroradiological variables alone (sensitivity = 0.75; specificity = 0.8235), successfully classifying 9/12 individuals with PSE and 28/34 non-PSE cases. CONCLUSIONS Neuroimaging measures appear to be important in PSE. Future work is needed to determine which specific variables are key. Imaging may complement standard behavioural measures and aid clinicians and researchers.
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Affiliation(s)
- David C Gillespie
- Department of Clinical Neurosciences (DCN), Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, UK.
| | - Ajay D Halai
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge CB2 7EF, UK
| | - Robert M West
- School of Medicine, University of Leeds, Leeds LS2 9JT, UK
| | - David A Dickie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | - Matthew Walters
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
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Broomfield NM, West R, Barber M, Quinn TJ, Gillespie D, Walters M, House A. TEARS: a longitudinal investigation of the prevalence, psychological associations and trajectory of poststroke emotionalism. J Neurol Neurosurg Psychiatry 2022; 93:jnnp-2022-329042. [PMID: 35483914 DOI: 10.1136/jnnp-2022-329042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 04/06/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE There are few longitudinal studies of poststroke emotionalism (PSE) and our understanding of the psychological associations of PSE is limited, constraining assessment of existing interventions and the development of new therapies. This study aimed to assess the prevalence and course of PSE over the first year poststroke, and its psychological associations. METHODS Consenting stroke survivors who were physically and cognitively able to participate were assessed within 2 weeks, 6 and 12 months of stroke to determine PSE point prevalence using a diagnostic, semistructured PSE interview (Testing Emotionalism After Recent Stroke-Diagnostic Interview). At the same assessments, neuropsychological and disability status were determined using Hospital Anxiety and Depression Scale, Abbreviated Mental Test, National Institute of Health Stroke Scale, Barthel Index and Euro-Qol. RESULTS Two hundred and seventy seven stroke survivors were recruited between 1 October 2015 and 30 September 2018. Diagnostic data were available at baseline for 228 of 277 cohort participants. Point prevalence for PSE was 27.2% at 2 weeks; estimated prevalence at 6 months adjusted for baseline was 19.9% and at 12 months 22.3%. PSE was associated with symptoms of anxiety and event-related distress. INTERPRETATION PSE affects at least one in five stroke patients acutely following their stroke, and continues to affect one in eight longer term. PSE is associated with anxiety and event-related distress but is not simply a manifestation of mood disorder over time. Such psychological correlates may have implications for longer term social rehabilitation.
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Affiliation(s)
| | - Robert West
- University of Leeds Faculty of Medicine and Health, Leeds, UK
| | | | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - David Gillespie
- Department of Clinical Neurosciences (DCN), NHS Lothian, Edinburgh, UK
| | - Matthew Walters
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Fitzgerald S, Gracey F, Trigg E, Broomfield N. Predictors and correlates of emotionalism across acquired and progressive neurological conditions: A systematic review. Neuropsychol Rehabil 2022; 33:945-987. [PMID: 35323084 DOI: 10.1080/09602011.2022.2052326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Emotionalism can develop following a range of neurological disorders; however the aetiology of emotionalism is still unclear. To identify anatomical, neuropsychological and psychological predictors and correlates of emotionalism across neurological disorders: stroke, Parkinson's disease, multiple sclerosis, traumatic brain injury, Alzheimer's disease, vascular dementia and amyotrophic lateral sclerosis. To explore if these predictors and correlates of emotionalism differ across neurological disorders. A comprehensive systematic search was completed of four databases: MEDLINE, CINAHL Complete, PsycINFO and EMBASE. Methodological quality was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and each study was graded according to the level of evidence using the Scottish Intercollegiate Guidelines Network. Fifty papers (participants N = 1922) were included. 25 studies were rated as "Fair," 21 "Good" and 4 "Poor." The review identified predictors and correlates found in several neurological disorder such as bulbar networks, serotonergic pathways, genetics and female gender. Multiple studies across diseases (stroke, MS, ALS) indicate emotionalism is associated with cognitive impairment, especially frontal deficits. Due to the disproportionate number of studies identified across neurological disorders, it is difficult to draw definitive answers. Further research is required across neurological disorders to explore similarities and differences in anatomical, neuropsychological and psychological predictors and correlates.
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Affiliation(s)
- Sophie Fitzgerald
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Fergus Gracey
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Emma Trigg
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Niall Broomfield
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
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Atomoxetine (Strattera)-Induced Pathologic Laughing in a Patient With Pontine Hemorrhage: A Case Report. Clin Neuropharmacol 2021; 44:77-79. [PMID: 33480614 DOI: 10.1097/wnf.0000000000000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Pathologic laughing, characterized by episodes of abrupt and inappropriate laughter occurring irrespective of a person's emotional feelings, has been reported in patients with neurologic deficits. Some pharmacotherapies, including selective serotonin reuptake inhibitors, are effective in alleviating pathologic laughing. However, contrary to previous reports, we report a case of pathologic laughing that developed after a patient with pontine hemorrhage was administered atomoxetine (Strattera). CASE PRESENTATION A 55-year-old man was diagnosed with acute intracerebral hemorrhage in the right pons and midbrain. The patient showed mild cognitive impairment, and he was administered 10 mg of atomoxetine once daily as a cognitive enhancer. On the day of atomoxetine administration, he suddenly developed episodes of inappropriate laughter that was uncontrollable. The Pathological Laughter and Crying Scale showed a score of 4 of 54 on the day he started taking atomoxetine, and his score was 18 on the second day. He was administered atomoxetine for 3 consecutive days, but it was stopped on the fourth day. His laughing diminished, and his score improved to 5. His smiling expression and a score of 1 on the scale lasted for 1 week. On day 8 of drug discontinuation, his score was zero and all symptoms disappeared. CONCLUSIONS Previously, no single medication has been reported to cause pathologic laughing. Atomoxetine is a stimulant that increases norepinephrine and dopamine levels in the prefrontal cortex. This report suggests that, unlike what is known thus far, norepinephrine and dopamine might play a crucial role in the development of pathologic laughing.
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7
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Mainka T, Balint B, Gövert F, Kurvits L, van Riesen C, Kühn AA, Tijssen MAJ, Lees AJ, Müller-Vahl K, Bhatia KP, Ganos C. The spectrum of involuntary vocalizations in humans: A video atlas. Mov Disord 2019; 34:1774-1791. [PMID: 31651053 DOI: 10.1002/mds.27855] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 07/22/2019] [Accepted: 08/21/2019] [Indexed: 12/11/2022] Open
Abstract
In clinical practice, involuntary vocalizing behaviors are typically associated with Tourette syndrome and other tic disorders. However, they may also be encountered throughout the entire tenor of neuropsychiatry, movement disorders, and neurodevelopmental syndromes. Importantly, involuntary vocalizing behaviors may often constitute a predominant clinical sign, and, therefore, their early recognition and appropriate classification are necessary to guide diagnosis and treatment. Clinical literature and video-documented cases on the topic are surprisingly scarce. Here, we pooled data from 5 expert centers of movement disorders, with instructive video material to cover the entire range of involuntary vocalizations in humans. Medical literature was also reviewed to document the range of possible etiologies associated with the different types of vocalizing behaviors and to explore treatment options. We propose a phenomenological classification of involuntary vocalizations within different categorical domains, including (1) tics and tic-like vocalizations, (2) vocalizations as part of stereotypies, (3) vocalizations as part of dystonia or chorea, (4) continuous vocalizing behaviors such as groaning or grunting, (5) pathological laughter and crying, (6) vocalizations resembling physiological reflexes, and (7) other vocalizations, for example, those associated with exaggerated startle responses, as part of epilepsy and sleep-related phenomena. We provide comprehensive lists of their associated etiologies, including neurodevelopmental, neurodegenerative, neuroimmunological, and structural causes and clinical clues. We then expand on the pathophysiology of the different vocalizing behaviors and comment on available treatment options. Finally, we present an algorithmic approach that covers the wide range of involuntary vocalizations in humans, with the ultimate goal of improving diagnostic accuracy and guiding appropriate treatment. © 2019 The Authors. Movement Disorders published by Wiley Periodicals, Inc. on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Tina Mainka
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Bettina Balint
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK.,Department of Neurology, University Hospital Heidelberg, Heidelberg, Germany
| | - Felix Gövert
- Department of Neurology, University Hospital Schleswig-Holstein, Christian-Albrechts-University, Kiel, Germany
| | - Lille Kurvits
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Christoph van Riesen
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany.,Department of Neurology, University Medicine Göttingen, Göttingen, Germany
| | - Andrea A Kühn
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Marina A J Tijssen
- Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Andrew J Lees
- Reta Lila Weston Institute of Neurological Studies, UCL, Institute of Neurology, London, UK
| | - Kirsten Müller-Vahl
- Clinic of Psychiatry, Socialpsychiatry and Psychotherapy, Hannover Medical School, Hannover, Germany
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, UK
| | - Christos Ganos
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
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Finegan E, Chipika RH, Li Hi Shing S, Hardiman O, Bede P. Pathological Crying and Laughing in Motor Neuron Disease: Pathobiology, Screening, Intervention. Front Neurol 2019; 10:260. [PMID: 30949121 PMCID: PMC6438102 DOI: 10.3389/fneur.2019.00260] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/26/2019] [Indexed: 12/11/2022] Open
Abstract
Pathological crying and laughing (PCL) has significant quality-of-life implications in amyotrophic lateral sclerosis (ALS); it can provoke restrictive life-style modifications and lead to social isolation. Despite its high prevalence and quality of life implications, it remains surprisingly understudied. Divergent pathophysiological models have been proposed, centered on corticobulbar tract degeneration, prefrontal cortex pathology, sensory deafferentation, and impaired cerebellar gate-control mechanisms. Quantitative MRI techniques and symptom-specific clinical instruments offer unprecedented opportunities to elucidate the anatomical underpinnings of PCL pathogenesis. Emerging neuroimaging studies of ALS support the role of cortico-pontine-cerebellar network dysfunction in context-inappropriate emotional responses. The characterization of PCL-associated pathophysiological processes is indispensable for the development of effective pharmacological therapies.
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Affiliation(s)
| | | | | | | | - Peter Bede
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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Fitzgerald KC, Salter A, Tyry T, Fox RJ, Cutter G, Marrie RA. Pseudobulbar affect: Prevalence and association with symptoms in multiple sclerosis. Neurol Clin Pract 2018; 8:472-481. [PMID: 30588376 DOI: 10.1212/cpj.0000000000000523] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 07/09/2018] [Indexed: 11/15/2022]
Abstract
Background We sought to determine the prevalence of pseudobulbar affect (PBA) in a large MS population and assess its association with disability and symptom severity. Methods North American Research Committee on MS (NARCOMS) registry participants completed the Center for Neurologic Study-Lability Scale (CNS-LS), a validated 7-question self-report measure of PBA. A composite PBA score was derived from the sum of responses to the 7 questions. We categorized individuals as PBA-positive (PBA[+]) if they had a composite score ≥17 without current depression. Participants also reported their demographic characteristics and their clinical characteristics using Patient-Determined Disease Steps and Performance Scales. We compared clinical and disease characteristics for PBA(+) responders with those without PBA using descriptive statistics and multivariable multinomial logistic regression. Results Of the 8,136 responders, 574 (7%) had scores ≥17 on the CNS-LS; however, only 200 (2.5%) individuals had scores ≥17 without comorbid depression, of whom only 22 (11%) reported a diagnosis of PBA. PBA(+) individuals tended to be younger (mean [SD] 53.4 [11.0] vs 57.2 [10.3] years), non-white (13% vs 9%), and have lower socioeconomic status (≤$30,000 annual income: 28% vs 22%). In multivariable models, PBA(+) was associated with increased odds of more severe cognitive impairment (moderate vs mild disability OR: 1.37; 95% CI: 1.01, 1.84). Conclusions Our findings suggest that the prevalence of PBA in MS is low, but similar symptoms may co-occur or overlap with depression, highlighting the importance of concomitant assessment of mood when evaluating potential PBA. PBA may be associated with cognitive impairment in people with MS.
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Affiliation(s)
- Kathryn C Fitzgerald
- Department of Neurology (KCF), Johns Hopkins School of Medicine, Baltimore, MD; Division of Biostatistics (AS), Washington University in St. Louis School of Medicine, MO; Dignity Health (TT), St. Joseph's Hospital and Medical Center, Phoenix, AZ; Mellen Center for Multiple Sclerosis (RJF), Cleveland Clinic Foundation, OH; Department of Biostatistics (GC), University of Alabama in Birmingham School of Public Health, AL; and Departments of Internal Medicine and Community Health Sciences (RAM), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Amber Salter
- Department of Neurology (KCF), Johns Hopkins School of Medicine, Baltimore, MD; Division of Biostatistics (AS), Washington University in St. Louis School of Medicine, MO; Dignity Health (TT), St. Joseph's Hospital and Medical Center, Phoenix, AZ; Mellen Center for Multiple Sclerosis (RJF), Cleveland Clinic Foundation, OH; Department of Biostatistics (GC), University of Alabama in Birmingham School of Public Health, AL; and Departments of Internal Medicine and Community Health Sciences (RAM), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Tuula Tyry
- Department of Neurology (KCF), Johns Hopkins School of Medicine, Baltimore, MD; Division of Biostatistics (AS), Washington University in St. Louis School of Medicine, MO; Dignity Health (TT), St. Joseph's Hospital and Medical Center, Phoenix, AZ; Mellen Center for Multiple Sclerosis (RJF), Cleveland Clinic Foundation, OH; Department of Biostatistics (GC), University of Alabama in Birmingham School of Public Health, AL; and Departments of Internal Medicine and Community Health Sciences (RAM), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Robert J Fox
- Department of Neurology (KCF), Johns Hopkins School of Medicine, Baltimore, MD; Division of Biostatistics (AS), Washington University in St. Louis School of Medicine, MO; Dignity Health (TT), St. Joseph's Hospital and Medical Center, Phoenix, AZ; Mellen Center for Multiple Sclerosis (RJF), Cleveland Clinic Foundation, OH; Department of Biostatistics (GC), University of Alabama in Birmingham School of Public Health, AL; and Departments of Internal Medicine and Community Health Sciences (RAM), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Gary Cutter
- Department of Neurology (KCF), Johns Hopkins School of Medicine, Baltimore, MD; Division of Biostatistics (AS), Washington University in St. Louis School of Medicine, MO; Dignity Health (TT), St. Joseph's Hospital and Medical Center, Phoenix, AZ; Mellen Center for Multiple Sclerosis (RJF), Cleveland Clinic Foundation, OH; Department of Biostatistics (GC), University of Alabama in Birmingham School of Public Health, AL; and Departments of Internal Medicine and Community Health Sciences (RAM), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Ruth Ann Marrie
- Department of Neurology (KCF), Johns Hopkins School of Medicine, Baltimore, MD; Division of Biostatistics (AS), Washington University in St. Louis School of Medicine, MO; Dignity Health (TT), St. Joseph's Hospital and Medical Center, Phoenix, AZ; Mellen Center for Multiple Sclerosis (RJF), Cleveland Clinic Foundation, OH; Department of Biostatistics (GC), University of Alabama in Birmingham School of Public Health, AL; and Departments of Internal Medicine and Community Health Sciences (RAM), Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
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Girotra T, Lowe F, Feng W. Pseudobulbar affect after stroke: a narrative review. Top Stroke Rehabil 2018; 25:1-7. [PMID: 30213256 DOI: 10.1080/10749357.2018.1499300] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 07/07/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pseudobulbar affect (PBA) is a neuropsychological condition of emotional lability and affective dysregulation associated with a variety of neurological conditions such as stroke, traumatic brain disease, and neurodegenerative disease. The true prevalence and medico-social burden of PBA associated with stroke is unclear. Often confused with post-stroke mood disorders, PBA is under-recognized and under-treated. OBJECTIVE To provide a comprehensive narrative synthesis of published literature on the topic of PBA. METHODS Literature review was performed by searching the key words "pseudobulbar atrophy", "emotional incontinence," and "stroke" in PubMed. Only manuscripts published in English were appraised and relevant content was extracted, synthesized, and summarized. RESULTS A narrative overview was performed on the following topics: epidemiology, pathophysiology, clinical features of differential diagnosis, impact on public health, and therapeutic options. CONCLUSION PBA remains an under-treated condition with significant psychosocial burden on both effected stroke survivors and their families. Advances have been made in developing consensus-based clinical diagnostic criteria for PBA. Early identification and prompt initiation of therapeutic measures are required in these stroke patients. Further research is needed to develop better PBA diagnostic criteria and more cost-effective therapeutic treatment options.
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Affiliation(s)
- Tarun Girotra
- a Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
| | - Forrest Lowe
- a Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
| | - Wuwei Feng
- a Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
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Zorowitz RD, Alexander DN, Formella AE, Ledon F, Davis C, Siffert J. Dextromethorphan/Quinidine for Pseudobulbar Affect Following Stroke: Safety and Effectiveness in the PRISM II Trial. PM R 2018; 11:S1934-1482(18)30352-6. [PMID: 29964212 DOI: 10.1016/j.pmrj.2018.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 06/12/2018] [Accepted: 06/17/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Dextromethorphan (DM) / quinidine (Q) was approved for pseudobulbar affect (PBA) treatment based on efficacy and safety trials in patients with PBA caused by amyotrophic lateral sclerosis or multiple sclerosis. The PRISM II trial evaluated DM/Q as PBA treatment in patients with stroke, dementia, or traumatic brain injury. OBJECTIVE To report results from the stroke cohort of PRISM II, including the Stroke Impact Scale (SIS). DESIGN Open-label trial evaluating twice-daily DM/Q over 90 days. STUDY PARTICIPANTS Adults (n = 113) with a clinical diagnosis of PBA secondary to stroke; stable psychiatric medications were allowed. METHODS PRISM II was an open-label, 12-week trial enrolling adults with PBA caused by dementia, stroke (reported here), or TBI. All study participants received DM/Q 20/10 mg twice daily. Study visits occurred at baseline and at days 30 and 90. SETTING 150 U.S. centers. MAIN OUTCOME MEASUREMENTS Primary efficacy measure was changed from baseline to day 90 in Center for Neurologic Study-Lability Scale (CNS-LS) scores. Secondary outcomes included PBA episodes (estimated over 7 days), Clinical and Patient/Caregiver Global Impression of Change (CGI-C and PGI-C), Quality of Life-Visual Analog Scale (QOL-VAS), SIS, Patient Health Questionnaire (PHQ-9), and Mini-Mental State Examination (MMSE). RESULTS Compared with baseline, CNS-LS scores (SD) improved by -6.2 (6.1, P < .001) at day 30 and -7.6 (6.7, P < .001) at day 90. PBA episodes were reduced by 65% and 75% at day 30 and 90, respectively. Seventy-five percent of clinicians and 67% of patients/caregivers rated PBA as "much" or "very much improved." All SIS items significantly improved from baseline (P < .05, all). Adverse events included diarrhea (4.4%), headache (3.5%), constipation (2.7%), and dizziness (2.7%); 5.3% had adverse events leading to study discontinuation. CONCLUSIONS DM/Q effectively treated PBA and was associated with global and functional improvement; adverse events were consistent with the known safety profile of DM/Q.
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Affiliation(s)
- Richard D Zorowitz
- MedStar National Rehabilitation Network, 102 Irving Street, NW, Washington, DC 20010.
| | | | | | - Fred Ledon
- Avanir Pharmaceuticals, Inc, Aliso Viejo, CA
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Huang Y, Aronson JP, Pilitsis JG, Gee L, Durphy J, Molho ES, Ramirez-Zamora A. Anatomical Correlates of Uncontrollable Laughter With Unilateral Subthalamic Deep Brain Stimulation in Parkinson's Disease. Front Neurol 2018; 9:341. [PMID: 29887826 PMCID: PMC5980955 DOI: 10.3389/fneur.2018.00341] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 04/30/2018] [Indexed: 01/11/2023] Open
Abstract
Introduction Subthalamic nucleus deep brain stimulation (STN-DBS) is a well-established treatment for the management of motor complications in Parkinson’s disease. Uncontrollable laughter has been reported as a rare side effect of STN stimulation. The precise mechanism responsible for this unique phenomenon remains unclear. We examined in detail the DBS electrode position and stimulation parameters in two patients with uncontrollable laughter during programming after STN-DBS surgery and illustrated the anatomical correlates of the acute mood changes with STN stimulation. Case report Unilateral STN-DBS induced uncontrollable laughter with activation of the most ventral contacts in both patients. However, the location of the electrodes responsible for this adverse effect differed between the patients. In the first patient, the DBS lead was placed more inferiorly and medially within the STN. In the second patient, the DBS lead was implanted more anteriorly and inferiorly than initially planned at the level of the substantia nigra reticulata (SNr). Conclusion Unilateral STN-DBS can induce acute uncontrollable laughter with activation of electrodes located more anterior, medial, and inferior in relationship with the standard stereotactic STN target. We suggest that simulation of ventral and medial STN, surrounding limbic structures or the SNr, is the most plausible anatomical substrate responsible for this acute mood and behavioral change. Our findings provide insight into the complex functional neuroanatomical relationship of the STN and adjacent structures important for mood and behavior. DBS programming with more dorsal and lateral contacts within the STN should be entertained to minimize the emotional side effects.
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Affiliation(s)
- Yonglu Huang
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States.,Department of Neurology, The Second Hospital of Anhui Medical University, Hefei, China
| | - Joshua P Aronson
- Department of Surgery, Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical Center, Albany, NY, United States
| | - Lucy Gee
- Department of Neurosurgery, Albany Medical Center, Albany, NY, United States
| | - Jennifer Durphy
- Department of Neurology, Albany Medical Center, Albany, NY, United States
| | - Eric Steven Molho
- Department of Neurology, Albany Medical Center, Albany, NY, United States
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, FL, United States
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Wang Y, Wang Y, Ma W, Lu S, Chen J, Cao L. Correlation between cognitive impairment during the acute phase of first cerebral infarction and development of long-term pseudobulbar affect. Neuropsychiatr Dis Treat 2018; 14:871-877. [PMID: 29636612 PMCID: PMC5880411 DOI: 10.2147/ndt.s161792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The relationship between cognitive impairment during the acute phase of first cerebral infarction and the development of long-term pseudobulbar affect (PBA) has not been elucidated. Therefore, in this study, we aimed to determine if cognitive impairment during the acute phase of cerebral infarction will increase the risk of long-term post-infarction PBA. PATIENTS AND METHODS This was a nested case-control study using a prospective approach. A consecutive multicenter matched 1:1 case-control study of cognitive impairment cases following acute cerebral infarction (N=26) with 26 sex-, education years-, and age-matched controls. Univariate and multivariate conditional logistic regression analyses were performed to study the clinical features and changes in cognitive domain as well as the risk factors for PBA. RESULTS Long-term PBA was independently predicted by low Montreal cognitive assessment (MoCA) scores at baseline. Multivariable regression models showed that post-infarction low MoCA scores remained independent predictors of long-term PBA (odds ratio [OR]=0.72; 95% confidence interval [CI]=0.54-0.95; P=0.018). Among all cognitive disorders, digit span test (DST) scores (OR=0.39; 95% CI=0.16-0.91, P=0.030), StroopC time (OR=1.15; 95% CI=1.01-1.31; P=0.037), and clock-drawing task (CDT) scores (OR=0.62; 95% CI=0.42-0.90; P=0.013) were found to be the independent risk factors for PBA. CONCLUSION Cognitive impairment during the acute phase of cerebral infarction increased the risk of cerebral infarction-induced long-term PBA. Development of PBA was closely associated with executive function, attention, and visuospatial disorder.
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Affiliation(s)
- Yuan Wang
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, People's Republic of China.,Department of Neurology, Binzhou Medical University Hospital, Binzhou, People's Republic of China
| | - Yuliang Wang
- Department of Neurology, Binzhou Medical University Hospital, Binzhou, People's Republic of China
| | - Wenbin Ma
- Department of Neurology, Binzhou Medical University Hospital, Binzhou, People's Republic of China
| | - Shujun Lu
- Department of Neurology, Binzhou Medical University Hospital, Binzhou, People's Republic of China
| | - Jinbo Chen
- Department of Neurology, Binzhou Medical University Hospital, Binzhou, People's Republic of China
| | - Lili Cao
- Department of Neurology, Qilu Hospital of Shandong University, Jinan, People's Republic of China
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Bede P, Finegan E. Revisiting the pathoanatomy of pseudobulbar affect: mechanisms beyond corticobulbar dysfunction. Amyotroph Lateral Scler Frontotemporal Degener 2017; 19:4-6. [DOI: 10.1080/21678421.2017.1392578] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Peter Bede
- Quantitative Neuroimaging Group, Academic Unit of Neurology, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
| | - Eoin Finegan
- Quantitative Neuroimaging Group, Academic Unit of Neurology, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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Liu T, Li J, Huang S, Li C, Zhao Z, Wen G, Chen F. Altered resting-state functional activity in isolated pontine infarction patients with pathological laughing and crying. Oncotarget 2017; 8:84529-84539. [PMID: 29137445 PMCID: PMC5663617 DOI: 10.18632/oncotarget.19307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 06/24/2017] [Indexed: 12/11/2022] Open
Abstract
We used resting-state functional magnetic resonance imaging to investigate the global spontaneous neural activity involved in pathological laughing and crying after stroke. Twelve pathological laughing and crying patients with isolated pontine infarction were included, along with 12 age- and gender-matched acute isolated pontine infarction patients without pathological laughing and crying, and 12 age- and gender-matched healthy controls. We examined both the amplitude of low-frequency fluctuation and the regional homogeneity in order to comprehensively evaluate the intrinsic activity in patients with post-stroke pathological laughing and crying. In the post-stroke pathological laughing and crying group, changes in these measures were observed mainly in components of the default mode network (medial prefrontal cortex/anterior cingulate cortex, middle temporal gyrus, inferior temporal gyrus, superior frontal gyrus, middle frontal gyrus and inferior parietal lobule), sensorimotor network (supplementary motor area, precentral gyrus and paracentral lobule), affective network (medial prefrontal cortex/anterior cingulate cortex, parahippocampal gyrus, middle temporal gyrus and inferior temporal gyrus) and cerebellar lobes (cerebellum posterior lobe). We therefore speculate that when disinhibition of the volitional system is lost, increased activation of the emotional system causes pathological laughing and crying.
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Affiliation(s)
- Tao Liu
- Department of Neurology, Hainan General Hospital, Haikou 570311, China
| | - Jianjun Li
- Department of Radiology, Hainan General Hospital, Haikou 570311, China
| | - Shixiong Huang
- Department of Neurology, Hainan General Hospital, Haikou 570311, China
| | - Changqinq Li
- Department of Radiology, Hainan General Hospital, Haikou 570311, China
| | - Zhongyan Zhao
- Department of Neurology, Hainan General Hospital, Haikou 570311, China
| | - Guoqiang Wen
- Department of Neurology, Hainan General Hospital, Haikou 570311, China
| | - Feng Chen
- Department of Radiology, Hainan General Hospital, Haikou 570311, China
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Abstract
Pseudobulbar affect, thought by many to be a relatively newly described condition, is in fact a very old one, described as early as the 19th century. It refers to those who experience inappropriate affect, disconnected from internal state, or mood, generally thought to be the result of an upper motor neuron injury or illness. One possible explanation for this condition's relative obscurity is the dearth of treatment options; clinical medicine is not typically in the habit of identifying conditions that cannot be modified. Now, however, there is good evidence for the treatment of pseudobulbar affect, and even a therapy approved for use by the U.S. Food and Drug Administration (FDA). As a result, appropriate identification and subsequent management of pseudobulbar affect is more important than ever. This article purports to summarize the origins of pseudobulbar affect, most current hypotheses as to its physiopathology, clinical identification, and evidence for management.
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