Pharmacotherapy for the pseudobulbar affect in individuals who have sustained a traumatic brain injury: a systematic review protocol

Analysing Joker: an attempt to establish diagnosis for a film icon

Todd Phillips's film Joker, a 2019 psychological thriller, has stirred up strong reactions to the portrayal of the lead character's mental disorder, which is never specified. I used DSM-5 criteria to study whether Joker/Arthur Fleck showed signs of a real mental disorder. The psychopathology Arthur exhibits is unclear, preventing diagnosis of psychotic disorder or schizophrenia; the unusual combination of symptoms suggests a complex mix of features of certain personality traits, namely psychopathy and narcissism (he meets DSM-5 criteria for narcissistic personality disorder). He also shows the symptoms of pseudobulbar affect due to traumatic brain injury. This apparent co-occurrence of both mental disorder and a neurological condition may be confusing for audiences trying to understand mental illness.

Pharmacotherapy for the Pseudobulbar Affect in Individuals Who Have Sustained a Traumatic Brain Injury: a Systematic Review

Pseudobulbar affect is a debilitating condition that significantly reduces quality of life for many individuals following traumatic brain injury (TBI). It is characterized by embarrassing and often uncontrollable episodes of crying or laughter. The aim of this systematic review was to evaluate the effectiveness of pharmacotherapy as compared to all other comparators for the management of pseudobulbar affect in adults who have sustained TBI. Six databases were searched, with additional hand searching of journals, clinical trials registries and international drug regulators to identify published and unpublished studies in English up to June 2018. Studies were eligible for this review if they included adults who had sustained a medically confirmed TBI and presented with pseudobulbar affect. All pharmacotherapy and comparator interventions were considered for inclusion, and study design was not limited to randomised controlled trials. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. Two quasi-experimental studies examining the effectiveness of dextrometamorphan/quinidine (DM/Q) were identified. These studies reported that DM/Q was effective in reducing symptoms of pseudobulbar affect and had a positive safety profile, over follow-up periods of 3 months (n = 87) and 12 months (n = 23). However, both studies were limited by lack of a control group and a high dropout rate. The findings of twelve case reports examining the effectiveness of DM/Q (n = 6) and anti-depressants (n = 6) are also discussed. Further research is required to determine which pharmacological interventions provide the best outcomes for individuals with pseudobulbar affect following TBI, with consideration given to side effect profiles and financial costs.