Posterior Fossa Lesion Load and Pathological Laughing and Crying in Multiple Sclerosis

Predictors and correlates of emotionalism across acquired and progressive neurological conditions: A systematic review

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.

Pseudobulbar Affect Presenting as Aggressive Behavior

Pseudobulbar affect (PBA) is an affective disorder of emotional expression characterized by frequent uncontrollable outbursts of laughing or crying. It is usually associated with stroke, traumatic brain injury, and other neurological conditions. This disorder can present a challenge to clinicians to distinguish this from mood disorders or to diagnose this disorder in the context of underlying mood disorders. In addition, the delay in the diagnosis can impact patients' quality of life.

We describe a 48-year-old man who presented with frequent episodes of sudden, frequent, uncontrollable laughing two years after his recurrent stroke. The patient initially had his first stroke about three years ago and had a recurrent stroke eight months after his first stroke. A few days after getting discharged after his second stroke, the patient was admitted to the psychiatric unit after his family members reported aggressive behavior. The patient also reported symptoms of depression and was discharged on escitalopram for mood and divalproex for his aggressive behavior. Unfortunately, the patient was not compliant with these medications with no resolution of his symptoms. The patient was then treated with dextromethorphan-quinidine, escitalopram, and divalproex, resulting in significant improvement in his mood and aggressive behavior with a resolution of uncontrollable laughing spells. 

Clinicians are encouraged to inquire about symptoms of pseudobulbar affect in the context of stroke or other neurological disorders. Appropriate management of this condition can help improve patients' symptoms and positively affect their wellbeing. 

Pseudobulbar Affect: An Overview

Pseudobulbar affect (PBA) is a disorder that develops in the context of a brain injury or underlying neurological dysfunction. It is characterized as an affective disorder of emotional expression. PBA manifests as frequent uncontrollable outbursts of laughing or crying, incongruent with the individual's internal emotional state. It can be challenging for clinicians to differentiate PBA from mood disorders, contributing to its high rate of misdiagnosis. This lack of recognition leads to ineffective and insufficient treatment, impacting patients' quality of life. The current article provides an overview of PBA, including its history, prevalence, pathophysiology, diagnostic criteria, clinical implications, and treatment. [Journal of Psychosocial Nursing and Mental Health Services, 58(9), 19-24.].