A time to cry and a time to laugh

A

Barts-MS rose-tinted-odometer: ★

When I met her for the first time she was in her early fifties. She had had multiple sclerosis for over 20 years. Her family now kept her at home; isolated from the wider world. Her behaviour would embarrass them. Why? She suffered from pathological laughter and occasionally inappropriate crying and her husband and children could not deal with this in public. It was clear she was very disabled when I met her in the clinic; she was unsteady on her feet, had a slurred speech and dancing eyes from cerebellar problems. She had gross cognitive impairment. When I had introduced myself to her she had burst into tears. Within in two to three months of starting sertraline, a selective serotonin reuptake inhibitor (SSRI), her husband informed me that her laughing and crying episodes had improved by over 50% and the family were now taking her out on a regular basis. He was very grateful that I had been able to educate them about her symptoms and more importantly been able to help her and them as a family deal with this problem.

Pathological or inappropriate laughing and crying are common in pwMS; it is defined as an emotional expression that is exaggerated or incongruent with underlying mood. From my experience, it is much commoner than studies suggest it is and if you ask about the symptom many pwMS suffer from a mild form of it. 

In short inappropriate laughing and crying is due to frontal lobe or brainstem damage as a result of MS and in my experience is associated with cognitive and mood problems. It is important to realise that inappropriate laughing and crying are symptoms of MS as that they respond to tricyclic and SSRI antidepressants and a combination pill that includes dextromethorphan/quinidine (Nuedexta®). 

The medical or neurological name for inappropriate laughing and crying is a ‘pseudobulbar affect’ and is diagnosed using standardised scales or questionnaires, which can be self-administered

I would be interested to know how many of you have inappropriate laughing and crying and how disruptive these symptoms are to your life? Does your MS team ask about these symptoms and have you been offered a screening questionnaire for this problem? If you have been diagnosed as having a pseudobulbar affect have you been treated for it, what treatments did you receive and how have you responded to these treatments? 

You may realise that inappropriate laughing and crying in pwMS are another two neglected symptoms that often go undetected and untreated in many pwMS. This doesn’t have to be the case.

Hanna et al. The association of pathological laughing and crying and cognitive impairment in multiple sclerosis. J Neurol Sci. 2016 Feb 15;361:200-3.

Background: Pathological laughing and crying (PLC) is common in multiple sclerosis (MS), defined as emotional expression that is exaggerated/incongruent with underlying mood. In other neurological disorders, PLC is associated with cognitive impairment (CI). Few studies have examined this relationship in MS.

Objective: To determine the association between PLC and CI in an MS population.

Methods: Retrospective chart review study of 153 MS subjects assessed in an outpatient clinic for CI. Data was collected on the minimal assessment of cognitive function in MS (MACFIMS), the Center for neurological study-lability scale (CNS-LS), a screening measure for PLC symptoms and the hospital anxiety and depression scale (HADS). Analyses of covariance compared performance on the MACFIMS between PLC (CNS-LS score ≥ 17, HADS-D ≤ 7) and non-PLC groups.

Results: MS subjects positive for PLC on the CNS-LS but without depression had lower scores on the controlled oral word association test, a measure of verbal fluency, and the California verbal learning test – 2 immediate recall score, a verbal memory measure.

Conclusions: This study demonstrates a connection between CI, specifically verbal fluency and verbal learning, and PLC in MS subjects. Further studies are warranted to explore the causative relationship between CI and PLC.

CoI: multiple

Twitter: @gavinGiovannoni                               Medium: @gavin_24211

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.

15 comments

  • Inappropriate laughing is common in autism and dementia too.
    A non pharmacological alternative treatment would be my preference. Perhaps CBT and having strategies in place when this happens.

  • Oh my yes! I have the pseudobulbar effect and wow how it has and probably always will effect me has been so difficult. I could write a lot here but will keep it short as I am rushed. I absolutely dread events such as funerals, weddings and such as I spend the time putting all my energy in to not laughing! I really hate it! I’d say I have ptsd from the decades of trying to convince doctors that I had ms because I couldn’t walk properly amongst the many other symptoms but because I couldn’t control my crying I was labelled a depressive hypochondriac and difficult to treat patient because I refused to take antidepressants! I just couldn’t convince them – they should have known better!
    Yoga classes I will giggle uncomfortably and uncontrollably and everyone thinks I am happy but I am not!
    Whether happy or sad I cannot control my laughing or crying at the most inconvenient of times – or when I should be sad I laugh, it is awful!
    I don’t like meds and I find anything that has an effect on my brain chemistry makes me feel awful but the one thing that has taken the edge off this pseudobulbar has been amantadine – not sure how or why but it does. I take it if I know I have an event approaching. But it also makes my insomnia worse so I don’t take it everyday – although it is anti viral so probably a good thing to take at the moment…. Anyway yes I know all about pseudobulbar and I wish more awareness was made of it! X

  • I’ve been reading more into this and many people experience inappropriate laughter. It’s a part of life and can be due to nervousness, PTSD, cultural differences and personality type. It’s also can be due to epilepsy too.

    So we shouldn’t be too hard on ourselves and others about it, if it happens.
    And I feel there should be no rush to blame it on the MS, unless it is causing an real problem.

  • I have onyl inappropriat cyring but not from my MS. Lost my uterus because of ovarien cancer and ist started directley after surgery.

  • I have to laugh when I see the ever increasing list of MS symptoms (eg spasticity, inappropriate laughing and crying, incontinence, cognitive impairment, speech problems, swallowing problems, vision problems…….blah, blah, blah) and I have to cry when the solution is another pill! Advanced MSers must sound like rattles if they take the prescribed pill for the myriad of worsening symptoms that MS delivers with time.

    Surely, rather than dishing out pills which have limited affect on these numerous and often awful symptoms (see example of the woman in Prof G’s case above), a better option would be to identify a treatment which stops the destruction of the brain / spinal cord? Perhaps a New Year resolution for a bright, young MSologist, is to identify such a treatment. The woman (and her family) in the case above, deserved so much better!

  • I got the crying part quite strongly for weeks after a 4 hour surgery last year – I think is was related to the narcotics.

    I also seem to get it sometimes after Tizanidine wears off?

  • I have to tell you about the first neurologist I ever saw. He laughed inappropriately and he was a neuro registrar. I told him I banged my head severely before the vertigo and double vision started and that I felt euphoric straight after the head bang.

    He laughed and said ‘if it feels that good, why don’t you do it again’ and laughed again loudly. He said the head bang couldn’t be related to the vertigo and double vision, which I don’t agree with.

  • Good to know that it’s just not me. For me laughing turns into inexplicable crying when laughing about one particularly area, namely the sweet but funny things my children did when they were. I’ll be telling a someone a funny story about them and then my laughing turns to full on crying from out of nowhere!

  • I wouldn’t say that I laugh or cry ‘inappropriately’, inasmuch as I do it in response to things that are objectively ‘sad’ or ‘funny’, but the threshold at which I start crying is much, much lower than it was – the slightest thing sets me off. In terms of laughing, I laugh uncontrollably a lot more than I used to.

    In both cases, I feel there is a progression happening.

  • I need to carry a board around with me to explain my inconvenient laughing – just like in the film “The Joker”!
    I can’t go into the shops around remembrance Sunday as I have laughed – it is so bloody awful! This is how bad it gets & I really hate it!
    Need more awareness about this pseudobulbar! X

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