Emotional Incontinence (Pathological Laughing or Crying) in Stroke

Disturbances in the voluntary control of emotional expression after a stroke were first reported in the nineteenth century. Various terms have since been used, such as pathologic laughing and crying, pseudobulbar affect, emotionalism, emotional lability, involuntary emotional expression disorder, and post-stroke emotional incontinence (PSEI). The prevalence of PSEI has been reported to be 6–34% (mostly 10–20%). The frequency and intensity of PSEI decrease over time. Although there still are controversies, imaging studies have shown that lesions affecting frontal-internal capsular-pontine base circuitry most often produce PSEI. Cerebellar, basal ganglionic, and thalamic lesions are occasionally associated with PSEI. It has been proposed that PSEI is caused by disinhibiting a brainstem fasciorespiratory control center for emotional expression secondary to lesions affecting descending pathways from higher cortical brain centers. It is currently believed that deficits in any areas of the brain network related to emotional expression (cortico-limbic subcortical-thalamic-ponto-cerebellar system) can lead to PSEI. Studies have shown that serotonin dysfunction plays an essential role in producing PSEI. Selective serotonin reuptake inhibitors (SSRIs) are recommended as first-line agents for treating PSEI. When SSRIs are ineffective or poorly tolerated, tricyclic antidepressants, selective adrenergic receptor inhibitors, or dopaminergic agents may be considered.