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
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