Clinical Geriatrics

CASE PRESENTATION
Mrs. B is a 52-year-old divorced Caucasian woman with a 20-year history of multiple sclerosis, relapsing-remitting type. She has been followed by a neurologist who specializes in multiple sclerosis and related disorders. Over the years she has been treated with steroids, interferon-beta, and was enrolled in a clinical trial of a monoclonal antibody. She is no longer ambulatory, but uses a motorized wheelchair independently.

She is referred for psychiatric evaluation due to episodes of spontaneous crying that occur without warning, usually while she is engaged in a conversation. In addition, she sometimes displays episodes of laughing and giggling. Mrs. B was treated in the past with amitriptyline, and later with sertraline for depression, but has not been taking any psychotropic medications over the past 3-4 years. Her current medications include glatiramer acetate 20 mg subcutaneously daily and azathioprine 50 mg orally daily for treatment of her multiple sclerosis. In addition, she takes oxybutynin chloride extended-release 15 mg daily for urinary incontinence, baclofen 10 mg 3 times per day for muscle spasms, and zolpidem 10 mg as needed for insomnia. Prior to referring Mrs. B for psychiatric evaluation, the neurologist treated her with a course of intravenous mitoxantrone for multiple sclerosis in the belief that it may help reduce her symptoms. Sertraline 50 mg per day was resumed as well. Unfortunately, the episodes of emotional lability persisted, causing the patient significant distress.

Mrs. B was neatly dressed and groomed, and presented in a very professional, business-like manner. She was calm in appearance and very cooperative. Her speech was slightly dysarthric, and she episodically started crying spontaneously while answering questions. Mrs. B was clearly embarrassed and distressed by this, stating, “I have put up with this disease for more than 20 years, raised three children after my husband left me, but this is making me crazy.” She also displayed brief periods of giggling that were unrelated to the content of her speech. She described her mood as angry, and did not seem depressed. Her affect was appropriate, but marked by these episodes of crying and giggling that lasted for 2-3 minutes and occurred more than 6 times during the hour-long interview. She complained of having more difficulty paying attention to things such as reading, but was performing her job well. She scored 30 out of 30 on a Mini-Mental State Examination and was able to accurately draw a clock.

Mrs. B reported that sertraline had not been helpful and requested anything that would help reduce the outbursts of crying and laughing. She was fearful that her giggling and crying out during meetings would cause her to lose her job as an editor; she stated that she needs some relief.

DISCUSSION
Pathologic laughter and crying is a syndrome associated with a variety of neurologic disorders, including multiple sclerosis, stroke syndromes, amyotrophic lateral sclerosis, Huntington’s disease, traumatic brain injury, and certain brain tumors, such as those affecting the cerebellopontine angle.1 This syndrome is characterized by episodes of spontaneous crying and tearfulness that are not accompanied by depressed mood and are often unrelated to the affect or emotional tone of the patient’s thinking. Pathologic crying is far more common than episodes of laughing, which tends to occur in fewer than 5% of patients.2 However, episodes of mood-incongruent giggling and laughing are often far more disabling and distressing to patients and families.3 Terms including emotional incontinence, affective lability, essential crying, and pseudobulbar affect (PBA), or palsy have been used to describe this syndrome.1-3 Each term refers to the symptoms of spontaneous crying without sadness and unanticipated laughter in the absence of humor.