Is this normal? Recognizing pathological laughing and crying

by: Nicholas Olney, M.D.
Co-Director, Providence ALS Center

Pathological laughing and crying is a disorder of emotional expression that occurs in the setting of neurologic disease. The majority of people without neurologic disease can recall a time that they had intense laughter or intense crying that was next to impossible to control. This fits within the spectrum of normal emotion and is not considered pathological laughing and crying.

Pathological laughing and crying, otherwise known as pseudobulbar affect (PBA), is when intense laughter or intense crying is easily triggered and difficult to control. It occurs in the setting of numerous neurologic diseases, including amyotrophic lateral sclerosis (ALS), progressive supranuclear palsy, multiple sclerosis (MS), stroke, traumatic brain injury (TBI) and other neurologic disorders. Pathological laughing and crying is often a change from a patient’s baseline control of emotion and occurs in the setting of neurologic disease, which suggests that it is not psychological.

PBA is most common in the setting of amyotrophic lateral sclerosis (ALS).   The actual mechanism is poorly understood, but there is currently FDA approved medication if the symptoms of pseudobulbar affect are recognized. One of my first studies, which was published in Brain 2011, showed in patients with ALS that these episodes of pathological laughing and crying were linked to specific triggers and the first episodes were triggered by strong emotions consistent with the emotions being displayed.

When I see patients in ALS clinic, I often use a basic screening question, “Do you have any episodes or laughing or crying that are now more difficult to control?” I get varied answers. Given ALS is a terminal illness, it is an emotional time for most patients, and crying is appropriate.

However, every once in a while, I will meet someone who has pathological laughing and they find it odd, given they are having intense episodes of laughing after being given a serious neurodegenerative diagnosis. Often months after a patient is coming to terms with their serious diagnosis, intense pathological crying continues and can make it difficult to interact with family or uncomfortable going out in public. Patients with pathological laughing may feel uncomfortable attending weddings or funerals for fear they may have an outburst of inappropriate emotional display.

I often find providing education to patients can provide some relief to validate that what they are experiencing is a known phenomenon. This often then leads to the discussion of whether the only FDA-approved medication for PBA (Nuedexta) is something they would like to try if the symptoms are bothersome to them.

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