Emotional and behavioral dyscontrol after traumatic brain injury.

Emotional and behavioral dyscontrol are relatively common neuropsychiatric sequelae of traumatic brain injury and present substantial challenges to recovery and community participation. Among the most problematic and functionally disruptive of these types of behaviors are pathologic laughing and crying, affective lability, irritability, disinhibition, and aggression. Managing these problems effectively requires an understanding of their phenomenology, epidemiology, and clinical evaluation. This article reviews these issues and provides clinicians with brief and practical suggestions for the management of emotional and behavioral dyscontrol.

Pathological laughing and crying : epidemiology, pathophysiology and treatment.

Pathological laughing and crying (PLC) is characterized by frequent, brief, intense paroxysms of uncontrollable crying and/or laughing due to a neurological disorder. When sufficiently frequent and severe, PLC may interfere with the performance of activities of daily living, interpersonal functioning, or both, and is a source of distress for affected patients and their families. PLC is also often misunderstood by patients and their families, and is under-recognized by the clinicians caring for patients with this disorder. However, this syndrome is easily recognized when understood properly and is highly responsive to treatment with a variety of pharmacological agents. This review aims to facilitate the diagnosis and treatment of patients with PLC, and begins by providing definitions of mood and affect that will help clinicians distinguish between mood disorders, such as major depression and mania, and disorders of affect, such as PLC. In addition, the various terms used to describe this syndrome are reviewed and a recommendation for the use of the term PLC is made. The core clinical features of PLC are also presented and the epidemiology of this syndrome is reviewed. A discussion of the pathophysiology of PLC, including the neuroanatomic and neurochemical bases, is provided. Finally, the evaluation and treatment of patients with PLC is described. Based on the pathophysiology of PLC and on a detailed review of published treatment studies, SSRIs are recommended as first-line pharmacotherapy for this disorder. When SSRIs are ineffective or poorly tolerated, other treatment options, including TCAs, noradrenergic reuptake inhibitors, novel antidepressants, dopaminergic agents and uncompetitive NMDA receptor antagonists may be useful second-line treatments.

Treatment of pathologic laughing and crying.

Pathologic laughing and crying (PLC) denotes paroxysms of involuntary and uncontrollable crying and/or laughing resulting from neurologic illnesses. These paroxysms of affect are often provoked by nonsentimental stimuli; even when the inciting stimulus is sentimentally meaningful, the intensity of the affective response is excessive. The crying and/or laughing of PLC are variably accompanied by episode-congruent subjective emotional feelings. In unusual cases, episode-related feelings are of a valence contradictory to the expressed affect (ie, feeling happy while crying, or vice versa). PLC does not bear a predictable relationship to the prevailing mood of the patient, and the occurrence of such episodes does not produce a sustained mood disturbance. Therefore, patients with PLC must not be misunderstood as "depressed" or "manic" solely on the basis of their frequent episodic crying or laughing. In rare circumstances, PLC or PLC-like symptoms may be the presenting symptom of a neurologic illness. In such circumstances, a prompt and thorough diagnostic evaluation for that neurologic illness should be undertaken before initiating treatment for PLC. Selective serotonin reuptake inhibitors (SSRIs) are efficacious, safe, and well-tolerated treatments for PLC and are recommended as first-line treatments for this condition. Tricyclic antidepressants, dextromethorphan/quinidine, or dopaminergic agents may be useful alternative treatments in patients in whom SSRIs are ineffective or poorly tolerated. Education and supportive therapy may help patients and families mitigate the social isolation and embarrassment that PLC episodes frequently produce.