A cry for help: Treating involuntary emotional expression disorder
Pharmacotherapy can lessen the impact of uncontrollable laughing or crying.
A combination dextromethorphan and quinidine (DM/Q) is being evaluated for IEED. This compound has demonstrated efficacy in IEED patients with ALS19 and MS20 and is in Phase III clinical development. DM/Q is thought to be a potent activator of the sigma-1 receptor system as well as an N-methyl-D-aspartate antagonist.21
Table 4
IEED: Evidence for antidepressants
| Drug | Study design/population | Dosage | Outcome |
|---|---|---|---|
| Tricyclics | |||
| Amitriptyline | Schiffer et al;13 double-blind crossover; 12 multiple sclerosis patients | Mean: 57.8 mg/d | 8 patients showed significant improvement compared with placebo |
| Nortriptyline | Robinson et al;12 double-blind, placebo-controlled; 28 stroke patients | ≤100 mg/d | Patients receiving nortriptyline reported significantly greater improvement on PLACS at 4 and 6 weeks compared with placebo |
| Selective serotonin reuptake inhibitors | |||
| Citalopram | Anderson et al;14 double-blind, placebo-controlled crossover; 16 stroke patients | 10 to 20 mg/d | Citalopram decreased the number of daily crying episodes by ≥50% compared with placebo |
| Fluoxetine | Choi-Kwon et al;2 double-blind placebo-controlled; 152 patients | 20 mg/d | Fluoxetine significantly improved measures of IEED and anger proneness but not depression |
| Paroxetine | Müller et al;15 consecutive case series, comparison with citalopram; 26 patients with traumatic brain injury or stroke | 10 to 40 mg/d | Both paroxetine and citalopram resulted in significant improvements in measures of emotionalism |
| Sertraline | Burns et al;16 double-blind, placebo-controlled; 28 stroke patients | 50 mg/d | Patients receiving sertraline had significant improvements in measures of emotionalism |
| IEED: involuntary emotional expression disorder; PLACS: Pathological Laughing and Crying Scale | |||
CASE CONTINUED: Effective pharmacotherapy
After diagnosing IEED, you start Mrs. R on sertraline, 50 mg/d. She experiences a nearly immediate reduction in the number of daily IEED episodes. As a result, she feels more comfortable engaging in social activities.
Effective pharmacologic intervention can greatly improve patients’ quality of life.19,20 Use scales that measure IEED severity to gauge treatment effectiveness (Box 2).12,19,20,22-25 Because treatment failure is a realistic possibility,17 you may need to try a variety of agents to determine which regimen provides the greatest efficacy and therapeutic effects.
- Involuntary emotional expressive disorder (for healthcare professionals). www.ieed.org/hp.
- Pathological laughing and crying scale (PLACS). Robinson RG, Parikh RM, Lipsey JR, et al. Pathological laughing and crying following stroke: validation of a measurement scale and a double-blind treatment study. Am J Psychiatry 1993;150:286-93.
- Center for neurologic study—lability scale (CNS-LS). Moore SR, Gresham LS, Bromberg MB, et al. A self report measure of affective lability. J Neurol Neurosurg Psychiatry 1997;63:89-93.
- Amitriptyline • Elavil, Endep
- Citalopram • Celexa
- Dextromethorphan/quinidine • Zenvia*
- Fluoxetine • Prozac
- Levodopa • Larodopa
- Mirtazapine • Remeron
- Nortriptyline • Aventyl
- Paroxetine • Paxil
- Sertraline • Zoloft
- * IN PHASE III DEVELOPMENT
Dr. Grill reports no financial relationship with any company whose products are mentioned in the article or with manufacturers of competing products.
Dr. Cummings is a consultant to Acadia Pharmaceuticals, Astellas Pharma, Avanir Pharmaceuticals, Cephalon, CoMentis, Eisai, Eli Lilly and Company, EnVivo Pharmaceuticals, Forest Pharmaceuticals, Janssen, L.P., Lundbeck, Merck, Merz Pharma, Myriad, Neurochem, Novartis, Ono Pharmaceutical Co., Pfizer Inc., and sanofi-aventis. He is a speaker for Eisai, Forest Pharmaceuticals, Janssen, L.P., Lundbeck, Merz Pharma, Novartis, and Pfizer Inc.
