The Journal of Psychiatry and Neuroscience (Canadian,
bilingual), an open-access publication, has a regular column entitled
Psychopharmacology for the Clinician (Psychopharmacologie
pratique). Typically the column contains a case
report and a brief discussion of practical issues in treatment.
The most recent (September 2007) issue describes a case of poststroke
pathological laughing and crying (PLC). PLC is a mysterious
condition, something that is impossible to explain using behavioral or
After a stroke, 7 to 48 percent of patients experience disinhibition of
emotional displays, including crying and/or laughing. In some
patients, the threshold for activation of these displays is reduced.
In others, the displays appear to be entirely spontaneous.
It is not directly harmful, but it is annoying. Moreover, it
can lead to some degree of disability because it can be disruptive.
Note that this is not due to poststroke depression or mania.
Although affective disorders commonly occur after stroke, PLC
is not associated with a full set of symptoms that would support a
diagnosis of mania or depression.
Now, you might think that an antidepressant would not have any effect,
since the patients do not have depression.
However, such expectations next to useless in psychiatry. The
only way to learn anything in psychiatry is to try it and see what
happens. So, what happens when a person with PLC takes an
treatment of poststroke pathological laughing and crying
Peter Giacobbe, MD
Alastair Flint, MBA 60-year-old man with left-sided limb
weakness after a stroke was referred for assessment and treatment of
depression. The patient reported that, after his stroke 2 weeks ago,
he has been crying “for no reason” several times a
described that the crying spells last several seconds and cannot be
resisted. The patient denies depressed mood or symptoms consistent
with a mood disorder. On examination, stereotyped paroxysms of crying
lasting 5–10 seconds were noted during the interview,
to any emotional themes discussed. The patient was diagnosed with
pathological crying and was started on citalopram 10 mg orally at
night. On follow-up, he reported that his crying spells stopped
within days of initiating the selective serotonin reuptake inhibitor
The column reviews the (scant) literature on the subject,
indicating that several studies have shown that antidepressants are
effective. Curiously, they take effect within a few days, a
time scale too short for an antidepressant effect. So they
work by some other mechanism, but that mechanism is not known.
…In pooled data of 93 people from these
placebo-controlled trials of nortriptyline, fluoxetine, sertraline and
citalopram 96% of patients who received antidepressant medication
demonstrated a greater than 50% reduction in the number of crying
episodes at the end of the treatment trials, compared with 27.5% of
patients who received placebo, yielding a number needed to treat (NNT)
So not only does the response occur quickly, it occurs in a high
percentage of people. An NNT as low as 1.5 is unusual in
psychiatry, as it is in most areas of medicine.