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Emotional Disturbances in Hallucinating and Deluded Patients
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These are best portrayed by the patient with a orid delirium Threatened by imaginary gures and voices that seem real and Table 25-1 Neurology of emotional disturbances I Disturbances of emotionality due to: A Perceptual abnormalities (illusions and hallucinations) B Cognitive derangements (delusions) II Disinhibition of emotional expression A Emotional lability B Pathologic laughing and crying III Rage reactions and aggressivity IV Apathy and placidity A Kluver-Bucy syndrome B Other syndromes (frontal and thalamic) V Altered sexuality VI Endogenous fear, anxiety, depression, and euphoria
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inescapable, the patient trembles, struggles to escape, and displays the full picture of terror The patient s affect, emotional reaction, and visceral and somatic motor responses are altogether appropriate to the content of the hallucinations We have seen a patient slash his wrists and another try to drown himself in response to hallucinatory voices that admonished them for their worthlessness and the shame they had brought on their families But the abnormality in these circumstances is one of disordered perception and thinking, and we have no reason to believe that there is a derangement of the mechanisms for emotional expression There also occurs a state dif cult to classify of overwhelming emotionality in patients who are in severe acute pain The patient s attention can be captured only brie y, but within moments there is a return to an extreme state of angst, groaning, and anger We have encountered this with spinal subdural hemorrhage, subarachnoid hemorrhage, explosive migraine, trauma with multiple fractures, and intense pelvic, renal, or abdominal pain, all understandable as responses to extralimbic stimuli
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Table 25-2 Causes of pseudobulbar affective display Bilateral strokes (lacunes in the cerebral hemispheres or pons most often, and after several strokes in succession) Binswanger diffuse leukoencephalopathy (Chap 34) Amyotrophic lateral scerlosis with pseudobulbar palsy Progressive supranuclear palsy Multiple sclerosis with bilateral corticobulbar demyelinative lesions Bilateral traumatic lesions of the hemispheres Hypoxic-ischemic encephalopathy Pontine myelinolysis Wilson disease
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Disinhibition of Emotional Expression
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Emotional Lability It is a commonplace clinical experience that cerebral diseases of many types, seemingly without respect to location, weaken the mechanism of control of emotional expression a mechanism that has been acquired over years of maturation The degree to which this pertains varies with gender and ethnicity and has more to do with social norms than with biology In certain cultures, women are permitted to cry in public but men are not In the realm of neurologic disease, a patient whose cerebrum has been damaged for example, by a series of vascular lesions may suffer the humiliation of crying in public upon meeting an old friend or hearing the national anthem, or of displaying uncontrollable laughter in response to a mildly amusing remark or an attempt to tell a funny story There may also be easy vacillation from one state to another, an emotional lability that has for more than a century been accepted as a sign of organic brain disease In this type of emotional disturbance, the response, while excessive, does not reach the degree of forced emotionality of the special form of lability described as pseudobulbar (see below); furthermore, it is appropriate to the stimulus and the affect is congruent with the visceral and motor components of the expression The anatomic substrate is obscure Perhaps lesions of the frontal lobes more than those of other parts of the brain are conducive to this state, but the authors are unaware of a critical clinicoanatomic study that substantiates this impression Emotional lability is a frequent accompaniment of diffuse cerebral diseases such as Alzheimer disease, but these diseases, of course, also involve the limbic cortex Also under this heading might be included the tearfulness and facile mood that so often accompany chronic diseases of the nervous system, and the shallow facetiousness (Witzelsucht) and behavioral disinhibition of the patient with frontal lobe disease Pathologic (Pseudobulbar, Forced, Spasmodic) Laughing and Crying This form of disordered emotional expression, characterized by outbursts of involuntary, uncontrollable, and stereotyped laughing or crying, has been well recognized since the late nineteenth century Numerous references to these conditions (the Zwangslachen and Zwangsweinen of German neurologists and the rire et pleurer spasmodiques of the French) can be found in the writings of Oppenheim, von Monakow, and Wilson (see Wilson
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for historical references) The term emotional incontinence applied by psychiatrists is perhaps accurate but a bit pejorative Forced laughing and crying always has a pathologic basis in the brain, either diffuse or focal; hence this stands as a syndrome of multiple causes It may occur with degenerative and vascular diseases of the brain (Table 25-2) and no doubt is the direct result of them, but often the diffuse nature of the underlying disease precludes useful topographic analysis and clinicoanatomic correlation The best examples of pathologic laughing and crying are provided by lacunar vascular disease but also by amyotrophic lateral sclerosis, multiple sclerosis, and progressive supranuclear palsy, in each case the lesions being distributed bilaterally and generally involving the motor tracts, more speci cally, the corticobulbar motor system, as discussed further on They may also be part of the residue of the more widespread lesions of hypoxic-hypotensive encephalopathy, Binswanger ischemic encephalopathy, cerebral trauma, or encephalitis Typical in our experience is a sudden hemiplegia from a stroke that is engrafted upon a pre-existent (and often clinically silent) lesion in the opposite hemisphere; this sets the stage for the pathologic emotionality In this state there is often a striking incongruity between the loss of voluntary movements of muscles innervated by the motor nuclei of the lower pons and medulla (inability to forcefully close the eyes, elevate and retract the corners of the mouth, open and close the mouth, chew, swallow, phonate, articulate, and move the tongue) and the preservation of movement of the same muscles in yawning, coughing, throat clearing, and spasmodic laughing or crying (ie, in re exive pontomedullary activities) This is the motor syndrome of pseudobulbar palsy (page 427) for which reason the term pseudobulbar affective state has been applied to the emotional disorder In such cases, on the slightest provocation and sometimes for no apparent reason, the patient is thrown into a stereotyped spasm of laughter that may last for many minutes, to the point of exhaustion Or, far more often, the opposite happens the mere mention of the patient s family or the sight of the doctor provokes an uncontrollable spasm of crying or, more accurately stated, a caricature of crying The severity of the emotional incontinence or the ease with which it is provoked does not always correspond with the severity of the pseudobulbar paralysis or with an exaggeration of the facial and masseter ( jaw jerk ) tendon re exes In some patients with forced crying and laughing, there is little or no detectable weakness of facial and bulbar muscles; in others, forced laughing and crying are lacking despite a severe upper motor neuron weakness of these muscles In certain diseases, such as progressive
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