Lamotrigine Treatment for Post-Stroke Pathological Laughing and Crying

Well at least this one is only 11 years old, still incompent but not mind-boggling.
http://journals.lww.com/clinicalneuropharm/Abstract/2003/09000/Lamotrigine_Treatment_for_Post_Stroke_Pathological.6.aspx

Ramasubbu, Rajamannar

Abstract

Pathologic laughing and crying (PLC) is a common distressing and socially disabling condition in stroke patients. Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), have been increasingly recognized as the treatment of choice for pathologic crying (PC). However, little is known about etiologies and other treatment options for various clinical manifestations of PLC. This case report illustrates the beneficial effect of lamotrigine, a novel antiepileptic drug with antidepressant and mood-stabilizing properties in post-stroke PLC. A 60-year-old woman developed PLC after an ischemic stroke affecting the left frontal and temporal lobes. She was treated with lamotrigine initially at the dose of 50 mg a day, which was gradually increased to 100 mg a day over a 4-week period. There was a significant and rapid recovery in both laughing and crying components of PCL with lamotrigine treatment. The symptoms of pathologic laughing have shown a better response to lamotrigine than PC. Controlled investigations are needed to evaluate the beneficial as well as the differential effects of lamotrigine on PLC.

The syndrome of pathologic laughing and crying (PLC) involves uncontrollable motor expression of emotion in the absence of corresponding feelings of sadness or happiness. PLC is often precipitated by nonspecific stimuli. 1 Emotional lability is a second type of pathologic affect that represents a rapid fluctuation in emotional expression that is out of proportion to an appropriate stimulus or situation and is accompanied by an alteration in mood states. 1 The validity of the existence of these two types has not been substantiated because of a great deal of overlap in the phenomenology between PLC and emotional lability. 2 In this context, a commonly used instrument, namely the pathologic laughing and crying scale (PLCS), has included items to measure both the intensity of pathologic laughing (PL) and pathological crying (PC) and also the severity of emotional lability. 3 The other terms used in the literature to describe the pathologic affect of laughing and crying include emotionalism, 4 emotional incontinence, 5 and pseudobulbar affect. 6

PLC is a common emotional consequence of stroke. Approximately 15% to 20% of patients may experience this condition during the first year after stroke. 7 Pathologic crying is the most common manifestation in stroke patients. However, some patients may have episodes of laughing without episodes of crying and some display both laughing and crying. Brain stem lesions and right frontal damage are frequently associated with PLC. 7 Double-blind placebo-controlled studies documented the efficacy of both tricyclics (nortriptyline, amitriptyline) and selective serotonin reuptake inhibitors (SSRIs) (citalopram, fluoxetine, sertraline) in PLC. 3,8–11 However, since the controlled treatment studies to date focused largely on patients with PC and only a few patients with PL were in the cohort, our understanding of the efficacy of antidepressants in PL is limited. Furthermore, anecdotal reports described a rapid transition of PC to PL during treatment with SSRIs 12 and a slow transformation of PC to PL as a natural course of PLC in some patients. 13,14

L-dopa was reported to be effective in patients with PL in an open trial. 15 However, taking into account the depressogenic side effect of l-dopa 16 and the frequent co-occurrence of depression with PLC in stroke patients, 7 l-dopa may not be a suitable agent for post-stroke patients with PLC and depression. This report describes a case of post-stroke PLC that markedly improved with lamotrigine, a novel antiepileptic drug with antidepressant and mood stabilizing properties.