The neuroanatomical findings in a recently studied patient with PLC, along with new knowledge on the neurobiology of emotion and feeling, gave us an opportunity to revisit the traditional view and propose an alternative. In that view, the lesions \`disinhibit' or \`release' the laughter and crying centre. The traditional and currently accepted view is that PLC is due to the damage of pathways that arise in the motor areas of the cerebral cortex and descend to the brainstem to inhibit a putative centre for laughter and crying. PLC is a disorder of emotional expression rather than a primary disturbance of feelings, and is thus distinct from mood disorders in which laughter and crying are associated with feelings of happiness or sadness. The episodes occur either without an apparent triggering stimulus or following a stimulus that would not have led the subject to laugh or cry prior to the onset of the condition. Patients with pathological laughter and crying (PLC) are subject to relatively uncontrollable episodes of laughter, crying or both. This term indicates the general position of the lesion The term supranuclear bulbar paralysis would be more accurate. GENERAL CONSIDERATIONS The designation "pseudobulbar palsy" is a misnomer. Hunter and Robertson⁶ and Oettinger⁷ reported typical cases. Ross⁴ reviewed cases from an anatomic-functional point of view, and Oppenheim and Siemerling⁵ differentiated pseudobulbar from true bulbar palsy. Jolly² described a patient with multiple sclerosis and "progressive bulbar paralysis" whose bulbar nuclei were normal at autopsy Barlow³ emphasized the relation of bilateral cortical lesions to the syndrome. Magnus¹ first reported a case in which there were features characteristic of pseudobulbar palsy following multiple apoplectic attacks he discussed the postmortem observations. It is our purpose, therefore, to present an anatomic and physiologic analysis of this condition. Pseudobulbar palsy is a syndrome about which little is known in spite of the fact that it not uncommonly follows cerebral vascular accidents and other forms of neurologic disease. Depression Major depression Major depression has been defined in the Diagnostic and Statistical Manual (DSM-IV) as a syndrome consisting of five or more symptoms that have been present during the same 2-week period and that represents a change from previous functioning. Usually, mood and affect are congruent, but in the disorder of pseudobulbar affect, this is not the case. “Affect,” on the other hand, is an objective rating of a person's mood. Definitions The term “mood” refers to an individual's subjective sense of emotional well being. What all the disorders have in common, however, is the deleterious effect they exert on quality of life, not only for the individual with MS but also for family members and caregivers. As the data will make clear, some of these disorders have been well studied while others have remained in relative obscurity. This chapter will outline the clinical characteristics of each disorder, discuss possible mechanisms underlying etiology, and provide recommendations for treatment. For the purposes of this chapter, only two subdivisions will be discussed, namely major depression and subsyndromal depression. Depression may be further subdivided according to the taxonomy followed. Introduction Disorders of mood and affect in multiple sclerosis (MS) may be separated into four main categories: depression, bipolar disorder, euphoria, and pseudobulbar affect. Currently, the exact neurological basis of of this disorder is not fully understood according to one of the first hypotheses it is determined by the loss of voluntary inhibition of a presumed center controlling laughing and crying located in the brainstem (disinhibition hypothesis), able to regulate breathing and facial movements associated with laughing and crying. Pathological laughing and crying is one of the four most common affective disorders described in MS, characterized by sudden, uncontrollable and incongruous episodes of laughing and crying that may occur alternately and are not associated to any stimulus. It has been regarded as a consequence of cognitive impairment or one of the consequences of the loss of reasoning skills resulting from severe involvement of the frontal lobes and their connections. Many literature data have described both euphoria and pathological laughing and crying in MS patients.Euphoria is considered a pathological condition when the emotional resonance is disproportionate to the real situation.
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