"Diagnoses would include tests such as 'Pathological Laughing and Crying Scale', in which the doctor could ask various questions like how long the episode lasted, how they affect your mood and social situation, and how much distress did the individual feel afterwards."
The Joker’s maniacal laughter stands for unbridled menace In the DC comic book universe, but Todd Phillips’ Joker adds a layer of health challenges behind that menacing glee. The movie is going strong and steady at the box office and Joaquin Phoenix has earned rave reviews for his powerful performance. But it is not only the acting, direction and camera skills the movie is being talked — it has also brought to the fore a lesser-known medical condition known as the Pseudobulbar affect or PBA.
Characterised by uncontrolled crying or laughing, which may be disproportionate or inappropriate to the social context, PBA may often go unnoticed or may be misdiagnosed as generalised anxiety disorder, schizophrenia, a personality disorder, and even epilepsy. “There is a disparity between the patient’s emotional expression and his or her emotional experience. In PBA, there is a disconnect between the frontal lobe (which controls emotions) and the cerebellum and brain stem (where reflexes are mediated). The effects are uncontrollable and can occur without an emotional trigger,” explains Dr Madhusudan B K, senior consultant neurologist & epileptologist & stroke specialist, BGS Gleneagles Global Hospital, Bengaluru.
In the film, Phoenix’s Arthur Fleck is shown to have the condition, as a result of which he experiences uncontrollable bouts of laughter even as he is being cornered by drunk men on a subway. There are other similar moments, with one showing him giving out a card to a woman on a bus — who asks him to stay away from her child that was seemingly enjoying the exchange with Fleck — explaining his condition and requesting her to not get offended.
“The character depicted the suffering of this condition. He was prone to fits of uncontrollable laughter at inappropriate moments. It is a condition which, more often than not, gets him into trouble, earns him scowls and sideways glances, and contributes to a crushing sense of loneliness that characterises his life, which is a portrayal of the life of individuals with this diagnosis,” says Dr Prakriti Poddar, mental health expert, director Poddar Wellness Ltd and managing trustee of Poddar Foundation.
While the exact prevalence of the condition in India is not known, experts say that in the USA, prevalence rates ranged from 9.4 per cent to 37.5 per cent, resulting in an estimated 1.8–7.1 million affected individuals as per recent reports. “The range of estimates of prevalence in various neurological disorders is high, ranging from 5 per cent to well over 50 per cent, depending on diagnostic criteria, methodologies, and patient populations studied,” adds Dr Madhusudan.
According to Dr Rohit Gupta, Director, Neurology, Fortis Escorts Faridabad, the condition is also prevalent among patients suffering from borderline personality disorder, depression, multiple sclerosis, dementia and stroke. Some common symptoms associated with the condition include: frequent, involuntary and uncontrollable outbursts of crying or laughing that are exaggerated or not connected to one’s emotional state. Laughter often turns to tears, and the person’s mood will appear normal between episodes, which can occur at any time. Crying appears to be a more common sign of PBA than laughing.
“The degree of the emotional response caused by PBA is often striking — crying or laughing — lasting up to several minutes. For example, you might laugh uncontrollably in response to a mildly amusing comment. Or you might laugh or cry in situations that others don’t see as funny or sad. These emotional responses typically represent a change from how you would have previously responded,” explains Dr Poddar.
She adds that since the pseudobulbar affect often involves crying, the condition is frequently mistaken for depression. “However, PBA episodes tend to be short in duration, while depression causes a persistent feeling of sadness. Also, people with PBA often lack certain features of depression, such as sleep disturbances or a loss of appetite. But depression is common among those who have pseudobulbar affect,” Dr Poddar tells indianexpress.com.
But how can the condition be diagnosed?
By correlating the symptoms and signs, “it can be diagnosed through neuropsychological evaluation by a neurologist or psychiatrist,” says Dr Preeti Singh, senior consultant, clinical psychology & psychotherapy, Paras Hospitals. Adding, Dr Poddar says that doctors usually do not conduct tests to diagnose pseudobulbar affect although they may use an electroencephalogram (EEG) to rule out a form of epilepsy that can cause similar symptoms.
“Diagnoses would include tests such as ‘Pathological Laughing and Crying Scale’ (PLACS) in which the doctor could ask various questions like how long the episode lasted, how they affect your mood and social situation, and how much distress did the individual feel afterwards. They could also rely on ‘Center for Neurologic Study – Lability Scale’ (CNS-LS) which tries to find out answers about the symptoms, how often they occur and how they make an individual feel,” she explains.
However, Dr Madhusudan says that while the condition is not curable, it is treatable. “Both pharmacologic and non-pharmacologic interventions exist. If medications are considered the best course of treatment by your doctor, you might be prescribed some type of antidepressant, antipsychotic, or anticonvulsant. The only FDA-approved drug for the treatment of PBA is dextromethorphan hydro bromide/quinidine sulfate. Educating caregivers and other family members is also important,” he says.
These coping techniques may help:
1. Be open about the problem so people aren’t surprised or confused when you have an episode.
2. Distract yourself by counting the number of objects on a shelf or by thinking about something unrelated when you think you’re about to have an episode.
3. Take slow deep breaths until you’re in control.
4. Relax your forehead, shoulders and other muscle groups that tense up during an episode.
5. Change your body position. Note your posture when you’re having an episode. When you think you’re about to cry or laugh, change your position.
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