Evidence-Based Reviews

A cry for help: Treating involuntary emotional expression disorder

Current Psychiatry. 2008 March;7(3):101-111

References

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A combination dextromethorphan and quinidine (DM/Q) is being evaluated for IEED. This compound has demonstrated efficacy in IEED patients with ALS¹⁹ and MS²⁰ and is in Phase III clinical development. DM/Q is thought to be a potent activator of the sigma-1 receptor system as well as an N-methyl-D-aspartate antagonist.²¹

Table 4

IEED: Evidence for antidepressants

Drug	Study design/population	Dosage	Outcome
Tricyclics
Amitriptyline	Schiffer et al;¹³ double-blind crossover; 12 multiple sclerosis patients	Mean: 57.8 mg/d	8 patients showed significant improvement compared with placebo
Nortriptyline	Robinson et al;¹² double-blind, placebo-controlled; 28 stroke patients	≤100 mg/d	Patients receiving nortriptyline reported significantly greater improvement on PLACS at 4 and 6 weeks compared with placebo
Selective serotonin reuptake inhibitors
Citalopram	Anderson et al;¹⁴ double-blind, placebo-controlled crossover; 16 stroke patients	10 to 20 mg/d	Citalopram decreased the number of daily crying episodes by ≥50% compared with placebo
Fluoxetine	Choi-Kwon et al;² double-blind placebo-controlled; 152 patients	20 mg/d	Fluoxetine significantly improved measures of IEED and anger proneness but not depression
Paroxetine	Müller et al;¹⁵ consecutive case series, comparison with citalopram; 26 patients with traumatic brain injury or stroke	10 to 40 mg/d	Both paroxetine and citalopram resulted in significant improvements in measures of emotionalism
Sertraline	Burns et al;¹⁶ double-blind, placebo-controlled; 28 stroke patients	50 mg/d	Patients receiving sertraline had significant improvements in measures of emotionalism
IEED: involuntary emotional expression disorder; PLACS: Pathological Laughing and Crying Scale

CASE CONTINUED: Effective pharmacotherapy

After diagnosing IEED, you start Mrs. R on sertraline, 50 mg/d. She experiences a nearly immediate reduction in the number of daily IEED episodes. As a result, she feels more comfortable engaging in social activities.

Clinical Point

First-line treatment is pharmacotherapy with tricyclic antidepressants or selective serotonin reuptake inhibitors

Recommendations. We recommend using pharmacologic therapy for IEED. Because of the presence of underlying brain damage, IEED patients are likely to require treatment for other chronic or progressive conditions. Choose first-line therapy based on the patient’s medication regimen and comorbid conditions, as well as the drug’s side-effect profile.

Effective pharmacologic intervention can greatly improve patients’ quality of life.^19,20 Use scales that measure IEED severity to gauge treatment effectiveness (Box 2).^{12,19,20,22-25} Because treatment failure is a realistic possibility,¹⁷ you may need to try a variety of agents to determine which regimen provides the greatest efficacy and therapeutic effects.

Related Resources

Involuntary emotional expressive disorder (for healthcare professionals). www.ieed.org/hp.
Pathological laughing and crying scale (PLACS). Robinson RG, Parikh RM, Lipsey JR, et al. Pathological laughing and crying following stroke: validation of a measurement scale and a double-blind treatment study. Am J Psychiatry 1993;150:286-93.
Center for neurologic study—lability scale (CNS-LS). Moore SR, Gresham LS, Bromberg MB, et al. A self report measure of affective lability. J Neurol Neurosurg Psychiatry 1997;63:89-93.

Drug brand names

Amitriptyline • Elavil, Endep
Citalopram • Celexa
Dextromethorphan/quinidine • Zenvia*
Fluoxetine • Prozac
Levodopa • Larodopa
Mirtazapine • Remeron
Nortriptyline • Aventyl
Paroxetine • Paxil
Sertraline • Zoloft
* IN PHASE III DEVELOPMENT

Disclosures

Dr. Grill reports no financial relationship with any company whose products are mentioned in the article or with manufacturers of competing products.

Dr. Cummings is a consultant to Acadia Pharmaceuticals, Astellas Pharma, Avanir Pharmaceuticals, Cephalon, CoMentis, Eisai, Eli Lilly and Company, EnVivo Pharmaceuticals, Forest Pharmaceuticals, Janssen, L.P., Lundbeck, Merck, Merz Pharma, Myriad, Neurochem, Novartis, Ono Pharmaceutical Co., Pfizer Inc., and sanofi-aventis. He is a speaker for Eisai, Forest Pharmaceuticals, Janssen, L.P., Lundbeck, Merz Pharma, Novartis, and Pfizer Inc.