INTRODUCTION
Pathologic laughing and crying, also known as pseudobulbar affect, is defined as improper laughter and crying, which is independent from the surrounding emotions or feelings. The disruption of cortico–ponto–cerebellar circuits induce disinhibition and produce pathologic laughing and crying. We report a case of pathologic laughing developed after administration of atomoxetine(Strattera®) in a pontine hemorrhage patient.
CASE PRESENTATION
A 55-year-old Asian male patient, at April 19, 2020 sudden loss of strength in left extremities and dysarthria occurred. He was diagnosed with acute intracerebral hemorrhage in right pons and midbrain (Fig. 1), and was referred to our hospital for rehabilitation.
At initial evaluation, the patient's Korean version of Mini Mental State Exam score was 26 of 30. His initial aphasia quotient of the Korean-Western Aphasia Battery was 88.7(92.6%ile) and language quotient was 91.4(94.5%ile). He had no previous emotional disorders, and had no emotional problems at the time of administration. At May 12, 2020, 10mg of atomoxetine(Strattera®) was added once a day as cognitive enhancer. At the day of atomoxetine administration, he suddenly developed inappropriate laughing that he could not control by himself. His laughter was abrupt and lasted for less than a minute, and it occurred several times a day. He had no crying, depression or any correlating emotional changes. The pathologic laughing and crying scale(PLACS) was 4 on the day he started taking medication. On the second day of drug administration, the score became 18 points consisting only of pathologic laughing components. There were no other causes for pathologic laughing, such as other medication or environmental changes. The medication was taken for three consecutive days. As he stopped taking atomoxetine on the fourth day, his laughing diminished and the PLACS improved to 5. His sudden laughter disappeared, but the smiling facial expression lasted for another week, with PLACS 1 for a week. On the eighth day of drug discontinuation, the PLACS reached 0 and all symptoms disappeared (Fig 2.).
CONCLUSION
Drugs that modulate serotonin or glutamate neurotransmitters, such as tricyclic antidepressants, selective serotonin reuptake inhibitors, antiglutamatergics agents are known to be effective as treatment for pathologic laughing and crying. Recent cases has reported that in addition to levodopa and serotonin-norepinephrine reuptake inhibitor were also effective as treatment. However, evidence of these drug efficacy is limited and based on case studies or small group studies.Atomoxetine(Strattera®) is a stimulant that increases norepinephrine and dopamine levels in the prefrontal cortex. This patient developed pathologic laughing while taking atomoxetine, and after he stopped taking it, the laughing disappeared. This is a case report to prove a crucial role of norepinephrine and dopamine levels in the development of pathologic laughing. |
