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Multiple Sclerosis and Involuntary Emotional Expression Disorder
Transcript from the Multiple Sclerosis Association of America's Educational Web Video

This program is being supported by an educational grant from Avanir Pharmaceuticals. Welcome to the Multiple Sclerosis Association of America’s educational web video, Learning About Involuntary Emotional Expression Disorder. Joining us is Dr. Daniel Wynn, Director, Clinical Research and Co-Director, Consultant in Neurology, MS Center in Chicago. Dr. Wynn, welcome to the program. Can you briefly describe the condition known as IEED?

Involuntary emotional expression disorder, or IEED, is a neurological symptom in patients with illnesses such as multiple sclerosis, stroke or head injury, or personal experience involuntary episodes of emotional expression – crying, laughter, or irritability.

In the past, neurologists commonly used the term, pseudobulbar affect. Psychiatrists commonly use the term emotional lability or emotional incontinence. The term involuntary expression disorder was chosen as it’s somewhat more precise and less pejorative, more strictly defines the condition where patients really have involuntary expression of emotion, as a consequence of a neurological disorder, as opposed to a primary mental illness.

When patients experience period of crying or other emotional responses, they may relate it to depression. How can patients know what they are experiencing is IEED?

A common confusion is confusing IEED and depression. In depression, the mood is always congruent, it always goes along with symptoms at hand. If something – if a person feels sad, they will cry. Sometimes in IEED, people will laugh at things that are otherwise sad. As example, the young women we care for, who when a close friend of her died and she was at the funeral, couldn’t stop laughing, was humiliated by this and quickly ran to her car at the cemetery. This is something that a depressed person would not do.

Depression is common in MS. Response to therapy for depression, the medications and psychotherapy is helpful. When you’re not responding to therapy, an important question to ask, is there something here more than depression, or instead, something completely separate?

 Dr. Wynn, you mentioned one example of IEED behavior. Can you give us another example?

A man I take care of who is a minister, who is a minister to people at very difficult times throughout his life, got to the point where he couldn’t even drive in the care with the radio on without causing uncontrollable weeping. So sometimes things occur, which you might anticipate crying at a funeral, but uncontrollably so. Or an individual who normally spent his entire life ministering to others at their difficult time, find themselves even uncontrollable – unable to control his emotions at simple stimuli, listening to the radio in the car.

How can patients become more aware of the symptoms of IEED?

Some symptoms of multiple sclerosis are more obvious than others. If suddenly I was dragging my foot, suddenly I couldn’t see out of my eye, I’d go to a doctor. Although sometimes people have other symptoms which are less obviously related to their MS. One of them is involuntary emotional expression disorder. You’re not having any trouble with weakness, there’s no sudden change in fatigue, but suddenly you’re snapping at people.

Suddenly, at the most minor stimuli, you’re having these episodes of crying which may come on explosively, you can’t control. They may occur in response to a stimulus, or may just appear out of the blue, that you find yourself crying at your desk. When you have a symptom like this, realize that this is not normal. This is something which there is help for. This not a symptom you have to learn to live with.

Dr. Wynn, what is the cause of IEED?

The cause of IEED is still incompletely known. We know that emotion often comes from deep structures inside the brain, whereas the frontal lope of the brain is very important in controlling when we cry and when we laugh. For example, when we express our emotions.

This flows to the brain stem in the back of our brain to control the movements of our face when we cry or laugh. If there is a disconnection between these two areas from a lesion in the brain from MS, then people will have that thought of sadness or happiness or laughter, and immediately express in a situation where ordinarily one wouldn’t.

 For example, when we were three or four years old and someone pokes us, we maybe turn around right away, or someone tickles us we laugh right away. Doesn’t matter if we’re in church or in the bedroom with our closest friend. Then we get to be fiver or six years old and someone poked me from behind, I waited ‘til recess and then I poked them back on the playground.

 In MS, if a lesion occurs in that area, one will quickly respond to it in a way which one wouldn’t have before, one would have censored the expression of that emotion. How this occurs in the brain has a lot to do with the different neurotransmitters or chemicals in the brain and the imbalance occurs when lesion occurs in certain parts of the brain, resulting in the condition we now refer to as IEED.

 How does a physician diagnose IEED?

To get diagnosed with involuntary emotional expression disorder, requires both you giving the history to your doctor if you’re having symptoms like this, but also having a doctor who is seasoned clinician in taking care of patients with MS and other neurological illnesses. It’s important for them to think, maybe this is something other than depression. In MS, depression may occur in as many a half of individuals. IEED may occur in as many as 20% of individuals with MS. One can have both depression and IEED. They can occur together. They can occur separately and they require, sometimes, different treatment.

There are some scales that can be used. The Central Nervous System Lability Scale or CNS-LS and the PLCS scale, Pathological Laughter and Crying Scale – these scale which have primarily been used for research, are easy scale to see on internet and to just score yourself. They’re a simple – it’s a scale with very simple questions. Do you find yourself laughing at times when there’s nothing really funny going on? Do you find yourself crying and can’t control the crying? Simple questions like this are characteristic of it. They’re very simple questions to ask.

When we teach medical students each year how to do physical examinations, I always look forward to them asking me one question. They always ask, which stethoscope should I buy and I answer, it doesn’t matter which stethoscope you buy, it’s whose ears you put it on. For an individual with MS, with a symptom of pathological laughter or crying, it’s important for your doctor to learn to listen for this in the same way that a cardiologist may listen for a particular murmur.

Are there drugs available to treat IEED?

Although there are no FDA approved drugs specifically indicated for IEED, commonly as physicians we’ll use the antidepressant medications. While not specifically targeted to this condition, they often have a significant benefit for individuals with this condition. Don’t worry, however, have hope. There are other medications on the way which are being targeted specifically to this condition, specifically designed to treat the neurochemical imbalance that often occurs from lesions in certain areas of the brain.

What can MS patients and their families do to help manage their IEED?

The most important is simply to learn about it and to learn to recognize it. If your loved one has IEED and they snap at your or are crying uncontrollably, don’t necessarily come to their aid with a large handkerchief or run the other direction. Recognize this symptom, like certain other odd symptoms in MS, can be a symptom of MS, and it’s not necessarily personal. Usually when our spouse snaps at us, we assume they’re angry. This is not necessarily a sign of anger.

Prolonged uncontrolled lapses of crying are not necessarily a symptom of depression, that something is wrong, other than what’s wrong is having MS. When one has new symptoms in MS, whether or not it’s involuntary emotional expression disorder, or a new motor weakness, tremor or other neurological symptom, one would want to talk to one’s doctor and find out, is there something I can do about this to help make this go away?

One thing that patients can do to minimize the disability from MS is to become educated. Educational programs such as by the MS Association can help us learn to recognize more symptoms, both patients as well as doctors, so we can provide more specific exact therapy. One of the marks of medicine is a more precise diagnosis can lead to more accurate and more effective therapy.