Editorial - (2021) Volume 9, Issue 1
Emotionalism is the abnormal expression of emotions like crying and laughing and could follow stroke, traumatic brain injury, multiple sclerosis and amyotrophic lateral sclerosis. Emotionalism has been known to respond therapeutically to different classes of drugs including tricyclic antidepressants like imipramine, Selective Serotonin Reuptake Inhibitors (SSRI) like sertraline and citalopram, anticonvulsants like lamotrigine, dopamine precursors like levodopa and NMDA receptor antagonists like dextromethorphan. Classical antipsychotics are hardly prescribed for emotionalism alone without psychotic features. In this case report, an eighty year old woman with a dominant fronto-temporal infarctive stroke with right faciohemiparesis presented with frequent crying (dacrystic) episodes after a month of onset of stroke and who did not satisfy DSM IV criteria for depression nor had other psychotic features. Serial trial of SSRIs and dextromethorphan/quinidine could not help until risperidone, an antipsychotic was introduced with resolution of crying episodes. The response to risperidone after trial of SSRIs and dextromethorphan/quinidine which are considered the gold standard for post-stroke emotionalism (PSE), could be another therapeutic dimension in the management of emotionalism in general and PSE in particular.
The dacrystic episode started within a month of suffering a stroke in this patient which is in consonance with the natural history of the onset of PSE, and usually it begins within the 1st month to 1 year of the preceding vascular event.[6] She had more than one risk factor for a stroke. Her age and heart condition and dyslipidemia were risk factors for a vascular event. Remarkably, she did not satisfy the criteria for the diagnosis of depression, though it is a differential diagnosis. Her poor response to antidepressants is noteworthy as it suggests the absence of depression. The response to conventional treatment like SSRI such as sertraline was poor and the introduction of the relatively expensive dextromethorphan/quinidine which is presently the gold standard for PSE made no remarkable difference. PSE is known to respond with remission and cessation of crying and/or laughing episodes to SSRIs, tricyclic antidepressants, lamotrigine, and a combination of dextromethorphan/quinidine, but this was not the case in this patient.[10]
The complete cessation of crying episodes with the introduction of risperidone, an atypical antipsychotic medication, is the stand-out feature here and in our opinion may convey a novel message on emotionalism generally and PSE in particular.
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