Objective: To increase awareness of Involuntary Emotional Expressive Disorder (IEED) in clinicians assessing patients affected with involuntary laughter and/or crying variants (in stroke and traumatic brain injury), in conditions affecting structural brain changes (multiple sclerosis, TIAs) & other neurological conditions eg. PD (1,2) (where diaschisis may play a role (3), in order to facilitate appropriate and adequate treatment of IEED.

Background: Accurate diagnosis and appropriate treatment of IEED continue to elude clinicians, & patients continue to suffer as a result (4).

Symptoms associated with IEED (inappropriate episodes of laughing or crying without stimuli), are often confused with mood disorders such as depression due to the complexity of symptom manifestation and related socio-behavioural associations precluding the link to the involuntary expressive motor nature of the condition, rather than mood (4).

Method: Two cases presented with either variant were diagnosed with IEED through a series of assessment approaches comprising thorough history-taking, incl. social history in the presence of a family member/carer, & use of appropriate assessment tools as required, such as the CNS-Liability scale (1).

Results: The patient with crying variant sustained a left striato-capsular infarction resulting in right hemiparesis, expressive dysphasia, dysarthria, and oropharyngeal dysphagia. MRI of brain showed left capsular syndrome involving deep branches of the left middle cerebral artery, left caudate infarct with right fronto-parietal-occipital infarct.

The patient with laughing variant was diagnosed with grade 4 subarachnoid haemorrhage with right arterio-venous malformation rupture.

A selective serotonin reuptake inhibitor (SSRI) was used to treat both variants with success, in reduction of symptoms (1 wk post SSRI for crying, 2 wks for laughter), increased interaction with friends & family, & return to social activities.

The patient with laughing variant had scored 19/40 on the CNS-Liability scale pre SSRI, & 7/40 approx. 5 weeks post.

Conclusion: There is a pressing need for increased understanding & awareness leading to logical assessment strategies to distinguish between mood and the clinical, organic disorder of affect that is IEED. A sound index of clinical suspicion for IEED must be added to the repertoire of differential diagnoses of similar presentations where conditions affecting the brain are involved.

References: 1. Latoo et al. Often overlooked neuropsychiatric syndromes in Parkinson’s disease. BJMP 2013;6(1):a603
2. Phuong L, Garg S, Duda JE, Stern MB, Weintraub D. Involuntary emotional expression disorder (IEED) in Parkinson’s disease. Parkinsonism Relat Disord. 2009 Aug;15(7):511-5. doi: 10.1016/j.parkreldis.2009.01.001. Epub 2009 Jan 31. PMID: 19181560; PMCID: PMC3524499.
3. Parvisi et al. Neuroanatomy of Pathological Laughing and Crying: A Report of the American Neuropsychiatric Association Committee on Research (2009). The Journal of Neuropsychiatry and Clinical Neurosciences doi: 10.1176/jnp.2009.21.1.75
4. May TS. Involuntary Emotional Expression Disorder Often Misdiagnosed and Untreated. Psychiatric Times. Found at https://www.psychiatrictimes.com/view/involuntary-emotional-expression-disorder-often-misdiagnosed-and-untreated. Accessed 13 March 2023

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