This is part 2 of a 2 part article.
When you are wondering if you have Emotionalism, what can you do?
The goal of this treatment is to improve the quality of life for these patients by reducing the intensity and frequency of emotional outbursts.
Although episodes of laughing, anger, or crying may seem appropriate for the triggering event (a thought, seeing or hearing something funny, mad, or sad), they tend to be more difficult to restrain (are ‘closer to the surface’) and can be more intense and last longer than would ordinarily be expected. However, they can also be relatively minor and subtle, such as getting choked up, growing mad, or having a brief giggle.
Emotionalism can have a substantial impact on the lives of those experiencing the condition, and on their family members and caregivers. I said it is the first part, but I am saying it again: It can cause embarrassment and anxiety, leading to withdrawal and social isolation. It creates an additional burden for patients who already have a serious underlying neurologic condition.
There are some things you can do to deal with Emotionalism. First, waiting for Emotionalism episodes, in a nutshell, to pass patiently while it’s happening. Two, you can use distraction to move your mind to something different from Emotionalism. Third, humor is an excellent way to focus on instead of Emotionalism. Fourth, is that optimism is the manner to deal with Emotionalism. Finally, having your social support is a successful means of managing the condition.
Emotionalism can be managed with oral medications sometimes.
The goal of treatment is to reduce the frequency and severity of episodes of laughing, getting angry, or crying. Drugs that are used to treat Emotionalism include:
- Antidepressants. Tricyclic antidepressants (amitriptyline, nortriptyline), selective serotonin reuptake inhibitors (citalopram, fluoxetine, sertraline, fluvoxamine), and norepinephrine/serotonin reuptake inhibitors (venlafaxine, duloxetine, and others) may be effective in managing symptoms. Lower doses of antidepressants are used than the doses required to treat depression, and are effective much quicker than expected when treating depression.
- Nuedexta® (dextromethorphan/quinidine sulfate). A combination of dextromethorphan, a cough suppressant, and a very low dose of quinidine sulfate, a drug used in the past to treat cardiac arrhythmias, has been approved as the first drug specifically developed to treat Emotionalism. Although improvement in symptoms usually occurs within the first week of starting treatment (when taking only one capsule daily), a greater benefit occurs when taking the full dose (two capsules daily), and continues with no evidence of losing efficacy.
- Other medications. Other drugs may be used for patients who do not respond to first-line treatments.
Until recently, the main treatment for Emotionalism was antidepressants. Tricyclic antidepressants, and selective serotonin reuptake inhibitors/serotonin and norepinephrine reuptake inhibitors have been used off-label for treatment. The evidence for increasing serotonin to improve Emotionalism symptoms has been limited to mainly case reports and small trials. It is thought that increasing levels of serotonin may decrease emotional lability and improve Emotionalism symptoms.
The first treatment for Emotionalism was FDA-approved in 2010. Nuedexta is a fixed combination dosage capsule with 20 mg of dextromethorphan hydrobromide and 10 mg of quinidine sulfate. Normally, dextromethorphan is rapidly metabolized by CYP2D6 to dextrorphan, which appears to have a similar receptor binding profile.
Although the mechanism of how dextromethorphan decreases the number of episodes of involuntary laughing and crying is unknown, it is related to dextromethorphan’s uncompetitive low-affinity antagonism at the N-methyl-D-aspartate (NMDA) glutamate ion channel and/or its potent agonism at the sigma-1 receptor. Moreover, dextromethorphan inhibits the re-uptake of both serotonin and norepinephrine, which may also contribute to its mechanism of action.
The role of low-dose quinidine, an antiarrhythmic medication, is to utilize its potent inhibition of the CYP2D6 metabolic enzyme that slows down the metabolism of dextromethorphan and increases brain exposure. Pharmacokinetically, this increases the half-life of dextromethorphan from roughly 2 hours to 13 hours, hence allowing for a low dose and a BID daily dosing schedule.
A 12-week, double-blind, randomized, controlled trial of dextromethorphan/quinidine reported a reduction in the Emotionalism episode rate of 46.9 % to 49.0 %, depending on dextromethorphan dose, compared with placebo.10 The exact mechanism is unknown, but it likely reduces symptoms of Emotionalism through modulation of excitatory neurotransmission in disrupted neural circuits.
Antidepressants may reduce the frequency and severity of crying or laughing episodes, based on very low-quality evidence.
The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post-stroke emotionalism.
Future trials investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardized method to diagnose emotionalism, determine the severity and assess change over time; provide treatment for a sufficient duration and follow-up to better assess rates of relapse or maintenance and include careful assessment and complete reporting of adverse events.
People with negative experiences to Emotionalism described greater disability, avoidance, and mood problems. Positive experiences to it were shaped by a better understanding of the condition, an increased sense of control, social support, and optimism.
Professionals play a key role in raising awareness that emotionalism is a neurological condition and not a clinical mood disorder, as this will promote better understanding for patients, their families, and those around them.
Encouraging patients to talk about their emotional reactions early after a stroke will normalize their experiences and may prevent them from developing unhelpful beliefs that could affect their approach to recovery.
The goal of treatment is to improve the quality of life for these patients by reducing the intensity and frequency of emotional outbursts.
Emotionalism can have a substantial impact on the lives of those experiencing the condition, and on their family members and caregivers. It can cause embarrassment and anxiety, leading to withdrawal and social isolation. It creates an additional burden for patients who already have a serious underlying neurologic condition.
Other coping techniques may help:
- Be open about the problem, so people aren’t surprised or confused when you have an episode.
- Distract yourself by counting the number of objects on a shelf or by thinking about something unrelated when you think you’re about to have an episode.
- Take slow, deep breaths until you’re in control.
- Relax your forehead, shoulders, and other muscle groups that tense up during an episode.
- Change your body position. Note your posture when you’re having an episode. When you think you’re about to cry, get angry, or laugh, change your position.
I used these 4 items to deal with it:
- Give it time because most get better over time.
- Be open about it and tell others. You’ll be less embarrassed if you do become emotional in front of others.
- Tell people when it’s the real feelings or a side-effect of your stroke.
- Distract yourself when you feel inappropriate feelings. Recite some mantra to yourself.
It is all part of the stroke voyage. We didn’t sign up for it, but we are on the journey!
(Remember, please seek professional help when you are concerned about your feelings!)