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Emotional incontinence and executive function in ischemic stroke: A case-controlled study

  • W.K. TANG (a1), YANGKUN CHEN (a1), WYNNIE W.M. LAM (a2), VINCENT MOK (a3), ADRIAN WONG (a2), GABOR S. UNGVARI (a1), Y.T. XIANG (a1) and KA SING WONG (a2)...


Frontal and basal ganglia infarcts and executive dysfunction are thought to be involved in the pathophysiology of poststroke emotional incontinence (PSEI). The study examined whether patients with PSEI have more frontal and/or basal ganglia infarcts and impairment in executive function. A total of 516 Chinese patients with acute ischemic stroke consecutively admitted to the acute stroke unit of a university-affiliated regional hospital in Hong Kong were screened for PSEI 3 months after the index stroke. According to Kim’s criteria, 39 (7.6%) had PSEI. Thirty-nine stroke patients without PSEI served as matched control group. The PSEI group had significantly more frontal and/or basal ganglia infarcts, had lower Chinese Frontal Assessment Battery scores, required more time to complete the Stroop Test, and made more omission and commission errors in the Go–NoGo test. There was no significant correlation between frontal or basal ganglia infarcts and executive function. The correlation between frontal infarct and severity of PSEI was .420. Further follow-up and functional imaging studies are warranted to explore the relationship between PSEI, brain infarcts, and executive dysfunction. (JINS, 2009, 15, 62–68.)


Corresponding author

*Correspondence and reprint requests to: W.K. Tang, Department of Psychiatry, Shatin Hospital, Shatin, N.T., Hong Kong SAR, China. E-mail:


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Andersen, G., Vestergaard, K., & Riis, J.O. (1993). Citalopram for post-stroke pathological crying. Lancet, 342, 837839.
Andersen, G., Vestergaard, K., & Lauritzen, L. (1994). Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram. Stroke, 25, 10991104.
Andersen, G. (1997). Post-stroke depression and pathological crying: Clinical aspects and new pharmacological approaches. Aphasiology, 11, 651664.
Asfora, W.T., DeSalles, A.A., Abe, M., & Kjellberg, R.N. (1989). Is the syndrome of pathological laughing and crying a manifestation of pseudobulbar palsy? Journal of Neurology, Neurosurgery & Psychiatry, 52, 523525.
Black, D.W. (1982). Pathological laughter: A review of literature. Journal of Nervous and Mental Disease, 170, 6771.
Brott, T., Adams, H.P., Olinger, C.P., Marler, J.R., Barsan, W.G., Biller, J., Spilker, J., Holleran, R., Eberle, R., Hertzberg, V., Rorick, M. ,Moomaw, C.J., & Walker, M. (1989). Measurement of acute cerebral infarctions: A clinical examination scale. Stroke, 20, 864870.
Brown, K.W., Sloan, R.L., & Pentland, B. (1998). Fluoxetine as a treatment for post-stroke emotionalism. Acta Psychiatrica Scandinavica, 98, 455458.
Caplan, L.R. (2000). Caplan’s stroke: A clinical approach. Boston, MA: Butterworth-Heinemann.
Ceccaldi, M., Poncet, M., Milandre, L., & Rouyer, C. (1994). Temporary forced laughter after unilateral strokes. European Neurology, 34, 3639.
Chiu, H.F.K, Lee, H.C.B., & Chung, D. (1994). Reliability and validity of the Cantonese version of the Mini-Mental State Examination: A preliminary study. Hong Kong Journal of Psychiatry, 4, 2528.
Chiu, H.F., Chan, C.K., Lam, L.C., Ng, K.O., Li, S.W., Wong, M., & Chan, W.F. (1997). The modified Verbal Fluency Test: A validation study in Hong Kong. Journals of Gerontology, Series B-Psychological Sciences & Social Sciences, 52, 247250.
Choi-Kwon, S., Han, S.W., Kwon, S.U., Kang, D.W., Choi, J.M., & Kim, J.S. (2006). Fluoxetine treatment in poststroke depression, emotional incontinence, and anger proneness: A double-blind, placebo-controlled study. Stroke, 37, 156161.
Cummings, J.L. (1993). Frontal-subcortical circuits and human behaviours. Archives of Neurology, 50, 873880.
Cummings, J.L. (1995). Anatomic and behavioral aspects of frontal-subcortical circuits. Annals of the New York Academy of Sciences, 769, 113.
Dark, F.L., McGrath, J.J., & Ron, M.A. (1996). Pathological laughing and crying. The Australian and New Zealand Journal of Psychiatry, 30, 472479.
Dubois, B., Slachevsky, A., Litivan, I., & Pillon, B. (2000). The FAB: A frontal assessment battery at bedside. Neurology, 55, 16211626.
Fazekas, F., Chawluk, J.B., Alavi, A., Hurtig, H.I., & Zimmerman, R.A. (1987). MR signal abnormalities at 1.5 T in Alzheimer’s dementia and normal aging. American Journal of Roentgenology, 149, 351356.
Feinstein, A., Feinstein, K., Gray, T., & O’Connor, P. (1997). Prevalence and neurobehavioral correlates of pathological laughing and crying in multiple sclerosis. Archives of Neurology, 54, 11161121.
Feinstein, A., Connor, P., Gray, T., & Feinstein, K. (1999). Pathological laughing and crying in multiple sclerosis: A preliminary report suggesting a role for prefrontal cortex. Multiple Sclerosis, 5, 6973.
Folstein, M.F., Folstein, S.E., & McHugh, P.R. (1975). “Mini-mental state”. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189198.
Ghaffar, O., Chamelian, L., & Feinstein, A. (2008). Neuroanatomy of pseudobulbar affect: A quantitative MRI study in multiple sclerosis. Journal of Neurology, 255, 406412.
Heaton, R.K., Chelune, G.J., Talley, J.L., Kay, G.G., & Curtiss, G. (1993). Wisconsin Card Sorting Test manual revised and expanded. Psychological Assessment Resources, Inc., Florida, USA.
House, A., Dennis, M., Molyneux, A., Warlow, C., & Hawton, K. (1989). Emotionalism after stroke. British Medical Journal, 298, 991994.
Kim, J.S. (1997). Pathologic laughter after unilateral stroke. Journal of the Neurological Sciences, 148, 121125.
Kim, J.S. & Choi-Kwon, K.S. (2000). Poststroke depression and emotional incontinence: Correlation with lesion location. Neurology, 54, 18051810.
Kim, J.S. (2002). Post-stroke emotional incontinence after small lenticulocapsular stroke: Correlation with lesion location. Journal of Neurology, 49, 805810.
Langworthy, O.R. & Hesser, F.H. (1940). Syndrome of pseudobulbar palsy. Anatomic and physiologic analysis. Archives of Internal Medicine, 64, 106121.
Lopez, O.L., Zivkovic, S., Smith, G., Becker, J.T., Meltzer, C.C., & DeKosky, S.T. (2001). Psychiatric symptoms associated with cortical-subcortical dysfunction in Alzheimer’s disease. Journal of Neuropsychiatry & Clinical Neurosciences, 13, 5660.
Malloy, P., Bihrle, A., & Duffy, J. (1993). The orbitomedial frontal syndrome. Archives of Clinical Neuropsychology, 8, 185201.
Marin, R.S., Butters, M.A., Mulsant, B.H., Pollock, B.G., & Reynolds, C.F. 3rd. (2003). Apathy and executive function in depressed elderly. Journal of Geriatric Psychiatry & Neurology, 16, 112116.
McCullagh, S., Moore, M., Gawel, M., & Feinstein, A. (1999). Pathological laughing and crying in amyotrophic lateral sclerosis: An association with prefrontal cognitive dysfunction. Journal of the Neurological Sciences, 169, 4348.
Mok, V.C., Wong, A., Lam, W.W., Fan, Y.H., Tang, W.K., Kwok, T., Hui, A.C., & Wong, K.S. (2004). Cognitive impairment and functional outcome after stroke associated with small vessel disease. Journal of Neurology, Neurosurgery & Psychiatry, 75, 560566.
Mok, V.C., Wong, A., Yim, P., Fu, M., Lam, W.W., Hui, A.C., Yau, C., & Wong, K.S. (2004). The validity and reliability of Chinese frontal assessment battery in evaluating executive dysfunction among Chinese patients with small subcortical infarct. Alzheimer Disease & Associated Disorders, 18, 6874.
Morris, P.L.P., Robinson, R.G., & Raphae, B. (1993). Emotional lability after stroke. The Australian and New Zealand Journal of Psychiatry, 27, 601605.
Muller, U., Murai, T., Bauer-Wittmund, T., & von Cramon, D.Y. (1999). Paroxetine versus citalopram treatment of pathological crying after brain injury. Brain Injury, 13, 805811.
Murai, T., Barthel, H., Berrouschot, J., Sorger, D., von Cramon, D.Y., & Muller, U. (2003). Neuroimaging of serotonin transporters in post-stroke pathological crying. Psychiatry Research, 123, 207211.
Parvizi, J., Anderson, S.W., Martin, C.O., Damasio, H., & Damasio, A.R. (2001). Pathological laughter and crying: A link to the cerebellum. Brain, 124, 17081719.
Piamarta, F., Iurlaro, S., Isella, V., Atzeni, L., Grimaldi, M., Russo, A., Forapani, E., & Appollonio, I. (2004). Unconventional affective symptoms and executive functions after stroke in the elderly. Archives of Gerontology & Geriatrics, 9(Suppl), 315323.
Robinson, R.G., Parikh, R.M., Lipsey, J.R., Starkstein, S.E., & Price, T.R. (1993). Pathological laughing and crying following stroke: Validation of a measurement scale and a double-blind treatment study. American Journal of Psychiatry, 150, 286293.
Ross, E.D. & Stewart, R.S. (1987). Pathological display of affect in patients with depression and right frontal brain damage. An alternative mechanism. Journal of Nervous and Mental Disease, 175, 165172.
Rubia, K., Russell, T., Overmeyer, S., Brammer, M.J., Bullmore, E.T., Sharma, T., Simmons, A., Williams, S.C., Giampietro, V., Andrew, C.M., & Taylor, E. (2001). Mapping motor inhibition: Conjunctive brain activations across different versions of Go/No-Go and Stop tasks. Neuroimage, 13, 250261.
Schacher, R. & Logan, G.D. (1990). Impulsivity and inhibitory control in normal development and childhood psychopathology. Developmental Psychology, 26, 710720.
Schiffer, R. & Pope, L.E. (2005). Review of pseudobulbar affect including a novel and potential therapy. Journal of Neuropsychiatry & Clinical Neurosciences, 17, 447454.
Stroop, J.R. (1992). Studies of interference in serial verbal reactions. Journal of Experimental Psychology, 18, 643662.
Tang, W.K., Chan, S.S.M., Chiu, H.F.K., Ungvari, G.S., Wong, K.S., Kwok, T.C.Y., Wong, K.T., Richards, P.S., & Ahuja, A.T. (2004). Emotional incontinence in Chinese stroke patients: Diagnosis, frequency, and clinical and radiological correlates. Journal of Neurology, 251, 865869.
Tang, W.K., Chan, S.S., Chiu, H.F., Ungvari, G.S., Wong, K.S., Kwok, T.C., Mok, V., Wong, K.T., Richards, P.S., & Ahuja, A.T. (2006). Frequency and clinical determinants of poststroke cognitive impairment in nondemented stroke patients. Journal of Geriatric Psychiatry & Neurology, 19, 6571.
Tekin, S. & Cummings, J.L. (2002). Frontal-subcortical neuronal circuits and clinical neuropsychiatry: An update. Journal of Psychosomatic Research, 53, 647654.
Vataja, R., Pohjasvaara, T., Mantyla, R., Ylikoski, R., Leppavuori, A., Leskela, M., Kalska, H., Hietanen, M., Aronen, H.J., Salonen, O., Kaste, M., & Erkinjuntti, T. (2003). MRI correlates of executive dysfunction in patients with ischaemic stroke. European Journal of Neurology, 10, 625631.
Wilson, S.A.K. (1924). Some problems in neurology. The Journal of Neurology and Psychopathology, 4, 299333.



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