I don’t know if such neuronal defects exist in sleep disorder patients. Do you? Or are the emotional outbursts of sleep disorder patients driven only by their lack of sleep? If so, the obvious solution is to help them sleep.

But still, I have to ask–where are these people? Apart from nursing homes and the hospital wards…sleep disorder patients are everywhere, supposedly. Shouldn’t we be seeing random strangers breaking out into hysterical laughter or uncontrollable weeping? I’m being sarcastic, obviously–I too have my skepticism of “expanding the market” efforts on the part of pharma.

Uncontrollable laughing/Crying can also occur in stroke patients, and patients w/sleep disorders. Looks like a Pretty wide market to me.

From Medscape:

In This Article

The Phenomenology and Diagnosis of Mania
Prognosis
The Management of Acute Mania
Maintenance

——————————————————————————–

References

From Medscape Family Medicine/Primary Care

Topics in Adult Primary Care - Bipolar Disorder Expert Column
The Recognition and Management of Mania
Posted 08/26/2004

William Coryell, MD

The Phenomenology and Diagnosis of Mania
A manic episode distinguishes bipolar I disorder, a condition estimated to have a lifetime prevalence of 1.6% in the United States.[1] In contrast to the female predominance that characterizes other affective disorders, the sex ratio of bipolar I disorder is nearly even. Onset occurs most often in the 20s, but childhood and adolescent onsets have been increasingly recognized in the past decade with the realization that the phenomenology and course at these ages differ from typical presentations in adults.[2-5] Numerous medical conditions can produce manic syndromes,[6] and the first occurrence of a manic episode in older individuals should invite a careful screening for underlying conditions.

Some manic episodes develop with remarkable speed, although gradual onsets spanning weeks to months occur as well. An individual being treated for depression may abruptly switch into a manic phase and mania may evolve quickly to depression.

The DSM-IV definition of mania lists 8 symptoms and requires euphoria or irritability. Either of these may occur alone or in combination with the other, and either may be ascertained by the patient’s subjective report or by clinical observation.

Patients with mania experience the decreased sleep that is present in many other disorders. The distinguishing quality in mania is the absence of resultant fatigue. A useful probe is, “Have you found that you need less sleep than usual to feel rested and energetic?”

A decreased need for sleep is typically accompanied by another manic symptom — increased activity. Whereas individuals with depression or anxiety disorder who are unable to sleep often remain in bed and brood about their need for sleep, manic patients are likely to be up and busy at night. Increased activity should be apparent to others in the patient’s environment to be included as a manic symptom.

Manic patients may or may not acknowledge racing thoughts, but the examiner often appreciates a flight of ideas on interview. The patient typically moves rapidly from one topic to another but, in contrast to the thought disorder of schizophrenia, the connection between thoughts is usually perceptible. Patients with pressured speech are not simply circumstantial, but speak rapidly and expressively. In clinical settings, such patients are more likely than other patients to address all present and to be socially intrusive.

Grandiosity may shade from modest overestimation of talent, intelligence, or economic prospects to grandiose delusions in which the individual has worldwide or cosmic importance. These beliefs are often complicated by persecutory delusions that may then dominate the clinical picture.

The sense of optimism and invulnerability that accompanies grandiosity often combines with increased activity to fuel reckless behavior. This feature is responsible for much of the morbidity consequent to manic episodes. Excessive spending is perhaps its most common form, but patients often also come to regret impulsive sexual liaisons, abrupt travel, ill-advised business decisions, and excessive alcohol use.

The distinction between bipolar I disorder and bipolar II disorder hinges on the boundary between mania and hypomania. Patients with mania experience a mood disturbance that is, according to DSM-IV, “sufficiently severe to cause marked impairment in occupational functioning or unusual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.” Those with hypomania do not, by definition, have this level of severity. This may seem an arbitrary separation of syndromes, but the results of family[7] and follow-up studies[8,9] support its validity. Bipolar II disorder occurs far more frequently in the families of bipolar II probands than in the families of bipolar I probands, and patients with only a history of hypomania are much more likely to develop manic episodes during extended follow-up periods than are those with histories of mania.

I think I experienced an episode of hypomania the weekend I painted my entire kitchen and dining room–a process that involved 5 coats of paints.

The literature on PBA (the uncontrollable crying/laughing describes an actual physical defect between the frontal lobe and the area that controls emotion. A person in a manic or hypomanic episode would not have such an actual physical deficit.

If “involuntary emotional expression disorder … another way of saying uncontrollable laughing or crying” is not a description of mania (which the Oxford English dictionary defines as: “mental illness marked by periods of excitement, delusions, and overactivity”), then what is the psychiatric definition for mania and hypomania? Please state a reference, not your opinion.

The literature does report instances where MS was first diagnosed BECAUSE of uncontrollable emotional outbursts, which I find very interesting, just from an intellectual standpoint.

I think what the literature describes as PBA is a real problem–we aren’t talking occasional outbursts, but disruptive, embarrassing incidents that occur frequently. But I am with you totally that of course Avenir will try to make this into a more commonplace “disease.” I have to say though, that I get around as much as the next person, you know, going to the grocery store and church and the gym, and I have never seen anyone laughing or crying uncontrollably. Where are all these people?

I’m not sure I would be wanting my mother or other elderly relative to be dosed up with an antiarrhythmic drug with a long list of adverse effects and inconvenient interactions (quinidine) just because she was a bit tearful. And if I had MS or ALS I might think emotional outbursts were a natural response to the depression that would almost automatically tend to go with such miserable conditions.

This is another of those “drug / disease mission creep” stories, isn’t it? Like several above, I can believe a few people have this problem in a very disabling way, to the point where a treatment would be useful, but it does have that “medicating the normal behaviour spectrum will make us $$$” feel to it.

And as for the company and their “rounding up a coalition of the like minded…” Hmm. Nothing terribly surprising there, sadly - probably standard practise. Though given that drugs already exist which might do something for this, I am surprised a bunch of hard-nosed venture capital types would front up a heap of cash for (as Horuscat described it) “cough syrup plus quinidine”. It will certainly take a lot of marketing campaign. Perhaps their idea is to get all those folks to take it who are either terrified of taking tricyclics/SSRIs, or would refuse them “because I’m not depressed”.

Anyway, if I was feeling cynical I might be tempted to say “As usual, one person’s syndrome focus group is another persons’s disease mongering”.

Thanks for peeking. And someone else raised the point about the drug being a combo of a cough syrup and CV med. Interesting.

Anyway, I think you hit the nail on the head - yes, PBA has been fingered, but the issue is/was the extent to which Avanir’s new name for the affliction, and its assorted efforts, are an attempt to generate a wider clientele.

Depending upon one’s frame of reference, the number of MS and ALS patients taken together may or may not be a lot. But then add others who exhibit what appear to be the symptoms of IEED, such as it is. Potentially, that’s a much bigger market. Hence, interest from investors. Whether managed care will laugh or cry at the idea of coverage remains to be seen.

Regards
ed

I don’t know enough about the patenting process to know how they are getting dextromethorphan plus quinidine patented.

It does appear that PBA commonly occurs in diseases like ALS and MS, as well as traumatic brain injury. Who’d of thunk it?

What I think the medical community may legitimately be skeptical about is any effort to generalize what appears to be a legitimate, but very specific, syndrome to those not suffering from diseases like MS and ALS. And the legitimate question of whether one would treat the syndrome in those suffering from really severe problems like MS. I am good friends with a MS researcher; I’ll ask him how often he sees it, if he treats it and what he thinks about this.

Fair enough. Although the last line does seem to jive with the report from the NYT about various treatment options. In any event, the irony I pointed out would still stand, yes?

Also, out of curiosity, did the authors whose work appeared in PubMed disclose who funded their work? I ask because the earlier story raised the point that the company was actively lining up support in the medical community, where skepticism about the matter seems to exist.

Cheers
ed