Why Is The Joker Laughing? What Is Pseudobulbar Affect?

 Imagine being at a funeral. According to social norms, the appropriate way of behaving at funerals almost everywhere in the world is to be sad, right?

After all, someone has left us, and we will never see them again. It's usually painful and sad if you don't have a special problem with the person. Someone who existed a few days ago, no longer exists.

But let's say at a funeral like this, you start laughing uncontrollably. It starts first in the form of giggles, then turns into the laughter you know. No, there's nothing funny. And you didn't think of anything funny. In fact, the death of this person you know really upsets you. So you feel sad. But the expression of this feeling is not experienced in the form of curling your lips down, closing your eyelids slightly, and curling the inner corners of your eyebrows up. So you're not reflecting the facial expressions associated with sadness. On the contrary... You're laughing as you know! Uncontrollably, join in!

That's not all. Normally, you know how you feel when you have a good laugh. Your abdominal and facial muscles start to ache after a while, but it was worth it. Because you released cortisol, adrenaline, dopamine, and growth hormone throughout the laughter. This chemical soup causes your brain to fill with peace and happiness; rather, the presence of these hormones is "felt"in our brain by these emotions. The efficiency of your defense system's T cells increases. Your resistance to the negative effects caused by stress increases. So laughter makes you healthier.

Here's the problem: during the funeral, you laugh under the uncomfortable gaze of everyone, but you don't experience any of the positive changes that a good laugh will create in you. Because your laughter is a distorted expression of your pain and trauma that wings you...

Why the Joker laughs: What is the Pseudobulbar Affect (PBA)?

We all know The Joker's famous characteristic smile. But Joaquin Phoenix, who played the character Arthur Fleck in the Joker (2019), directed by Todd Phillips, had an unusual neuropsychiatric condition. According to this Joker interpretation, he himself experienced emotional expression only with laughter in a moment of resentment or sadness, as he was unable to express his state of emotion. So he laughs and laughs involuntarily, even when he cries.

The Joker's condition is called Pseudobulbar Affect. It is also possible to find many other names for this in the literature: emotional incontinence (lack of control of emotions), pathological laughing and crying, emotionalism (emotionalism) are just a few of them... But it's widely known as the pseudobulbar effect.

The name comes from a combination of the words pseudo, meaning false or false, and bulbar, meaning onion. This onion part points to the medulla oblongata region of the brain, which looks like an onion. Because this region is the region that controls involuntary functions such as breathing, heart rate, sexual arousal, and when the pseudobulbar effect was first noticed, uncontrolled laughter was also thought to be caused here. But now that we know things aren't so obvious, we'll come to that.

In pseudobulbar effect, the emotions experienced by the person, that is, the state of emotion, and the expression revealed by the person may be completely incompatible. In other words, a person can project any emotion to the outside with violent laughter or violent crying while experiencing it. A PBA patient can experience such episodes of laughter or crying for up to a few minutes. In other words, it would not be right to limit the pseudobulbar effect to Laughing only in inappropriate situations. It is also possible to cry in unexpected situations and even turn this cry into laughter within a few seconds. And the film shows it very well.

As we can see in the film, people who suffer from this effect often experience social isolation, because the general public is not used to such psychological problems, and very few people can tolerate someone laughing with laughter in situations that would not happen. Social isolation can drag a person down to depression.

You may see the danger here: depressed people also have impaired emotional balance, so they are generally called Mood Disorders. Pseudobulbar effect and depression symptoms, if not carefully analyzed, can be confused. Accordingly, an incorrect diagnosis can be made and incorrect treatment can be applied. So the differences between PBA and depression should be well understood.

The PBA usually comes in short-term episodes. Irrepressible laughter or crying lasts a few seconds or minutes. Depression, on the other hand, is long-lasting; it can last for weeks or months. In PBA, a person cannot control himself; if they are depressed, they can control themselves, although it is difficult. PBA can cause laughter regardless of the situation in which it is located, while depression is highly dependent on emotions and is usually seen in situations such as sadness, anxiety, and guilt. While there is no deterioration in perception in PBA, the perceptions of depressed people towards themselves and their environment are negatively distorted. In other words, it is not impossible to distinguish between pseudobulbar effect and depression, but it is necessary to be careful.

Who Has This Affect, How Often?

And how do you think a person can get caught up in such an unusual disorder? As you can imagine, pseudobulbar effect is closely related to neurological diseases. Research shows that this effect is often associated with the following diseases:

• ALS (Amyotrofik Lateral Skleroz)
• MS (Multipl Skleroz)
• Extrapyramidal and cerebellum-related diseases
• Traumatic brain injuries
• Alzheimer's
• Dementia
• Stroke
• Brain tumors

For example, between 28% and 52% of stroke cases and around 49% of ALS patients experience PBA.

In addition, involuntary laughter attacks can be seen in kuru disease, which is an infectious prion disease. A Papua New Guinea tribe has also identified infectious proteins with folding disorders that are seen to be transmitted from human brains that have been eaten after cannibalism. Prions also cause another neurodegenerative disease, known in humans as Creutzfeldt-Jakob disease (CJD). For all these reasons, in the past, the pseudobulbar effect was also called "laughing disease", that is, "laughing disease".

So while popular culture may therefore sound "cool" and "intriguing," the pseudobulbar affect may actually indicate very serious health problems. It's more of a case of pseudobulbar affects caused by trauma in early childhood, which we also saw in the Joker movie...

 

What Causes Unstoppable Laughter?

The main factor causing the pseudobulbar affect is not yet fully known. I mean, in the brain, we can't say that the person starts laughing involuntarily. Impressions of the diagnosis of the disease 19. it goes back to the century. Even Charles Darwin has written articles in his books about the relationship of behaviors such as uncontrolled crying with people's mental health. In 1886, researchers such as Oppenheim and Wilson suggested that a bilateral lesion on the descending corticobulbar pathway, the pathway from the cerebral cortex to the spinal cord, could cause this. Other researchers believe that the damage caused by nerve diseases such as MS or ALS to the brain causes it.

 

Another interesting hypothesis focuses on the "gateway" task that the cerebellum, located at the back of the brain, sees in "socially acceptable behavior." Signals from the Motor cortex and frontal/temporal cortices to the brainstem are controlled by the cerebellum. Motor inputs are suppressed in this process and regulated depending on social conditions. So, thanks to your cerebellum, you can control where and how you should behave. It is believed that the damage or defects that occur in this suppression process cause a pseudobulbar effect and therefore behavior incompatible with the current situation.

 

In fact, all this shows us how mechanical our brain is. Damage to a neural pathway deprives us of our complex social functions, which we perceive as purely human. You believe that you are completely free-willingly controlling how you should behave when you are in a guest house or sitting with your girlfriend. This feeling reinforces our self-drive. However, damage to several neural pathways consisting entirely of biological connections deprives you of control over how you should behave in what environment.

How Often Is It Seen?

Research on the prevalence of the disease is very limited, and the results can be contradictory. According to a study pseudobulbar affect only 1.5-2 million people (1% often) is a rare disease, while in 2013, according to a published article, ALS, MS, Alzheimer's, stroke, Parkinson's disease, and traumatic brain injury are seen in patients who, in %9.4-can often be seen 37.5 (this is also a total of 1.8 million patients corresponds to 7.1). Therefore, more research is needed on this issue.

How Is It Treated?

Unfortunately, the exact treatment of the disease is not yet available. But some measures can be taken to control the symptoms and at least facilitate the daily life of the patient.

These measures start with informing the family and the person correctly. Pseudobulbar effect; can be confused with crying attacks, depression and anxiety. This distinction should be made well.

In medical treatment, it is believed that antidepressants, especially sertraline, fluoxetine (Prozac), citalopram, nortriptyline and amitriptyline, may have a symptomatic effect. In addition, according to some studies, dextromethorphan, which is normally cough syrup, may also be good for symptoms.

As research on this issue continues, we hope that new methods of treatment and management will also emerge.