Pathological joking is no laughing matter

By John Murphy, MDLinx
Published March 30, 2018

Key Takeaways

It’s not an April Fool’s prank. Joke addiction is a real disorder.

Called Witzelsucht (from the German words for joke, “Witz,” and addiction, “Sucht”), the disorder manifests as a compulsion to constantly make and tell jokes. An article in The Journal of Neuropsychiatry and Clinical Neurosciencesdescribed two cases of patients diagnosed with Witzelsucht as well as moria (ie, inappropriate cheerfulness) of Jastrowitz.

The Pestering Punster

The first case involved a 69-year-old man with a 5-year history of compulsive joking. His need to jest and clown around was so great that he would wake his wife in the middle of the night to tell her the jokes he had thought up. At her request, he started writing down these jokes so he wouldn’t feel so compelled to wake her.

“As a result, he brought to our office approximately 50 pages filled with his jokes, most of which were either puns or silly jokes with a sexual or scatological content,” wrote neurologists Elias D. Granadillo, MD, and Mario F. Mendez, MD, PhD, of the David Geffen School of Medicine, University of California, Los Angeles.

One riddle, for example: “What did the proctologist say to his therapist?” (You can guess the punchline.)

In addition to the constant joking, the patient displayed disinhibited behavior. He showed excessive and unwelcome affection toward younger women, made borderline offensive comments, and shoplifted candy (occasionally getting caught).

The Impractical Joker

The second case involved a 57-year-old man who had a 3-year history of progressively worsening behavioral changes. He constantly made childish jokes and comments, many of which were borderline sexual or political in content, and then laughed at his own humor.

He too had become disinhibited, saying or doing inappropriate things and becoming overly familiar with strangers. “He lost his job after blurting out, ‘Who the hell chose this God-awful place?’” Drs. Granadillo and Mendez noted.

He also began to display conspicuous compulsive behaviors, such as hoarding coffee grinders and Hawaiian shirts in his garage. He developed changes in his dietary habits (repeatedly eating the exact same fast foods) and in his hygiene (not bathing for weeks at a time).

Right frontal damage

In both cases, these men had frontal damage to both lobes of the brain. In the first case, bifrontal damage followed a stroke in the head of the left caudate nucleus, an area that mediates the frontosubcortical tracts. Five years before the stroke, he had a subarachnoid hemorrhage complicated by hydrocephalus. He received a right ventriculoperitoneal shunt, and suffered a small area of encephalomalacia in the right frontal region around the shunt.

In the second case, the patient had behavioral variant frontotemporal dementia. Autopsy revealed he had frontotemporal Pick’s disease that was greater on the right side than the left.

Although bifrontal injury is typical in patients with pathological humor, damage to the right frontal lobe appears to be critical to this disorder. Patients with right frontal lesions will laugh at simple jokes, slapstick, or puns, but they can’t appreciate externally generated, complex, or novel jokes.

“On examination, both were able to detect jokes and identify them as funny, but they did not experience or feel others’ jokes as funny or amusing,” Drs. Granadillo and Mendez noted. “In essence, their humor was entirely internally driven.”

To really appreciate a joke, a person must use both lobes of the brain, and particularly the frontal lobes, the authors explained. The left frontal lobe is more responsive to simple humor, while the right frontal lobe engages with more externally generated, complex humor.

“Investigators agree that all types of humor require the right frontal lobe, including the ventromedial prefrontal cortex and adjacent anterior cingulate cortex for surprise when something is unexpected, and the triggering of humor appreciation through frontal connections with limbic and dopaminergic reward areas,” Drs. Granadillo and Mendez wrote.

Unfortunately, no pharmacological therapies are approved to treat pathological humor, although treatment for disinhibition may apply to patients with Witzelsucht, the researchers noted. Selective serotonin reuptake inhibitors are the first line of treatment (which didn’t work in these two patients), followed by psychoactive antiseizure medications. In addition, dextromethorphan/quinidine (which was used in the first patient) may reduce pathological laughter.

“Finally, when these medications fail and further treatment trials are indicated, clinicians may resort to low-dose atypical antipsychotics to relieve the effects of pathological humor,” the authors advised.

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