The pathophysiologic mechanism responsible for pseudobulbar affect is attributed to dysfunction of the cortical–ponto–cerebellar network, where decreased inhibitory afferences from the brain cortex interfere with cerebellar control of motor expression. Supportive criteria include the presence of exaggerated gag reflex, tongue weakness, bradylalia, dysarthria, and dysphagia (pseudobulbar syndrome) or autonomic signs and irritability or anger proneness. The symptoms must cause significant impairment in social or occupational functioning and cannot be attributed to another medical condition. The main proposed diagnostic criteria for pseudobulbar affect states that the emotional expression should be excessive or incongruent with the emotional experience and independent or in excess of the evoking stimulus. The above-mentioned characteristics make the Joker’s laughing episodes compatible at first sight with the pseudobulbar affect, a clinical entity characterized by episodes of exaggerated or involuntary expression of emotions, including uncontrolled laughing or crying. Below, we will discuss some important features for differential diagnosis in relation with the movie. Laughter may be a medical phenomenon in many neurologic and psychiatric entities, including pseudobulbar affect, tics, hallucinations, psychogenic disorders, stereotypes, and seizures.
In all the episodes, laughter significantly interferes with his daily activities and deteriorates his quality of life. When the laughter subsides, he expresses a state of sadness and despair. In all these scenes, we see that Arthur tries unsuccessfully to stop his laughter, and sometimes, he also has some additional symptoms like sweating and nausea. For example, when he witnesses a group of young men harassing a woman in the subway (00:30:30–00:32:10) when he confronts Thomas Wayne, a man who Arthur thought was his father (01:06:30–01:07:15), or when he finds out he was adopted and his mother allowed her partner to physically abuse him during childhood, causing multiple traumas (01:13:52–1:15:50). Throughout the movie, different scenes are shown in which the laughter appears in situations with an important emotional impact, totally opposite to the feeling of joy or happiness. In that scene, we can notice he is obviously distressed by the physical aggression he had experienced. This scene is followed by the first episode of pathological laughter, which takes place when he meets his social worker and tells her “Is it just me, or is it getting crazier out there?” (movie time points 00:03:53 - 00:05:05). For example, in the first scene of the film, we see how Arthur Fleck, dressed as a clown, is beaten up by a gang of youths. Moreover, there is a clear division between the protagonist’s expressed emotion and his feelings, which is evident when the character is distressed, ashamed, or sad while laughing uncontrollably. It can happen in people with brain injury or certain neurological conditions. It’s a medical condition causing sudden frequent and uncontrollable laughter that doesn’t match how you feel. He even carries a card with the legend “Forgive my laughter: I have a condition. Immediately, Arthur begins to laugh uncontrollably while he tries to cover his mouth and makes gestures to explain that it is not his intention but that he cannot avoid it. For example, in the scene where Arthur Fleck is trying to make a child laugh on the bus, the child’s mother reproaches him. In the film, laughing episodes are excessive and inappropriate in relation to the context in which they occur.
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