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It is described as Arthur suffers from a mental disorder in which he bursts out into fits of laughter regardless of his will, even in situations that are far from laughter, as tears come out even when he tries to force his mouth to smile, and his mouth immediately falls down when he lets go of his hand.[15] Before Arthur awakens as the Joker, he is out of breath every time he laughs, and even when he starts coughing, he laughs until the seizure stops, so he clearly looks like he is in pain and suffering, and even though he is misunderstood by people around him due to his sudden bursts of laughter in situations where he should not be laughing

Watts P J, Greenberg H L, Khachemoune A

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