understanding Pseudobulbar Affect
• Pseudobulbar affect (PBA) is a condition characterized by bouts of uncontrolled crying or laughing that are disproportionate or inappropriate to the social context and are not associated with depression or anxiety.1, 2
• Episodes of laughing or crying are often disconnected to the mood or feelings of the individual, with intense crying or laughing that persists for some time and cannot be suppressed.
• An estimated 2 to 7 million individuals in the United States have PBA.3
• PBA typically occurs in patients who have a brain injury or neurologic disorder.
• These disorders include amyotrophic lateral sclerosis, extrapyramidal and cerebellar disorders (e.g., Parkinson’s disease), multiple sclerosis, traumatic brain injury, Alzheimer’s disease and other dementias, stroke, and brain tumors.2
• The exact cause is unknown, but it appears that the disease or injury disrupts the neural networks and neurotransmitters that are responsible for expression of emotion, especially in the cerebellum.2
Symptoms of PBA
Excessive crying in response to mildly sad or touching situations
Uncontrollable laughter in response to mildly amusing situations
Episodes of crying or laughter may persist for several minutes
DIAGNOSING PBA
1
PBA is often underrecognized and undertreated.
2
PBA is typically diagnosed based on patient history as part of a neurologic evaluation.
• Screening tools exist but are generally not used in routine practice.
3
PBA is often misdiagnosed and can be mistaken for mood disorders (e.g., depression, bipolar disorder) or post-traumatic stress disorder.
5
Criteria used for diagnosing PBA include:3
• Is the emotional response (crying or laughing) occurring involuntarily, suddenly, and without the patient’s ability to control the emotion?
• Is the emotional response inconsistent with or disproportionate to the patient’s mood or inner feelings?
• Does expression of the emotion provide a feeling of relief?
• Does the emotional response cause significant distress or limit the ability to work or interact socially?
4
PBA can co-occur with depression and other mood disorders but can be distinguished from depression based on several criteria.4, 5
• Is the emotional response caused by another psychiatric or neurologic disorder?
• Is the emotional response due to a drug?
Distinguishing Between PBA and Depression
Clinical Component PBA Depression
Spectrum of emotional lability Crying, laughing, or both Crying, loss of interest, thoughts of worthlessness or suicide
Episode duration
Stimulus
Seconds to minutes, sporadic Weeks to months
No evident stimuli Speci c mood-related scenarios
Episode control None Coping mechanisms may shorten episodes
Underlying neurologic condition Neurologic disease of brain May or may not possess underlying injury always present neurologic condition
A ect Exaggerated or incongruent Flattened, saddened, or apprehenwith situational context sive; rarely demonstrate elation
Thoughts of death, dying, Absent May be present or suicide
Appetite Usually una ected May be increased or decreased
PBA = pseudobulbar affect.
Source: References 4 and 5.
TREATING PBA
Goals of treatment include reducing severity and frequency of episodes.
Treatment options can reduce symptoms and improve quality of life.
Behavioral strategies should always be considered for patients and caregivers — particularly when symptoms are mild or do not impact the patient’s quality of life — and may be adequate for treatment.
Pharmacologic options may also provide benefit for appropriate patients.
First-line treatment Second-line treatment Third-line treatment
• Dextromethorphan/ quinidine
PBA = pseudobulbar affect.
Sources: References 1, 2, 6-8.
• Selective serotonin reuptake inhibitors or
• Tricyclic antidepressants
• Levodopa, reboxetine, venlafaxine, mirtazapine, lamotrigine, methylphenidate, dexamphetamine, or amantadine
For all patients, incorporate behavioral management strategies and caregiver support
When selecting medications, consider: drug-drug interactions, advere effects, impact on patient comorbidities (including neurological conditions), contraindications, and impact on symptoms of PBA
