What is pseudobulbar affect (PBA)?
Pseudobulbar affect (PBA) is a neurological condition that causes outbursts of uncontrolled or inappropriate laughing or crying. It is also known by other names including emotional lability, pathological laughing and crying, involuntary emotional expression disorder, compulsive laughing or weeping, or emotional incontinence. PBA is sometimes incorrectly diagnosed as a mood disorder – especially depression or bipolar disorder.
Although episodes of laughing or crying may seem appropriate for the triggering event (a thought, seeing or hearing something funny or sad), they tend to be more difficult to restrain (are ‘closer to the surface’) and can be more intense and last longer than would ordinarily be expected. However, they can also be relatively minor and subtle, such as getting choked up or a brief giggle.
PBA can have a substantial impact on the lives of those experiencing the condition, and on their family members and caregivers. It can cause embarrassment and anxiety, leading to withdrawal and social isolation. It creates an additional burden for patients who already have a serious underlying neurologic condition.
How common is pseudobulbar affect (PBA)?
It is estimated that between 2 and 7 million people in the United States have PBA depending on the severity of symptoms, with the lower number representing individuals with more severe symptoms.
Symptoms and Causes
What are the symptoms of pseudobulbar affect (PBA)?
- Uncontrolled or sudden outbursts of laughing or crying usually in response to a triggering event with an emotion either appropriate or inappropriate to the event.
- Laughing or crying that is out of proportion to the trigger and mood or inner feelings of the person. The person may also start laughing or crying for no apparent reason.
- Emotional outbursts that are more intense, frequent, or exaggerated than previously experienced by the individual.
- Outbursts of anger or frustration may also occur.
What causes pseudobulbar affect (PBA)?
It is not completely known why pseudobulbar affect (PBA) occurs, but it is essentially always associated with neurological disorders or diseases that cause brain damage or injury. Disorders, diseases, or injuries that are associated with PBA include:
- Alzheimer’s disease and other forms of dementia
- Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease
- Brain tumors
- Cerebellar lesions (including spinocerebellar atrophy)
- Multiple sclerosis (MS)
- Neurosyphilis (an infection in the brain or spinal cord caused by spirochetes that causes syphilis)
- Parkinson’s disease
- Progressive supranuclear palsy (a brain disorder that causes problems with walking, balance, speech, thinking, vision, mood and behavior)
- Traumatic brain injury
- Wilson disease (a disorder in which copper builds up in the brain, liver and other organs)
PBA occurs when there is a lack or loss of voluntary control over emotional responses. Various brain regions along a cerebro-ponto-cerebellar pathway are likely responsible for a loss of inhibitory or regulatory control on expression of emotions. Part of this pathway includes the cerebellum, which plays a key role in modulating or monitoring emotional responses and ensures they are appropriate to the social situation. Disruption of the neural (nerve) pathways from certain areas of the brain to the cerebellum may lead to a loss or lack of control over emotional expression.
Neurotransmitters, such as serotonin, norepinephrine, dopamine, and glutamate, are also thought to play a role in PBA.
Diagnosis and Tests
How is pseudobulbar affect (PBA) diagnosed?
Pseudobulbar affect (PBA) tends to go undiagnosed, underdiagnosed, or is misdiagnosed as a type of mood disorder, especially as depression. This is especially the case when crying is the emotion more commonly expressed. Although people with PBA may also have depression, either independently or as a result of the PBA, the crying episodes are more explosive in onset, of shorter duration, and usually not associated with longstanding internal sadness. Even though depressed individuals possess a persistent mood of sadness, they do not tend to have frequent crying episodes; if they do, they last much longer than PBA episodes. In addition, other symptoms often observed in depression, such as sleep disturbances or loss of appetite, are not observed in PBA. Also, the display of emotion by people with PBA is not in sync with their moods, or is exaggerated relative to their feelings.
PBA is informally diagnosed by your doctor during a neurological evaluation. The doctor uses the following criteria to help make the diagnosis:
- Is the emotional response (crying or laughing) occurring involuntarily, suddenly, and without the person’s control?
- Is the emotional response inconsistent with or disproportionate to the person’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?
- Is the emotional response caused by another psychiatric or neurological disorder?
- Is the emotional response due to a drug?
Other methods of diagnosing PBA involve the use of standardized scales (questionnaires). A high score suggests the presence of PBA. The Pathological Laughter and Crying Scale (PLACS) is a doctor interviewer-based series of questions that ask about the person’s episodes of laughing and crying. It has been used more commonly to study PBA occurring after strokes. The Center for Neurologic Study-Lability Scale (CNS-LS) is a self-administered scale consisting of seven questions about a person’s emotional episodes, including their frequency, intensity, and appropriateness. This scale has been validated in studies of PBA occurring in ALS and MS.
Management and Treatment
How is pseudobulbar affect (PBA) treated?
There is no cure for pseudobulbar affect (PBA), although the condition can be managed with oral medications.
The goal of treatment is to reduce the frequency and severity of episodes of laughing or crying. Drugs that are used to treat PBA include:
- Antidepressants. Tricyclic antidepressants (amitriptyline, nortriptyline), selective serotonin reuptake inhibitors (citalopram, fluoxetine, sertraline, fluvoxamine), and norepinephrine/serotonin reuptake inhibitors (venlafaxine, duloxetine and others) may be effective in managing symptoms. Lower doses of antidepressants are used than the doses required to treat depression, and are effective much quicker than expected when treating depression.
- Nuedexta® (dextromethorphan/quinidine sulfate). A combination of dextromethorphan, a cough suppressant, and a very low dose of quinidine sulfate, a drug used in the past to treat cardiac arrhythmias, has been approved as the first drug specifically developed to treat PBA. Although improvement in symptoms usually occurs within the first week of starting treatment (when taking only one capsule daily), a greater benefit occurs when taking the full dose (two capsules daily), and continues with no evidence of losing efficacy.
- Other medications. Other drugs may be used for patients who do not respond to first-line treatments.
The choice of medication depend on the patient’s tolerance and the potential side effects or adverse effects of the drug. Some medications may interact with the drugs prescribed for other conditions, and this needs to be watched for.
Outlook / Prognosis
What is the prognosis for patients with pseudobulbar affect (PBA)?
The prognosis depends on the patient’s underlying condition. Many patients with PBA also have a chronic neurological disorder, such as ALS, MS, or Parkinson’s disease. The goal of treatment is to improve the quality of life for these patients by reducing the intensity and frequency of emotional outbursts.
What are some tips for better coping with pseudobulbar affect (PBA)?
Some tips for dealing with and potentially better controlling sudden or involuntary episodes of laughing or crying include:
- Taking slow, deep breaths until the episode subsides
- Thinking about or focusing on something else during an episode
- Relaxing your shoulder and facial muscles to reduce tension
- Changing the position of your body, if possible
- Telling other people about your condition so they know what to expect