Pseudobulbar Affect (PBA)

What is pseudobulbar affect (PBA)?

Pseudobulbar affect (PBA) is a neurological condition that causes outbursts of uncontrolled or inappropriate laughing or crying. These episodes don’t match your internal emotional state. PBA develops as the result of a brain injury or underlying neurological condition, such as amyotrophic lateral sclerosis (ALS).

Although episodes of laughing or crying may seem appropriate for the triggering event (such as seeing or hearing something funny or sad), they tend to be more difficult to restrain. They can also be more intense and last longer than you would ordinarily expect.

PBA may be called several other names, including:

• Emotional lability.
• Pathological laughing and crying.
• Involuntary emotional expression disorder.
• Compulsive laughing or weeping.
• Emotional incontinence.

PBA can have a substantial impact on your life and the lives of your family members and caregivers. It can cause embarrassment and anxiety, leading to withdrawal and social isolation.

How common is pseudobulbar affect?

Researchers estimate that 2 million to 7 million people in the United States have PBA. This range is large because PBA can vary in severity, and it’s often misdiagnosed.

Who does PBA affect?

Pseudobulbar affect (PBA) affects children and adults who have an underlying neurological condition.

Studies estimate that PBA affects:

• Up to 50% of people with amyotrophic lateral sclerosis (ALS).
• Up to 48% of people with traumatic brain injury.
• Up to 46% of people with multiple sclerosis (MS).

Is the pseudobulbar affect a mental illness?

Some people consider PBA a psychiatric disorder (mental illness) since the observable emotional changes (laughing or crying) are associated with mood. However, since PBA results from damaged neurological circuitry in your brain, PBA is best classified as a neuropsychiatric syndrome. In other words, PBA is a brain condition accompanied by dysfunctional emotional expression.

What are the symptoms of pseudobulbar affect (PBA)?

It’s important to know the difference between mood and affect when understanding PBA. Mood is your subjective experience of an emotion. It’s your inner feelings, such as sadness, anger or happiness. Affect is the visible display of emotion that others can see, such as smiling, laughing or crying.

Based on this, the main symptom of pseudobulbar affect is affects — often crying or laughing — that don’t match your mood or the intensity of your mood.

The laughing and/or crying can:

• Be unpredictable, sudden and involuntary.
• Be out of proportion to the trigger.
• Happen for no apparent reason.

Involuntary outbursts of anger or frustration may also occur.

Since PBA is often associated with underlying neurological conditions, such as a brain injury or ALS, people with PBA will likely have other symptoms that correspond with the underlying condition.

What causes pseudobulbar affect (PBA)?

Researchers don’t know the exact cause of pseudobulbar affect. They think it happens as the result of disruption to the neurological pathways in your brain that regulate emotional expression.

Several neurological conditions can cause this disruption and are associated with PBA, including:

• Traumatic brain injury.
• Amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig’s disease.
• Multiple sclerosis (MS).
• Alzheimer’s disease and other forms of dementia.
• Stroke.
• Parkinson’s disease.
• Brain tumors.
• Epilepsy.
• Wilson’s disease.

What part of the brain does PBA affect?

PBA likely affects various brain regions along a cerebro-ponto-cerebellar pathway.

Part of this pathway includes your cerebellum, which plays a key role in monitoring emotional responses and ensuring they’re appropriate to the social situation. Disruption of the neural (nerve) pathways from certain areas of your brain to your cerebellum may lead to a loss or lack of control over emotional expression.

The following neurotransmitters may also play a role in PBA:

• Serotonin.
• Norepinephrine.
• Dopamine.
• Glutamate.
• Acetylcholine.

How is pseudobulbar affect diagnosed?

Pseudobulbar affect (PBA) can be difficult to diagnose. Healthcare providers often misdiagnose it as a mood disorder — especially depression or bipolar disorder.

Currently, there’s no definitive test to diagnose PBA. Healthcare providers base a diagnosis on a thorough understanding of your:

• Symptoms.
• Medical history, especially neurological conditions.
• Mental health history.
• Finding from a physical exam.

Why is pseudobulbar affect misdiagnosed as depression?

Pseudobulbar affect (PBA) tends to be misdiagnosed as a type of mood disorder, especially depression.

This often happens when crying is the affect you more commonly experience in PBA. People with PBA may also have depression, either due to other causes or as a result of PBA. However, compared to depression, PBA leads to crying episodes that:

• Are more explosive in onset.
• Are of shorter duration.
• Usually aren’t associated with longstanding internal sadness.

Even though people with depression have a persistent mood of sadness, they don’t tend to have frequent crying episodes. If they do, they last much longer than PBA episodes. In addition, other symptoms of depression, such as sleep disturbances or eating changes, don’t occur in PBA.

How is pseudobulbar affect treated?

There’s no cure for pseudobulbar affect (PBA), but certain medications can help manage it. The goal of treatment is to reduce the frequency and severity of episodes of laughing or crying.

Medications that healthcare providers prescribe for PBA include:

• Dextromethorphan/quinidine sulfate (Nuedexta®): The FDA has approved 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) as the first drug specifically developed to treat PBA.
• Antidepressants: Tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs) and norepinephrine/serotonin reuptake inhibitors may help manage the symptoms of PBA. The doses are typically lower than the doses required to treat depression.

All medications have possible side effects. You’ll work with a provider to determine the best treatment plan for you.

Can I prevent pseudobulbar affect?

Since pseudobulbar affect results from brain damage and neurological conditions, there’s nothing you can do to prevent developing it.

What is the prognosis for pseudobulbar affect (PBA)?

The prognosis (outlook) for PBA varies.

Left undiagnosed and untreated, people with PBA are at an increased risk of:

• Depression.
• Anxiety.
• Impaired social interaction.
• Decreased quality of life.

Medication can help manage symptoms. It may be difficult to receive a diagnosis and treatment, but it’s important to continue to advocate for yourself. Healthcare providers who may know more about the condition include neuropsychologists, neurologists and psychiatrists.

How long does pseudobulbar affect last?

Pseudobulbar affect is usually chronic (lifelong) since the underlying conditions that cause it are often chronic, such as multiple sclerosis or Alzheimer’s disease.

How can I cope with having PBA?

Some tips for dealing with PBA and potentially better managing 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 shoulders 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.
• Seeing a mental health professional if PBA is interfering with your mental health.

When should I see my healthcare provider?

If you have PBA and your treatment isn’t working or you have unpleasant side effects, talk to your provider about a new treatment strategy.

A note from Cleveland Clinic

Laughing or crying uncontrollably can be challenging, embarrassing and difficult for other people to understand. Know that pseudobulbar affect (PBA) is a medical condition, and it’s manageable with medication. Talk to a healthcare provider if you develop signs of PBA. They’re available to help you.