I have to admit that this is a term I had not heard before, or at least remembered hearing, until just the other day. I had to look it up, and was quite intrigued by what I read. Another way of referring to this symptom is “emotional lability,” and that is something I’ve been aware of for quite a long time. Basically, it involves an involuntary and uncontrollable episode of crying and/or laughing, seen in persons who have suffered some kinds of brain injury or neurological diseases. The episode of crying or laughing may be inappropriate or incongruent to the situation. (For example, the person may sob broken-heartedly and uncontrollably in reaction to what others would see as a mildly upsetting experience, or he may laugh hysterically in response to grief or sorrow.)
A number of different terms have been used to describe this disorder, through history. These include pseudobulbar affect, pathological laughter and crying, emotional lability, emotionalism, emotional dysregulation, or involuntary emotional expression disorder (IEED). Less frequently, terms such as forced crying, involuntary crying, pathological emotionality, and emotional incontinence, have been used. However, now that the FDA has recognized a treatment for the disorder, pseudobulbar affect, or PBA, will most likely become the preferred terminology.
The characteristics of PBA include the sudden and unpredictable onset of severe and, at times inappropriate, crying or laughing. This can last for a few seconds to several minutes, and may happen multiple times during a day. There may or may not be a triggering stimulus that would explain the reasons for such behavior. The person who has the disorder may laugh or cry uncontrollably, for what seems like no reason at all. Or, he may laugh hysterically in response to pain or anger, or when experiencing something that others might find mildly amusing.
PBA is a disorder that has been written about for more than 130 years. It’s symptoms were described by Charles Darwin in his work, “The Expression of the Emotions in Man and Animals.” However, the specific pathophysiology behind the disorder is still under investigation, and are viewed with some controversy. The researchers Wilson and Oppenheim hypothesized early on that it was due to bilateral lesions in the corticobulbar tract, causing failure of involuntary control of emotions. Other theories point to the prefrontal cortex as being responsible for the disorder.
PBA is a secondary condition. It does not occur by itself, but rather is noted in persons who have specific types of neurological damage or disease, thought to be due to disruptions of neural networks controlling and regulating the motor output of emotions. It is commonly seen in persons who have experienced traumatic brain injury or stroke. But it can also be observed in those with diseases such as Alzheimer’s disease and other forms of dementia, multiple sclerosis, amyotrophic lateral sclerosis, Lyme disease, and Parkinson’s disease. Other disorders that can be associated with PBA include brain tumors, Wilson’s disease, syphilitic pseudobulbar palsy, some forms of encephalitis, and certain other rare disorders.
Persons with PBA can experience profound social withdrawal, and can find their interactions with other persons severely restricted. This is especially true if they are cognitively intact, as they will undoubtedly become quite concerned with how their outbursts are viewed by other persons. The disorder may also interfere significantly with activities of daily living and employment, and generally have a negative impact on healthcare.
PBA can often be misdiagnosed as depression, however there are many important differences between the two disorders. For instance, in depression and grief, crying is seen as a sign of sadness, which is usually explained by some triggering event. In PBA, however, the crying is often seen in contrast to the person’s mood, or is in excess of what would be expected by the underlying mood or triggering event. Episodes of PBA are usually short and sudden, whereas the crying that is seen in depression often lasts longer and is steadier in its strength. A person who is depressed can usually control, or modulate, their crying to some extent, whereas the one with PBA will not be able to do so. Depression can occur along with PBA, however. In a person who is cognitively intact, depression is not an uncommon response to the presence of PBA, as the person begins to withdraw socially because of embarrassment over his emotional outbursts.
It is also not uncommon for persons with PDA to be misdiagnosed as having another disorder. Some of these include, in addition to depression, bipolar disorder, schizophrenia, generalized anxiety disorder, personality disorder, and even epilepsy.
The number of people with PBA in the United States may number as many as 1.5 to 2 million. However, given that it commonly occurs along with other neurological disorders, its prevalence may be much higher. Some speculate that as doctors become more familiar with the disorder, it will be diagnosed more frequently.
PBA is one of the more commonly reported symptoms evidenced after a stroke, with as many as 28 to 52% of persons displaying the disorder. It does appear to be more frequent in older persons who have had a stroke, or those who have experienced multiple strokes. It should also be noted, however, that depression is common in stroke survivors, and the presence of depression may worsen PBA symptoms. It is estimated that 10% of persons with multiple sclerosis have difficulty with PBS, most generally in the later stages of the disease. One study showed that 49% of persons with amyotrophic lateral sclerosis also have PBA. It is estimated that anywhere from 50 to 80% of survivors of traumatic brain injury have signs of PBA.
The first step in treatment of PBA is recognition of the disease. Education of patients, families, and caregivers is also very important. It is important for all to realize that these symptoms are part of an involuntary syndrome, but that it is manageable. Some antidepressants have been used successfully, including fluoxetine, citalopram, and amitriptyline. Recently, the FDA approved the use of dextromethorphan/quinidine (Nuedexta) for the treatment of PDA.