There are over one million people in the United States who are experiencing Pseudobulbar Affect. Pseudobulbar affect (PBA) is the name of the neurological condition that usually manifests as uncontrollable outburst of laughter or crying or other emotional displays.
Patients with PBA may begin to cry uncontrollably at something that is only slightly sad. Or one may burst into laughter controllable at something that may not be funny at all. Sometimes the outbursts are seemingly mood-incongruent, for example a patient might laugh uncontrollably when frustrated or angry, for example.
PBA is a neurological condition, not a psychological one. PBA falls in the category of “disinhibition syndrome” in which certain pathways that involve serotonin and other neurotransmitters are disrupted. It is often misidentified as a mood disorder.
Many people think the symptoms could be related to depression because of the tears or bi polar disorder because of the apparent mood swings. PBA usually follows a neurological disease or some kind of brain trauma. Alzheimer’s disease, multiple sclerosis, stroke, and traumatic brain injury are just a few of the known associated causes of PBA.
Unfortunately awareness of PBA is quite low. Therefore patients may be suffering needlessly for want of proper care and attention.
There are several characteristic features of PBA that can be recognized by a professional and validated by measurements and tests.
The episodes of emotion are usually perceived by others to be unprovoked or disconnected from the social context, or as being way out of proportion to the moods and the feelings the patient is actually experiencing. With PBA there is a disparity between the outward emotional display and the actual emotional experience of the patient.
The trigger for tears is often something that may be emotionally touching, but that would not normally trigger such an emotional response. Common examples are a sad television show, or a display of affection from a child or a grandchild. Common triggers for uncontrollable laughter with PBA are often described as something that is only mildly amusing that may have produced a small chuckle under other circumstances.
The degree of emotional response from the patient is usually very pronounced with the laughter or crying persisting for a sizable period of time. The outburst is unable to be controlled by the patient, and outbursts of crying seem to be more common than outbursts of laughter.
In distinguishing PBA from depression, it is useful to note the length of the experience. PBA demonstrate emotional outbursts and then feel almost emotionally normal, where as depression usually lasts weeks or months. Also the exaggerated emotional display and the chasm between the patient’s outward display and inner experience is characteristic of PBA and not depression.
Depression usually is accompanied by sleeplessness and loss of appetite that is not characteristic of PBA.
The psychological consequences and the stress and impact PBA may have on social interactions is often substantial. Often patients say the PBA has caused embarrassment for themselves and the friends and family and caregivers of the patient.
Patients may become afraid of social interactions because they don’t know when they will have an emotional outburst of tears of laughter. This pressure can even affect the rehabilitation process, as patients may exhibit increased anxiety symptoms.
The overlap of neurological conditions like this one and depression is complex. Patients who demonstrated PBA are found to have higher frequency of depression symptoms, and lower scores regarding emotional well being than patients without PBA.
Patients often say that their lives are built around their PBA and minimizing its reactions. It can be a very isolating condition because the patient has to consciously avoid emotional situations. The laughter can occur in a very solemn situation, like a funeral. Patients often feel like people think they are crazy or disrespectful.
Pseudobulbar Affect Treatment
Pseudobulbar Affect treatment in the past has been with the utilization of anti-depressants. These medications are only moderately successful in treating PBA. In January of 2011 the Food and Drug Administration approved a medication specifically for Pseudobulbar Affect treatment, called Nuedexta.
In the clinical trials it proved more effective than the placebos, but it has not seen a head to head trial versus anti-depressants. Many patients who have suffered from PBA for years and have been using anti-depressants claim that when they switched to Nuedexta they felt an immediate and significant improvement in the frequency of their outbursts and also in their ability to control the outbursts. Unfortunately the new medication can cost many times more than the antidepressants.
If you are caring for someone who has PBA, whether diagnosed or undiagnosed you should understand that they feel very badly about their uncontrollable outburst. A recent survey showed that 60% of post stroke patients felt that their PBA symptoms prevented them from intimating and maintaining friendships.
First you should reassure them that they are not alone. You are there for them and there are millions of people who suffer from the same PBA symptoms. You should remind them that their physical symptoms are an uncontrollable function of the brain. It is a physical condition not a psychological one. Let them know that no one blames them for their outbursts.
Be open and supportive to hearing their frustrations and concerns. Let them tell you how the PBA outbursts are affecting them individually and emotionally. Another useful mechanism is to keep an “episode diary”. This should be done in a careful manner so as not to upset the patient. This is not a matter or recording for later embarrassment.
The diary is meant to ensure better communication with your doctor and to help him or her make an accurate diagnosis. The diary may also help the patient cope with PBA in their life. They may learn to avoid certain situations that are likely to trigger an emotional outburst.
The most important thing is just to care for the patient with PBA. Never exaggerate the humiliation in the social context. Always be caring and understanding. Show compassion for them because this is uncontrollable, and they are made just as uneasy as everyone else is when the outbursts occur.