Pseudobulbar affect

Pseudobulbar affect, also called PBA, is a brain condition in which a person suddenly starts to laugh or cry and can't manage the reaction. The term "pseudobulbar" means a condition in the brainstem's corticobulbar pathways that control facial and emotional expression. The word "affect" means how a person shows emotions. These emotional reactions typically do not fit the situation or how the person is feeling. PBA usually happens in people with certain neurological conditions or injuries that affect how the brain controls emotions.

If you have pseudobulbar affect, you feel emotions like you usually do. But sometimes you laugh or cry too much or at the wrong times. It may be more than usual for a situation. For example, something that would cause you to smile instead leads you to laughter that doesn't match your feelings. Or a sad moment in a movie leads to intense sobbing. Since you can't know when this may happen, it may embarrass you or make daily life difficult.

Pseudobulbar affect often goes undiagnosed. Sometimes, it's mistaken for a mood disorder. But once the condition is diagnosed, you may be able to manage PBA with medicine.

One of the main signs of pseudobulbar affect is suddenly beginning to cry or laugh when you don't feel sad or find something funny. Or those behaviors may be an overreaction to the situation. The reaction may happen at any time and may last for several minutes. You may start laughing, but it often turns into tears. Crying appears to be more common than laughing.

With PBA, you cannot manage when you laugh or cry. For example, you might laugh too much in response to a mildly amusing comment. Or you might laugh or cry at something others don't see as funny or sad. These emotional responses are not how you would typically react.

Pseudobulbar affect is often mistaken for depression because of the crying. While some people with PBA also may have depression, the two conditions are different. With PBA, crying lasts only a short time. Depression is a feeling of sadness that doesn't go away. People with PBA also do not have problems sleeping or eating, which are common signs of depression. PBA also may be mistaken for bipolar disorder because both conditions cause sudden emotional changes.

When to see a doctor

If you think you have pseudobulbar affect, talk with your healthcare professional. If you're being treated for a neurological condition, your specialist may be able to diagnose PBA.

Many people with pseudobulbar affect likely don't report the condition or get a diagnosis due to a lack of awareness about the condition. Talk with your healthcare professional if you have symptoms that concern you.

The exact cause of pseudobulbar affect is not completely understood. While further research is needed, a possible cause of PBA may be an injury to the pathways in the brain that manage how you show emotions. Increases and decreases in certain brain chemicals that send messages between nerve cells also play a role in PBA.

People with certain neurological conditions or injuries have a higher risk of pseudobulbar affect. These include:

• Stroke.
• Amyotrophic lateral sclerosis, also called ALS.
• Multiple sclerosis, also called MS.
• Alzheimer's disease.
• Parkinson's disease.
• Progressive supranuclear palsy.
• Brain tumors.
• Dementia.
• Traumatic brain injury.

Being unable to manage laughing or crying due to pseudobulbar affect may cause people to isolate themselves from others. Since the condition may be misdiagnosed, a lack of understanding and correct treatment of the condition also may cause anxiety and depression. A misdiagnosis may lead to other mood disorders.

The condition might affect your ability to work and do daily tasks, especially if you're already coping with a neurological condition.

There are no known ways to prevent pseudobulbar affect. It's caused by neurological conditions or brain injuries. While PBA cannot be prevented, there are some ways to lower the risk:

• Protect your brain. Wearing seat belts and helmets and taking other steps to protect your brain may help prevent injuries that could lead to PBA.
• Manage neurological conditions. If you have a condition such as MS or Parkinson's disease, following treatment plans and keeping your brain healthy may help reduce the chance of developing PBA.
• Early detection. If you or someone you know experiences sudden laughing or crying that doesn't match emotions, talk with a healthcare professional about PBA. Early treatment can help manage symptoms.

Pseudobulbar affect is typically diagnosed during a neurological exam. Your care team checks how well the brain, spinal cord and nerves are working. You generally begin with a detailed medical history and if necessary, you have imaging tests such as a CT scan or an MRI. Specialists who can diagnose PBA include internists, neuropsychologists, neurologists and psychiatrists.

Pseudobulbar affect is often misdiagnosed as depression, bipolar disorder, generalized anxiety disorder, schizophrenia, personality disorder or epilepsy. To help your healthcare professional determine whether you have PBA, share specific details about when you laugh and cry unexpectedly and how you feel.

The goal of treatment for pseudobulbar affect is to reduce how strongly and how often you have an emotional reaction you don't expect. There are medicines and techniques to help you manage your show of emotions. Your care team can help you choose the best treatment for you.

Medicines may include:

• Dextromethorphan hydrobromide-quinidine sulfate (Nuedexta). This combination medicine works to block some receptors and activate others in the brain. Receptors are proteins on the surface of cells that receive messages from areas throughout the body. Nuedexta is the only medicine approved by the U.S. Food and Drug Administration to treat pseudobulbar affect.
• Antidepressants. Medicines used to treat depression also may be used to treat pseudobulbar affect symptoms. Antidepressants such as tricyclic antidepressants, also called TCAs, and selective serotonin reuptake inhibitors, also called SSRIs, may help reduce PBA episodes. These medicines help balance chemicals in the brain, such as dopamine, epinephrine and norepinephrine. These chemicals are called neurotransmitters. They send signals between nerve cells.

Treatment also includes different techniques and therapies that may help manage your symptoms:

• Identifying what triggers your reactions.
• Distracting yourself before they happen.
• Relaxing if you have a sudden emotional reaction.

Therapy may include mindfulness-based therapy, breathing exercises and meditation, which may help you manage your emotions.

It is important your care team recognize and diagnose pseudobulbar affect so that the right medicines and treatments are used to manage the condition. Education and treatment can help to manage symptoms and improve your quality of life. Ask your healthcare professional about PBA.

Knowing that pseudobulbar affect is a neurological condition, not a mental health issue, may help you better understand what is happening with your emotions. But living with pseudobulbar affect may, at times, still make you feel embarrassed or stressed. It might help to explain to family, friends and co-workers how the condition affects you, so they aren't surprised or confused by your behavior.

Talking with other people who have PBA also might help you feel understood and give you a chance to discuss tips for coping with the condition.

To cope with an episode:

• Distract yourself.
• Take slow, deep breaths.
• Relax your body.
• Change your position.

What you can do

• Keep a symptom diary. Use a notebook to write down details about your emotional reactions. Was the reaction voluntary? How long did it last? Was it true to how you were feeling? Was there a trigger for your reaction? Do these reactions you cannot control cause problems in your social interactions?
• Prepare important information. Be ready to discuss any major stresses or recent life changes with your care team. Also, create a list of all medicines, vitamins, herbs and supplements that you are taking. If you have any past exams or formal testing results, bring them with you.

What to expect from your doctor

These are some of the questions your healthcare professional may ask you:

• Do you cry easily?
• Do you laugh at things that aren't really funny?
• Does laughter often turn to tears?
• Are you able to manage your crying or laughter?
• Is it hard to stop your emotional response?
• Do you have emotional responses that are not how you really feel or that are more than you would typically have?
• Do your emotional reactions reflect what you're feeling at the time?
• Do you avoid spending time with others because you're worried you'll laugh or cry at the wrong time?
• Do you have any signs or symptoms of depression or other mood disorders?