Health Care and Pseudobulbar Affect

Have you seen those TV commercials lately with actor Danny Glover talking about a neurological disorder that causes people to break out into uncontrollable laughter or crying? This health care issue is known as pseudobulbar affect or PBA, and its debilitating characteristics effects tens of thousands of newly diagnosed cases per year.

Pseudobulbar affect (PBA), emotional lability, labile affect, or emotional incontinence refers to a neurologic disorder characterized by involuntary crying or uncontrollable episodes of crying and/or laughing, or other emotional displays. PBA occurs secondary to a neurologic disease or brain injury. 

Patients may find themselves crying uncontrollably at something that is only moderately sad, being unable to stop themselves for several minutes. Episodes may also be mood-incongruent: a patient might laugh uncontrollably when angry or frustrated, for example.

PBA episodes can be described in two key ways, according to PBAinfo.com:

·         PBA outbursts can be inappropriate: The crying or laughing episodes are inappropriate to the situation in which they occur. Sometimes these are spontaneous crying or laughing eruptions that don’t reflect the way a person is actually feeling.

·         PBA outbursts can be exaggerated: Another characteristic of PBA episodes is that though the crying or laughing may be appropriate for a given situation, they’re exaggerated – they’re more intense or last longer than the situation calls for.

One of the jobs of the brain is to figure out how we feel in the moment. That information is then sent down to the brainstem, also known as the “bulb.” The brainstem then sends signals to the face and other parts of the body that show emotion.

PBA is believed to be the result of a disruption of these signals. When people have certain neurologic conditions or brain injuries, it can cause damage in the brain tissue that creates a disconnection between the parts of the brain that express emotion and those that control emotion.

The result is the frequent outbursts of involuntary crying or laughing known as pseudobulbar affect. If you break the term down literally, “pseudo” means false, “bulbar” refers to the brainstem and “affect,” describes how the body shows mood or emotion. More details can be found at this website: http://www.pbainfo.org/science .

The side-effects for PBA sufferers include feelings of emotional exhaustion and, frequently, social isolation, according to Psychology Today. Without realizing that they have a medical problem, people with PBA often adapt their lives to avoid things that trigger the response, including interacting with others unless they absolutely have to. With social isolation comes more negative emotion that can over time manifest as depression.  

While all of this may sound like new knowledge about a recently discovered disease, PBA has actually been well-documented in the medical literature for more than 100 years, though it has been labeled at least ten different things during that time. More detailed material is found at this site: https://www.psychologytoday.com/blog/neuronarrative/201110/not-all-crying-is-depression-understanding-pseudobulbar-affect .

According to the National Institutes of Health, although it is most commonly misidentified as a mood disorder, particularly depression or a bipolar disorder, there are characteristic features that can be recognized clinically or assessed by validated scales, resulting in accurate identification of PBA, and thus permitting proper management and treatment. Mechanistically, PBA is a disinhibition syndrome in which pathways involving serotonin and glutamate are disrupted.

This knowledge has permitted effective treatment for many years with antidepressants, particularly tricyclic antidepressants and selective serotonin reuptake inhibitors. A recent therapeutic breakthrough occurred with the approval by the Food and Drug Administration of a dextromethorphan/quinidine combination as being safe and effective for treatment of PBA.

Side effect profiles and contraindications differ for the various treatment options, and the clinician must be familiar with these when choosing the best therapy for an individual, particularly elderly patients and those with multiple comorbidities and concomitant medications. A much more detailed clinical explanation and overview is available at this site: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3849173/ .

To distinguish PBA from depression or other causes, doctors may administer a questionnaire rating episode frequency, duration, voluntary control and appropriateness to context and inner feelings. Additional details can be found at this website: http://alsn.mda.org/article/pba-symptoms-no-laughing-matter .

According to the American Stroke Association, in January 2011, the FDA approved a new drug called Nuedexta™ (dextromethorphan quinidine) specifically for PBA. In clinical trials, it proved effective against placebo, but it has not been compared directly to antidepressants. Analyzing data across studies, it appears to be faster acting than the anti-depressants with few side effects. Nuedexta™ is not recommended for patients with certain arrhythmias: prolonged Q-T interval, complete heart block, history of torsades de point (a type of ventricular tachycardia) or heart failure.

As with any new drug, there is a considerable cost difference when compared to older, off-patent medications. Nuedexta™ is manufactured by Avanir Pharmaceuticals and costs $200–300 for a month’s supply. The SSRIs mentioned in the article are $10–$12/month. Though off-patent antidepressants are often used in treating PBA, Nuedexta™ is the only prescription drug currently indicated specifically for PBA by the FDA. Avanir, like many pharmaceutical companies, does have a Patient Assistance Program. More detail on this medication and PBA is available at this website: http://www.strokeassociation.org/STROKEORG/LifeAfterStroke/RegainingIndependence/EmotionalBehavioralChallenges/Pseudobulbar-Affect-PBA_UCM_467457_Article.jsp

One of the best ways to deal with PBA is to tell your friends, co-workers, and family that you have it. Explain what PBA is and what causes it. Let the people around you know that you may have uncontrolled emotional outbursts. That way, when you suddenly burst into tears or start laughing they won’t be surprised or shocked. And you won’t have to always worry about losing control at the wrong moments, according to HealthLine.com.

You can gain some control over your symptoms with a few simple tricks. When you start feeling the urge to laugh or cry, try to distract yourself. Think about something different. If you’re crying, try to focus on something upbeat or funny. For example, you could think about a funny movie you saw recently. Take slow, deep breaths. And relax the muscles that start to tense up whenever you have an episode. More info is located at this site: http://www.healthline.com/health/multiple-sclerosis/pseudobulbar-affect#Medicines8 .

PBA can have an enormous impact on a person's social life. Emotional episodes caused by the disease can be embarrassing and can damage interpersonal relationships. The Brain Injury Association of America study indicates that 60% of people with brain injuries feel that PBA and its accompanying outbursts make it hard for them to initiate and maintain friendships. The disease was also the cited culprit in being housebound for 40% of people in the survey.

For caregivers of people with PBA, it can be difficult trying to deal with a person who feels isolated and alone because of their disease.  PBAinfo.org offers a few tips for caregivers to help them interact positively with emotionally explosive loved ones:

·         Let them know that you support them and they are not alone. Reassure them that many people suffer from the symptoms of PBA.

·         Remind them that their outbursts are caused by a physical disease, not a mental condition.

·         Indicate your willingness to listen to their frustrations and concerns.

·         Keep an "episode diary." By recording PBA episodes, you can ensure better communication with your doctor and help him or her make an accurate diagnosis.

According to the American Stroke Association, these episodes can strike a person up to 100 times a day. They can be a few seconds to a few minutes long. More information about this topic for seniors and others is available at this website: https://www.agingcare.com/Articles/crying-is-not-always-depression-148580.htm .

Psuedobulbar Affect has been identified in several million patients, both men and women. It is a disease that can be managed, but not readily identified unless the doctor knows what to look for and how to treat it. More people suffer every day from PBA. The good news is that there are therapies to help overcome PBA and its impact on the lives of those who have it. If you think you may be symptomatic, or know someone whom you may suspect exhibits the symptoms, see your healthcare provider to get a proper diagnosis.

Until next time.

Health Care and Hypertension

Hypertension, or high blood pressure as it is commonly called, is a dangerous health care issue, and can be a killer. Tens of millions of men and women, as well as some children, suffer from this malady on a daily basis; and for some, hypertension is a lifelong struggle.

Hypertension (HTN or HT), also known as high blood pressure or arterial hypertension, is a chronic medical condition in which the blood pressure in the arteries is persistently elevated. Blood pressure is expressed by two measurements, the systolic and diastolic pressures, which are the maximum and minimum pressures, respectively, in the arterial system.

The systolic pressure occurs when the left ventricle is most contracted; the diastolic pressure occurs when the left ventricle is most relaxed prior to the next contraction, according to JAMA, the Journal of the American Medical Association. The publication has a lot of info about this medical topic, and you can locate it at this site: http://jama.jamanetwork.com/journal.aspx .

According to the American Society of Hypertension, hypertension--the most prevalent cause of stroke and kidney failure--is part of a bigger disease conglomerate almost always accompanied by obesity, diabetes, kidney disease or many other co-existing problems involving lifestyle and/or genetics. More details are located at this site: http://www.ash-us.org/About-Hypertension/Hypertension-Information.aspx

Here are some statistics provided by the Centers for Disease Control at this site http://www.cdc.gov/nchs/fastats/hypertension.htm :

·         Percent of adults ages 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 32.5% (2011-2012).

·         Number of visits to physician offices with essential hypertension as primary diagnosis: 38.9 million.

·         Number of visits to hospital outpatient departments with essential hypertension as primary diagnosis: 3.7 million.

·         Number of deaths from essential hypertension and hypertensive renal disease: 30,770.

·         Deaths per 100,000 population from essential hypertension and hypertensive renal disease: 9.7.

One in three Americans are at risk for hypertension, according to the American Heart Association. Science has identified several factors that can increase your risk of developing hypertension, or high blood pressure. One big contributor is that it may be in your genes. Family history has a lot to do with your risk of hypertension. Height, hair and eye color runs in families --- so can high blood pressure. If your parents or close blood relatives have had hypertension, you are more likely to develop it, too.

You might also pass that risk factor on to your children. That's why it's important for children as well as adults to have regular blood pressure checks. You can't control heredity, but you can take steps to live a healthy life and lower your other risk factors. Lifestyle choices have allowed many people with a strong family history of HBP (hypertension/high blood pressure) to avoid it themselves.  Much more detail can be found at this site: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/UnderstandYourRiskforHighBloodPressure/Understand-Your-Risk-for-High-Blood-Pressure_UCM_002052_Article.jsp .

You'll likely have your blood pressure taken as part of a routine doctor's appointment. Ask your doctor for a blood pressure reading at least every two years starting at age 18, according to the Mayo Clinic. Blood pressure generally should be checked in both arms to determine if there is a difference. Your doctor will likely recommend more frequent readings if you've already been diagnosed with high blood pressure or other risk factors for cardiovascular disease. Children age 3 and older will usually have blood pressure measured as a part of their yearly checkups.

If you don't regularly see your doctor, you may be able to get a free blood pressure screening at a health resource fair or other locations in your community. You can also find machines in some stores that will measure your blood pressure for free. Public blood pressure machines, such as those found in pharmacies, may provide helpful information about your blood pressure, but they may have some limitations.

The accuracy of these machines depends on several factors, such as a correct cuff size and proper use of the machines. More information about hypertension can be found at this website: http://www.mayoclinic.org/diseases-conditions/high-blood-pressure/basics/definition/con-20019580 .

According to the Cleveland Clinic, approximately 1% of Americans with hypertension are estimated to be affected by hypertensive crises. Hypertensive crisis broadly covers both hypertensive urgency and emergency. Hypertensive emergencies are more common in patients with essential hypertension (20%-30% in Caucasians and 80% in African Americans). Factors such as renal failure, heart failure, cerebrovascular accidents, and nonadherence to antihypertensive therapy are associated with hypertensive crisis. Illicit drug use is an important cause for hypertensive crisis.

One in 3 Americans over the age of 18 years suffers from hypertension. The prevalence is higher among older individuals, women and non-Hispanic blacks. The prevalence of hypertension increases progressively with age. Significant clinical data is available for review at this site: http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/nephrology/arterial-hypertension/

About 72 million Americans are estimated to have high blood pressure. High blood pressure occurs more often in blacks—in 41% of black adults compared with 28% of whites and 28% of Mexican Americans. It also occurs with high frequency in people whose ancestors are from China, Japan, and other East Asian or Pacific areas (such as Koreans, Thais, Polynesians, Micronesians, Filipinos, and Maori), according to Merck.

The consequences of high blood pressure are worse for blacks. High blood pressure occurs more often in older people—in about two thirds of people aged 65 or older, compared with only about one fourth of people aged 20 to 74. People who have normal blood pressure at age 55 have a 90% risk of developing high blood pressure at some point in their life. High blood pressure is twice as common among people who are obese as among those who are not. 

In the United States, only an estimated 81% of people with high blood pressure have been diagnosed. Of people with a diagnosis of high blood pressure, about 73% receive treatment, and of the people receiving treatment, about 51% have adequately controlled blood pressure. Although many have a solution, a significant number still do not.

To many people, the word hypertension suggests excessive tension, nervousness, or stress. In medical terms, hypertension refers to high blood pressure, regardless of the cause. This site has a substantial amount of info about hypertension: http://www.merckmanuals.com/home/heart-and-blood-vessel-disorders/high-blood-pressure/high-blood-pressure.  Because it usually does not cause symptoms for many years—until a vital organ is damaged—hypertension has been called "the silent killer." Here is the high level overview of hypertension as a summary:

·         Often no cause for high blood pressure can be identified, but sometimes it occurs as a result of an underlying disorder of the kidneys or a hormonal disorder.

·         Obesity, a sedentary lifestyle, stress, smoking, and excessive amounts of alcohol or salt in the diet all can play a role in the development of high blood pressure in people who have an inherited tendency to develop it.

·         In most people, high blood pressure causes no symptoms.

·         Doctors make the diagnosis after measuring blood pressure on two or more occasions.

·         People are advised to lose weight, stop smoking, and decrease the amounts of salt and fats in their diets.

·         Antihypertensive drugs are given.

Hypertension, or high blood pressure, should not be ignored. If you feel that you may be suffering from symptoms, then see your doctor. If you have hypertension, follow your physician’s directions on how to treat it or how you can get rid of it if possible. Each person needs to have a diagnosis specific to him/her, but hypertension can kill you if you’re not careful. Don’t be another statistic.

Until next time.