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.