Pseudobulbar affect (PBA)
Pseudobulbar affect (PBA) is a neurological disorder that causes uncontrollable episodes of laughter, crying, or anger, often occurring at inappropriate times and disconnected from a person's true emotions. This condition, also known as emotional dysregulation or emotional lability, can lead individuals to laugh during sad moments or cry when they are happy, creating confusion for both the person affected and those around them. PBA is believed to result from damage to brain regions that regulate emotional responses, such as the prefrontal cortex and cerebellum, and is often linked to traumatic brain injuries, neurological diseases (like Alzheimer's and multiple sclerosis), and certain thyroid disorders.
The disorder affects between two and seven million people in the U.S., with symptoms that can manifest multiple times a day. Diagnosing PBA typically involves assessments like the Pathological Laughing and Crying Scale and the Center for Neurologic Study-Lability Scale. Treatment often includes medications such as antidepressants, and a specific drug approved by the FDA, dextromethorphan/quinidine (Nuedexta), targets PBA symptoms directly. Patients are encouraged to communicate openly with friends and family about their condition to reduce misunderstandings and stigma, while also employing coping strategies to manage episodes.
On this Page
Subject Terms
Pseudobulbar affect (PBA)
Pseudobulbar affect (PBA) is a nervous system disorder characterized by uncontrollable bouts of laughter, crying, or both. It can also manifest as irrational and intense episodes of anger. PBA is also referred to as emotional dysregulation, emotional incontinence, emotional lability, involuntary crying, and pathological laughing and crying. PBA symptoms are sudden and uncontrollable fits of laughter, crying, or anger that often occur randomly at inappropriate times. These symptoms can occur multiple times a day or periodically throughout the month. Many times, people’s facial expressions that result from PBA do not match their actual emotions, and PBA has no link to a person’s actual mood. For example, those suffering from PBA often laugh while sad or cry while happy. The condition may be mistaken for mental disorders such as depression, borderline personality disorder (BPD), and bipolar disorder. Individuals with PBA often experience other mental disorders as a result of having PBA, however, such as anxiety and depression.
Background
Between two and seven million people in the United States have PBA. The smallest percentage of this population represents those with the most severe symptoms. Possible references to the disorder date back to the late nineteenth century, when Charles Darwin documented the facial and emotional expressions of the insane in his book The Expression of the Emotions in Man and Animals. In this book, Darwin discusses the extreme exhibitions of emotion seen in patients suffering from brain disease, mentioning conditions such as “senile decay” and “brain-wasting” as having a tendency to provoke violent emotions in affected individuals.
Experts do not fully understand the cause of PBA. Reigning theories hold that PBA may result from damage to parts of the brain that cause disruptions to the neural network, so identifying one specific region as the culprit is not often possible. Research points to damage to the prefrontal cortex region of the brain as a likely precursor to the disorder. This area of the brain helps control emotions, so injuring it can impact how a person experiences, interprets, and expresses emotions. Damage to the cerebellum, another brain region involved in the management and monitoring of emotions, is also a suspected cause of PBA. Research has shown that neurotransmitters such as serotonin, glutamate, dopamine, and norepinephrine may play a role in the development of PBA. PBA has been linked to traumatic brain injury (TBI), with many patients developing the condition following a blow to the head. It has also been associated with neurological diseases such as Alzheimer’s disease, multiple sclerosis (MS), stroke, Parkinson’s disease, and amyotrophic lateral sclerosis (ALS). PBA has also been reported as a symptom of certain thyroid disorders and diseases such as Grave’s disease. Other medical conditions linked to PBA include epilepsy, neurosyphilis, brain tumors, progressive supranuclear palsy, and Wilson’s disease.
Overview
The main symptom of PBA is sudden, unprovoked, uncontrollable outbursts of laughter, sadness, or anger. These involuntary displays are often not representative of the actual feelings that a person experiences during the episode, and the intense bouts of crying or laughter are often extremely exaggerated. Sometimes during an episode, a person’s laughter will turn to tears or vice versa. Crying is more often reported with PBA than laughing. A person’s mood between PBA fits is usually completely normal, and triggers of the episodes vary from person to person. One person with PBA may begin laughing uncontrollably at a mildly funny situation. Many of those affected laugh, cry, or become angry at inappropriate times with little to no prompting. It can be difficult for observers to know what is occurring, and PBA sufferers who usually cry may be mistaken for having depression. Despite being very different from depression, depression is often common among those with PBA because of the social anxiety and embarrassment it can invoke.
PBA can be diagnosed with a number of testing methods. The Pathological Laughing and Crying Scale (PLACS) involves a set of questions about the severity of laughing or crying fits and how they are connected to a person’s mood and social setting. The Center for Neurologic Study-Lability Scale (CNS-LS) is another diagnosis method that involves a set of questions about symptoms. Treatment of PBA often involves prescription medications such as anti-depressants, which are thought to control the symptoms of the disorder. In 2010, the Food and Drug Administration (FDA) approved a new drug to specifically treat PBA called dextromethorphan/quinidine (Nuedexta), which studies have shown can also help control PBA outbursts in patients with MS and ALS.
Doctors encourage people with PBA to be open and communicative about their condition, making friends and family aware of the symptoms and how the disorder affects their social life. This will limit confusion or embarrassment should an episode occur in their presence. Doctors also suggest that patients keep track of each outburst in a diary, making sure to detail what led up to the outburst and how it lasted. This can help a patient better understand the fits and potentially help predict when one may occur. Doctors also recommend several methods to cope with PBA. For instance, when patients feel an episode coming on, it is recommended that they shift their position or attempt to distract themselves from the episode. Doctors also encourage patients to learn breathing techniques to regain control of a situation, breathing slowly and deeply during the episode until a sense of control is re-established. After an episode, it is important to relax the body, which likely tenses greatly during the fit. Relax the neck, shoulders, and face while recovering.
Bibliography
Darwin, Charles. The Expression of the Emotions in Man and Animals. John Murray, 1872.
“MS and the Pseudobulbar Affect.” Healthline, 26 Feb. 2019, www.healthline.com/health/multiple-sclerosis/pseudobulbar-affect. Accessed 9 Mar. 2020.
“Pseudobulbar Affect.” Genetic and Rare Disease Information Center, 9 Nov. 2016, rarediseases.info.nih.gov/diseases/12012/pseudobulbar-affect. Accessed 9 Mar. 2020.
“Pseudobulbar Affect.” MayoClinic, 16 May 2018, www.mayoclinic.org/diseases-conditions/pseudobulbar-affect/diagnosis-treatment/drc-20353741. Accessed 10 Mar. 2020.
“Pseudobulbar Affect (PBA).” American Stroke Association, 21 Nov. 2018, www.stroke.org/en/about-stroke/effects-of-stroke/emotional-effects-of-stroke/pseudobulbar-affect. Accessed 9 Mar. 2020.
“Pseudobulbar Affect (PBA).” Cleveland Clinic, my.clevelandclinic.org/health/diseases/17928-pseudobulbar-affect-pba. Accessed 10 Mar. 2020.
“Pseudobulbar Affect (PBA).” WebMD, 25 Sept. 2019, www.webmd.com/brain/pseudobulbar-affect#2. Accessed 10 Mar. 2020.
Watson, Stephanie. “Could It Be PBA? 7 Signs Caregivers Should Look For.” Healthline, 21 May 2018, www.healthline.com/health/pba/pba-signs. Accessed 9 Mar. 2020.
“What is PseudoBulbar Affect (PBA)?” PBA Info, www.pbainfo.org/about-pba. Accessed 10 Mar. 2020.