PSEUDOBULBAR AFFECT (PBA) AND DEPRESSION
Pseudobulbar Affect (PBA) is commonly comorbid with depression and other mood or behavioral disorders 1
Depression is highly prevalent among patients with neurologic conditions such as dementia and multiple sclerosis (MS). 4 Since PBA occurs secondary to neurologic conditions or brain injuries, it makes sense that PBA is also commonly comorbid with depression. It is crucial to evaluate your patients with complex neurologic conditions for all possible diagnoses to ensure that they get the right treatment to reduce their symptoms.
In a 90-day, open-label, single-arm study, more than half of patients who were diagnosed with PBA had comorbid depression (N=367). 70.8% of patients in the study were taking psychopharmacologic medications. 5, a, b
a PRISM II was a 90-day, open-label, single-arm, 74-site, U.S. trial in adult patients with dementia, stroke, or TBI. All patients received a clinical diagnosis of PBA by their physician and had a Center for Neurologic Study-Lability Scale (CNS-LS) score of 13 or greater at baseline. CNS-LS is a seven-item self-report rating scale that measures perceived frequency and control over laughing and/or crying episodes. It was validated as a PBA screening tool in amyotrophic lateral sclerosis (ALS) and multiple sclerosis (MS) populations. CNS-LS of 13 or greater may suggest PBA but does not confer a PBA diagnosis. 5-7
b Based on Patient Health Questionnaire-9 (PHQ-9), a nine-item assessment of depressive symptoms. Scores range from 0 to 27, with higher scores indicating increased depression severity. 5
Depression and PBA may be difficult to distinguish 1
While depression and PBA can occur together, it is common to mistake PBA crying episodes for symptoms of depression and other disorders with symptoms of mood lability. But there are many clinical features that distinguish PBA episodes from depression symptoms. The most prominent feature is duration. Depression symptoms last weeks to months, whereas PBA episodes last seconds to minutes. 1
OF LONG-TERM CAREGIVERS
In a web-based survey of 265 caregivers working at geriatric long-term care facilities, 80.4% of participants reported that they would have attributed PBA episodes to depression before gaining knowledge and experience with PBA. To learn more, visit our PBA in Long-Term Care Settings page.
Recognize the different characteristics of crying 8
PBA is a neurologic condition, not a psychologic or psychiatric disorder. One of the major differences between PBA and depression is the relationship between crying episodes and mood. PBA alters a patient’s expression, or affect, causing involuntary crying that is exaggerated or incongruent with their underlying mood. 8 A patient with PBA may cry when they’re not sad, or they may cry uncontrollably when they’re only a little sad. If you suspect your patient has mood lability, consider asking them whether their crying matches how they feel.
- Matches how the patient feels
- Mostly controllable; stops when mood changes
- Onset and duration defined by mood
- Disproportionate to or inconsistent with how the patient feels
- Happens frequently, suddenly, and may be brief
These are not all the diagnostic features of depression. 8 Formal diagnosis of depression or PBA can only be made by a qualified healthcare practitioner.
When to screen for PBA
Use the Center for Neurologic Study-Lability Scale (CNS-LS) c or review the Steps to Diagnosis to screen for PBA when patients with neurologic conditions or brain injury are diagnosed with and treated for depression but are still experiencing involuntary, sudden, frequent laughing and/or crying episodes. 1-4
When evaluating a patient, review their chart for medications commonly prescribed for mood or behavioral disorders. These many include tricyclic antidepressants, nontricyclic antidepressants (e.g., SSRIs, SNRIs), and antipsychotics.
In the PRISM study, psychotropic medication use was significantly higher in patients with symptoms suggestive of PBA (CNS-LS score ≥ 13) compared to use in patients without (CNS-LS score <13). 4, c The reason for psychotropic medication use was not captured in the study.
|Score*||Proportion of patients taking at least one antidepressant or antipsychotic medication|
|CNS-LS ≥ 13 (N=1,944)||53%|
|CNS-LS ≥ 21 (N=492)||61.6%|
|CNS-LS < 13 (N=3,346)||35.4%|
* The proportion of patients taking at least one antidepressant or antipsychotic medication was significantly higher among those with scores suggestive of PBA versus those without scores suggestive of PBA (P < 0.0001 for both comparisons, chi-square test).
c CNS-LS is a seven-item self-report rating scale that measures perceived frequency and control over laughing and/or crying episodes. It was validated as a PBA screening tool in ALS and MS populations. The presence of PBA symptoms (uncontrollable episodes of laughing and/or crying) was defined as a CNS-LS score of 13 or greater. Higher CNS-LS scores are indicative of more frequent uncontrollable laughing and/or crying episodes. This scale does not confer a PBA diagnosis. 6, 7
Various mood and behavioral disorders can affect patients with neurologic conditions or brain injury. 2
Depression is only one of the mood disorders that has signs and symptoms similar to PBA. Crying and other episodes are common among mood and behavioral disorders that often co-occur with a patient's underlying condition.1, 3, 4, 8-10
Patients with traumatic brain injury may experience anxiety or post-traumatic stress disorder, and patients with dementia may experience aggression, delusions, and personality changes.9,10 If your neurologic patient's chart includes symptoms of affective or mood lability, consider screening them for PBA too.
It could be time to screen for PBA.