Diagnosing Pseudobulbar Affect (PBA)

Actor portrayal of a patient with Pseudobulbar Affect, or PBA, crying symptoms

Based on data from 2011, many patients with Pseudobulbar Affect (PBA) may remain undiagnosed¹⁷

For patients with complex neurologic conditions and comorbid mood or behavioral disorders, crying and other outbursts can be common. This can make your evaluation of their symptoms challenging. But getting to the right diagnosis is crucial to reducing the impact of PBA episodes on your patients’ lives.

DO YOU KNOW THE SYMPTOMS OF PBA?

Screening for PBA, or following the steps below, can make all the difference. PBA is a distinct, treatable condition, but it can only be treated with the correct diagnosis.

According to a 2011 online survey of patients and caregivers that was used to estimate the prevalence of PBA in the United States (N=2,318), of the 937 respondents who screened positive for PBA symptoms:¹⁷

73.6% (637)

talked to their doctor about their episodes.

41% of those that spoke to their doctor (227)

were given a diagnosis.

None (0)

of the reported diagnoses were for PBA.

^a A positive screening for PBA was determined by a Center for Neurologic Study-Lability (CNS-LS) score of 13 or greater and/or a report of sudden laughing and/or crying episodes. The 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. Higher CNS-LS scores are indicative of more frequent uncontrollable laughing and/or crying episodes. This scale does not confer a PBA diagnosis.^18,19

A proper PBA diagnosis starts with you

PBA occurs secondary to certain neurologic conditions or brain injuries. It is also often comorbid with depression and/or other mood and behavioral disorders. PBA is distinct from other forms of mood, affective, or emotional lability. If your patients with a neurologic condition or brain injury who have been diagnosed with and treated for depression are still experiencing involuntary, sudden, frequent laughing and/or crying episodes, it could be time to screen for PBA.^1-4

Also, keep in mind that PBA episodes may not appear when the patient is with their doctor, so asking the right questions of your patients, their caregivers, and your medical team is important for reaching an accurate diagnosis.

Identifying Patients with PBA

In this video, Dr. Nick Palladino and Dr. Jennifer McVige provide insight into their experiences with patients who exhibited signs of PBA and the steps they took to make a PBA diagnosis.

Download a transcript of this video.

Three steps to PBA diagnosis

To start your evaluation, you need to know the symptoms of the condition and the criteria against which to judge.

It can also be helpful to ASK your patients and their caregivers:

Can you tell me about any changes in your laughing and/or crying since your stroke diagnosis?

If laughing and/or crying episodes are impacting your patient, take these three steps.

1

CONFIRM if there is an underlying neurologic condition or brain injury—including but not limited to:^1,4,5

Stroke
Traumatic brain injury (TBI)
Multiple sclerosis (MS)
Dementia/Alzheimer's disease
Amyotrophic lateral sclerosis (ALS)
Parkinson's disease

Common comorbidities and other considerations

Mood disorders or behavior changes commonly co-occur with many underlying neurologic conditions. As such, while a mood-related condition is not required for a PBA diagnosis, PBA is often comorbid with mood and behavioral disorders.

When exploring a PBA diagnosis, it can also help to review your patient's chart for:

History of any mood-related conditions with which the underlying condition may co-occur: ^{3, 20, 21}

Depression
Delusions
Aggression
Personality changes
Anxiety
Post-traumatic stress disorder (PTSD)

In a clinical study, 57.5 percent of patients who were diagnosed with PBA had comorbid depression, out of 367 patients in total.

Current list of medications, such as those taken to treat mood or behavioral disorders:

Antidepressants
Anxiolytics
Antipsychotics
Sedatives and hypnotics
Psychostimulants
Anticonvulsants

In a clinical study, 62.5 percent of patients with PBA symptoms were taking psychotropic medication, out of 1,944 patients in total.

2

DETERMINE if their laughing and/or crying symptoms and presentation suggest PBA. Patients may describe their uncontrollable laughing and/or crying episodes in different ways.^6,7

Some of the hallmarks of Pseudobulbar Affect episodes include:^1,3-6,8

INVOLUNTARY

It happens in public. I can’t control it.

SUDDEN

I cry for no reason. It comes out of the blue.

FREQUENT

I cry more than I used to. The littlest thing sets me off.

PBA episodes can also be exaggerated and/or incongruent.^{6, 8, 9, 11-13}

EXAGGERATED

Excessive or disproportionate in relation to mood or stimulus.³ Patients may experience variability in the initiation, duration, and intensity of their laughing and/or crying episodes.

I overreact to things now.

Laughing and/or crying episodes are excessive but consistent with stimulus and feelings.⁸

I can’t stop myself from crying.

Laughing and/or crying episodes are sudden, uncontrollable, and may be stronger than normal reactions.^6,8

INCONGRUENT

Inappropriate or inconsistent in relation to mood or stimulus.⁶ Episodes may not follow a stereotyped pattern in terms of length and severity, and expression of laughing and/or crying.^6,8

I don’t know why I am crying.

Laughing and/or crying episodes don’t match feelings, and there may be no meaningful stimulus.⁸

It comes out of nowhere.

Laughing and/or crying episodes are sudden, uncontrollable, and may be brief (seconds or minutes).^6,8

PBA involves a disconnect between:^6,14

Affect

Expression of emotion

Mood

Underlying emotional state

In PBA, crying may be indistinguishable from normal crying.^{6, 8-10}
Click on the navigation on the right to view examples of PBA crying episodes.

Appears with or without tears

Tears may or may not be present when crying.

In PBA, crying may:

Appear with or without tears
Sound noiseless or quiet
Sound noisy with increasing volume
Appear with or without grimacing

Download transcripts of these videos.

Nurses and other staff members may also describe your patient’s symptoms in different ways. Look for some of these terms on patient charts that may suggest PBA: ^1,14

Emotional incontinence
Emotional lability
Inappropriate affect

Involuntary expression
Mood incongruence
Pathological laughing and crying

Sudden or emotional outbursts of laughing or crying

3

DOCUMENT your diagnosis

Once you've confirmed your diagnosis, you can document it with ICD-10 code F48.2.¹⁵

PBA is treatable with NUEDEXTA — the first and only FDA-approved treatment for PBA.¹⁶

Learn More About Treatment With NUEDEXTA

Download the Steps to Diagnosis Tool

This quick guide includes what to consider when confirming an underlying condition, determining the hallmarks of PBA episodes, and documenting an appropriate diagnosis. This resource was designed with nurses in mind and can be a helpful tool for anyone on your care team.

Save a copy

Are you a healthcare provider working in the long-term care setting?

Learn more about identifying residents with PBA

Co-Pay, Sample & Voucher Requests

CO-PAY SAVINGS CARD

Share this card to help your patients save on their NUEDEXTA prescription and refills. By enrolling, your commercially insured patients may pay as little as $0 for a 90-day supply, or $20 for a 30-day supply.

Print Co-Pay Savings Card Restrictions apply. Most commercially insured patients pay as little as $0 for a 90-day supply or $20 for a 30-day supply. Benefit cap applies regardless of co-pay amount.

NUEDEXTA sample bottle for PseudoBulbar Affect (PBA) patients

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References: 1. Miller A, Pratt H, Schiffer RB. Pseudobulbar affect: the spectrum of clinical presentations, etiologies and treatments. Expert Rev Neurother. 2011;11(7):1077-1088. 2. Colamonico J, Formella A, Bradley W. Pseudobulbar affect: burden of illness in the USA. Adv Ther. 2012;29(9):775-798. 3. Parvizi J, Arciniegas DB, Bernardini GL, et al. Diagnosis and management of pathological laughter and crying. Mayo Clin Proc. 2006;81(11):1482-1486. 4. Brooks BR, Crumpacker D, Fellus J, Kantor D, Kaye RE. PRISM: a novel research tool to assess the prevalence of pseudobulbar affect symptoms across neurological conditions. PLoS ONE. 2013;8(8):e72232. 5. Hammond FM, Alexander DN, Cutler AJ, et al. PRISM II: an open-label study to assess effectiveness of dextromethorphan/quinidine for pseudobulbar affect in patients with dementia, stroke or traumatic brain injury. BMC Neurol. 2016;16:89. 6. Cummings JL, Arciniegas DB, Brooks BR, et al. Defining and diagnosing involuntary emotional expression disorder. CNS Spectr. 2006;11(S6):1-7. 7. Data on file. Avanir Pharmaceuticals, Inc. 8. Lauterbach EC, Cummings JL, Kuppuswamy PS. Toward a more precise, clinically-informed pathophysiology of pathological laughing and crying. Neurosci Biobehav Rev. 2013;37(8):1893-1916. 9. Olney NT, Goodkind MS, Lomen-Hoerth C, et al. Behaviour, physiology and experience of pathological laughing and crying in amyotrophic lateral sclerosis. Brain. 2011;134(12):3458-3469. 10. Poeck K. Pathophysiology of emotional disorders associated with brain damage. In Vinken PJ, Bruyn GW, eds. Handbook of Clinical Neurology. Vol 3. Amsterdam: North Holland Publishing; 1969:343-367. 11. Calvert T, Knapp P, House A. Psychological associations with emotionalism after stroke. J Neurol Neurosurg Psychiatry. 1998;65(6):928-929. 12. House A, Dennis M, Molyneux A, Warlow C, Hawton K. Emotionalism after stroke. BMJ. 1989;298(6679):991-994. 13. Andersen G, Ingeman-Nielsen M, Vestergaard K, Riis JO. Pathoanatomic correlation between poststroke pathological crying and damage to brain areas involved in serotonergic neurotransmission. Stroke. 1994;25(5):1050-1052. 14. Ahmed A, Simmons Z. Pseudobulbar affect: prevalence and management. Ther Clin Risk Manag. 2013;9(1):483-489. 15. World Health Organization.ICD-10-CM tabular list of diseases and injuries (2021).https://www.cdc.gov/nchs/icd/icd10cm.htm.Published 2021. AccessedJune 21, 2021. 16. NUEDEXTA [package insert]. Rockville, MD: Otsuka America Pharmaceutical, Inc. 17. Work SS, Colamonico JA, Bradley WG, Kaye RE. Pseudobulbar affect: an under-recognized and under-treated neurological disorder.Adv Ther. 2011;28(7):586-601. 18. Moore SR, Gresham LS, Bromberg MB, Kasarkis EJ, Smith RA. A self report measure of affective lability.J Neurol Neurosurg Psychiatry. 1997;63(1):89-93. 19. Smith RA, Berg JE, Pope LE, Callahan JD, Wynn D, Thisted RA. Validation of the CNS emotional lability scale for pseudobulbar affect (pathological laughing and crying) in multiple sclerosis patients.Mult Scler.2004;10(6):679-685. 20. Engelman WA, Hammond FM, Malec JF. Diagnosing pseudobulbar affect in traumatic brain injury. Neuropsychiatr Dis Treat. 2014;10;1903-1910. 21. Crumpacker DW, Engleman WA. Identifying pseudobulbar affect in Alzheimer's disease and dementia. US Neurol. 2014;10(1);10-14

INDICATION and IMPORTANT SAFETY INFORMATION for NUEDEXTA^® (dextromethorphan HBr and quinidine sulfate)

INDICATION

NUEDEXTA is indicated for the treatment of pseudobulbar affect (PBA).

PBA occurs secondary to a variety of otherwise unrelated neurologic conditions, and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying. PBA episodes typically occur out of proportion or incongruent to the underlying emotional state. PBA is a specific condition, distinct from other types of emotional lability that may occur in patients with neurologic disease or injury.

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS:

Quinidine and Related Drugs: NUEDEXTA contains quinidine and should not be used concomitantly with other drugs containing quinidine, quinine, or mefloquine.
Hypersensitivity: NUEDEXTA is contraindicated in patients with a history of NUEDEXTA-, quinine-, mefloquine-, or quinidine-induced thrombocytopenia, hepatitis, bone-marrow depression, lupus-like syndrome, or known hypersensitivity to dextromethorphan (e.g., rash, hives).
MAOIs: NUEDEXTA is contraindicated in patients taking monoamine oxidase inhibitors (MAOIs), or in patients who have taken MAOIs within the preceding 14 days, due to the risk of serious and possibly fatal drug interactions, including serotonin syndrome. Allow at least 14 days after stopping NUEDEXTA before starting an MAOI.
Cardiovascular: NUEDEXTA is contraindicated in patients with a prolonged QT interval, congenital long QT syndrome, history suggestive of torsades de pointes, heart failure, patients receiving drugs that both prolong QT interval and are metabolized by CYP2D6 (e.g., thioridazine and pimozide), patients with complete atrioventricular (AV) block without implanted pacemaker, or at high risk of complete AV block.

Thrombocytopenia and Other Hypersensitivity Reactions: Quinidine can cause immune-mediated thrombocytopenia that can be severe or fatal. Non-specific symptoms, such as lightheadedness, chills, fever, nausea, and vomiting, can precede or occur with thrombocytopenia. NUEDEXTA should be discontinued immediately if thrombocytopenia occurs.

Hepatotoxicity: Hepatitis, including granulomatous hepatitis, has been reported in patients receiving quinidine, generally during the first few weeks of therapy. Discontinue immediately if this occurs.

Cardiac Effects: NUEDEXTA causes dose-dependent QTc prolongation. QT prolongation can cause torsades de pointes–type ventricular tachycardia, with the risk increasing as the degree of prolongation increases. When initiating NUEDEXTA in patients at risk for QT prolongation and torsades de pointes, electrocardiographic (ECG) evaluation of QT interval should be conducted at baseline and 3 to 4 hours after the first dose. Some risk factors include use with CYP3A4 inhibitors or drugs that prolong QT interval, electrolyte abnormalities, bradycardia, or left ventricular hypertrophy or dysfunction. If patients taking NUEDEXTA experience symptoms that could indicate the occurrence of cardiac arrhythmias (e.g., syncope or palpitations), NUEDEXTA should be discontinued, and the patient further evaluated.

Concomitant Use of CYP2D6 Substrates: NUEDEXTA inhibits CYP2D6 and may interact with other drugs metabolized by CYP2D6. Adjust dose of CYP2D6 substrates as needed.

Dizziness: NUEDEXTA may cause dizziness. Take precautions to reduce the risk of falls.

Serotonin Syndrome: Use of NUEDEXTA with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants increases the risk of “serotonin syndrome.”

Anticholinergic Effects of Quinidine: Monitor for worsening in myasthenia gravis.

Adverse Reactions: The most common adverse reactions (incidence of ≥3% and two-fold greater than placebo) in patients taking NUEDEXTA are diarrhea, dizziness, cough, vomiting, asthenia, peripheral edema, urinary tract infection, influenza, increased gamma-glutamyltransferase, and flatulence.

These are not all the risks for use of NUEDEXTA.

To report SUSPECTED ADVERSE REACTIONS, contact Otsuka America Pharmaceutical, Inc. at 1-800-438-9927 or FDA at 1-800-FDA-1088 (www.fda.gov/medwatch).

Please see FULL PRESCRIBING INFORMATION.