HOW TO HELP IDENTIFY PBA

Actor portrayal of a patient with PseudoBulbar Affect (PBA) crying symptoms

As you may know, pseudobulbar affect (PBA) is commonly comorbid with depression and/or other mood and behavioral disorders. It's important to ask your patients probing questions because PBA episodes do not typically appear when the patient is with the doctor.1-4

A real patient with multiple sclerosis (MS) and PseudoBulbar Affect (PBA)
Barriers to Identifying PBA

Watch this short video to get more insight into why PBA is often hard to detect. A multiple sclerosis (MS) patient and his spouse explain that, while the patient has been seeing his doctor for 19 years, he never experienced a PBA episode while being examined. As a result, his doctor did not screen for PBA.

Making a correct diagnosis for PBA

The first step to a correct diagnosis is to know the symptoms of the condition and the criteria against which to judge.

Here’s a place to start: If 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, consider screening those patients for PBA.5 Then, ask yourself these four questions because they contain some of the hallmarks of PBA.6

1

CONFIRM if there is an underlying neurologic condition or brain injury—including but not limited to1:

  • Stroke
  • Dementia
  • Traumatic brain injury
  • Amyotrophic lateral sclerosis
  • Multiple sclerosis
  • Parkinson's disease

2

QUESTION about crying presentation. In PBA, crying may be indistinguishable from normal crying.6-9 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

3

INVESTIGATE to see if uncontrollable laughing and/or crying episodes are related to underlying mood or stimulus or don’t reflect how the patient actually feels. Remember that PBA episodes can be exaggerated or incongruent.6-8,10-12

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.

Actor portrayal of a patient with PseudoBulbar Affect (PBA) laughing symptoms

I overreact to things now.

Laughing and/or crying episodes are excessive but consistent with stimulus and feelings.7

I can’t stop myself from crying.

Laughing and/or crying episodes are sudden, uncontrollable, and may be stronger than normal reactions.3,7

Incongruent

Inappropriate or inconsistent in relation to mood or stimulus.6 Episodes may follow a stereotyped pattern in terms of length and severity, and expression of laughing and/or crying.6,7

Actor portrayal of patient with PseudoBulbar Affect (PBA) symptoms that are incongruent to what he is feeling

I don’t know why I am crying.

Laughing and/or crying episodes don’t match feelings, and there may be no meaningful stimulus.7

It comes out of nowhere.

Laughing and/or crying episodes are sudden, uncontrollable, and may be brief (seconds or minutes).6,7

PBA involves a disconnect between:1,13

Affect

Expression of emotion

Mood

Underlying emotional state

4

ESTABLISH if laughing and/or crying episodes are also involuntary, sudden, and frequent. Patients may describe their uncontrollable laughing and/or crying episodes in different ways.6,14

Actor portrayal of a patient with PseudoBulbar Affect (PBA) crying symptoms

INVOLUNTARY

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

SUDDEN

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

FREQUENT

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

Video resources to help you recognize PBA

Doctor Fisher discusses how to identify patients in your practice with PBA.

Prevalence of PBA in Your Practice
Hear the common ways patients with PBA describe their condition.
The Importance of Screening for PBA
Find out why some doctors screen all their patients for PBA.
Why You May Not See PBA Episodes in Your Clinic
Discover why PBA symptoms may not be detectable in the office.

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. 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. 8. 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. 9. 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. 10. Calvert T, Knapp P, House A. Psychological associations with emotionalism after stroke. J Neurol Neurosurg Psychiatry. 1998;65(6):928-929. 11. House A, Dennis M, Molyneux A, Warlow C, Hawton K. Emotionalism after stroke. BMJ. 1989;298(6679):991-994. 12. 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. 13. Ahmed A, Simmons Z. Pseudobulbar affect: prevalence and management. Ther Clin Risk Manag. 2013;9(1):483-489. 14. Data on file. Avanir Pharmaceuticals, Inc. 

INDICATION AND USAGE

NUEDEXTA® (dextromethorphan HBr and quinidine sulfate) 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 (eg, 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 (eg, thioridazine and pimozide), patients with complete atrioventricular (AV) block without implanted pacemaker, or at high risk of complete AV block.

WARNINGS AND PRECAUTIONS

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 (eg, 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. Please see Full Prescribing Information.

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