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
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
CONFIRM if there is an underlying neurologic condition or brain injury—including but not limited to1:
- Traumatic brain injury
- Amyotrophic lateral sclerosis
- Multiple sclerosis
- Parkinson's disease
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:
In PBA, crying may:
- Appear with or without tears
- Sound noiseless or quiet
- Sound noisy with increasing volume
- Appear with or without grimacing
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
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.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
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
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
Expression of emotion
Underlying emotional state
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
It happens in public. I can’t stop it.
I cry for no good reason. It comes out of the blue.
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.