Diagnosing Pseudobulbar Affect (PBA)

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

Based on data from 2011, many patients with PBA may remain undiagnosed

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 in reducing the impact of PBA episodes on your patients’ lives.¹

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=2318), of the 937 respondents who screened positive for PBA symptoms¹:

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.

^aA 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.^2,3

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.^4-7

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 Help Assess for PBA

PBA can only be diagnosed following a complete assessment by a qualified healthcare provider.⁷

1

Ask this simple question to help uncover PBA⁸

“Do you ever cry or laugh but it feels odd because you’re not actually sad or amused?”

2

Differentiate between PBA and depression^9-11

3

Document your confirmed diagnosis with ICD-10 code F48.2^12*

*ICD-10 diagnosis codes are provided for informational purposes only and do not guarantee that billing codes will be appropriate or that coverage and reimbursement will result. Providers should consult with their payers for all relevant coverage, coding, and reimbursement requirements. It is the sole responsibility of the provider to select proper codes and ensure the accuracy of all claims used in seeking reimbursement. This resource is not intended as legal advice or as a substitute for a provider’s independent professional judgment.

Consider treatment with NUEDEXTA if you confirm that your patient has PBA

Learn about prescribing NUEDEXTA for patients with PBA.

Co-Pay Card & Sample 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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Eligible healthcare providers can request a free 10-day sample of NUEDEXTA for appropriate patients.

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References: 1. 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. 2. 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. 3. 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. 4. Miller A, Pratt H, Schiffer RB. Pseudobulbar affect: the spectrum of clinical presentations, etiologies and treatments. Expert Rev Neurother. 2011;11(7):1077-1088. 5. Colamonico J, Formella A, Bradley W. Pseudobulbar affect: burden of illness in the USA. Adv Ther. 2012;29(9):775-798. 6. Parvizi J, Arciniegas DB, Bernardini GL, et al. Diagnosis and management of pathological laughter and crying. Mayo Clin Proc. 2006;81(11):1482-1486. 7. 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. 8. Suavé WM. Recognizing and treating pseudobulbar affect. CNS Spectr. 2016;21(S1):34-44. doi:10.1017/S1092852916000791 9. Kekere V, Qureshi D, Thanju A, Fouron P, Olupona T. Pseudobulbar affect mimicking depression: a case report. Cureus. 2022;14(6): e26235. doi:10.7759/cureus.26235 10. NUEDEXTA. Package insert. Otsuka America Pharmaceutical, Inc.; 2022. 11. 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. 12. Centers for Disease Control and Prevention. ICD-10-CM tabular list of diseases and injuries. Accessed March 7, 2024. https://ftp.cdc.gov/pub/health_statistics/nchs/publications/ICD10CM/2022/icd10cm-tabular-2022-April-1.pdf

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

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.

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.