Based on the Gerontological Society of America publication, Insights and Implications in Gerontology: Understanding Pseudobulbar Affect
Pseudobulbar Affect:
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A DECISION TREE FOR HEALTHCARE PROVIDERS
Pseudobulbar Affect (PBA) is a condition characterized by bouts of uncontrolled crying or laughing that are disproportionate or inappropriate to the social context and are not associated with depression or anxiety.1 PBA is often underdiagnosed or misdiagnosed and can be mistaken for mood disorders (e.g., depression). PBA is often undertreated even when it has been diagnosed.2
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Symptoms of Pseudobulbar Affect
Excessive crying in response to mildly sad or touching situations
Uncontrollable laughter in response to mildly amusing situations
Episodes of crying or laughter may persist for several minutes
1
Diagnosing PBA
Distinguishing Between PBA and Depression
Conduct a neurologic evaluation.
Clinical Component
PBA
Depression
Criteria used for diagnosing PBA include:3
Spectrum of emotional lability
Crying, laughing, or both
Crying, loss of interest, thoughts of worthlessness or suicide
Episode duration
Seconds to minutes, sporadic
Weeks to months
Stimulus
No evident stimuli
Specific mood-related scenarios
Episode control
None
Coping mechanisms may shorten episodes
Underlying neurologic condition
Neurologic disease of brain injury always present
May or may not possess underlying neurologic condition
Affect
Exaggerated or incongruent with situational context
Flattened, saddened, or apprehensive; rarely demonstrate elation
Thoughts of death, dying, or suicide
Absent
May be present
Appetite
Usually unaffected
May be increased or decreased
• Is the emotional response (crying or laughing) occurring involuntarily, suddenly, and without the patient’s ability to control the emotion?
• Is the emotional response inconsistent with or disproportionate to the patient’s mood or inner feelings?
• Does expression of the emotion provide a feeling of relief? • Does the emotional response cause significant distress or limit the ability to work or interact socially?
• Is the emotional response caused by another psychiatric or neurologic disorder?
• Is the emotional response due to a drug? Two validated rating scales for assessing PBA have also been developed:
• Center for Neurologic Study-Liability Scale (CNS-LS) (self-administered)4 • Pathological Laughter and Crying Scale (PLACS) (interviewer-administered)5
2
Treating PBA
PBA = pseudobulbar affect
Interprofessional Wheel of Care
Goals of treatment for PBA include reducing severity and frequency of episodes
Primary Care Provider Neurologists/ Other Specialists
Behavior Strategies
1. Educate family, caregivers, and friends so that they better understand the
Caregivers
condition, its symptoms, and expectations for behavior, including how to respond during an episode.
2. Determine strategies to help the patient cope with an episode, such a relaxation practices, distraction techniques, and mindfulness techniques.
3. Consider occupational therapy to help the patient perform everyday tasks. 4. Maintain a diary to track when symptoms occur, along with preceding
P AT I E N T
Coordinated care from the interprofessional health care team, along with the patient’s caregivers, can optimize management and outcomes for patients.
Nurses
Occupational Therapists Social Workers Pharmacists
factors, to help identify episode triggers that might be avoided in the future.
Pharmacolgic Options PBA Treatment Algorithm
First-line treatment
Second-line treatment
Third-line treatment
• Dextromethorphan/ quinidine
• Selective serotonin reuptake inhibitors or • Tricyclic antidepressants
• Levodopa, reboxetine, venlafaxine, mirtazapine, lamotrigine, methylphenidate, dexamphetamine, or amantadine
For all patients, incorporate behavioral management strategies and caregiver support When selecting medications, consider: drug-drug interactions, advere effects, impact on patient comorbidities (including neurological conditions), contraindications, and impact on symptoms of PBA
Source: References 1, 6-9
References 1. Cruz MP. Nuedexta for the treatment of pseudobulbar affect: a condition of involuntary crying or laughing. P T. 2013;38(6):325–328. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3737988/pdf/ptj3806325.pdf 2. 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. doi:10.1007/s12325-011-0031-3 3. Cleveland Clinic. Pseudobulbar Affect (PBA). April 23, 2019. Accessed March 9, 2022. https://my.clevelandclinic.org/health/diseases/17928-pseudobulbar-affect-pba
8. Woodard TJ, Kim C, Calderon F, Hill C. Review of the diagnosis and management of pseudobulbar affect. US Pharmacist. 2017;42(11):31–35. https://www.uspharmacist.com/article/review-of-the-diagnosis-and-management-of-pseudobulbar-affect 9. Wortzel HS, Oster TJ, Anderson CA, Arciniegas DB. Pathological laughing and crying: epidemiology, pathophysiology and treatment. CNS Drugs. 2008;22(7):531–545. doi:10.2165/00023210-200822070-00001
4. Smith RA, Berg JE, Pope LE, et al. 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. doi:10.1191/1352458504ms1106oa 5. Robinson RG, Parikh RM, Lipsey JR, et al. Pathological laughing and crying following stroke: validation of a measurement scale and a double-blind treatment study. Am J Psychiatry. 1993;150(2):286–293. doi:10.1176/ajp.150.2.286 6. Ahmed A, Simmons Z. Pseudobulbar affect: prevalence and management. Ther Clin Risk Manag. 2013;9:483–489. doi:10.2147/TCRM.S53906
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7. Pioro EP. Review of dextromethorphan 20 mg/quinidine 10 mg (Nuedexta®) for pseudobulbar affect. Neurol Ther. 2014;3(1):15–28. doi:10.1007/s40120-014-0018-5
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