Pseudobulbar affect

Refers to emotional lability, labile affect, or emotional incontinence as a neurologic disorder characterized by involuntary crying or uncontrollable episodes of crying and/or laughing, or other emotional displays.

PBA may occur secondary to a neurologic disease or brain injury.

Patients may cry uncontrollably at something that is only moderately sad, being unable to stop themselves for several minutes.

Uncontrollable episodes may also be mood-incongruent, meaning a patient might laugh uncontrollably when angry or frustrated.

Associated with a pathologically lowered threshold for exhibiting the behavioral response of laughter, crying, or both.

Patients exhibit episodes of laughter and/or crying without an apparent motivating stimulus or in response to stimuli that would not have elicited such an emotional response before the onset of their underlying neurologic disorder.

In some patients, the emotional response is exaggerated.

In some patients, the character of the emotional display can be incongruent.

The onset can be sudden and unpredictable.

It has been described by some as coming on like a seizure.

Emotional outbursts have a typical duration of a few seconds to several minutes.

These emotional outbursts may occur several times a day.

PBA can be severe, unremitting and disabling to patients, and may significantly impact quality of life for caregivers.

Uncontrollable emotional outbursts may lead to social withdrawal, interfere with activities of daily living, social and professional pursuits.

PBA can have a negative impact on overall healthcare.

Often be misdiagnosed as clinical depression.

In depression and grief syndromes, crying is typically a sign of sadness.

With PBA the pathological displays of crying are often in contrast to the underlying mood, or greatly in excess of the mood or eliciting stimulus.

PBA episodes are sudden, and briefly episodic, while crying in depression is a more sustained presentation and closely relates to the underlying mood state.

The level of control that one has over the crying episodes in PBA is minimal or nonexistent.

With depression, typically crying can be modulated by the situation.

The trigger for episodes of crying in patients with PBA may be nonspecific, minimal or inappropriate.

With depression the stimulus is specific to the mood-related condition.

Depressed mood and PBA may co-exist, as depression is one of the most common emotional changes in patients with neurodegenerative disease or post-stroke sequelae.

The specific pathogenic mechanisms of PBA remain controversial.

Theories include: lesions in the descending corticobulbar tract causing failure of voluntary control of emotion, or an abnormal prefrontal cortex.

It can occurs secondary to neurological disease or brain injury, and is thought to result from disruptions of neural networks that control the generation and regulation of motor output of emotions.

Commonly observed in people with neurologic injuries such as traumatic brain injury, stroke, and neurologic diseases such as dementias including Alzheimer’s disease, attention deficit/hyperactivity disorder (ADHD), multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), Lyme disease, PANDAS in children and adults, and Parkinson’s disease (PD).

Has been reported as a symptom of hyperthyrodism, Graves’ Disease, or hypothyroidism in combination with depression.

Has been observed in association with a variety of other brain disorders, including brain tumors, Wilson’s disease, syphilitic pseudobulbar palsy, and various encephalitides.

Rarer conditions associated with PBA include gelastic epilepsy, central pontine myelinolysis, olivopontinocerebellar atrophy, lipid storage diseases, nitrous oxide and insecticide exposure), and Angelman syndrome.

It is suspected that neurologic injuries and diseases impact chemical signaling in the brain, which in turn disrupts the neurologic pathways that control emotional expression.

It is one of the most frequently reported post-stroke behavioral syndromes, with a range of reported prevalence rates from 28% to 52%.

PBA has a higher prevalence rates in stroke patients who are older and/or who have a history of prior stroke.

Approximately 10% of patients with multiple sclerosis will experience at least one episode of emotional lability, as it is associated with later stages of the disease.

Approximately 49% of patients with amyotrophic lateral sclerosis also have PBA.

Traumatic brain injury has a reported a 55% prevalence of PBA, and occurs particularly in patients with more severe head injury.

It is an involuntary syndrome that is manageable.

Traditionally, antidepressants are prescribed with some efficacy.


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