What is Pseudobulbar Affect?

Category: Multiple Sclerosis by Lisa Binsin, PharmD - August 30, 2013 | Views: 6849 | Likes: 0 | Comment: 0

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Pseudobulbar Affect

What is pseudobulbar affect

Pseudobulbar affect (PBA) is also known as emotional lability, pathological crying and laughing, or emotional incontinence. It is a medical condition that causes sudden moments of uncontrollable episodes of crying or laughing. Most of these emotional outbursts occur at inappropriate times, causing uncomfortable situations for not only the patient but also people around them. PBA can be commonly misdiagnosed as depression. PBA is not depression.

Pseudobulbar affect statistics

  • Affects ~1 million people in the US
  • 53% of stroke survivor respondents reported symptoms of PBA
  • Less than 1 in 5 stroke survivor respondents knew about PBA
  • ~4 in 10 respondents feel that PBA interfere with their daily life
  • >25% of patients with PBA indicate they experience frequent outbursts
  • ~38% of patients with PBA symptoms were treated for their episodes

What causes pseudobulbar affect

PBA can occur in people with neurologic disorders such as stroke, dementia, multiple sclerosis (MS), Lou Gehrig’s disease, or people with traumatic brain injury.

What are the symptoms of pseudobulbar affect

  • Uncontrollable laughing
  • Uncontrollable crying

The Center for Neurologic Study-Lability Scale (CNS-LS) developed simple 7 question scale that can help you determine if you should talk to your doctor about PBA. A score of 13 or higher can be suggestive of PBA. Remember that only doctors can diagnose PBA. If you feel like you may have PBA, consult with your doctor.

CNS-LS Questionnaire:

  1. There are times when I feel fine 1 minute, and then I’ll become tearful the next over something small or for no reason at all.
  2. Others have told me that I seem to become amused very easily or that I seem to become amused about things that really aren’t funny.
  3. I find myself crying very easily.
  4. I find that even when I try to control my laughter, I am often unable to do so.
  5. There are times when I won’t be thinking of anything happy or funny at all, but then I’ll suddenly be overcome by funny or happy thoughts.
  6. I find that even when I try to control my crying, I am often unable to do so.
  7. I find that I am easily overcome by laughter.

Take the test and get your score here.

Treatments

Non-drug Management:

Experts recommend the following non-drug related approaches for managing PBA:

  • You should not keep your condition a secret. Let close relatives and friends know about it so they can help support you when you do get an episode.
  • Distraction is key. Try to distract yourself when you feel like an episode is about to occur. Some people feel like it is helpful to count numbers or think of something unrelated.
  • Breathe. Take long deep breaths and try to keep focused until the episode subsides.
  • Relax your body. Try to relax all muscle groups during these emotional outbursts. Many times, your muscle can tense up. Relax your forehead and shoulders. 

Drug treatment:

The most important step in treating PBA is to make sure the correct diagnosis is made. Due to the symptoms which include uncontrollable crying, PBA was often previously misdiagnosed as depression. Therefore, many drugs prescribed for PBA patients in the past included tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRI). Nuedexta (previously called Zenvia) is the only drug approved for PBA by the FDA.

Nuedexta (dextromethorphan HBr and quinidine sulfate) capsule was approved by the FDA for PBA (October 29th, 2010). 

Dosage forms: capsule containing 20 mg dextromethorphan hydrobromide and 10 mg quinidine sulfate in a brick red gelatin capsule with “DMQ/20-10” printed in white ink on the capsule.

Dosing: One capsule daily by mouth for the initial seven days of therapy and one capsule every 12 hours starting on the eighth day onward.

Common Side effects: diarrhea, dizziness, cough, vomiting, asthenia (lack of energy or abnormal physical weakness), peripheral edema, urinary tract infection, influenza, flatulence

Severe side effects: Thrombocytopenia (lower than normal blood cell fragments called platelets which can lead to bleeding), hepatitis (inflammation of the liver), QT prolongation (causing abnormality in your heart’s electrical system causing abnormal heartbeats), left ventricular hypertrophy or dysfunction

Efficacy: The efficacy of Nuedexta was demonstrated in a 12-week trial. 107 patients were on Nuedexta ( dextromethorphan 20 mg/quinidine 10 mg), 110 patients on Nuedexta (dextromethorphan 30 mg/quinidine 10 mg), and 109 patients on placebo. Participants had an underlying amyotrophic lateral sclerosis (ALS) or multiple sclerosis. There was a statistically significant reduction in laughing and crying episodes with patients on Nuedexta versus placebo.           

Resources

National Stroke Association: Pseudobulbar Affect 

Nuedexta. Avanir Pharmaceuticals, inc.(2013). Prescribing Information

 

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