PseudoBulbar Affect (PBA) - Emotional Incontinence

PseudoBulbar Affect (PBA) - Pathological Laughter and Crying

by Don Drake, Connelly Law Offices, Ltd.

A little-known disorder called PseudoBulbar Affect (PBA) came to our attention a few weeks ago when someone described the behaviors of a loved one to us. They told us that at first, they thought it was depression following a stroke, but as it turned out, it was something quite different, and not at all emotionally based. PBA has been called many things, including a rather insensitive description -- "the joker's laugh", referring to the Batman character and his incessant laughter during the most inappropriate times.

"Those who have PBA engage in episodes of laughing or crying, often disproportionate to the situation," stated certified elder law Attorney RJ Connelly III. "PBA is often associated with brain disorders like a stroke, ALS, multiple sclerosis, seizure disorders, Parkinson's, traumatic or acquired brain injuries, and even Alzheimer's. For the person who has PBA, the condition can be embarrassing and the cause of tremendous stress."

Ronald's PBA

Ronald, now in his early sixties, recalls his final tour of duty in Iraq when a suicide bomber was able to get into the base and detonate his deadly backpack. "I was standing with a group of buddies after having lunch when I was just getting ready to return to my post. Then, I just remember a huge fireball zooming past me and being knocked to the ground by what felt like a thousand punches," he painfully recalled. "When I came to, I could see the sunlight shining through smoke and people, including my friends, lying dead or injured next to me on the ground. My head hurt, I couldn't hear and when I tried to get up, I just collapsed." Ron was transferred to the base hospital where he was treated for burns, and shrapnel wounds and ended up being diagnosed with a traumatic brain injury and PTSD.

Suicide bombing left Ron with a Traumatic Brain Injury

"When I came home, I had a really tough time dealing with my feelings and telling others my experiences," Ron said. "Then I started with episodes of hysterical crying, for no reason it seemed, and my doctors at the VA stated I was suffering from depression and put me on antidepressants. But it did not help, and my crying episodes became more frequent and seemed to last longer. It was embarrassing."

So embarrassing was this for Ron that he became fearful of going into public or socializing with his friends and even family. "I had one crying jag at a holiday party and my brother said, 'well, here he goes again', which really made me want to crawl into a hole. I had no control over this," he said. "My driving was also affected, and I would pull over when the crying started and wait for it to stop. It began to cripple me."

He then began to do some research on his own and found information about PBA that sounded just like his experience. "When I told the VA doctor about this, he was not all that familiar with the condition but said he would get back to me, which he did. After we had a discussion with the neurological team, they came up with a plan and some medications that are helping. It was also great to find others who have the same thing and to know that I'm not alone with this."

"Ron's experiences are typical of the few people I have met with this disorder," said Attorney Connelly. "Family members are often confused by what they see, because the emotions that are being expressed may not correspond to the situation that is presenting itself, this leads to anger at times and accusations of someone drama seeking. This then leads to the person with PBA avoiding social interactions and the important social supports that they need."

Quick Facts About PBA

Before we learn more about PBA, its causes, and the treatments being used, let's look at some quick facts to remember about this condition:

  1. PBA does not occur by itself; it is associated with a secondary neurological condition or a brain injury. This is important because should such behaviors emerge following a stroke or TBI, your treating medical professional should be on the lookout for PBA as a possible answer.

  2. Following a brain injury or the diagnosis of a neurological disorder, people are understandably upset and may be prone to depression. Because crying is a common symptom of depression, many this emotional response up to this psychological disorder. But PBA also causes crying and it's a neurological condition, much different than depression.

  3. One of the cues that the behaviors may be PBA rather than psychological is that the episodes can occur at any time and involve uncontrollable crying or laughter, lasting anywhere from just a few seconds to several minutes.

  4. Those with PBA often describe the experiences as embarrassing and frustrating. Those who provide care for them often feel the same way. Because of this, many more areas of life for those with PBA are affected, including family relationships, social outings, employment, and overall quality of life. Treatment can help.

  5. The PBA episodes may range from being just mildly disturbing to seizure like-episodes.

Below, please watch a trailer for a PBA special video.

What Causes This Condition?

The exact cause of PBA is not known. Those who study it believe it is a combination of damage to the central nervous system and those areas of your brain involving emotional control. It has long been believed that the cerebellum is the emotional regulator of the brain so lesions that may be in this area make an individual more likely to be susceptible to PBA.

"The frustrating thing about PBA is that it often goes undiagnosed," said Attorney Connelly. "Those with multiple sclerosis are believed to be overrepresented in those with PBA." To receive a PBA diagnosis, the following criteria must be met, with a focus on the individual's previous emotional responses:

  1. A notable change in the way the individual responds emotionally.

  2. Emotional responses that are inconsistent or disproportionate to mood.

  3. The response is not dependent on the stimulus or excessive to the stimulus.

  4. This response causes distress and/or social/occupational impairment.

  5. The response is not the result of another identified psychiatric or neurological disorder.

  6. Drug use or abuse is not present.

Treatment of PBA

Treatment for PBA is aimed primarily at the reduction of the frequency and severity of the episodes. This has been accomplished through the 'off label' use of antidepressants that target the neurotransmitters noradrenaline (both a neurotransmitter and a hormone. It plays a vital role in your body's “fight-or-flight” response), serotonin (a chemical that carries messages between nerve cells in the brain and throughout your body) and glutamate (the most abundant excitatory neurotransmitter in your brain and central nervous system. It's needed to keep your brain functioning properly. Glutamate plays a key role in shaping learning and memory).

Today, the drug Nuedexta has been approved for the use of PBA. This drug combines dextromethorphan, a cough suppressant, and quinidine, which affects the way that the heart beats and is used in people with certain heart rhythm disorders. There are several contraindications with this medication, one of which is that it should not be used in those having a heart rhythm disorder. The literature also states that it may take up to three months to gain the maximum benefits of this medication.

Other ways of treating PBA include psychotherapy and engaging in support groups -- interacting with other people who have PBA can help a person feel understood and give them chance to discuss tips for coping with the condition. For some who have lived with PBA, some tips they give include:

  1. Find ways to distract yourself.

  2. Take slow, deep breaths when you feel an episode coming on.

  3. Learn how to relax your body.

  4. Change the position of your body.

"Successful treatment of those with PBA really depends on the underlying cause," says Attorney Connelly. "But through the use of medication and becoming involved in support groups, it is possible for many to identify those things that trigger the outbursts and develop ways to distract themselves once they feel an episode coming on."

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