Pseudobulbar Affect

3 min read

Many people with multiple sclerosis (MS) experience pseudobulbar affect (PBA). PBA is a neurological (nerve) condition that causes episodes of uncontrolled laughing or crying. The outbursts do not match your mood or emotions. They may be stronger or last longer than you would expect.^1,2

PBA develops because of an underlying neurological condition, such as MS. PBA can cause a large emotional burden and lead to social anxiety. But it can be managed with medicine. Talk to your doctor if you notice signs of PBA.^1,2

What causes PBA?

We do not yet know what causes PBA. A part of the brain, called the cerebellum, helps monitor emotional responses. Damage to nerve pathways to the cerebellum may cause a loss of control over emotional expression.^1,3

Several neurological conditions can cause this damage. This is why PBA is linked to neurological conditions, including:¹

MS
Traumatic brain injury
Amyotrophic lateral sclerosis (ALS)
Alzheimer’s, Parkinson’s, and Wilson’s diseases
Stroke
Brain tumors
Epilepsy

PBA may be called other names. These include:^1,3

Emotional lability
Pathological laughing and crying
Involuntary emotional expression disorder
Compulsive laughing and weeping
Emotional incontinence

How common is PBA?

It is hard to estimate the number of people with PBA. This is because PBA can vary greatly in severity. Symptoms also overlap with depression and anxiety. This makes it hard to diagnose PBA. Estimates suggest that between 2 million and 7 million people in the United States have PBA.^1,3,4

PBA is common for children and adults with an underlying neurological condition. Between 25 and 50 percent of people with MS have PBA. This is similar for people with ALS or traumatic brain injury.^1,3,4

What are symptoms?

The main symptom of PBA is that your affect does not match your mood. Your affect is how you display emotion. Smiling, laughing, and crying are examples of your affect. Your mood refers to your inner feelings, such as sadness or happiness. PBA does not alter your mood.^1,2

In PBA, the intensity of your affect does not match the intensity of your mood. Some common examples are:^1,2

Unpredictable laughing or crying
Laughing or crying that is stronger than the trigger
Laughing or crying that happens for no reason
Outbursts of anger or frustration

How is PBA diagnosed?

PBA is hard for doctors to diagnose. Many people with PBA are misdiagnosed with a mood disorder, such as depression. Episodes of crying may appear to be persistent sadness. But the crying episodes in PBA tend to be:¹

More intense than in depression
Shorter than in depression
Not linked to persistent internal sadness

It is possible for people with PBA to also have depression. This can happen from other causes or as a result of PBA. In the case of depression, other symptoms may occur, such as sleep disturbance or eating changes.^1,4

There are not yet any tests to confirm PBA. Doctors will diagnose PBA based on your:¹

Symptoms
History of neurological conditions
Mental health history
Findings from physical exams

How is it treated?

The goal of PBA treatment is to reduce the frequency and severity of episodes. The most common medicine used to treat PBA is Nuedexta® (dextromethorphan and quinidine sulfate). This is a combination of a cough suppressant and a heart drug. It is the first and only drug specifically approved to treat PBA.^1,2

Antidepressants may also help reduce symptoms of PBA. These include Celexa® (citalopram) and Zoloft® (sertraline). All medicines have possible side effects. Talk to your doctor about the risks and benefits of all PBA treatments.^1,2

Coping with PBA

PBA can have a large impact on your life. For many people, PBA causes embarrassment and anxiety. This can lead to withdrawal and social isolation. People with PBA have a higher risk of:¹

Depression and anxiety
Lower quality of life
Decreased social interactions

Coping with PBA can help reduce the emotional burden. Talk to your doctor about ways to manage episodes of laughing or crying. Your doctor can also suggest ways to take care of your mental health. Some tips for coping with PBA include:¹

Taking slow, deep breaths until the episode goes away
Thinking about something else during an episode
Relaxing your face and shoulders to reduce tension
Changing the position of your body during an episode
Talking to other people about your condition
Talking to a therapist or mental health professional

Treatment results and side effects can vary from person to person. This treatment information is not meant to replace professional medical advice. Talk to your doctor about what to expect before starting and while taking any treatment.

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CommunityMember734 Member
 I definitely have it. For me, when I start talking about something (and it could be anything, really) I can feel the tears about to come, so I often stop thinking about that particular thing while the urge subsides a little. I may not loop back around and finish my thought, because sometimes the urge to cry is too strong and I just move on. This has gotten slightly better, perhaps under the influence of an anti-depressant (Duloxitine, aka Cymbalta), but it still hits me sometimes. It's embarrassing to get teary about a TV commercial. I know what's happening, but I still don't want it to happen. It really doesn't happen when I'm alone, despite constantly talking to myself!); it's when I speak to others that it's an issue. 
1. Therry Neilsen Moderator & Contributor
 <inline-mention username="CommunityMember734" user-id="4732175"/> I remember a wonderful TV show from DECADES ago, and of course I can't remember the name of the show, but one of the characters was complaining about how easily she cried: "I cry at funerals, I cry at weddings, I cry at auto shows and cat food commercials." You are not alone!
Erin Rush Community Admin
I know it can be an embarrassing, <inline-mention username="CommunityMember734" user-id="4732175"/>, but be gentle with yourself. It's like you're trying to make this happen! And hey, letting off some emotion is healthy. I'm glad the meds seem to be helping and limiting the number of emotional moments you have out of the blue. But, still. I hear you. No one wants to come across as overly emotional, especially at odd times or with strangers! Best, Erin, Team Member.
f5hwo4 Member
I only had one episode where I was crying uncontrollably. My husband and I had taken my mother in-law out to her favorite breakfast place for mothers day. My son told me the day before that he wasn't spending any mothers day with me anymore. He was spending every mothers day fishing with his father in-law. All I did was ask him if wanted to join us for breakfast. I was looking around at all of the families enjoying themselves and self destructed. My son didn't go fishing again or spend mother's day with me. I did some research and found out the children with severe ADD will start into a anger stage in their 40's. He lives in another country and calls us ranting and raving about trivial things. Of it''s my fault. Potter
1. Erin Rush Community Admin
 <inline-mention username="f5hwo4" user-id="3977349"/>, oh, Potter. I am so sorry. That was a pretty hurtful thing for him to do and I think you had every reason to break down and cry. I do hope you comes out of his anger phase and comes back around before you know it. Gentle Hugs, Erin, Team Member.
stuckey17 Member
I may have it. My wife has said why are you dying of laughter but when I try it doesn't sound that funny to her. But I am already on 17 or more meds.I think that just what I need another med
1. Erin Rush Community Admin
 <inline-mention username="stuckey17" user-id="4021187"/>, it can be such a weird thing to experience, can't it? Best, Erin, Team Member.