If you’re like most people, you probably laugh when you’re happy and cry when you’re sad. But for those affected by a condition called Pseudobulbar affect (PBA), their physical reactions could be out of sync with their emotions, making it confusing, and stressful, for the person affected, as well as for family, friends, and co-workers.

What is PBA?

“Pseudobulbar affect, which is also sometimes referred to as emotional lability, emotional incontinence, involuntary emotional expression disorder, and pathological laughing and crying, is a distressing and socially incapacitating neurologic disorder characterized by sudden, frequent, and involuntary outbursts of crying or laughing that lack an appropriate trigger and are incongruent with the underlying emotional state of the affected individual,” explains José Biller, MD, FACP, FAAN, FANA, FAHA, professor and chair, Department of Neurology, Loyola University Chicago Stritch School of Medicine in Maywood, Illinois.

“Although its prevalence is unknown, PBA symptoms occur in approximately one-third of patients with a wide variety of neurologic disorders including stroke, Alzheimer disease, Parkinson disease, amyotrophic lateral sclerosis (aka motor neuron disease or Lou Gehrig disease), multiple sclerosis, brain tumors, and traumatic brain injury,” Dr. Biller says. “Patients with PBA may demonstrate spastic (tightness) weakness of the lower cranial nerves with slurred speech, swallowing difficulties, exaggerated gag reflex, tongue weakness, and pathological grimacing. Crying appears to be a more frequent manifestation of PBA than laughter,” he adds.  PBA outbursts may last a few seconds to minutes and may occur several times during the day, often leading to depression and social isolation.

Simply put, this means that any one of a variety of neurological diseases and injuries can impair the way the brain regulates emotions, which can lead patients to exhibit the exaggerated, or inappropriate, responses.

Athletes Tackling PBA

This previously little-known condition was thrust into the spotlight in 2015 when former professional football player Barry Sanders, who is an NFL Hall of Famer, got involved with an initiative designed to raise awareness about PBA. Sanders told several media outlets he was drawn to the cause because head injuries have been linked to PBA and he suspects many of his former teammates–who have suffered from repeated concussions and blows to the head during play–are grappling with the symptoms even if they have not been formally diagnosed with the condition.

In fact, a study conducted by Gridiron Greats Assistance Fund, Inc. found that 99% of former football players experienced a head injury at some point in their professional career. Further, about 1/3 of them revealed they have symptoms of PBA, even though the majority of them have not raised these issues with their healthcare providers.

The hope is that in spreading the word about PBA, people will also recognize that non-athletes–people of all ages and all walks of life–can be affected by treatable neurological conditions like PBA.

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One Patient’s Story

Wayne B, a 52-year-old father of three and former IT and logistics manager for an import/export company in Illinois is living with the impact of PBA. He preferred his full name not be used to protect his privacy but through his wife, Susan shared his experiences with PBA. Wayne wants to help others coping with the effects of this condition, which for him can be quite debilitating.

“My husband had a good job and used to enjoy hobbies including woodworking and reading mystery novels,” Susan explains. But 7 years ago, at the age of 45, he suffered a hemorrhagic stroke and PBA has been one of the consequences of this traumatic health event.

“Unlike some who suffer from PBA, Wayne does not typically laugh at sad things or vice-versa. But he will cry uncontrollably at things that aren’t really all that sad or he will laugh hysterically at things that aren’t funny at all,” she says.

“He can’t control his emotional responses to keep them in ‘normal’ ranges. He also will respond to non-personal triggers, like crying if he sees a child fall down, even if he doesn’t know the child and it’s obvious the child isn’t hurt. His ‘cry’ response is much stronger than his ‘laugh’ response–he cries more readily and more often than he laughs,” she points out.

Further, while PBA doesn’t affect Wayne every day, when he’s out in public, it can be very stressful to worry about what he will do and how people may react. “When Wayne is being inappropriate, he gets embarrassed and aggravated that he can’t stop. When he isn’t aware that his actions are exaggerated to the circumstance, he gets frustrated and angry because he doesn’t understand why he’s being asked to stop crying or laughing, and people around him don’t understand that he can’t control his responses, so you get strange looks or sometimes unkind comments,” Susan says.

This has impacted his overall quality of life in so many ways.

“I won’t take him to funerals unless it’s only immediate family as he cannot control his sobbing and wailing. Our children don’t like him attending some of the activities they are involved in because of his crying (plays, concerts, anything when they would be receiving an award or recognition). Movies are a crapshoot, it’s better to watch at home because we never know what will set him off. We tend to avoid anything in public that seems as if it would trigger an exaggerated response,” she adds.

Treatment Exists

In terms of treatment, Susan says that she plays a big part in trying to calm down a PBA episode but of course she can’t be with him round the clock.

“If I am present during an episode, I will try using a calm voice and simple reasoning to help him realize that his response is exaggerated. Sometimes it works and he can gain control of his response. Sometimes it doesn’t work. Often, he will try to get away from the situation (go to his bedroom at home, or try to find a quiet/private place he can sit for a while and try to settle down),” she says.

While Wayne does not look to pharmaceuticals to manage his PBA, since he is also managing a variety of other symptoms caused by his stroke, “numerous classes of drugs have been used (off-label) to treat patients with PBA, including tricyclic antidepressants, selective serotonin reuptake inhibitors (SSRIs), and other centrally-acting drugs.

Subsequently, the FDA approved the combination dextromethorphan hydrobromide/quinidine sulfate (Nuedexta) for selective patients with PBA,” Dr. Biller says.

A study published in the Annuals of Neurology in 2010 found that patients in a clinical trial reduced PBA episodes by 44% in the first week of trying his drug, and by the end of 12 weeks, had reduced episodes by 82% on average.

When considering treatment, “treating physicians should be vigilant of the contraindications, monitoring, and potential drug interactions when prescribing any of these agents,” Dr. Biller adds.

The Need for Improved Awareness

While the research is encouraging, for people living with PBA, coping with the effects can be difficult, even with medicine. Wayne wants others to know is that PBA exists, and it is out of the person’s control.

“General public awareness of PBA will be helpful for those who suffer to not feel embarrassed or feel the need/desire to isolate themselves,” Susan says.

Despite the ongoing public awareness attempts that are underway, she says PBA is still not well recognized. Wayne and his family hope that in the future, more people will take the time to learn more about the condition so he and others suffering from it feel safer, more understood, and better accepted.

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Last Updated: May 30, 2018