What is pba

Both the exaggerated emotional response and the discordance between mood and emotional display are the other characteristics of PBA that are not expected with depression. PBA patients often lack the neurovegetative features of depression such as sleep disturbances and loss of appetite.

There are published criteria to help differentiate PBA from depression. Other neurological and psychiatric disorders within the differential diagnosis can usually be distinguished in a straightforward manner by clinicians, including various forms of epilepsy, tics, and dystonia. Drug-induced effects should also be considered in the differential diagnosis. PBA is most often judged to be present by the clinician in an informal manner, as part of his or her neurological evaluation.

Criteria have been established in an attempt to define the syndrome more objectively. These have clarified that the emotional response is not necessarily inconsistent with mood — although it may be — but the degree of the emotional response is disproportionate. PBA may be more objectively measured by published scales. Raising the cutoff to 17 for patients with MS improved the specificity without meaningfully affecting the sensitivity.

The Pathological Laughter and Crying Scale PLACS is an interviewer-administered instrument consisting of 18 questions inquiring about sudden episodes of laughter and crying. Scores for each question range from zero normal to three excessive emotional lability. A cutoff score of 13 yielded high sensitivity and specificity of 0. Both of these instruments have been used in studies of treatment of PBA, as described below. In practice, PBA is likely underdiagnosed, perhaps because of confusion with depression and other neurologic and psychiatric disorders.

The goal of treatment of PBA is to diminish the severity and frequency of episodes. The targets of treatment are primarily norepinephrine, serotonin, or glutamate, using tricyclic antidepressants TCAs , selective serotonin reductase inhibitors SSRIs , and, most recently, the cough suppressant dextromethorphan. Historically, dopaminergic medications such as levodopa and amantadine have been used as well, but with lower response rates. SSRIs have a relatively narrow mechanism of action, directed toward enhancing serotonergic function, whereas TCAs alter a broader range of neurotransmitter functions.

This results in extremely low plasma concentrations of dextromethorphan even with the administration of very high oral doses. Blockade of hepatic metabolism can be accomplished by the concurrent administration of the cardiac antiarrhythmic drug quinidine sulfate, 24 leading to higher and sustained plasma concentrations of dextromethorphan at a fraction of the dose required if quinidine sulfate was not used.

Until recently, all treatments have, of necessity, been off-label. Four major uncontrolled trials of antidepressants in PBA all used SSRIs and reported favorable outcomes Table 3 , although the severity scales used as outcome measures were unvalidated. Six of them used some form of a severity scale and had 20 or more patients Table 4. The efficacy of antidepressants appears to be unrelated to the treatment of depression, based upon several pieces of evidence: 1 the onset of action may occur within a few days, which is faster than expected for depression; 2 doses are lower than those usually used to treat depression; and 3 most patients with PBA are not depressed.

Uncontrolled trials of selective serotonin reductase inhibitors in pseudobulbar affect. This compound contains dextromethorphan 20 mg and quinidine 10 mg, thus taking advantage of the blockade exerted by quinidine on the first-pass hepatic metabolism of dextromethorphan. The treated group of patients demonstrated only about half as many laughing and crying episodes as were recorded in the placebo-treated cohort.

When determining which treatment to select, the clinician must consider tolerance and the potential for adverse effects as major factors. TCAs, with their broad effects on monoaminergic, cholinergic, and histaminergic neurotransmission, may produce a wide range of side effects including dry mouth, constipation, orthostatic hypotension, confusion, sedation, and potential cardiotoxicity.

The elderly often tolerate TCAs particularly poorly. However, TCAs may facilitate sleep if given as a nighttime dose. Also, their anticholinergic properties make them useful for control of sialorrhea in patients such as those with bulbar ALS in whom this may be particularly troublesome. The actions of SSRIs, being largely limited to the enhancement of serotonergic function, generally have a much more limited side effect profile, resulting in a much lower rate of discontinuation. However, the most common side effects are dizziness, diarrhea, falls, headache, nausea, fatigue, nasopharyngitis, constipation, and dysphagia.

At the dose contained in the approved compound, quinidine did not demonstrate adverse cardiac effects. The FDA-approved dosing is one capsule daily for 7 days, followed by an increase to one capsule every 12 hours.

PBA can impact quality of life and disease burden in patients with many commonly encountered neurological disorders, independent of disturbances of mood.

By managing PBA with an appropriate pharmacologic approach, clinicians can have a meaningful impact on symptoms that are socially embarrassing and functionally limiting for these patients. National Center for Biotechnology Information , U.

Ther Clin Risk Manag. Published online Nov Aiesha Ahmed and Zachary Simmons. Author information Copyright and License information Disclaimer. Non-commercial uses of the work are permitted without any further permission from Dove Medical Press Limited, provided the work is properly attributed. This article has been cited by other articles in PMC. Keywords: pseudobulbar affect, emotional lability, depression, amyotrophic lateral sclerosis, multiple sclerosis.

Introduction Pseudobulbar affect PBA is characterized by uncontrolled crying or laughing which may be disproportionate or inappropriate to the social context. Epidemiology The disorder occurs in association with a variety of brain disorders Table 1. Table 1 Neurological disorders most commonly associated with pseudobulbar affect. Open in a separate window.

Pathophysiology The underlying mechanism in PBA appears to be a lack of voluntary control, also termed disinhibition, but the pathways are complex and are as yet incompletely understood. Figure 1. Clinical presentation Clinicians are familiar with the manner in which the behavior of these patients is conveyed to them by those close to the patient.

Differential diagnosis The clinician may easily mistake the exaggerated and disproportionate crying seen in PBA for depression. Diagnosis PBA is most often judged to be present by the clinician in an informal manner, as part of his or her neurological evaluation. Treatment General principles The goal of treatment of PBA is to diminish the severity and frequency of episodes. Table 4 Placebo-controlled trials of medications in pseudobulbar affect. Specific recommendations When determining which treatment to select, the clinician must consider tolerance and the potential for adverse effects as major factors.

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Updated visitor guidelines. Top of the page. What causes PBA? What are the symptoms? When you have PBA, you may: Suddenly cry or laugh for no reason. When your behavior is out of sync with people around you, it can be embarrassing or upsetting. And it can be stressful when your behavior upsets others. Have trouble controlling how long or intensely you laugh or cry. Feel none of the usual relief after crying or laughing. How is PBA diagnosed? How is it treated? Medicine that affects certain brain chemicals usually improves PBA.

You also have a neurologic condition or brain injury. You may or may not have a neurologic condition or brain injury. Crying is part of your depression that can last weeks or months. It can be frustrating, because you're not sad, despite how it looks. Or things aren't as funny as they may seem. Because PBA symptoms always happen as a result of another neurologic condition or brain injury, they can feel like yet another difficulty to deal with.

Pseudobulbar affect: burden of illness in the USA. Embarrassment from the Situation. Personal Discouragement. Wondering if you or someone you love might have PBA?