Someone's laughing mouth and its reflection in a handheld mirror

How to Recognize Pseudobulbar Affect in MS

By Sara Lindberg
Reviewed by Dana Cooper, M.D.
September 22, 2023

Have you ever been caught off guard by episodes of laughing or crying that you couldn’t control or that felt out of sync with the situation you were in?

We all have the capacity to cry or laugh if certain events are intense enough to trigger it, says Gary Belt, M.D., a board-certified neurologist at the Comprehensive Stroke Center in Summit, New Jersey. But if someone has difficulty controlling those responses, the emotional episodes may be a sign of a neurological condition called pseudobulbar affect (PBA).

Living with multiple sclerosis (MS) can increase the risk of developing PBA. It’s estimated that about 11% to 35% of people living with MS have the condition, according to a 2022 meta-analysis published in the Journal of Clinical Neuroscience.

PBA can affect a person’s quality of life and be just as debilitating, if not more so, than any physical issue with MS, Belt says. Living with it can be a confusing experience that can lead to embarrassment, anxiety, and social isolation, making it important to talk to your doctor early if you or other people are noticing the signs.

Here’s what you should know about PBA in MS, including symptoms, how it’s treated, and when to see your doctor.

What Is PBA?

PBA is a neurological condition that may develop over time, or it can come on quickly, says Sharon Stoll, D.O., a board-certified neurologist, neuroimmunologist, and assistant professor in the Department of Neurology at Yale School of Medicine in Stamford, Connecticut. Some of the more common signs of PBA include laughing or crying that:

  • Occurs in sudden, frequent, and involuntary outbursts
  • Lasts several seconds to minutes
  • Is difficult or impossible to stop
  • Seems extreme for the situation and/or seems like an inappropriate response to the event
  • Isn’t necessarily connected to inner feelings of sadness or joy

According to the Cleveland Clinic, other terms for PBA can include:

  • Emotional incontinence
  • Emotional lability
  • Pathological laughing or crying
  • Involuntary emotional expression disorder

Whatever triggers the episode doesn’t necessarily have to be very strong, Belt says. It may be the sensitive part of a movie, a warm memory, a not-so-funny joke, or the thought of a prior sad or emotional event. It’s also possible to experience PBA without an apparent trigger at all. Many people describe crying or laughing for no reason, he says.

Stoll explains that some of her patients have described going from crying to laughing to crying to screaming in a matter of minutes without being able to control their mood or behavior.

What Causes PBA?

The exact cause of PBA isn’t fully understood yet, but experts believe that it's related to lesions in certain areas of the brain that control mood, Stoll says. However, no one lesion has been found as the cause of PBA in MS.

Additionally, PBA is not unique to MS. It can occur with other illnesses or injuries that damage the brain, including Parkinson’s disease, traumatic brain injury, brain tumor, stroke, amyotrophic lateral sclerosis (ALS), and Alzheimer’s disease.

PBA vs. Depression

Although it is a distinct condition, PBA is often misinterpreted as a psychological problem, like depression, Belt says. That may come with associated stigma attached to it. And although depression can be a common mental health issue for people with MS, PBA often occurs without a depression diagnosis.

Getting an incorrect diagnosis can mean you don’t get the proper care for your symptoms. “Too often, patients are misinterpreted as being depressed and treated with antidepressants [only] instead of being treated with the proper medication for PBA,” Belt says.

Treatment for PBA in MS

Experts have limited resources to treat PBA. In general, the first-line PBA treatment is a medication called Nuedexta (dextromethorphan/quinidine). This medication is approved by the U.S. Food and Drug Administration for the treatment of pseudobulbar affect in people with multiple sclerosis. In a large clinical trial, people who took the medication experienced a nearly 50% reduction in daily episodes compared to people who took a placebo.

Your doctor may also talk to you about taking a low-dose antidepressant (such as an SSRI or tricyclic antidepressant) to reduce the frequency or severity of episodes.

In some cases, your doctor may recommend therapy to help cope with the stress or other feelings you may experience while managing PBA.

Talk to Your Doctor

If you think you have symptoms of PBA, talk with your doctor for a diagnosis and to learn the best way to treat and manage this neurological condition.

“Any time someone with MS has new symptoms or other people are telling them that they're acting differently or behaving differently, that's the time they should contact their physician to discuss what's going on and learn about treatment options,” Stoll says. Whether you have PBA or another condition like depression, your doctor can help recommend medication and/or therapy to help you cope.

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