Pseudobulbar affect (PBA) is a neurologic condition that is characterized by brief episodes of uncontrollable, sudden, and inappropriate emotions. The syndrome consists of uncontrollable crying or laughing, which usually is incongruent with the patient’s mood. Unfortunately, these involuntary emotional outbursts may be mistaken for symptoms of a mood disorder, such as major depression. Pseudobulbar affect often occurs secondary to a neurologic disorder, such as stroke, Alzheimer disease, traumatic brain injury, multiple sclerosis, and amyotrophic lateral sclerosis.
The prefix pseudo in ancient Greek language is used to represent something that is false. Pseudobulbar affect is appropriately named to describe an affect that may be incongruent with internal emotional states. This disorder was previously called emotional incontinence, pathological crying, and emotional lability. A likely reference to PBA appeared in Charles Darwin’s 1872 book, The Expression of the Emotions in Man and Animals. Charles Darwin stated, “Certain brain diseases, such as hemiplegia, brain-wasting, and senile decay, have a special tendency to induce weeping.”1 Although PBA has been documented in the literature for centuries, it continues to be misdiagnosed and underdiagnosed.
Mr. A, aged 52 years, was admitted to the ICU following an ischemic stroke. During the hospitalization he began having sudden, brief, uncontrollable crying episodes. A psychiatric consultation was obtained, and he was started on sertraline for MDD. Unfortunately, he had minimal response to the medication. He continued to have crying episodes at home and was unable to identify a trigger for these outbursts.
Mr. A had no previous psychiatric history; he had a family history of major depression in an aunt. He reported a depressed mood that began shortly after the onset of his unexplained emotional outbursts. Mr. A’s wife was present at all medical visits and insisted that he was depressed as a consequence of the stroke. She believed that he was in denial about his feelings. Mr. A reported that he previously enjoyed spending time with family, friends, and outdoors. However, he began spending all of his time at home and declined family gatherings. Mr. A attributed these behavioral changes to wanting to avoid the embarrassment of an uncontrolled crying episode in public.
AThese symptoms persisted for months, and he obtained a second consultation. During this consultation, his symptoms were further elucidated. The crying outbursts were sudden, involuntary, unpredictable, excessive, and incongruent with mood.
Pseudobulbar affect was diagnosed and Mr. A was started on a new treatment regimen. The symptoms decreased in frequency and intensity. His family and friends were educated about the condition, which decreased his embarrassment when an outburst occurred. Mr. A was able to resume spending time with family, friends, and restarted his outdoor activities.
Drs Lochhead and Nelson are Assistant Clinical Professors and Dr Maguire is Clinical Professor of Psychiatry, University of California Riverside School of Medicine, Riverside, CA.
Dr Lochhead and Dr Nelson report no conflict of interest regarding concerning the subject matter of this article. Dr Maguire has received research grants through UCR from Tera, Otsuka, Allergan, and Inracellular. He also is on the speakers bureau through UCR for Sunovion, Otsuka, Takeda, and Merck.
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