Pseudobulbar Affect (PBA)

Pseudobulbar affect (PBA) (also referred to as emotional lability, reflex crying or laughing, emotional incontinence, or involuntary emotional expression disorder) is a neuropsychiatric syndrome common in neurological disorders including stroke, amyotrophic lateral sclerosis (ALS), Parkinson’s Disease, traumatic brain injury, multiple sclerosis, dementia, Wilson’s disease, and brain tumors. PBA is not a mood disorder, but rather an abnormal display of affect that does not match an individual’s true (internal) feelings.

The prevalence of PBA varies greatly across different neurological conditions and depends on the case studies and series describing them. Thus, prevalence estimates are not perfectly accurate.^[1]

Patients with PBA can have episodes of uncontrollable laughing or crying which do not match their actual feelings (the episodes are often inappropriate or unrelated to the situation). Crying may be prolonged and difficult to stop. Discussing topics with emotional content can trigger crying or laughter that is disproportionate.

PBA occurs due to a disconnect between the frontal lobe (which regulates and emotions) and the cerebellum and brain stem (where basic reflexes are mediated). The loss of inhibition from the limbic motor neurons in the brain (which are responsible for control of muscles involved in primitive vocalization), may also be involved.

• Combination dextromethorphan-quinidine^[3]
• Antidepressants including selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs)
  • SSRIs should be picked first over TCAs due to better tolerability and safety profile.
• Valproic acid
• Lithium

• Bingelien, A., Shapiro, C. M., Sockalingam, S., & Hawa, R. J. (2016). Pathological laughing and crying post-stroke: liaison psychiatrist beware. Neuropsychiatry, 6(1), 15-21.
• Villeneuve, Y., Cruz-Santiago, D., Masson, H., & Clerc, D. (2020). Treatment of pseudobulbar affect in a mixed neurodegenerative disorder with compounded quinidine capsules and dextromethorphan cough syrup. SAGE Open Medical Case Reports, 8.