1. Pseudobulbar affect Deniz Erten-Lyons, Staff Neurologist Portland VA Medical Center

2. What is pseudobulbar affect? A neurological disorder that occurs secondary to damage to emotional pathways in the brain. Episodes of laughing or crying that are uncontrollable and unpredictable with little or no relationship to a person’s emotions.

3. PBA-other names – Involuntary emotional expression disorder – Emotional lability – Emotional incontinence – Pathological crying or laughing

4. What patients experience? Sudden and unpredictable attacks of laughing Duration of a few seconds to several minutes Outbursts may happen several times a day. Magnitude of the response is too extreme for the situation, or it may be inappropriate for the setting - such as crying at a funny movie.

5. PBA in MS 5229 patients with MS 48% exhibited symptoms of PBA One in seven patient felt episodes were extremely or very burdensome One third felt episodes interfered with spending time with family and friends One in four felt symptoms made it difficult to make and keep friends. One in five felt that PBA contributed to being housebound Results of survey administered by Avanir and Multiple Sclerosis Association

6. Impact on patients and families While not physically disabling, PBA effects an individuals social functioning and their relationship with others. – Embarrassment and social withdrawal – May interfere with activities of daily living, social and professional pursuits

7. Distinct from depression In depression crying is a sign of grief and sadness. In PBA crying may occur unrelated to the mood or out of proportion of the mood. Crying in PBA occurs suddenly, occurring in brief episodes where as crying in depression will continue longer. Other features that support depression such as negative view of self, sadness, worrying, apathy long duration of weeks to months, appetite loss, difficulty sleeping.

8. What diseases cause PBA? Multiple Sclerosis (10% of patients with MS) Amyotrophic Lateral Sclerosis Stroke Traumatic Brain Injury Parkinson’s disease Alzheimer’s disease Other less common neurological disorders

9. Mechanism in PBA Disruption of pathways in the brain that link centers that regulate voluntary control of emotion with the centers of laughing/crying in the brainstem.

10. Treatments Coping without medications: – Being open about the problem so others know what is going on. – Distraction, breathing techniques, relaxation Medications: – Nuedexta™(dextromethorphan/quinidine) (20mg/10mg) Adverse affects: nausea, dizziness, gastrointestinal complaints, muscle cramps, weakness, swelling, elevated liver enzymes. – Other medication Amitriptyline, nortriptyline Selective serotonin reuptake inhibitors

11. Questions?