Another patient sees her doctor because she's experiencing unexplained crying and laughing. She may be diagnosed with bipolar disorder and treated as such.
In both cases, the diagnosis may be correct, but the reason for these bursts of uncontrollable crying and, less often, laughing may be due to an illness called pseudobulbar affect (PBA). (The illness may be known by several names, and more recently has been called involuntary emotional expression disorder, or IEED.)
What Is PBA?The main symptom of PBA is sudden, unexplained and unstoppable crying that occurs multiple times a day for no apparent reason. Similar sudden laughing can also occur, as well as bursts of anger. Very often, patients become socially isolated out of embarrassment, which can lead to other depressive symptoms.
Pseudobulbar affect is a condition that occurs due to other neurologic conditions, and may occur in patients with amytrophic lateral sclerosis (ALS or Lou Gehrig's Disease), multiple sclerosis (MS), Alzheimer's disease, and Parkinson's disease. Traumatic brain injury via accident or stroke may cause PBA to appear as well. Sometimes PBA symptoms uncover a hidden brain injury.
Although the illness was described over a century ago, it continues to be misdiagnosed with great frequency. Part of the reason is that it can cause depression, as well as lead to other symptoms associated with both depression and bipolar illness. In addition, people with the illnesses PBA is associated with, such as multiple sclerosis, often also have depression or bipolar symptoms. And finally, treatments for mood disorders generally do have some effect in reducing the symptoms of PBA, though frequently not enough to allow the patient to feel normal again.
A major study found that 51% of people with PBA reported spending little to no time with friends and family, and 57% little to no time talking on the telephone. Thus the impact on daily life and functioning of this illness is extreme.
Differences Between PBA and Mood DisordersThe primary difference between pseudobulbar affect and other mental illnesses like depression and bipolar is that the outbursts of crying, laughing and/or anger happen for no reason, last a very short time, and can occur many times in the course of a day. Still, one can see where a patient who only has bouts of crying might be diagnosed with depression, especially since one study found that almost 90 percent of PBA patients also had significant depressive symptoms.
Since social withdrawal/isolation is so often a symptom of major depressive episodes, the reason for it has to be determined. In depression and bipolar disorder, this is a primary symptom, while in PBA, it happens because patients are fearful of being in social situations. Imagine bursting out laughing during a funeral, or suddenly crying in the middle of a board meeting. Such events could easily make a person avoid any situation where PBA symptoms would be inappropriate and embarrassing.
Some symptoms of depressive episodes aren't associated with PBA, such as changes in appetite and inappropriate feelings of hopelessness or guilt.
Treating PBAIt's only recently that a treatment specifically for PBA was found, and then only by accident. Researchers were testing a combination of two drugs to see if it helped symptoms of ALS, and although there was no effect on ALS, those patients who had PBA reported that the experimental treatment decreased their laughing and/or crying.
The combination consists of dextromethorphan and quinidine, a heart medication. Although dextromethorphan is a common ingredient in cough medicines, patients should not try to self-medicate for PBA, as the prescription medication is quite different.
More research is needed to determine whether the drug is safe for people with disorders like Parkinson's disease. There are concerns about problems arising from mixing it with medications for these illnesses. In addition, patients taking antidepressants that act on serotonin, or those with any risk of heart rhythm problems, need particular cautions.
Diagnosis or Misdiagnosis?Some reliable tests for PBA have been developed, and more are in the works. Because so many people are misdiagnosed as having depression, bipolar, or other illnesses such as anxiety disorders or even schizophrenia, it's impossible to know how many people in the U.S. actually have pseudobulbar affect. Estimates put the number of patients with PBA between one and two million. With time and education, more people will be identified as having PBA and have access to proper treatment.
Colamonico, J., Formella, A., and Bradley, W. "Pseudobulbar Affect: Burder of Illness in the USA." Advances in Therapy. 2012;29(9):775-798.
May, T.S. Involuntary Emotional Expression Disorder Often Misdiagnosed and Untreated. Psychiatric Times. 3:8. 1 Aug 2007.
DiSalvo, D. Not All Crying Is Depression: Understanding Pseudobulbar Affect. Psychology Today. 18 Oct. 2011.
Gordon, D. A Flood of Emotions: Treating the uncontrollable crying and laughing of pseudobulbar affect. Neurology Now. American Academy of Neurology. February/March 2012; Volume 8(1); p 26–29.