Pseudobulbar affect (PBA), or emotional incontinence, is a type of neurological disorder characterized by uncontrollable episodes of crying or laughing. PBA occurs secondary to a neurologic disorder or brain injury. Patients may find themselves crying uncontrollably at something that is only slightly sad, being unable to stop themselves for several minutes. Episodes may also be mood-incongruent: a patient may laugh uncontrollably when angry or frustrated, for example. Sometimes, the episodes may switch between emotional states, resulting in the patient crying uncontrollably before dissolving into fits of laughter.
The pseudobulbar affect, also referred to as emotional lability, should not be confused with depression that stem from emotional instability – affective dysregulation – commonly seen in mental illnesses and certain personality disorders.
Signs and symptoms
The cardinal feature of the disorder is a pathologically lowered threshold for exhibiting the behavioral response of laughter, crying, anger or all of the above. An affected individual exhibits episodes of laughter, crying, anger or a combination of these without an apparent motivating stimulus or in response to stimuli that would not have elicited such an emotional response before the onset of their underlying neurologic disorder. In some patients, the emotional response is exaggerated in intensity but is provoked by a stimulus with an emotional valence congruent with the character of the emotional display. For example, a sad stimulus provokes a pathologically exaggerated weeping response instead of a sigh, which the patient normally would have exhibited in that particular instance.
However, in some other patients, the character of the emotional display can be incongruent with, and even contradictory to, the emotional valence of the provoking stimulus or may be incited by a stimulus with no clear valence. For example, a patient may laugh in response to sad news or cry in response to stimuli with no emotional undertone, or, once provoked, the episodes may switch from laughing to crying or vice versa.
The symptoms of PBA can be severe, with persistent and unremitting episodes. Characteristics include: The onset can be sudden and unpredictable, and has been described by some patients as coming on like a seizure; The outbursts have a typical duration of a few seconds to several minutes; and, The outbursts may happen several times a day.
Many people with neurologic disorders exhibit uncontrollable episodes of laughing, crying, or anger that are either exaggerated or contradictory to the context in which they occur. Where patients have significant cognitive deficits (e.g., Alzheimer's) it can be unclear whether it is true PBA as opposed to a grosser form of emotional dysregulation, but patients with intact cognition often report the symptom as disturbing. Patients report that their episodes are at best only partially amenable to voluntary control, and unless they experience a severe change of mental status, as in traumatic brain injury they often have insight into their problem and judge their emotional displays as inappropriate and out of character. The clinical effect of PBA can be severe, with unremitting and persistent symptoms that can be disabling to patients, and may significantly affect quality of life for caregivers.
Social impact
While not as profoundly disabling as the physical symptoms of the most common diseases that cause it (such as ALS), PBA may significantly influence individuals' social functioning and their relationships with others. Such sudden, frequent, extreme, uncontrollable emotional outbursts may lead to social withdrawal and interfere with activities of daily living, social and professional pursuits, and reduce overall healthcare. For example, patients with ALS and MS are often cognitively normal. However, the appearance of uncontrollable emotions is commonly associated with many additional neurological disorders such as attention deficit hyperactivity disorder, Parkinson's disease, cerebral palsy, autism, epilepsy, and migraines. This may lead to avoidance of social interactions for the patient, which in turn impairs their coping mechanisms and their careers.
Depression
PBA may often be misdiagnosed as clinical depression or bipolar disorder; however, many clear distinctions exist.