When a person experiences a stroke, one unsettling consequence is the sudden onset of uncontrollable emotional outbursts. These episodes frequently involve crying or laughing that appears disproportionate to the situation or disconnected from the person’s true feelings. This phenomenon is distinct from normal emotional adjustments following a life-altering event. Understanding the difference between this pathological crying, which is a physical symptom of brain injury, and natural grief is key to effective management.
Defining Pseudobulbar Affect (PBA)
Pseudobulbar Affect (PBA), also called emotional lability or involuntary emotional expression disorder, is the condition responsible for these involuntary emotional displays. PBA is a recognized neurological condition resulting from brain damage caused by a stroke or other neurological diseases. It is characterized by frequent, sudden, and uncontrollable episodes of crying or laughing that are out of context or exaggerated compared to the patient’s internal emotional state.
The hallmark of PBA is a disconnect between the patient’s mood and their external emotional expression. For example, a person might sob uncontrollably over a mildly sad moment or laugh hysterically during a somber occasion. These emotional bursts are typically brief, lasting seconds to minutes. Individuals often feel frustrated or embarrassed because they cannot stop the episode once it begins. PBA is a physical manifestation of brain injury, not a psychological disorder, but it can be socially isolating, causing patients to avoid public gatherings out of fear of an unmanageable episode.
Is It PBA or Post-Stroke Depression?
Distinguishing PBA from Post-Stroke Depression (PSD) is a major diagnostic challenge because both conditions involve crying and are common after a stroke. Medical professionals use specific criteria to differentiate them, as they require distinct treatment approaches. PSD is a sustained, pervasive mood disorder characterized by a depressed mood, loss of interest, apathy, and feelings of worthlessness lasting at least two weeks.
The crying associated with PSD is congruent with the individual’s genuine feelings of sadness, is often sustained, and is tied to a broader mood disturbance. In contrast, PBA crying is involuntary, short-burst, easily triggered by mild stimuli, and the person’s underlying mood does not match the outward display. While PSD is a psychological complication, PBA is neurological, though the two conditions can occur together. PSD affects up to a third of stroke survivors, which contributes to the difficulty in accurately diagnosing PBA.
Neurological Basis: How Stroke Damages Emotional Control
PBA arises from physical damage to the brain pathways that modulate emotional expression, essentially disrupting the brain’s “volume control” for emotions. The proposed mechanism involves injury to the corticopontocerebellar pathways, a complex network connecting the cerebral cortex, the pons, and the cerebellum. These pathways regulate the duration and intensity of the muscle movements involved in expressing emotion.
A stroke can cause a disconnect between the brain’s emotional centers, such as the limbic system, and the motor control centers that execute the physical act of crying or laughing. Damage to white matter tracts, particularly those underlying the frontotemporal cortex, is consistently implicated in PBA development. This damage is conceptualized as a “dysmetria” of emotional expression, meaning the brain loses its ability to appropriately calibrate the emotional response intensity to the stimulus.
Managing Involuntary Emotional Episodes
The goal of managing PBA is to reduce the frequency and severity of episodes to improve the patient’s quality of life and social participation. Pharmacological treatment offers targeted relief. The FDA has approved a specific combination medication of dextromethorphan hydrobromide and quinidine sulfate for PBA treatment. Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs), are also used off-label to help reduce the number of episodes.
Non-pharmacological coping strategies provide patients with a sense of control during an impending episode. Techniques include distraction, such as counting objects or focusing on an unrelated thought when an outburst is felt coming on. Changing posture, taking slow, deep breaths, and relaxing muscle tension are helpful methods to disrupt the physical manifestation of the emotional response. Educating family members and caregivers about PBA is important, as it helps them understand that the emotional display is involuntary and not a reflection of the patient’s true feelings.