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Understanding Pseudobulbar Affect

Many diagnosed with depression suffer from a different, treatable disorder.

Perhaps this situation sounds familiar to you: you are having a calm discussion with a friend about a topic you don't find emotional whatsoever, and you notice that tears are welling up in your friend's eyes. You wonder what just happened. You ask your friend if you inadvertently said something hurtful, and the reply is, "No, I really don't know why I'm reacting this way, I'm fine." And a couple of minutes later the emotion disappears as quickly as it came.

If you reacted to that situation as I have in the past, you likely thought that your friend was suffering from depression. The tears, you assumed, were symptomatic of dark feelings unexpectedly breaking through the surface of awareness. That could be true, or your friend may be suffering from one of the most misunderstood and hidden of all neurological disorders--a condition called pseudobulbar affect (PBA).

People with PBA are subject to uncontrollable episodes of crying or laughing without an evident reason. While the exact causes of the disorder are not fully understood, it appears to be associated with injuries to neurological pathways in the brain that control emotional response. Diseases like ALS, MS, Alzheimer's, Parkinson's, and brain trauma resulting from stroke are all linked to PBA, and according to the latest research, approximately 50 percent of patients suffering from those diseases also suffer from PBA. In some cases, a patient with PBA has an underlying brain injury he or she wasn't even aware of.

Dr. Jonathan Fellus, a neurologist and expert on PBA, says that one of the reasons why PBA is misunderstood is that it's so often mistaken for depression. "Well-meaning medical professionals misinterpret symptoms and tell patients they are depressed and just don't know it. They then prescribe an antidepressant, which in most cases won't work and the patient continues to suffer."

To determine if a patient is suffering from depression or PBA (or possibly both), Dr. Fellus has developed a screening method that focuses in on what triggers the emotional response. During the course of a calm discussion with the patient, he narrows down the topics--perhaps having to do with family members or situations at work--and eventually he and the patient come across one that elicits unexpected crying or laughing. Once triggered, the response is uncontrollable and ends quickly.

"One of the main things that distinguish PBA from depression is that the emotional episodes are unpredictable and very short, ranging from seconds to minutes, and they occur multiple times a day. They require a great deal of energy to hold back."

The side-effects for PBA sufferers include feelings of emotional exhaustion and, frequently, social isolation. Without realizing that they have a medical problem, people with PBA often adapt their lives to avoid things that trigger the response, including interacting with others unless they absolutely have to. With social isolation comes more negative emotion that can over time manifest as depression.

While all of this may sound like new knowledge about a recently discovered disease, PBA has actually been well-documented in the medical literature for more than 100 years, though it has been labeled at least ten different things during that time. One of the earliest terms for the condition was "reflex crying" (a term now associated with babies' sudden, uncontrollable bouts of crying). Even Charles Darwin described the disorder in his seminal text, The Expression of the Emotions in Man and Animals, 130 years ago.

Until recently, however, PBA patients suffered without hope of treatment. About 15 years ago, a medication being tested to treat ALS patients was found to stop the episodes of laughing or crying these patients regularly experienced. As it turned out, the treatment was not approved to treat ALS but was subsequently approved to treat PBA and became available in January of this year.

Interestingly, the active ingredient in the medication (called Nuedexta, made by AVANIR Pharmaceuticals) is dextromethorphan--the same drug found in many brands of cough syrup. (You cannot, however, self treat PBA by taking cough syrup; the formulation in Nuedexta is significantly different than anything available over the counter.)

The ability to treat PBA can change lives, and it's crucial that more medical professionals get the facts about the disorder and its treatment. According to Dr. Fellus, "Doctors don't screen for PBA because they don't know about it, and patients don't tell their doctors about their symptoms because they don't recognize them as symptoms." That has to change, and when it does thousands of people who would otherwise suffer in silence will benefit.