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Pseudobulbar Affect

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Post  Admin on Mon Nov 09, 2015 5:41 pm

Pseudobulbar Affect

Pseudobulbar Affect Pba10

Arrow Diagnosis: uncontrolled crying or laughing which may be disproportionate or inappropriate to the social context.

Arrow Associated with:
• Amyotrophic lateral sclerosis
• Extrapyramidal and cerebellar disorders (Parkinson’s disease, multiple system atrophy, progressive supranuclear palsy)
• Multiple sclerosis
• Traumatic brain injury
• Alzheimer’s dementia
• Stroke
• Brain tumors

Arrow Pathophysiology:
• Disruption of corticopontine–cerebellar circuits results in impairment of this cerebellar modulation of  emotional responses.
• Reduction of the inhibitory input from the somatosensory cortex results in disinhibition of the cerebellum.
• Primary neurotransmitters involved: serotonin and glutamate.

According to Poeck following criteria's are required (but did not identify relationships with specific precipitants)
• The emotional response is situationally inappropriate
• The patient’s feelings and the affective response are not closely related
• The duration and severity of the episodes cannot be controlled by the patient
• Expression of the emotion does not lead to a feeling of relief

According to Cummings (included necessary elements of the episodes):
• A change from previous emotional responses
• Inconsistent with or disproportionate to mood
• Not dependent on a stimulus, or are excessive relative to that stimulus
• Cause significant distress or social/occupational impairment
• Not accounted for by another psychiatric or neurologic disorder
• Not due to a drug

The Center for Neurologic Study – Lability Scale (CNS-LS):
• seven-item self-administered questionnaire that asks about the control of laughter and crying.
• validated in patients with ALS and MS.
• Scores range from one to five for each question, resulting in a total score of seven (no excess emotional lability) to 35 (severe excess emotional lability).
• cutoff of 13 accurately predicted neurologists’ clinical diagnosis in 82% of ALS patients.
• Such a cutoff for patients with MS was less accurate, predicting the neurologist’s diagnosis 78% of the time in cases with low specificity, leading to a high number of false positives. Raising the cutoff to 17 for patients with MS improved the specificity without meaningfully affecting the sensitivity.

Pathological Laughter and Crying Scale (PLACS)
• consisting of 18 questions inquiring about sudden episodes of laughter and crying.
• validated in patients with acute stroke, and has shown excellent interrater and test–retest reliability.
• Scores for each question range from zero (normal) to three (excessive emotional lability).
• A cutoff score of 13 yielded high sensitivity and specificity of 0.96, and resulted in a positive predictive value of 0.83.

Arrow Clinical Presentation:

• Outbursts (crying or laughing episodes) can be inappropriate.
• Outbursts (crying or laughing episodes) can be exaggerated (more intense or last longer).

Arrow Differential Diagnosis:

----------------------- Pseudobulbar Affect ------------ Depression------
Emotions------------- crying, laughter or both-------- crying------------
Associated----------- neuro conditions----------------- may or may not--
Duration ------------- Brief ----------------------------- Longer ---------
Control of behavior --- poor --------------------------- fair -------------
Emotional experience-- exaggerated/inappropriate--- matches affect--
Accompanied by --- no specific thoughts---- worthlessness, hopelessness, death wishes.

Arrow Treatment:

SSRIs and TCAs: appears to be the most significant therapeutic mechanism in treatment, via an increase in availability of serotonin at the synapses in corticolimbic and cerebellar pathways.
Dextromethorphan: inhibits glutamatergic neurotransmission via actions at a variety of locations including N-methyl-D-aspartate receptors and σ-1 receptors.
• In October 2010, FDA approved Nuedexta®️ for the treatment of PBA, making this the first FDA-approved drug for this indication= contains dextromethorphan 20 mg and quinidine 10 mg, thus taking advantage of the blockade exerted by quinidine on the first-pass hepatic metabolism of dextromethorphan.

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