Understanding Treatment Options for Pseudobulbar Affect

PBA is a neurological disorder. Its main symptom is sudden, brief, and frequent bouts of crying or laughing that you cannot control. These emotions are often not triggered by an event or are out of proportion to the situation. They also do not always match how the person is feeling.

These episodes can make it confusing to know whether someone has an episode of depression or symptom of PBA. It may be possible to experience both conditions. In fact, about one-third of people with PBA also have depression.

People living with PBA may often experience embarrassment, worry, distress, or frustration over their emotions. This can affect their relationships and quality of life.

Certain brain diseases may cause PBA as a symptom, including:

• amyotrophic lateral sclerosis (ALS or Lou Gehrig’s disease)
• dementia, including Alzheimer’s disease
• traumatic brain injury
• multiple sclerosis
• Parkinson’s disease
• brain tumor
• epilepsy
• stroke

Experts believe these diseases may disrupt communication between areas of the brain that control emotions.

When treating any disease or disorder, it is important to consider your goals. The treatment goals for PBA include reducing the frequency and severity of emotional outbursts. Achieving this goal often fulfills other goals, such as improving your quality of life.

There are two main ways to accomplish PBA treatment goals — behavioral therapy and medications. Combining the two usually offers the best chance of reaching the treatment goal.

Learning and understanding triggers through behavioral therapy can help people with PBA avoid specific social scenarios and manage symptoms.

If you are the caregiver of a person with PBA, it can be helpful to understand how symptoms affect them. Creating a plan to communicate between each other can help caregivers assess and act in a situation.

Behavioral therapy involves the person living with PBA and their caregivers. It starts with education. It is important for everyone to be on the same page and know:

• PBA episodes have nothing to do with self-control and are not the person’s fault
• how the person with PBA would like to handle public episodes
• whether the person with PBA wants to share personal information about their diagnosis

Then, people can learn tips to help manage PBA episodes including:

• distraction skills, such as thinking about something else or counting objects
• physical interruptions, such as changing body positions or removing yourself from a situation
• relaxation practices, such as slow, deep breathing or consciously relaxing the muscles of the upper body

Currently, Nuedexta is the only medication with approval from the Food and Drug Administration (FDA) to treat PBA. Nuedexta is a combination of two drugs, dextromethorphan and quinidine. As the only FDA-approved drug, doctors usually consider it to be a first-line treatment for PBA.

Studies of the drug found that it reduced symptoms and helped people have more days without episodes of PBA. People taking the drug also reported improvements in quality of life and relationships.

Common side effects of this medication can include:

• diarrhea
• dizziness
• falls
• headache
• nausea

Drug interactions are also possible with this medication. And it may not be the right choice for everyone, depending on your other medical conditions. It is important to talk with your doctor about your medical history when considering this option.

If you cannot take Nuedexta, there are second-line treatments available. These medications are off-label for PBA, meaning doctors prescribe it for a condition other than its FDA-approved uses.

Common treatments include antidepressants such as:

• citalopram (Celexa)
• fluoxetine (Prozac)
• fluvoxamine (Luvox)
• nortriptyline (Pamelor)
• sertraline (Zoloft)

Although PBA and depression are different conditions, antidepressants can be effective for managing PBA. People tend to take lower doses when treating PBA symptoms compared to treating depression. These drugs also tend to work faster in people with PBA than in depression.

There are also third-line treatments, including:

• amantadine (Gocovri)
• carbidopa/levodopa (Sinemet)
• lamotrigine (Lamictal)
• mirtazapine (Remeron)
• reboxetine (Edronax)

In general, doctors save third-line treatments as an additional option for people whose symptoms are not improving or when first- and second-line medications are causing severe side effects.

Talk with your doctor about treatment options for PBA. As a team, you, your doctor, and your caregivers can manage PBA and find relief.