Pseudobulbar Affect Overview:

Pseudobulbar affect (PBA) is one of the most frequently reported post-stroke behavior conditions, with up to half of all stroke survivors experiencing it at some time. While not as prevalent in multiple sclerosis some people who live with MS do experience PBA.

PBA’s signature are sudden outbursts of uncontrollable crying or laughing. Sometimes PBA is referred to as emotional lability, pathological crying and laughing or emotional incontinence. An episode of PBA can occur at any time, even in inappropriate social situations and is often mistaken for depression.

PBA is often underdiagnosed, undertreated and sometimes inappropriately treated due to a person’s natural course of emotions.  It is not unusual for a person to laugh or cry for example.

Only a healthcare provider can diagnose PBA. However, the Center for Neurologic Study-Lability Scale (CNS-LS), developed by healthcare professionals, can help you assess whether you have symptoms of PBA. Your answers to this simple seven-question scale will help you determine whether to talk to your healthcare provider about PBA. A CNS-LS score of 13 or higher may suggest PBA. The scale is not intended as a substitute for professional medical assessment and/or advice.

You can see the assessment scale below.

PBA is not a new condition. In fact, it was first described in scientific medical literature over 130 years ago by none other than Charles Darwin.

What Causes Pseudobulbar Affect:

PBA can occur when certain neurologic diseases or brain injuries damage the areas in the brain that control normal expression of emotion. This damage can disrupt brain signaling, causing a ‘short circuit’ and triggering involuntary episodes of crying or laughing.

Click To EnlargeOne of the jobs of the brain is to figure out how we feel in the moment. That information is then sent down to the brainstem, also known as the “bulb.” The brainstem then sends signals to the face and other parts of the body that show emotion.

PBA is believed to be the result of a disruption of these signals. When people have certain neurologic conditions or brain injuries, it can cause damage in the brain tissue that creates a disconnection between the parts of the brain that express emotion and those that control emotion. The result is the frequent outbursts of involuntary crying or laughing known as pseudobulbar affect. If you break the term down literally, “pseudo” means false, “bulbar” refers to the brainstem and “affect,” describes how the body shows mood or emotion.

PBA is Different from Depression:

PBA is not depression though it is frequently mistaken for it. Many patients, however, may have both conditions. If you have PBA and depression, it’s important that each condition be diagnosed and treated separately. Generally speaking, depression is an ongoing and continuous state of sadness or hopelessness that can last over weeks or months, whereas PBA episodes are relatively brief, spontaneous eruptions that may not truly reflect what a person is feeling inside.

Symptoms of Pseudobulbar Affect:

Click To EnlargeAssessing PBA is relatively straight forward.

  • There is always an underlying neurological condition such as multiple sclerosis or stroke for example
  • Uncontrolled laughing, crying or both that may last for seconds or minutes .vs. depression which can last for weeks or months.
  • PBA is uncontrolled thus it cannot be suppressed through self-control
  • Outbursts have no apparent linkage towards current emotion or thoughts

Diagnosing Pseudobulbar Affect:

Diagnosing PBA would be easier for your doctor if you happened to have an outburst right in his or her office. But that doesn’t always happen.  Doctors have to rely on what patients and their caregivers tell them about their episodes.

Self-Assessment of Pseudobulbar Affect:

Today, PBA is treatable.  But before discussing treatments options, your doctor must be able to correctly diagnose your symptoms. That is why it’s so important to accurately describe your crying or laughing episodes to your physician. One way to be prepared for your next doctor’s visit is to take an assessment or ask yourself the following questions about your crying or laughing episodes:

  • Are my episodes sometimes exaggerated or inappropriate?
  • Do my episodes actually reflect what I’m feeling inside?
  • Have I avoided spending time with my family or friends because of my unpredictable outbursts?
  • Could my crying episodes be mistaken for depression?

Once you’ve discussed your symptoms with your doctor, you can develop a treatment plan together that can help you manage your PBA outbursts.

Using the table below and a sheet of paper or by printing this page answer honestly each of the questions below on a scale of 1 – 5.  When completed total up the value of your answers.

If the total number is greater than 13 and you have a known underlying neurological disorder a visit to your health care provider is warranted to discuss if you are experiencing PBA.


If you suspect you may be experiencing PBA you should also document the episodes as they occur using the form below.  You can also print copies of the form below.


Click Here To Open Page And Then Print The Page

Treatments for PBA:

Several drugs are useful in treating this problem. Recently, a drug called Neudexta (dextromethorphan/quinidine) was approved by the FDA for treatment of PBA in people with MS. A number of tricyclic antidepressant medications are effective in resolving PBA, including Elavil (amitriptyline) and Prozac (fluoxetine). Another drug, Sinemet (levodopa), used in Parkinson’s disease, has been shown to be useful in treating PBA.

Tips for Living with PBA:

Be open about it. Let people know that you cannot always control your crying or laughing because of a neurologic condition. This can help ensure that people are not surprised, confused or insulted.

Distract yourself. If you feel an episode coming on, try to focus on something unrelated.

Breathe. Take slow deep breaths until you are in control.

Relax. Release the tension in your forehead, shoulders, and other muscle groups that tense up during a PBA episode.

Change your body positions. Note the posture you take when having an episode. When you think you are about to cry or laugh, change your position.

These tips are general coping techniques and are not substitutes for medical advice. Talk with your doctor about additional ways to cope with your PBA episodes and whether a treatment plan may be appropriate.

What can you do to help a loved one with PBA?

Relate. If someone you love has PBA, he or she may be embarrassed by his or her outbursts and reluctant to talk about his or her condition. You can help by letting that person know you understand that his or her episodes are involuntary and are not something they can control.

Remind. You can also remind your loved one that PBA is a neurologic condition, not a mental state, and can occur  when certain underlying neurologic diseases or injuries damage the areas of the brain that control normal expression  of emotions. This damage can disrupt brain signaling, causing a ‘short circuit’, triggering his or her episodes of involuntary crying or laughing.

Reassure. Finally, you can reassure your loved one that he or she is not alone. Nearly 2 million people suffer from the symptoms of PBA. They are looking for answers about this condition and ways to cope with it. And many of these PBA patients have loved ones who, like you, want to let them know that PBA does not change the way you feel about them.