Emotional extremes

The movie Joker is going strong at the box-office and Joaquin Phoenix has earned rave reviews for his powerful performance even as he exposes a layer of health challenges beneath that menacing glee. It’s not just the acting, direction and camera skills that the movie is being talked about for — it has also brought to the fore a lesser-known medical condition known as the pseudobulbar affect or PBA.

“Pseudobulbar affect is a nervous system disorder that can make you laugh, cry or become angry without being able to control when it happens. PBA has also been called emotional dysregulation, emotional incontinence, emotional liability, involuntary crying and pathological laughing and crying,” says Dr Charanteja Koganti, Consultant Neuropsychiatrist at KIMS.

Causes

Pseudobulbar affect (PBA) may occur in association with a variety of neuropsychiatric diseases. “It occurs in patients with various neurological diseases like stroke, traumatic brain injury, dementia, Parkinson’s disease, multiple sclerosis, Alzheimer’s disease, brain tumors, etc.  In PBA, the person will experience emotions normally, but express them in an exaggerated or inappropriate way. As a result, PBA can cause embarrassment, social isolation or anxiety,” says Dr Dhanashree Peddawad, MBBS, MD (Gen Med), DM (Neurology), Consultant Neuro-logist, Continental Hospitals.

Symptoms

The primary sign of pseudobulbar affect (PBA) is frequent, involuntary and uncontrollable outbursts of crying or laughing that are exaggerated or not connected to your emotional state. Laughter often turns to tears. Your mood will appear normal between episodes, which can occur at any time. However, crying appears to be a more common sign of PBA than laughing.  

“It is characterised by uncontrolled crying or laughing which may be disproportionate or inappropriate to the social context. Thus, there is a disparity between the patient’s emotional expression and his or her emotional experience. This results in embarrassment for the patient, family and caregivers with subsequent restriction of social interactions and a lower quality life. This contributes to additional disease burden in patients already impacted by a serious neurological disorder. It has been associated with a higher prevalence of diagnosable psychiatric disorders and about 30-35 per cent of patients with PBA have clinical depression,” says Dr Charanteja Koganti.

Diagnosis

PBA is most often judged to be present by the clinician in an informal manner, as part of his or her neuropsychiatric evaluation. There are many scales that objectively measure this. However, it is usually under-diagnosed in clinical practice. Sometimes, neuroimaging of the brain ( MRI etc ) can help understand the lesions in the cerebellum and cerebral cortex.

Treatment

There are clear therapeutic benefits in treating PBA with psychotropics along with addressing the causative disease. “Antidepressants, such as tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), can help reduce the frequency and severity of your PBA episodes,” says Dr Deepika Sirineni, Senior Consultant Neurophysician, Apollo Hospitals.

Complications

The patient may feel subdural embarrassment, social isolation, anxiety and depression. “The patient has episodes of sudden uncontrollable and inappropriate laughing on crying. The emotional response is usually disproportionate to the situation.  This condition can be embarrassing, and is caused due to damage in areas of the brain which control emotion,” explains Dr Deepika.

Mistaken for depression

Laughter can often turn into tears, and because uncontrollable crying is such a common symptom of PBA, it’s often mistaken for depression-which is also very common for sufferers of this condition.