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Talmasov D, Kelly S, Ecker S, Olivera A, Lord A, Gurin L, Ishida K, Melmed K, Torres J, Zhang C, Frontera J, Lewis A. Relationship Between Hemorrhage Type and Development of Emotional and Behavioral Dyscontrol After Hemorrhagic Stroke. J Neuropsychiatry Clin Neurosci 2024:appineuropsych20230114. [PMID: 38650464 DOI: 10.1176/appi.neuropsych.20230114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVE Emotional and behavioral dyscontrol (EBD), a neuropsychiatric complication of stroke, leads to patient and caregiver distress and challenges to rehabilitation. Studies of neuropsychiatric sequelae in stroke are heavily weighted toward ischemic stroke. This study was designed to compare risk of EBD following intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) and to identify risk factors for EBD following hemorrhagic stroke. METHODS The authors conducted a prospective cohort study of patients hospitalized for nontraumatic hemorrhagic stroke between 2015 and 2021. Patients or legally authorized representatives completed the Quality of Life in Neurological Disorders (Neuro-QOL) EBD short-form inventory 3 months after hospitalization. Univariable and multivariable analyses identified risk factors for EBD after hemorrhagic stroke. RESULTS The incidence of EBD was 21% (N=15 of 72 patients) at 3 months after hemorrhagic stroke. Patients with ICH were more likely to develop EBD; 93% of patients with EBD (N=14 of 15) had ICH compared with 56% of patients without EBD (N=32 of 57). The median Glasgow Coma Scale (GCS) score at hospital admission was lower among patients who developed EBD (13 vs. 15 among those without EBD). Similarly, admission scores on the National Institutes of Health Stroke Scale (NIHSS) and the Acute Physiology and Chronic Health Evaluation II (APACHE II) were higher among patients with EBD (median NIHSS score: 7 vs. 2; median APACHE II score: 17 vs. 11). Multivariable analyses identified hemorrhage type (ICH) and poor admission GCS score as predictors of EBD 3 months after hemorrhagic stroke. CONCLUSIONS Patients with ICH and a low GCS score at admission are at increased risk of developing EBD 3 months after hemorrhagic stroke and may benefit from early intervention.
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Affiliation(s)
- Daniel Talmasov
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Sean Kelly
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Sarah Ecker
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Anlys Olivera
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Aaron Lord
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Lindsey Gurin
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Koto Ishida
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Kara Melmed
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Jose Torres
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Cen Zhang
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Jennifer Frontera
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
| | - Ariane Lewis
- Departments of Neurology and Psychiatry, Columbia University, New York (Talmasov); Department of Neurology, New York University Langone Medical Center (Kelly, Ecker, Olivera, Lord, Gurin, Ishida, Melmed, Torres, Zhang, Frontera, Lewis)
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Tahedl M, Tan EL, Siah WF, Hengeveld JC, Doherty MA, McLaughlin RL, Hardiman O, Finegan E, Bede P. Radiological correlates of pseudobulbar affect: Corticobulbar and cerebellar components in primary lateral sclerosis. J Neurol Sci 2023; 451:120726. [PMID: 37421883 DOI: 10.1016/j.jns.2023.120726] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/02/2023] [Accepted: 06/28/2023] [Indexed: 07/10/2023]
Abstract
INTRODUCTION Pseudobulbar affect (PBA) is a distressing symptom of a multitude of neurological conditions affecting patients with a rage of neuroinflammatory, neurovascular and neurodegenerative conditions. It manifests in disproportionate emotional responses to minimal or no contextual stimulus. It has considerable quality of life implications and treatment can be challenging. METHODS A prospective multimodal neuroimaging study was conducted to explore the neuroanatomical underpinnings of PBA in patients with primary lateral sclerosis (PLS). All participants underwent whole genome sequencing and screening for C9orf72 hexanucleotide repeat expansions, a comprehensive neurological assessment, neuropsychological screening (ECAS, HADS, FrSBe) and PBA was evaluated by the emotional lability questionnaire. Structural, diffusivity and functional MRI data were systematically evaluated in whole-brain (WB) data-driven and region of interest (ROI) hypothesis-driven analyses. In ROI analyses, functional and structural corticobulbar connectivity and cerebello-medullary connectivity alterations were evaluated separately. RESULTS Our data-driven whole-brain analyses revealed associations between PBA and white matter degeneration in descending corticobulbar as well as in commissural tracts. In our hypothesis-driven analyses, PBA was associated with increased right corticobulbar tract RD (p = 0.006) and decreased FA (p = 0.026). The left-hemispheric corticobulbar tract, as well as functional connectivity, showed similar tendencies. While uncorrected p-maps revealed both voxelwise and ROI trends for associations between PBA and cerebellar measures, these did not reach significance to unequivocally support the "cerebellar hypothesis". CONCLUSIONS Our data confirm associations between cortex-brainstem disconnection and the clinical severity of PBA. While our findings may be disease-specific, they are consistent with the classical cortico-medullary model of pseudobulbar affect.
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Affiliation(s)
- Marlene Tahedl
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland
| | - Ee Ling Tan
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland
| | - We Fong Siah
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland
| | | | - Mark A Doherty
- Smurfit Institute of Genetics, Trinity College Dublin, Dublin, Ireland
| | | | - Orla Hardiman
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland
| | - Eoin Finegan
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland
| | - Peter Bede
- Computational Neuroimaging Group (CNG), School of Medicine, Trinity College Dublin, Ireland; Department of Neurology, St James's Hospital, Dublin, Ireland.
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Gondim FDAA, Pinto WBVDR, Chieia MAT, Correia CDC, Cunha FMB, Dourado MET, França Júnior MC, Marques Júnior W, Oliveira ASB, Rodrigues CL, Silva DJD, Dias-Tosta E. Definitions, phenomenology, diagnosis, and management of the disorders of laughter and crying in amyotrophic lateral sclerosis (ALS): Consensus from ALS and Motor Neuron Disease Scientific Department of the Brazilian Academy of Neurology. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:764-775. [PMID: 37647907 PMCID: PMC10468253 DOI: 10.1055/s-0043-1771176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
The spectrum of neuropsychiatric phenomena observed in amyotrophic lateral sclerosis (ALS) is wide and not fully understood. Disorders of laughter and crying stand among the most common manifestations. The aim of this study is to report the results of an educational consensus organized by the Brazilian Academy of Neurology to evaluate the definitions, phenomenology, diagnosis, and management of the disorders of laughter and crying in ALS patients. Twelve members of the Brazilian Academy of Neurology - considered to be experts in the field - were recruited to answer 12 questions about the subject. After exchanging revisions, a first draft was prepared. A face-to-face meeting was held in Fortaleza, Brazil on 9.23.22 to discuss it. The revised version was subsequently emailed to all members of the ALS Scientific Department from the Brazilian Academy of Neurology and the final revised version submitted for publication. The prevalence of pseudobulbar affect/pathological laughter and crying (PBA/PLC) in ALS patients from 15 combined studies and 3906 patients was 27.4% (N = 1070), ranging from 11.4% to 71%. Bulbar onset is a risk factor but there are limited studies evaluating the differences in prevalence among the different motor neuron diseases subtypes, including patients with and without frontotemporal dementia. Antidepressants and a combination of dextromethorphan and quinidine (not available in Brazil) are possible therapeutic options. This group of panelists acknowledge the multiple gaps in the current literature and reinforces the need for further studies.
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Affiliation(s)
- Francisco de Assis Aquino Gondim
- Universidade Federal do Ceará, Departamento de Clínica Médica, Núcleo de Desenvolvimento e Pesquisa de Medicamentos, Fortaleza CE, Brazil
| | - Wladimir Bocca Vieira de Rezende Pinto
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia/Ebserh, Setor de Investigações nas Doenças Neuromusculares, São Paulo SP, Brazil
| | - Marco Antônio Troccoli Chieia
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia/Ebserh, Setor de Investigações nas Doenças Neuromusculares, São Paulo SP, Brazil
| | | | | | | | | | - Wilson Marques Júnior
- Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Departamento de Neurociências, Ribeirão Preto SP, Brazil
| | - Acary Souza Bulle Oliveira
- Universidade Federal de São Paulo, Departamento de Neurologia e Neurocirurgia/Ebserh, Setor de Investigações nas Doenças Neuromusculares, São Paulo SP, Brazil
| | | | - Delson José da Silva
- Universidade Federal de Goiás, Hospital das Clínicas, Unidade de Neurologia e Neurocirurgia/Ebserh, Goiânia GO, Brazil
| | - Elza Dias-Tosta
- Comissão de Ética da Academia Brasileira de Neurologia, São Paulo SP, Brazil
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Fitzgerald S, Gracey F, Broomfield N. Post-stroke emotionalism (PSE): a qualitative longitudinal study exploring individuals' experience with PSE. Disabil Rehabil 2022; 44:7891-7903. [PMID: 34784814 DOI: 10.1080/09638288.2021.2002439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PURPOSE Post-stroke emotionalism (PSE) is a common consequence of stroke characterised by episodes of crying or laughing. There is only one published qualitative study exploring the experience of emotionalism to date. This study aimed to explore individual's experience of PSE and develop a theoretical client-derived framework to shape future psychological interventions. MATERIALS AND METHODS A primary analysis of the qualitative pseudonymised pre-collected semi-structured interview data of the TEARS study was completed. Participants were recruited from nine acute stroke units in Scotland with participants commencing the study at baseline (two-weeks) and they either continued or dropped out. Interviews were completed at two-weeks, six-months and 12-months post-stroke. RESULTS Data was analysed from 52 participants at two-weeks, 25 participants at six-months and 23 participants at 12-months. Three major themes were identified: "In the moment," describing characteristics and triggers, "Ways of coping," highlighted a variation of coping strategies including avoidance or acceptance and "Impact," outlining the longer-term effects of PSE such as individuals' beliefs. CONCLUSION The results indicate specific psychological aspects of PSE which could be viable targets in psychological interventions such as increasing adaptive coping strategies and challenging negatively held beliefs.IMPLICATIONS FOR REHABILITATIONEmotionalism can cause emotional consequences such as distress, embarrassment and fear.Helping individuals to develop insight into triggers for emotionalism could be beneficial to help gain understanding and awareness whereby post-stroke emotionalism (PSE) has the potential to be anticipated and adapted to psychologically.Potential adaptive responses such as acceptance or control and better anticipation of episodes of emotionalism could help to reduce the emotional consequences of PSE.
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Affiliation(s)
- Sophie Fitzgerald
- Department of Clinical Psychology, University of East Anglia, Norwich, UK
| | - Fergus Gracey
- Department of Clinical Psychology, University of East Anglia, Norwich, UK
| | - Niall Broomfield
- Department of Clinical Psychology, University of East Anglia, Norwich, UK
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Abstract
BACKGROUND Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2019. OBJECTIVES To evaluate the benefits and harms of pharmaceutical treatment in people with emotionalism after stroke. SEARCH METHODS We searched the Cochrane Stroke Group Register, CENTRAL, MEDLINE, Embase, four other databases, and three trials registers (May 2022). SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed risk of bias, extracted data from all included trials, and used GRADE to assess the certainty of the body of evidence. We calculated the mean difference (MD) or standardised mean difference (SMD) for continuous data and the risk ratio (RR) for dichotomous data, with 95% confidence intervals (CIs). We assessed heterogeneity using the I2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on the Center for Neurologic Study - Lability Scale (CNS-LS) or Clinician Interview-Based Impression of Change (CIBIC), or diminished tearfulness. MAIN RESULTS We did not identify any new trials for this update. We included seven trials with a total of 239 participants. Two trials had a cross-over design, but outcome data were not available from the first phase (precross-over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with a total of 213 participants. It is uncertain whether fluoxetine increases the number of people who have a 50% reduction in emotionalism when compared to placebo (risk ratio (RR) 0.26, 95% CI 0.09 to 0.77; P = 0.02; 1 trial, 19 participants) because the certainty of evidence is very low. Sertraline may lead to little to no difference in Center for Neurologic Study - Lability Scale (CNS-LS) scores and Clinician Interview-Based Impression of Change (CIBIC) scores when compared to placebo (RR 0.20, 95% CI 0.03 to 1.50; P = 0.12; 1 trial, 28 participants; low-certainty evidence). Antidepressants probably increase the number of people who experience a reduction in tearfulness (RR 0.32, 95% CI 0.12 to 0.86; P = 0.02; 3 trials, 164 participants; moderate-certainty evidence). No trials were found that evaluated the impact of other pharmaceutical interventions. Only two trial authors systematically recorded and reported adverse events, resulting in limited data on the potential harms of treatment. Six trials reported death as an adverse event and found no difference between the groups (antidepressants versus placebo) in the number of deaths reported (RR 0.59, 95% CI 0.08 to 4.50; P = 0.61; 172 participants; moderate-certainty evidence). This review provides very low- to moderate-certainty evidence that antidepressants may reduce the frequency and severity of emotionalism. The included trials were small and had some degree of bias. AUTHORS' CONCLUSIONS Antidepressants may reduce the frequency and severity of crying or laughing episodes when compared to placebo, based on very low-certainty evidence. Our conclusions must be qualified by several methodological deficiencies in the trials and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post-stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity, and assess change over time; provide treatment for a sufficient duration and follow-up to better assess rates of relapse or maintenance; and include careful assessment and complete reporting of adverse events.
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Affiliation(s)
- Sabine Allida
- Mental Health Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Allan House
- Division of Psychological and Social Medicine, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Maree L Hackett
- Mental Health Program, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
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Husbands E, Talbot K. Pathological laughter and crying in neurological disorders: recognition and treatment. Pract Neurol 2022; 22:486-490. [PMID: 35907635 DOI: 10.1136/pn-2021-003301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2022] [Indexed: 11/03/2022]
Abstract
Pathological laughter and crying is a disabling symptom complex associated with damage to various central nervous system pathways that control the reflex motor component of emotional expression. Many underlying conditions-including neurodegenerative diseases, CNS inflammation, vascular lesions and traumatic brain injury-can be associated with disinhibition of emotional reflex control. This suggests a disruption of anatomical and functional networks, rather than any specific unifying pathological process. There is a wide differential diagnosis, including depression, dementia and other forms of behavioural disturbance. Diagnostic criteria and rating scales can help with clinical assessments and facilitate clinical trials. There is now good-quality evidence for a combination of dextromethorphan and quinidine, with weaker evidence for tricyclic and selective serotonin reuptake inhibitor antidepressants. Pathological laughter and crying is disabling and underdiagnosed but potentially treatable, and its wider recognition is important.
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Affiliation(s)
| | - Kevin Talbot
- Clinical Neurosciences, Oxford University, Oxford, UK
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Pseudobulbar affect in neurodegenerative diseases: A systematic review and meta-analysis. J Clin Neurosci 2022; 100:100-107. [DOI: 10.1016/j.jocn.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/31/2022] [Accepted: 04/10/2022] [Indexed: 11/21/2022]
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Fitzgerald S, Gracey F, Trigg E, Broomfield N. Predictors and correlates of emotionalism across acquired and progressive neurological conditions: A systematic review. Neuropsychol Rehabil 2022; 33:945-987. [PMID: 35323084 DOI: 10.1080/09602011.2022.2052326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Emotionalism can develop following a range of neurological disorders; however the aetiology of emotionalism is still unclear. To identify anatomical, neuropsychological and psychological predictors and correlates of emotionalism across neurological disorders: stroke, Parkinson's disease, multiple sclerosis, traumatic brain injury, Alzheimer's disease, vascular dementia and amyotrophic lateral sclerosis. To explore if these predictors and correlates of emotionalism differ across neurological disorders. A comprehensive systematic search was completed of four databases: MEDLINE, CINAHL Complete, PsycINFO and EMBASE. Methodological quality was assessed using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and each study was graded according to the level of evidence using the Scottish Intercollegiate Guidelines Network. Fifty papers (participants N = 1922) were included. 25 studies were rated as "Fair," 21 "Good" and 4 "Poor." The review identified predictors and correlates found in several neurological disorder such as bulbar networks, serotonergic pathways, genetics and female gender. Multiple studies across diseases (stroke, MS, ALS) indicate emotionalism is associated with cognitive impairment, especially frontal deficits. Due to the disproportionate number of studies identified across neurological disorders, it is difficult to draw definitive answers. Further research is required across neurological disorders to explore similarities and differences in anatomical, neuropsychological and psychological predictors and correlates.
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Affiliation(s)
- Sophie Fitzgerald
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Fergus Gracey
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Emma Trigg
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Niall Broomfield
- Department of Clinical Psychology and Psychological Therapies, Norwich Medical School, University of East Anglia, Norwich, UK
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Wei QQ, Ou R, Lin J, Zhang L, Hou Y, Cao B, Chen Y, Yang T, Shang H. Prevalence and Factors Related to Pathological Laughter and Crying in Patients With Amyotrophic Lateral Sclerosis. Front Neurol 2021; 12:655674. [PMID: 34650501 PMCID: PMC8505736 DOI: 10.3389/fneur.2021.655674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 08/30/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: This study aimed to explore the prevalence and clinical correlates of pathological laughter and crying (PLC) in patients with amyotrophic lateral sclerosis (ALS). Methods: A total of 1,031 ALS patients were enrolled between August 2012 and August 2019. The PLC was recorded by a face-to-face interview. Other characteristics of patients, including depression, anxiety, cognition, and behavior function, were also evaluated. The potential associated factors of PLC were explored using forward binary regression analysis. Survival was analyzed in groups using propensity score matching (PSM) and Cox proportional hazards models. Results: The prevalence of PLC was 11.4% in all patients at baseline. Bulbar-onset and female patients had higher prevalence of PLC. The multivariate regression analysis indicated that PLC in ALS was associated with bulbar onset (p < 0.001), late disease stage (p < 0.001), and higher score in the Hamilton Depression Rating Scale (HDRS) (p = 0.012). The higher score of HDRS was significantly and independently associated with PLC occurrence in bulbar-onset patients (p = 0.032). The late disease stage was related to PLC occurrence in spinal-onset patients (p < 0.001). After comparison with matched pairs by using PSM, PLC at baseline had no impact on survival. Conclusion: PLC was not uncommon in ALS, especially in bulbar-onset and female patients. We highlighted that the emotional state other than cognitive function had possible relationship with PLC in ALS.
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Affiliation(s)
- Qian-Qian Wei
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, Sichuan University, Chengdu, China
| | - Ruwei Ou
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, Sichuan University, Chengdu, China
| | - Junyu Lin
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, Sichuan University, Chengdu, China
| | - Lingyu Zhang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, Sichuan University, Chengdu, China
| | - Yanbing Hou
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, Sichuan University, Chengdu, China
| | - Bei Cao
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, Sichuan University, Chengdu, China
| | - Yongping Chen
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, Sichuan University, Chengdu, China
| | - Tianmi Yang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, Sichuan University, Chengdu, China
| | - Huifang Shang
- Department of Neurology, Laboratory of Neurodegenerative Disorders, West China Hospital, Sichuan University, Chengdu, China
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Turell W, Roc A, Pioro E, Howson A. Living With the Burden of Pseudobulbar Affect: A Qualitative Analysis of the Effects of Education on Patient Experience. J Patient Exp 2021; 7:1324-1330. [PMID: 33457582 PMCID: PMC7786644 DOI: 10.1177/2374373519899597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Pseudobulbar affect (PBA) is associated with several neurological diseases and is underrecognized in clinical practice; however, PBA symptoms are often attributed to psychiatric or mood disorders rather than to neurological etiology. Until recently, there were no US Food and Drug Administration therapies approved for treating this condition, and there are currently few resources to support patients in the recognition and self-management of PBA symptoms. We evaluated the impact of a virtual education symposium on patient knowledge and self-efficacy via qualitative interviews. This evaluation of education impact provides unique insight into the experience of managing PBA symptoms; suggests that there is extensive need for educational resources to support patients with PBA and enable them to engage effectively with their providers; and affirms that online learning is an effective mechanism for delivering education to patients that enables them to more effectively self-manage symptoms in the context of chronic neurological conditions such as PBA.
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Affiliation(s)
- Wendy Turell
- CME Outcomes and Analytics, PlatformQ Health Education, Needham, MA, USA
| | - Anne Roc
- Medical Education and Strategy, PlatformQ Health Education, Needham, MA, USA
| | - Erik Pioro
- Section of ALS & Related Disorders, Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
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Raimo S, Santangelo G, Trojano L. The emotional disorders associated with multiple sclerosis. HANDBOOK OF CLINICAL NEUROLOGY 2021; 183:197-220. [PMID: 34389118 DOI: 10.1016/b978-0-12-822290-4.00009-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Multiple sclerosis (MS) is associated with a high prevalence of emotional and mood disorders. Emotional disorders may worsen during illness progression and affect the quality of life of patients and their families. MS is often associated with depression, with an increased risk of suicide, poor adherence to treatment, decreased functional status, and quality of life. The diagnosis and treatment of emotional and mood disorders in these patients is often challenging since several symptoms of these disorders overlap with those of MS. Other prevalent emotional disorders in MS include bipolar disorder, anxiety disorders, emotional blunting (apathy), and pseudobulbar affect. Early recognition and treatment of these comorbidities could contribute to the reduction of disability and even to decreased mortality. The aim of this chapter is to provide an up-to-date review of mood and emotional disorders that are often associated with MS, focusing on their epidemiology, clinical features, pathogenesis, assessment, and treatment. The interplay between the psychosocial impact of the chronic disability and the demyelinating structural lesions of the brain in precipitating emotional and mood disorders is discussed, as well as its implications for diagnosis and treatment.
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Affiliation(s)
- Simona Raimo
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy.
| | - Gabriella Santangelo
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy
| | - Luigi Trojano
- Department of Psychology, University of Campania "Luigi Vanvitelli", Caserta, Italy
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12
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Goldin DS. Pseudobulbar Affect: An Overview. J Psychosoc Nurs Ment Health Serv 2020; 58:19-24. [PMID: 32609863 DOI: 10.3928/02793695-20200624-08] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/02/2020] [Indexed: 01/31/2023]
Abstract
Pseudobulbar affect (PBA) is a disorder that develops in the context of a brain injury or underlying neurological dysfunction. It is characterized as an affective disorder of emotional expression. PBA manifests as frequent uncontrollable outbursts of laughing or crying, incongruent with the individual's internal emotional state. It can be challenging for clinicians to differentiate PBA from mood disorders, contributing to its high rate of misdiagnosis. This lack of recognition leads to ineffective and insufficient treatment, impacting patients' quality of life. The current article provides an overview of PBA, including its history, prevalence, pathophysiology, diagnostic criteria, clinical implications, and treatment. [Journal of Psychosocial Nursing and Mental Health Services, 58(9), 19-24.].
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Hicks AJ, Clay FJ, Ponsford JL, Perry LA, Jayaram M, Batty R, Hopwood M. Pharmacotherapy for the Pseudobulbar Affect in Individuals Who Have Sustained a Traumatic Brain Injury: a Systematic Review. Neuropsychol Rev 2020; 30:28-50. [PMID: 31942705 DOI: 10.1007/s11065-020-09427-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 01/03/2020] [Indexed: 12/11/2022]
Abstract
Pseudobulbar affect is a debilitating condition that significantly reduces quality of life for many individuals following traumatic brain injury (TBI). It is characterized by embarrassing and often uncontrollable episodes of crying or laughter. The aim of this systematic review was to evaluate the effectiveness of pharmacotherapy as compared to all other comparators for the management of pseudobulbar affect in adults who have sustained TBI. Six databases were searched, with additional hand searching of journals, clinical trials registries and international drug regulators to identify published and unpublished studies in English up to June 2018. Studies were eligible for this review if they included adults who had sustained a medically confirmed TBI and presented with pseudobulbar affect. All pharmacotherapy and comparator interventions were considered for inclusion, and study design was not limited to randomised controlled trials. Evidence quality was assessed using Joanna Briggs Institute Critical Appraisal Instruments. Two quasi-experimental studies examining the effectiveness of dextrometamorphan/quinidine (DM/Q) were identified. These studies reported that DM/Q was effective in reducing symptoms of pseudobulbar affect and had a positive safety profile, over follow-up periods of 3 months (n = 87) and 12 months (n = 23). However, both studies were limited by lack of a control group and a high dropout rate. The findings of twelve case reports examining the effectiveness of DM/Q (n = 6) and anti-depressants (n = 6) are also discussed. Further research is required to determine which pharmacological interventions provide the best outcomes for individuals with pseudobulbar affect following TBI, with consideration given to side effect profiles and financial costs.
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Affiliation(s)
- Amelia J Hicks
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia.
| | - Fiona J Clay
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Department of Forensic Medicine, Monash University, Southbank, Australia.,Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Jennie L Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Luke A Perry
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Mahesh Jayaram
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Rachel Batty
- Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Malcolm Hopwood
- Department of Psychiatry, University of Melbourne, Melbourne, Australia.,Albert Road Clinic, Department of Psychiatry, University of Melbourne, Melbourne, Australia
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McAleese N, Guzman A, O'Rourke SJ, Gillespie DC. Post-stroke emotionalism: a qualitative investigation. Disabil Rehabil 2019; 43:192-200. [PMID: 31136206 DOI: 10.1080/09638288.2019.1620876] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Introduction: Post-stroke emotionalism, outbursts of involuntary crying or laughing, is common after stroke. Little is known about the psychosocial factors associated with this neurological disorder.Aim: To investigate participant's experiences of emotionalism and explore how they managed their symptoms.Methods: A qualitative study that used framework analysis. Participants were recruited across inpatient and outpatient stroke settings. The average time since stroke was 4.3 months.Results: Eighteen semi-structured interviews were conducted. Four themes were identified: (1) Spontaneous and uncontrollable emotional reactions; (2) Incongruence; (3) Social reactions (sub-theme: The stigma of expressed emotions) and (4) Convalescence. Participants with negative experiences described greater disability, avoidance and mood problems. Positive experiences were shaped by a better understanding of the condition, an increased sense of control, social support and optimism. Few participants knew that their emotionalism was caused by stroke. Embarrassment and social withdrawal were commonly reported and had a detrimental effect on participant's mood and quality of life.Conclusions: Earlier recognition of emotionalism in clinical settings is needed as is promoting discussions about emotional reactions after-stroke. This will reduce the likelihood that patients will develop erroneous beliefs about emotionalism and unhelpful coping responses that may lead to adjustment difficulties in the months that follow their stroke.Implications for rehabilitationThe unpredictable and uncontrollable nature of emotionalism can be embarrassing and cause social withdrawal or avoidance.Waiting for emotionalism episodes to pass, distraction, humor or optimism and social support are successful means of managing the condition.Professionals play a key role in raising awareness that emotionalism is a neurological condition and not a clinical mood disorder as this will promote better understanding for patients, their families and those around them.Encouraging patients to talk about their emotional reactions early after stroke will normalize their experiences and may prevent them from developing unhelpful beliefs that could affect their approach to recovery.
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Affiliation(s)
- Niamh McAleese
- Clinical Neuropsychology Service, Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Azucena Guzman
- The School of Health in Social Science, University of Edinburgh, Edinburgh, UK
| | - Suzanne J O'Rourke
- The School of Health in Social Science, University of Edinburgh, Edinburgh, UK
| | - David C Gillespie
- Clinical Neuropsychology Service, Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
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Luhoway JA, Sharma M, Menon S, Rosehart H, Morrow SA. Posterior Fossa Lesion Load and Pathological Laughing and Crying in Multiple Sclerosis. Int J MS Care 2019; 21:135-142. [PMID: 31191179 PMCID: PMC6552995 DOI: 10.7224/1537-2073.2018-016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pathological laughing and crying (PLC) encompasses episodes of involuntary laughing, crying, or both that are contextually incongruous with the individual's subjective mood. Despite a 10% to 46% prevalence in people with multiple sclerosis (MS) and reduced quality of life, localization of neuroanatomical lesions associated with PLC remains poorly delineated. METHODS The relationship between posterior fossa lesions and PLC in people with MS was examined using a retrospective medical record review of people with MS (2012-2016) who had completed the Center for Neurologic Study-Liability Scale (CNS-LS) and had undergone 1.5-T magnetic resonance imaging within 6 months of each other. RESULTS Medical record review identified 80 potential cases, with 77 included. Brainstem and cerebellar lesions were counted, measured, and compared between people with MS who had positive results on the CNS-LS (scores ≥17, n = 22) with those who had negative results on the CNS-LS (scores ≤16, n = 55). Initial χ2 analysis showed no significant difference in lesion numbers in people with MS without (CNS-LS score ≤16) versus with (CNS-LS score ≥17) PLC. When analyzing only people with MS without evidence of depression, a significant inverse relationship was identified such that fewer posterior fossa lesions on automated magnetic resonance imaging was associated with the presence of PLC. CONCLUSIONS Posterior fossa lesion load is not indicative of which individuals could develop PLC. Further investigations to delineate the primary source of PLC symptoms would aid in diagnosis and treatment of this condition.
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Finegan E, Chipika RH, Li Hi Shing S, Hardiman O, Bede P. Pathological Crying and Laughing in Motor Neuron Disease: Pathobiology, Screening, Intervention. Front Neurol 2019; 10:260. [PMID: 30949121 PMCID: PMC6438102 DOI: 10.3389/fneur.2019.00260] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/26/2019] [Indexed: 12/11/2022] Open
Abstract
Pathological crying and laughing (PCL) has significant quality-of-life implications in amyotrophic lateral sclerosis (ALS); it can provoke restrictive life-style modifications and lead to social isolation. Despite its high prevalence and quality of life implications, it remains surprisingly understudied. Divergent pathophysiological models have been proposed, centered on corticobulbar tract degeneration, prefrontal cortex pathology, sensory deafferentation, and impaired cerebellar gate-control mechanisms. Quantitative MRI techniques and symptom-specific clinical instruments offer unprecedented opportunities to elucidate the anatomical underpinnings of PCL pathogenesis. Emerging neuroimaging studies of ALS support the role of cortico-pontine-cerebellar network dysfunction in context-inappropriate emotional responses. The characterization of PCL-associated pathophysiological processes is indispensable for the development of effective pharmacological therapies.
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Affiliation(s)
| | | | | | | | - Peter Bede
- Computational Neuroimaging Group, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland
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Abstract
BACKGROUND Antidepressants may be useful in the treatment of abnormal crying associated with stroke. This is an update of a Cochrane Review first published in 2004 and last updated in 2010. OBJECTIVES To determine whether pharmaceutical treatment reduces the frequency of emotional displays in people with emotionalism after stroke. SEARCH METHODS We searched the trial register of Cochrane Stroke (last searched May 2018). In addition, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; to May 2018), MEDLINE (1966 to 14 May 2018), Embase (1980 to 14 May 2018), CINAHL (1982 to 14 May 2018), PsycINFO (1967 to 14 May 2018), BIOSIS Previews (2002 to 14 May 2018), Web of Science (2002 to 14 May 2018), WHO ICTRP (to 14 May 2018), ClinicalTrials.gov (to 14 May 2018), and ProQuest Dissertations and Theses Database (to 14 May 2018). SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs comparing psychotropic medication to placebo in people with stroke and emotionalism (also known as emotional lability, pathological crying or laughing, emotional incontinence, involuntary emotional expression disorder, and pseudobulbar affect). DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, assessed risk of bias, extracted data from all included studies, and used GRADE to assess the quality of the body of evidence. We calculated mean difference (MD) or standardised mean difference (SMD) for continuous data and risk ratio (RR) for dichotomous data with 95% confidence intervals (CIs). We assessed heterogeneity using the I2 statistic. The primary emotionalism measures were the proportion of participants achieving at least a 50% reduction in abnormal emotional behaviour at the end of treatment, improved score on Center for Neurologic Study - Lability Scale (CNS-LS), Clinician Interview-Based Impression of Change (CIBIC) or diminished tearfulness. MAIN RESULTS We included seven trials with a total of 239 participants. Two trials were of cross-over design, and outcome data were not available from the first phase (precross-over) in an appropriate format for inclusion as a parallel randomised controlled trial (RCT). Thus, the results of the review are based on five trials with 213 participants. Treatment effects were observed on the following primary endpoints of emotionalism: There is very low quality of evidence from one small RCT that antidepressants increased the number of people who had 50% reduction in emotionalism (RR 16.50, 95% CI 1.07 to 253.40; 19 participants) and low quality evidence from one RCT of improved scores on Center for Neurologic Study - Lability Scale (CNS-LS) and Clinician Interview-Based Impression of Change (CIBIC) with antidepressants (RR 1.44, 95% CI 0.95 to 2.19; 28 participants). There was moderate quality evidence from three RCTS that they increased the number of people who had a reduction in tearfulness (RR 2.18, 95% CI 1.29 to 3.71; 164 participants); and low quality evidence from one RCT of improved scores on the Pathological Laughter and Crying Scale (PLCS) (MD 8.40, 95% CI 11.56 to 5.24; 28 participants).Six trials reported adverse events (death) and found no difference between the groups in death (RR 0.59, 95% CI 0.08 to 4.50; 6 RCTs, 172 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS Antidepressants may reduce the frequency and severity of crying or laughing episodes based on very low quality evidence. Our conclusions must be qualified by several methodological deficiencies in the studies and interpreted with caution despite the effect being very large. The effect does not seem specific to one drug or class of drugs. More reliable data are required before appropriate conclusions can be made about the treatment of post-stroke emotionalism. Future trialists investigating the effect of antidepressants in people with emotionalism after stroke should consider developing and using a standardised method to diagnose emotionalism, determine severity and assess change over time; provide treatment for a sufficient duration and follow-up to better assess rates of relapse or maintenance and include careful assessment and complete reporting of adverse events.
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Affiliation(s)
- Sabine Allida
- University of Technology SydneyFaculty of Health235 Jones StreetSydneySydneyAustralia2007
| | - Kulsum Patel
- University of Central LancashireClinical Practice Research Unit, School of HealthPrestonLancashireUKPR1 2HE
| | - Allan House
- Leeds Institute of Health Sciences, University of LeedsDivision of Psychological and Social MedicineRoom 1090c, Worsley BuildingClarendon WayLeedsUKLS2 9LJ
| | - Maree L Hackett
- The University of SydneySchool of Public HealthSydneyNSWAustralia2050
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Hakimi M, Maurer CW. Pseudobulbar Affect in Parkinsonian Disorders: A Review. J Mov Disord 2019; 12:14-21. [PMID: 30732430 PMCID: PMC6369372 DOI: 10.14802/jmd.18051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/14/2018] [Indexed: 12/11/2022] Open
Abstract
Pseudobulbar affect (PBA) is a neurological symptom of inappropriate and uncontrollable laughter or crying that occurs secondary to a variety of neurological conditions, including parkinsonian disorders. PBA is a socially and emotionally debilitating symptom that has been estimated to affect 3.6% to 42.5% of the population with Parkinson's disease. While indexing measures and treatment options for PBA have been extensively studied in neurological conditions such as amyotrophic lateral sclerosis and multiple sclerosis, there has been considerably less attention given in the literature to PBA in parkinsonian disorders. The purpose of this review is to discuss the pathophysiology of PBA, its prevalence and impact on quality of life in parkinsonian disorders, and the treatment options currently available. Areas requiring further study, including the development of standardized, cross-culturally validated methods of symptom assessment, and evidence-based studies exploring the efficacy of current treatment options in parkinsonian disorders, are also highlighted.
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Affiliation(s)
- Mathew Hakimi
- Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Carine W Maurer
- Department of Neurology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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The psychopharmacology of pseudobulbar affect. ACTA ACUST UNITED AC 2019; 165:243-251. [DOI: 10.1016/b978-0-444-64012-3.00014-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
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Low Testosterone Level as a Predictor of Poststroke Emotional Disturbances: Anger Proneness and Emotional Incontinence. J Stroke Cerebrovasc Dis 2018; 27:3549-3554. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.08.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 07/28/2018] [Accepted: 08/08/2018] [Indexed: 11/19/2022] Open
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Girotra T, Lowe F, Feng W. Pseudobulbar affect after stroke: a narrative review. Top Stroke Rehabil 2018; 25:1-7. [PMID: 30213256 DOI: 10.1080/10749357.2018.1499300] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2017] [Accepted: 07/07/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pseudobulbar affect (PBA) is a neuropsychological condition of emotional lability and affective dysregulation associated with a variety of neurological conditions such as stroke, traumatic brain disease, and neurodegenerative disease. The true prevalence and medico-social burden of PBA associated with stroke is unclear. Often confused with post-stroke mood disorders, PBA is under-recognized and under-treated. OBJECTIVE To provide a comprehensive narrative synthesis of published literature on the topic of PBA. METHODS Literature review was performed by searching the key words "pseudobulbar atrophy", "emotional incontinence," and "stroke" in PubMed. Only manuscripts published in English were appraised and relevant content was extracted, synthesized, and summarized. RESULTS A narrative overview was performed on the following topics: epidemiology, pathophysiology, clinical features of differential diagnosis, impact on public health, and therapeutic options. CONCLUSION PBA remains an under-treated condition with significant psychosocial burden on both effected stroke survivors and their families. Advances have been made in developing consensus-based clinical diagnostic criteria for PBA. Early identification and prompt initiation of therapeutic measures are required in these stroke patients. Further research is needed to develop better PBA diagnostic criteria and more cost-effective therapeutic treatment options.
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Affiliation(s)
- Tarun Girotra
- a Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
| | - Forrest Lowe
- a Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
| | - Wuwei Feng
- a Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
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Zorowitz RD, Alexander DN, Formella AE, Ledon F, Davis C, Siffert J. Dextromethorphan/Quinidine for Pseudobulbar Affect Following Stroke: Safety and Effectiveness in the PRISM II Trial. PM R 2018; 11:S1934-1482(18)30352-6. [PMID: 29964212 DOI: 10.1016/j.pmrj.2018.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 06/12/2018] [Accepted: 06/17/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Dextromethorphan (DM) / quinidine (Q) was approved for pseudobulbar affect (PBA) treatment based on efficacy and safety trials in patients with PBA caused by amyotrophic lateral sclerosis or multiple sclerosis. The PRISM II trial evaluated DM/Q as PBA treatment in patients with stroke, dementia, or traumatic brain injury. OBJECTIVE To report results from the stroke cohort of PRISM II, including the Stroke Impact Scale (SIS). DESIGN Open-label trial evaluating twice-daily DM/Q over 90 days. STUDY PARTICIPANTS Adults (n = 113) with a clinical diagnosis of PBA secondary to stroke; stable psychiatric medications were allowed. METHODS PRISM II was an open-label, 12-week trial enrolling adults with PBA caused by dementia, stroke (reported here), or TBI. All study participants received DM/Q 20/10 mg twice daily. Study visits occurred at baseline and at days 30 and 90. SETTING 150 U.S. centers. MAIN OUTCOME MEASUREMENTS Primary efficacy measure was changed from baseline to day 90 in Center for Neurologic Study-Lability Scale (CNS-LS) scores. Secondary outcomes included PBA episodes (estimated over 7 days), Clinical and Patient/Caregiver Global Impression of Change (CGI-C and PGI-C), Quality of Life-Visual Analog Scale (QOL-VAS), SIS, Patient Health Questionnaire (PHQ-9), and Mini-Mental State Examination (MMSE). RESULTS Compared with baseline, CNS-LS scores (SD) improved by -6.2 (6.1, P < .001) at day 30 and -7.6 (6.7, P < .001) at day 90. PBA episodes were reduced by 65% and 75% at day 30 and 90, respectively. Seventy-five percent of clinicians and 67% of patients/caregivers rated PBA as "much" or "very much improved." All SIS items significantly improved from baseline (P < .05, all). Adverse events included diarrhea (4.4%), headache (3.5%), constipation (2.7%), and dizziness (2.7%); 5.3% had adverse events leading to study discontinuation. CONCLUSIONS DM/Q effectively treated PBA and was associated with global and functional improvement; adverse events were consistent with the known safety profile of DM/Q.
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Affiliation(s)
- Richard D Zorowitz
- MedStar National Rehabilitation Network, 102 Irving Street, NW, Washington, DC 20010.
| | | | | | - Fred Ledon
- Avanir Pharmaceuticals, Inc, Aliso Viejo, CA
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Allen C, Zarowitz B, O'Shea T, Peterson E, Yonan C, Waterman F. Identification of pseudobulbar affect symptoms in the nursing home setting: Development and assessment of a screening tool. Geriatr Nurs 2017; 39:54-59. [PMID: 28807457 DOI: 10.1016/j.gerinurse.2017.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 06/02/2017] [Accepted: 06/09/2017] [Indexed: 11/25/2022]
Abstract
Pseudobulbar Affect (PBA) is a neurologic condition characterized by involuntary outbursts of crying and/or laughing disproportionate to patient mood or social context. Although an estimated 9% of nursing home residents have symptoms suggestive of PBA, they are not routinely screened. Our goal was to develop an electronic screening tool based upon characteristics common to nursing home residents with PBA identified through medical record data. Nursing home residents with PBA treated with dextromethorphan hydrobromide/quinidine sulfate (n = 140) were compared to age-, gender-, and dementia-diagnosis-matched controls without PBA or treatment (n = 140). Comparative categories included diagnoses, medication use and symptom documentation. Using a multivariable regression and best decision rule analysis, we found PBA in nursing home residents was associated with chart documentation of uncontrollable crying, presence of a neurologic disorder (e.g., Parkinson's disease), or by the documented presence of at least 2 of the following: stroke, severe cognitive impairment, and schizophrenia. Based on these risk factors, an electronic screening tool was created.
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Affiliation(s)
- Carrie Allen
- Omnicare Senior Health Outcomes - a CVS Health Company, Cincinnati, OH, USA.
| | - Barbara Zarowitz
- Omnicare Senior Health Outcomes - a CVS Health Company, Cincinnati, OH, USA
| | - Terrence O'Shea
- Omnicare Senior Health Outcomes - a CVS Health Company, Cincinnati, OH, USA
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Liu JY, Chen YH. Influence of acupoint-injection on TXB2 and 6-keto-PGF1a in patients with pseudobulbar palsy: a randomized controlled trial. JOURNAL OF ACUPUNCTURE AND TUINA SCIENCE 2017. [DOI: 10.1007/s11726-017-0969-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Doody RS, D'Amico S, Cutler AJ, Davis CS, Shin P, Ledon F, Yonan C, Siffert J. An open-label study to assess safety, tolerability, and effectiveness of dextromethorphan/quinidine for pseudobulbar affect in dementia: PRISM II results. CNS Spectr 2016; 21:450-459. [PMID: 26471212 DOI: 10.1017/s1092852915000620] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Dextromethorphan (DM)/quinidine (Q) is an approved treatment for pseudobulbar affect (PBA) based on trials in amyotrophic lateral sclerosis or multiple sclerosis. PRISM II evaluated DM/Q effectiveness and tolerability for PBA secondary to dementia, stroke, or traumatic brain injury; dementia cohort results are reported. METHODS This was an open-label, multicenter, 90 day trial; patients received DM/Q 20/10 mg twice daily. Primary outcome was change in Center for Neurologic Study-Lability Scale (CNS-LS) score. Secondary outcomes included PBA episode count and Clinical and Patient/Caregiver Global Impression of Change scores with respect to PBA (CGI-C/PGI-C). RESULTS 134 patients were treated. CNS-LS improved by a mean (SD) of 7.2 (6.0) points at Day 90/Endpoint (P<.001) vs. baseline. PBA episodes were reduced 67.7% (P<.001) vs. baseline; global measures showed 77.5% CGI-C and 76.5% PGI-C "much"/"very much" improved. Adverse events included headache (7.5%), urinary tract infection (4.5%), and diarrhea (3.7%); few patients dropped out for adverse events (10.4%). CONCLUSIONS DM/Q significantly reduced PBA symptoms in patients with dementia; reported adverse events were consistent with the known safety profile of DM/Q. Trial Registration clinicaltrials.gov identifier: NCT01799941.
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Affiliation(s)
| | | | - Andrew J Cutler
- Florida Clinical Research Center, LLC, Bradenton, Florida, USA
| | | | - Paul Shin
- Avanir Pharmaceuticals, Inc., Aliso Viejo, California, USA
| | - Fred Ledon
- Avanir Pharmaceuticals, Inc., Aliso Viejo, California, USA
| | - Charles Yonan
- Avanir Pharmaceuticals, Inc., Aliso Viejo, California, USA
| | - João Siffert
- Avanir Pharmaceuticals, Inc., Aliso Viejo, California, USA
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26
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Abstract
Pseudobulbar affect, thought by many to be a relatively newly described condition, is in fact a very old one, described as early as the 19th century. It refers to those who experience inappropriate affect, disconnected from internal state, or mood, generally thought to be the result of an upper motor neuron injury or illness. One possible explanation for this condition's relative obscurity is the dearth of treatment options; clinical medicine is not typically in the habit of identifying conditions that cannot be modified. Now, however, there is good evidence for the treatment of pseudobulbar affect, and even a therapy approved for use by the U.S. Food and Drug Administration (FDA). As a result, appropriate identification and subsequent management of pseudobulbar affect is more important than ever. This article purports to summarize the origins of pseudobulbar affect, most current hypotheses as to its physiopathology, clinical identification, and evidence for management.
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Foley K, Konetzka RT, Bunin A, Yonan C. Prevalence of pseudobulbar affect symptoms and clinical correlates in nursing home residents. Int J Geriatr Psychiatry 2016; 31:694-701. [PMID: 26526856 PMCID: PMC5215684 DOI: 10.1002/gps.4374] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Revised: 09/05/2015] [Accepted: 09/15/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Pseudobulbar affect (PBA) is a neurological disorder of emotional expression, characterized by uncontrollable episodes of crying or laughing in patients with certain neurological disorders affecting the brain. The purposes of this study were to estimate the prevalence of PBA in US nursing home residents and examine the relationship between PBA symptoms and other clinical correlates, including the use of psychopharmacological medications. METHODS A retrospective study was conducted between 2013 and 2014 with a convenience sample of residents from nine Michigan nursing homes. Chronic-care residents were included in the "predisposed population" if they had a neurological disorder affecting the brain and no evidence of psychosis, delirium, or disruptive behavior (per chart review). Residents were screened for PBA symptoms by a geropsychologist using the Center for Neurologic Study-Lability Scale (CNS-LS). Additional clinical information was collected using a diagnostic evaluation checklist and the most recent Minimum Data Set 3.0 assessment. RESULTS Of 811 residents screened, complete data were available for 804, and 412 (51%) met the criteria for the "predisposed population." PBA symptom prevalence, based on having a CNS-LS score ≥13, was 17.5% in the predisposed population and 9.0% among all nursing home residents. Those with PBA symptoms were more likely to have a documented mood disorder and be using a psychopharmacological medication, including antipsychotics, than those without PBA symptoms. CONCLUSIONS Pseudobulbar affect symptoms were present in 17.5% of nursing home residents with neurological conditions, and 9.0% of residents overall. Increasing awareness and improving diagnostic accuracy of PBA may help optimize treatment. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Kevin Foley
- College of Human MedicineMichigan State UniversityEast LansingMIUSA
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Hammond FM, Alexander DN, Cutler AJ, D'Amico S, Doody RS, Sauve W, Zorowitz RD, Davis CS, Shin P, Ledon F, Yonan C, Formella AE, Siffert J. PRISM II: an open-label study to assess effectiveness of dextromethorphan/quinidine for pseudobulbar affect in patients with dementia, stroke or traumatic brain injury. BMC Neurol 2016; 16:89. [PMID: 27276999 PMCID: PMC4899919 DOI: 10.1186/s12883-016-0609-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 05/23/2016] [Indexed: 12/11/2022] Open
Abstract
Background Phase 3 trials supporting dextromethorphan/quinidine (DM/Q) use as a treatment for pseudobulbar affect (PBA) were conducted in patients with amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS). The PRISM II study provides additional DM/Q experience with PBA secondary to dementia, stroke, or traumatic brain injury (TBI). Methods Participants in this open-label, multicenter, 90-day trial received DM/Q 20/10 mg twice daily. The primary outcome was the Center for Neurologic Study-Lability Scale (CNS-LS), assessing change in PBA episode frequency and severity. The CNS-LS final visit score was compared to baseline (primary analysis) and to the response in a previously conducted placebo-controlled trial with DM/Q in patients with ALS or MS. Secondary outcomes included change in PBA episode count and Clinical Global Impression of Change with respect to PBA as rated by a clinician (CGI-C) and by the patient or caregiver (PGI-C). Results The study enrolled 367 participants with PBA secondary to dementia, stroke, or TBI. Mean (standard deviation [SD]) CNS-LS score improved significantly from 20.4 (4.4) at baseline to 12.8 (5.0) at Day 90/Final Visit (change, −7.7 [6.1]; P < .001, 95 % CI: −8.4, −7.0). This magnitude of improvement was consistent with DM/Q improvement in the earlier phase-3, placebo-controlled trial (mean [95 % CI] change from baseline, −8.2 [−9.4, −7.0]) and numerically exceeds the improvement seen with placebo in that study (−5.7 [−6.8, −4.7]). Reduction in PBA episode count was 72.3 % at Day 90/Final Visit compared with baseline (P < .001). Scores on CGI-C and PGI-C showed that 76.6 and 72.4 % of participants, respectively, were “much” or ”very much” improved with respect to PBA. The most frequently occurring adverse events (AEs) were diarrhea (5.4 %), headache (4.1 %), urinary tract infection (2.7 %), and dizziness (2.5 %); 9.8 % had AEs that led to discontinuation. Serious AEs were reported in 6.3 %; however, none were considered treatment related. Conclusions DM/Q was shown to be an effective and well-tolerated treatment for PBA secondary to dementia, stroke, or TBI. The magnitude of PBA improvement was similar to that reported in patients with PBA secondary to ALS or MS, and the adverse event profile was consistent with the known safety profile of DM/Q. Trial registration Clinicaltrials.gov, NCT01799941, registered on 25 February 2013 Electronic supplementary material The online version of this article (doi:10.1186/s12883-016-0609-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Flora M Hammond
- Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, 4141 Shore Drive, Indianapolis, IN, 46254, USA.
| | | | | | | | | | | | | | | | - Paul Shin
- Avanir Pharmaceuticals, Inc., Aliso Viejo, CA, USA
| | - Fred Ledon
- Avanir Pharmaceuticals, Inc., Aliso Viejo, CA, USA
| | | | | | - Joao Siffert
- Avanir Pharmaceuticals, Inc., Aliso Viejo, CA, USA
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Chang YD, Davis MP, Smith J, Gutgsell T. Pseudobulbar Affect or Depression in Dementia? J Pain Symptom Manage 2016; 51:954-8. [PMID: 26899823 DOI: 10.1016/j.jpainsymman.2015.12.321] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 12/21/2015] [Accepted: 12/24/2015] [Indexed: 12/11/2022]
Affiliation(s)
- Young D Chang
- Department of Supportive Care, Moffitt Cancer Center, Tampa, Florida, USA
| | - Mellar P Davis
- Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
| | - Joshua Smith
- Department of Supportive Care, Moffitt Cancer Center, Tampa, Florida, USA
| | - Terrence Gutgsell
- Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Oosterman JM, Zwakhalen S, Sampson EL, Kunz M. The use of facial expressions for pain assessment purposes in dementia: a narrative review. Neurodegener Dis Manag 2016; 6:119-31. [DOI: 10.2217/nmt-2015-0006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Facial expressions convey reliable nonverbal signals about pain and thus are very useful for assessing pain in patients with limited communicative ability, such as patients with dementia. In this review, we present an overview of the available pain observation tools and how they make use of facial expressions. Utility and reliability of facial expressions to measure pain in dementia are discussed, together with the effect of dementia severity on these facial expressions. Next, we present how behavioral alterations may overlap with facial expressions of pain, and may even influence the extent to which pain is facially expressed. The main focus is on disinhibition, apathy and emotional changes. Finally, an overview of theoretical considerations and practical implications is presented for assessing pain using facial expressions in clinical settings.
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Affiliation(s)
- Joukje M Oosterman
- Radboud University Nijmegen, Donders Institute for Brain, Cognition & Behaviour, Nijmegen, The Netherlands
| | - Sandra Zwakhalen
- Maastricht University, Department of Health Services Research, CAPHRI School for Public Health & Primary Care, Maastricht, The Netherlands
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London Medical School, London, UK
- North Middlesex University Hospital, Barnet Enfield & Haringey Mental Health Trust, London, UK
| | - Miriam Kunz
- University of Groningen, University Medical Center Groningen, Department of General Practice, Section Gerontology, Groningen, The Netherlands
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31
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Perotti LP, Cummings LD, Mercado J. Behavioral Treatment of Pseudobulbar Affect: A Case Report. Perspect Psychiatr Care 2016; 52:82-7. [PMID: 27091117 DOI: 10.1111/ppc.12159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 01/08/2016] [Accepted: 01/30/2016] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To determine if it is possible to successfully treat pseudobulbar affect (PBA) using a behavioral approach. DESIGN AND METHODS Two experiments were conducted, each a double reversal design with the same single subject in both. The first experiment tested the hypothesis that the rate of PBA could be controlled by manipulation of its consequences. The second experiment tested the hypothesis that use of a self-control procedure would control the rate of PBA. FINDINGS Rate of PBA could not be controlled by consequence manipulation, but rate of PBA could be controlled through use of a self-control procedure. PRACTICE IMPLICATIONS Pending confirmatory research, behavioral interventions utilizing self-control procedures should be considered in patients with PBA.
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Affiliation(s)
- Laurence P Perotti
- Clinical Psychologist at the Multidisciplinary Clinic, Department of Behavioral Medicine, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Latiba D Cummings
- Physician Assistant in Brain Injury Rehabilitation Service, Department of Orthopedics, Brooke Army Medical Center, San Antonio, Texas, USA
| | - Janyna Mercado
- Neuropsychologist in Neuropsychology Service, Department of Behavioral Medicine, Brooke Army Medical Center, San Antonio, Texas, USA
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32
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Rudolph JL, Fonda JR, Hunt PR, McGlinchey RE, Milberg WP, Reynolds MW, Yonan C. Association of Pseudobulbar Affect symptoms with quality of life and healthcare costs in Veterans with traumatic brain injury. J Affect Disord 2016; 190:150-155. [PMID: 26519634 DOI: 10.1016/j.jad.2015.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/30/2015] [Accepted: 10/02/2015] [Indexed: 11/28/2022]
Affiliation(s)
- James L Rudolph
- Geriatric Research, Education and Clinical Center (GRECC) and Translational Research Center for TBI and Stress Disorders (TRACTS), VA Boston Healthcare System Boston, MA, United States; Center of Innovation in Geriatric Services, Providence VA Medical Center, Providence, RI, United States.
| | - Jennifer R Fonda
- Geriatric Research, Education and Clinical Center (GRECC) and Translational Research Center for TBI and Stress Disorders (TRACTS), VA Boston Healthcare System Boston, MA, United States; Department of Epidemiology, Boston University School of Public Health, Boston, MA, United States
| | - Phillip R Hunt
- Health Economics & Epidemiology, Evidera, Lexington, MA, United States
| | - Regina E McGlinchey
- Geriatric Research, Education and Clinical Center (GRECC) and Translational Research Center for TBI and Stress Disorders (TRACTS), VA Boston Healthcare System Boston, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - William P Milberg
- Geriatric Research, Education and Clinical Center (GRECC) and Translational Research Center for TBI and Stress Disorders (TRACTS), VA Boston Healthcare System Boston, MA, United States; Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | | | - Charles Yonan
- Health Economics and Outcomes Research, Avanir Pharmaceuticals, Inc., Aliso Viejo, CA, United States
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Pseudobulbar affect (PBA) in an incident ALS cohort: results from the Apulia registry (SLAP). J Neurol 2015; 263:316-321. [PMID: 26588919 DOI: 10.1007/s00415-015-7981-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 11/09/2015] [Accepted: 11/12/2015] [Indexed: 12/11/2022]
Abstract
The aim of this study is to investigate the frequency and the clinical correlations of pseudobulbar affect (PBA) in a population-based incident cohort of ALS patients. Incident ALS cases, diagnosed in 2011 and 2012, according to El Escorial criteria were enrolled from a prospective population-based registry in Apulia, Southern Italy. Neurological status was assessed using a standard neurological examination and the revised ALS Functional Rating Scale (ALSFRSr). The Center for Neurologic Study-Lability Scale (CNS-LS), a self-administered questionnaire, was used to evaluate the presence and severity of PBA. Total scores range from 7 to 35. A score ≥13 was used to identify the presence of PBA. One-hundred thirty-two sporadic incident ALS cases were enrolled. Median disease duration was 20 months (range 2-143), median onset-diagnosis interval (ODI) 12 months (range 2-131), median ALSFRSr at baseline 36/48 (range 2-47) and median ALSFRSr bulbar sub-score 10/12 (range 0-12). Neurological examination revealed presence of PBA in 34/132 patients (26%). Pathological CNS-LS score was found in 45/132 patients (34%). Median total CNS-LS score was 9/35 (range 7-29). The subgroup with pathological CNS-LS was characterized by a short disease duration from symptom onset, ODI, time to diffusion to a second region, time to generalization and ALSFRSr bulbar sub-score, bulbar onset, "definite" diagnostic category, bulbar upper motor-neuron involvement and presence of PBA at neurological examination. In population-based setting, one-third of ALS patients present PBA at diagnosis. The presence of PBA is associated with bulbar UMN involvement and markers of a more severe phenotype.
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Lapchak PA. Neuronal Dysregulation in Stroke-Associated Pseudobulbar Affect (PBA): Diagnostic Scales and Current Treatment Options. ACTA ACUST UNITED AC 2015; 6. [PMID: 26693049 PMCID: PMC4675467 DOI: 10.4172/2155-9562.1000323] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Until recently there was little understanding of the exact pathophysiology and treatment choices for stroke patients with Pseudobulbar affect (PBA). PBA is typically characterized by outbursts or uncontrollable laughing or crying and in the majority of patients, the outbursts being involuntary and incompatible with the patients' emotional state. PBA is a behavioral syndrome reported to be displayed in 28-52% of stroke patients with first or multiple strokes, and incidence may be higher in patients who have had prior stroke events, and higher in females. There is typically involvement of glutaminergic, serotoninergic and dopaminergic neuronal circuits of the corticolimbic-subcorticothalamic-pontocerebellar network. PBA is now understood to be a disinhibition syndrome in which specific pathways involving serotonin and glutamate are disrupted or modulated causing reduced cortical inhibition of a cerebellar/brainstem-situated "emotional" laughing or crying focal center. Stroke-induced disruption of one or more neuronal pathway circuits may "disinhibit" voluntary laughing and crying making the process involuntary. With a "new" treatment currently being marketed to treat PBA patients, this article will delve into the neurological and physiological basis for PBA in stroke, and review progress with the diagnosis and treatment of PBA.
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Affiliation(s)
- Paul A Lapchak
- Department of Neurology & Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
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35
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Abstract
A variety of outcome measures are used in clinical practice and in research to assess patients with amyotrophic lateral sclerosis (ALS). However, there may be discordance between traditional outcome measures such as strength and physical function, and patient-perceived measures of well-being. One such self-perceived measure, reflecting the patient's view, is quality of life (QOL). QOL in patients with severe medical disorder is often underestimated by others. Patients with ALS often have high QOL, and this may persist throughout the disease due to shifting expectations and to reprioritization of factors contributing to QOL. QOL instruments can measure health-related QOL (HRQOL) or global QOL, and can be generic or disease-specific. HRQOL refers primarily to physical and mental health. Global QOL is much broader, and is also determined by non-health-related factors. The choice of a QOL instrument depends on whether the setting is routine patient care or clinical research, whether or not the outcome of a specific intervention is being assessed, and upon the expected efficacy or toxicity of the intervention. Global QOL instruments are best for individual clinical patient care or for comparing groups. HRQOL or a combination of HRQOL and global QOL instruments are most appropriate for assessing specific interventions.
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Affiliation(s)
- Zachary Simmons
- Department of Neurology, Penn State Hershey Medical Center, EC 037, Hershey, PA, 17033, USA,
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36
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Fonda JR, Hunt PR, McGlinchey RE, Rudolph JL, Milberg WP, Reynolds MW, Yonan C. Identification of pseudobulbar affect symptoms in Veterans with possible traumatic brain injury. ACTA ACUST UNITED AC 2015; 52:839-49. [DOI: 10.1682/jrrd.2014.08.0191] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 05/29/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Jennifer R. Fonda
- Translational Research Center for Traumatic Brain Injury and Stress Disorders, and Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Boston Healthcare System, Boston, MA
| | | | - Regina E. McGlinchey
- Translational Research Center for Traumatic Brain Injury and Stress Disorders, and Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Boston Healthcare System, Boston, MA
| | - James L. Rudolph
- Translational Research Center for Traumatic Brain Injury and Stress Disorders, and Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Boston Healthcare System, Boston, MA;Medicine, Harvard Medical School, Boston, MA
| | - William P. Milberg
- Translational Research Center for Traumatic Brain Injury and Stress Disorders, and Geriatric Research, Education and Clinical Center, Department of Veterans Affairs Boston Healthcare System, Boston, MA
| | | | - Charles Yonan
- Health Economics and Outcomes Research, Avanir Pharmaceuticals Inc, Aliso Viejo, CA
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Pattee GL, Wymer JP, Lomen-Hoerth C, Appel SH, Formella AE, Pope LE. An open-label multicenter study to assess the safety of dextromethorphan/quinidine in patients with pseudobulbar affect associated with a range of underlying neurological conditions. Curr Med Res Opin 2014; 30:2255-65. [PMID: 25062507 PMCID: PMC4743597 DOI: 10.1185/03007995.2014.940040] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Pseudobulbar affect (PBA) is associated with neurological disorders or injury affecting the brain, and characterized by frequent, uncontrollable episodes of crying and/or laughing that are exaggerated or unrelated to the patient's emotional state. Clinical trials establishing dextromethorphan and quinidine (DM/Q) as PBA treatment were conducted in patients with amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS). This trial evaluated DM/Q safety in patients with PBA secondary to any neurological condition affecting the brain. OBJECTIVE To evaluate the safety and tolerability of DM/Q during long-term administration to patients with PBA associated with multiple neurological conditions. METHODS Fifty-two-week open-label study of DM/Q 30/30 mg twice daily. Safety measures included adverse events (AEs), laboratory tests, electrocardiograms (ECGs), vital signs, and physical examinations. CLINICAL TRIAL REGISTRATION #NCT00056524. RESULTS A total of 553 PBA patients with >30 different neurological conditions enrolled; 296 (53.5%) completed. The most frequently reported treatment-related AEs (TRAEs) were nausea (11.8%), dizziness (10.5%), headache (9.9%), somnolence (7.2%), fatigue (7.1%), diarrhea (6.5%), and dry mouth (5.1%). TRAEs were mostly mild/moderate, generally transient, and consistent with previous controlled trials. Serious AEs (SAEs) were reported in 126 patients (22.8%), including 47 deaths, mostly due to ALS progression and respiratory failure. No SAEs were deemed related to DM/Q treatment by investigators. ECG results suggested no clinically meaningful effect of DM/Q on myocardial repolarization. Differences in AEs across neurological disease groups appeared consistent with the known morbidity of the primary neurological conditions. Study interpretation is limited by the small size of some disease groups, the lack of a specific efficacy measure and the use of a DM/Q dose higher than the eventually approved dose. CONCLUSIONS DM/Q was generally well tolerated over this 52 week trial in patients with PBA associated with a wide range of neurological conditions.
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Affiliation(s)
- Gary L. Pattee
- Neurology Associates
Lincoln, NEUSA
- Address for correspondence:
Gary L. Pattee MD, Neurology Associates,
PC, 2631 South 70th Street, Lincoln, NE 68506, USA. Tel.: +1 402 483 7226; Fax: +1 402 483 5440;
| | - James P. Wymer
- The Neurosciences Institute, Albany Medical Center
Albany, NYUSA
| | | | - Stanley H. Appel
- Department of Neurology, Methodist Neurological Institute, The Methodist Hospital Research Institute, The Methodist Hospital
Houston, TXUSA
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38
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Pioro EP. Review of Dextromethorphan 20 mg/Quinidine 10 mg (NUEDEXTA(®)) for Pseudobulbar Affect. Neurol Ther 2014; 3:15-28. [PMID: 26000221 PMCID: PMC4381919 DOI: 10.1007/s40120-014-0018-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Indexed: 12/11/2022] Open
Abstract
Pseudobulbar affect (PBA) is a dysfunction of emotional expression characterized by involuntary outbursts of crying or laughing disproportionate or unrelated to mood, occurring in patients with various underlying neurologic disorders. This review describes the clinical data supporting dextromethorphan (DM) hydrobromide combined with quinidine sulfate (Q) as treatment of PBA and briefly surveys the ongoing debates concerning the terminology for dysfunction of emotional expression, as well as the ongoing searches for its brain substrates. Until recently, pharmacologic intervention consisted chiefly of off-label antidepressants. In October 2010, however, DM/Q at 20/10 mg twice daily received approval from the United States Food and Drug Administration for PBA in any setting, and in June 2013, dosages of 20/10 and 30/10 mg twice daily (labeled as 15/9 and 23/9 mg, respectively, DM/Q base) received approval from the European Medicines Agency. DM is an uncompetitive N-methyl-d-aspartate (NMDA) glutamate receptor antagonist, a sigma-1 receptor agonist, and a serotonin and norepinephrine reuptake inhibitor. To block DM hepatic metabolism, thereby increasing DM bioavailability, Quinidine, a cytochrome P450 2D6 inhibitor, is coadministered at a dosage well below those for treating cardiac arrhythmia. Three large-scale DM/Q trials have utilized PBA-episode counts and the Center for Neurologic Study-Lability Scale (CNS-LS), a validated PBA rating scale, to measure efficacy. In a 4-week study of patients with PBA in amyotrophic lateral sclerosis (ALS), DM/Q 30/30 mg was superior to its component drugs. A 12-week, double-blind, placebo-controlled study of DM/Q 30/30 mg showed similar efficacy in patients with PBA in multiple sclerosis (MS). A subsequent 12-week study of patients with PBA and ALS or MS showed superiority to placebo for the 20/10 and 30/10 mg doses. Efficacy was maintained during a 12-week, open-label extension (30/10 mg dose), with further improvement of mean CNS-LS scores. Across these studies, DM/Q was generally safe and well tolerated, with no evidence of clinically relevant cardiac or respiratory effects. DM/Q is being studied (currently unapproved) for conditions including agitation in autism and in dementia.
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Affiliation(s)
- Erik P Pioro
- Section of ALS and Related Disorders, Department of Neurology, S90, Neurological Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195 USA
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39
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Campbell K, Viswanathan R, Saunders R. Dextromethorphan/quinidine for pseudobulbar affect associated with subarachnoid hemorrhage. FUTURE NEUROLOGY 2014. [DOI: 10.2217/fnl.14.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT: Dextromethorphan/quinidine, sold under the brand name Nuedexta® (Avanir Pharmaceutics, CA, USA), is currently the only US FDA-approved medication for the treatment of pseudobulbar affect (PBA) in the USA. However, the clinical trials for approval of this medication only involved patients diagnosed with amyotrophic lateral sclerosis or multiple sclerosis. This case report describes a 43-year-old woman who developed PBA following an acute subarachnoid hemorrhage with a basilar artery aneurysm. After failing to respond to valproate or haloperidol, she was treated with dextromethorphan/quinidine and showed a reduction in her PBA symptoms. The patient's Center for Neurologic Study-Lability Scale score improved in 1 week and the improvement was maintained at 3 weeks.
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Affiliation(s)
- Kendra Campbell
- State University of New York Downstate Medical Center, Department of Psychiatry, MSC 1203, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
| | - Ramaswamy Viswanathan
- State University of New York Downstate Medical Center, Department of Psychiatry, MSC 1203, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
| | - Ramotse Saunders
- State University of New York Downstate Medical Center, Department of Psychiatry, MSC 1203, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
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Abstract
Pseudobulbar affect (PBA) is defined by episodes of involuntary crying and/or laughing as a result of brain injury or other neurological disease. Epidemiology studies show that 5.3%-48.2% of people with traumatic brain injury (TBI) may have symptoms consistent with (or suggestive of) PBA. Yet it is a difficult and often overlooked condition in individuals with TBI, and is easily confused with depression or other mood disorders. As a result, it may be undertreated and persist for longer than it should. This review presents the signs and symptoms of PBA in patients with existing TBI and outlines how to distinguish PBA from other similar conditions. It also compares and contrasts the different diagnostic criteria found in the literature and briefly mentions appropriate treatments. This review follows a composite case with respect to the clinical course and treatment for PBA and presents typical challenges posed to a provider when diagnosing PBA.
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Affiliation(s)
| | - Flora M Hammond
- Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - James F Malec
- Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
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Abstract
Pseudobulbar affect (PBA) may occur in association with a variety of neurological diseases, and so may be encountered in the setting of amyotrophic lateral sclerosis, extrapyramidal and cerebellar disorders, multiple sclerosis, traumatic brain injury, Alzheimer’s disease, stroke, and brain tumors. The psychological consequences and the impact on social interactions may be substantial. Although it is most commonly misidentified as a mood disorder, particularly depression or a bipolar disorder, there are characteristic features that can be recognized clinically or assessed by validated scales, resulting in accurate identification of PBA, and thus permitting proper management and treatment. Mechanistically, PBA is a disinhibition syndrome in which pathways involving serotonin and glutamate are disrupted. This knowledge has permitted effective treatment for many years with antidepressants, particularly tricyclic antidepressants and selective serotonin reuptake inhibitors. A recent therapeutic breakthrough occurred with the approval by the Food and Drug Administration of a dextromethorphan/quinidine combination as being safe and effective for treatment of PBA. Side effect profiles and contraindications differ for the various treatment options, and the clinician must be familiar with these when choosing the best therapy for an individual, particularly elderly patients and those with multiple comorbidities and concomitant medications.
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Affiliation(s)
- Aiesha Ahmed
- Department of Neurology, Penn State Hershey Medical Center, Hershey, PA, USA
| | - Zachary Simmons
- Department of Neurology, Penn State Hershey Medical Center, Hershey, PA, USA
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Abstract
Pregnancy increases the pharmacological management challenge of numerous neurological diseases as a result of complex physiological changes. Understanding pregnancy-induced changes in pharmacokinetic and pharmacodynamic parameters can lead to better outcomes for both the mother and baby. Although the application of pharmacogenomics in maternal-fetal medicine is in its infancy, further research and developments will provide important new developments for managing the efficacy of drug treatments during pregnancy and improving maternal-fetal safety. Although a wide variety of neurological medications are used during pregnancy, this article will focus on the drugs with currently known pharmacogenomic implications.
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Brooks BR, Crumpacker D, Fellus J, Kantor D, Kaye RE. PRISM: a novel research tool to assess the prevalence of pseudobulbar affect symptoms across neurological conditions. PLoS One 2013; 8:e72232. [PMID: 23991068 PMCID: PMC3749118 DOI: 10.1371/journal.pone.0072232] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 07/05/2013] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Pseudobulbar affect (PBA) is a neurological condition characterized by involuntary, sudden, and frequent episodes of laughing and/or crying, which can be socially disabling. Although PBA occurs secondary to many neurological conditions, with an estimated United States (US) prevalence of up to 2 million persons, it is thought to be under-recognized and undertreated. The PBA Registry Series (PRISM) was established to provide additional PBA symptom prevalence data in a large, representative US sample of patients with neurological conditions known to be associated with PBA. METHODS Participating clinicians were asked to enroll ≥20 consenting patients with any of 6 conditions: Alzheimer's disease (AD), amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), Parkinson's disease (PD), stroke, or traumatic brain injury (TBI). Patients (or their caregivers) completed the Center for Neurologic Study-Lability Scale (CNS-LS) and an 11-point scale measuring impact of the neurological condition on the patient's quality of life (QOL). Presence of PBA symptoms was defined as a CNS-LS score ≥13. Demographic data and current use of antidepressant or antipsychotic medications were also recorded. RESULTS PRISM enrolled 5290 patients. More than one third of patients (n = 1944; 36.7%) had a CNS-LS score ≥13, suggesting PBA symptoms. The mean (SD) score measuring impact of neurological condition on QOL was significantly higher (worse) in patients with CNS-LS ≥13 vs <13 (6.7 [2.5] vs. 4.7 [3.1], respectively; P<0.0001 two-sample t-test). A greater percentage of patients with CNS-LS ≥13 versus <13 were using antidepressant/antipsychotic medications (53.0% vs 35.4%, respectively; P<0.0001, chi-square test). CONCLUSIONS Data from PRISM, the largest clinic-based study to assess PBA symptom prevalence, showed that PBA symptoms were common among patients with diverse neurological conditions. Higher CNS-LS scores were associated with impaired QOL and greater use of antipsychotic/antidepressant medications. These data underscore a need for greater awareness, recognition, and diagnosis of PBA.
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Affiliation(s)
- Benjamin Rix Brooks
- Carolinas Medical Center, University of North Carolina School of Medicine–Charlotte Campus, Charlotte, North Carolina, United States of America
| | - David Crumpacker
- Baylor University Medical Center, Dallas, Texas, United States of America
| | - Jonathan Fellus
- International Brain Research Foundation, Flanders, New Jersey, United States of America
| | - Daniel Kantor
- Neurologique, Ponte Vedra Beach, Florida, United States of America
| | - Randall E. Kaye
- Avanir Pharmaceuticals, Inc., Aliso Viejo, California, United States of America
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King RR, Reiss JP. The epidemiology and pathophysiology of pseudobulbar affect and its association with neurodegeneration. Degener Neurol Neuromuscul Dis 2013; 3:23-31. [PMID: 30890891 PMCID: PMC6065587 DOI: 10.2147/dnnd.s34160] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Pseudobulbar affect is a disorder resulting from neurologic damage manifesting as sudden, stereotyped affective outbursts that are not reflective of internal emotion. A literature review was completed to examine the current understanding of the epidemiology, characterization, diagnosis, pathophysiology, and treatment of pseudobulbar affect. This review revealed that it is common in neurodegenerative disorders but is poorly recognized, placing significant impacts on patients and their families. The disorder appears to result from a disruption of the cortico-limbic-subcortical-thalamic-pontocerebellar network involved in emotional expression and regulation with resulting disruptions of neurotransmitter systems. Effective treatment is available with agents such as selective serotonin reuptake inhibitors and dextromethorphan combined with quinidine, but further well-designed comparative studies are needed. Advances in technology such as neuroimaging may enhance knowledge about the pathophysiology of this disorder, and help guide future interventions.
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Affiliation(s)
- Rebecca R King
- Department of Psychiatry, University of Western Ontario, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada,
| | - Jeffrey P Reiss
- Department of Psychiatry, University of Western Ontario, London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada,
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