Advances in Therapy

, Volume 29, Issue 9, pp 775–798 | Cite as

Pseudobulbar Affect: Burden of Illness in the USA

  • Jennifer Colamonico
  • Andrea FormellaEmail author
  • Walter Bradley
Open Access
Original Research



Pseudobulbar affect (PBA) is characterized by involuntary and uncontrollable laughing and/or crying episodes, occurring secondary to neurological disease or injury. The impact of PBA on social and occupational function, health status, quality of life (QOL), and quality of relationships (QOR) is not well studied.


This US survey conducted by Harris Interactive compared health status and daily function of patients with and without PBA. Eligible respondents were Harris Panel Online registrants previously diagnosed with stroke, multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, traumatic brain injury, or amyotrophic lateral sclerosis, or primary, nonpaid caregivers for such patients who were too debilitated to participate. PBA was identified by a Center for Neurologic Study lability scale score of 13 or greater. Measures included the 36-item short form health survey (SF-36), the work productivity and impairment (WPAI) questionnaire, visual analog scales (VAS) for impact of PBA symptoms on QOL and QOR, and customized questions related to burden and impact of involuntary laughing/crying episodes on patients’ lives. Survey responses were weighted to adjust for the relative proportion of the primary neurological conditions in the overall population and between group differences in patient age and gender. PBA and non-PBA group responses were compared using two-tailed t tests adjusted for severity of the primary neurological conditions.


The 1,052 respondents included 399 PBA group participants and 653 controls. The PBA group showed significantly worse scores versus non-PBA controls on component and summary SF-36 scores (P < 0.05 for all), VAS scores (P < 0.05 for both), and WPAI scores (P < 0.05). Among PBA group respondents, PBA contributed a great deal to or was the main cause of patients becoming housebound for 24% and being moved to supervised living placement for 9% of respondents.


PBA is associated with considerable burden incremental to that of the underlying neurological conditions, affecting QOL, QOR, health status, and social and occupational functioning.


Burden of illness Health status Occupational function Pseudobulbar affect Quality of life Social function 


  1. 1.
    Dark FL, McGrath JJ, Ron MA. Pathological laughing and crying. Aust NZ J Psychiatry. 1996;30:472–479.CrossRefGoogle Scholar
  2. 2.
    Schiffer R, Pope LE. Review of pseudobulbar affect including a novel and potential therapy. J Neuropsychiatry Clin Neurosci. 2005;17:447–454.PubMedCrossRefGoogle Scholar
  3. 3.
    Wortzel HS, Oster TJ, Anderson CA, Arciniegas DB. Pathological laughing and crying: epidemiology, pathophysiology and treatment. CNS Drugs. 2008;22:531–545.PubMedCrossRefGoogle Scholar
  4. 4.
    Arciniegas DB, Topkoff J. The neuropsychiatry of pathologic affect: an approach to evaluation and treatment. Semin Clin Neuropsychiatry. 2000;5:290–306.PubMedCrossRefGoogle Scholar
  5. 5.
    Work S, Colamonico JA, Bradley WG, Kaye RE. Pseudobulbar affect: an under-recognized and undertreated neurological disorder. Adv Ther. 2011;28:586–601.PubMedCrossRefGoogle Scholar
  6. 6.
    Wilson SAK. Some problems in neurology. II: pathological laughing and crying. J Neurol Psychopathol. 1924;4:299–333.PubMedCrossRefGoogle Scholar
  7. 7.
    Davison C, Kelman H. Pathologic laughing and crying. Arch Neurol Psychiatry. 1939;42:595–643.Google Scholar
  8. 8.
    Calvert T, Knapp P, House A. Psychological associations with emotionalism after stroke. J Neurol Neurosurg Psychiatry. 1998;65:928–929.PubMedCrossRefGoogle Scholar
  9. 9.
    Tateno A, Jorge RE, Robinson RG. Pathological laughing and crying following traumatic brain injury. J Neuropsychiatry Clin Neurosci. 2004;16:426–434.PubMedCrossRefGoogle Scholar
  10. 10.
    Siddiqui MS, Fernandez HH, Garvan CW, et al. Inappropriate crying and laughing in Parkinson disease and movement disorders. World J Biol Psychiatry. 2009;10:234–240.PubMedCrossRefGoogle Scholar
  11. 11.
    Strowd RE, Cartwright MS, Okun MS, Haq I, Siddiqui MS. Pseudobulbar affect: prevalence and quality of life impact in movement disorders. J Neurol. 2010;257:1382–1387.PubMedCrossRefGoogle Scholar
  12. 12.
    Tang WK, Chen Y, Lam WW, et al. Emotional incontinence and executive function in ischemic stroke: a case-controlled study. J Int Neuropsychol Soc. 2009;15:62–68.PubMedCrossRefGoogle Scholar
  13. 13.
    Choi-Kwon S, Kim JS. Poststroke emotional incontinence and decreased sexual activity. Cerebrovasc Dis. 2002;13:31–37.PubMedCrossRefGoogle Scholar
  14. 14.
    Petracca GM, Jorge RE, Ación L, Weintraub D, Robinson RG. Frequency and correlates of involuntary emotional expression disorder in Parkinson’s disease. J Neuropsych Clin Neurosci. 2009;21:406–412.CrossRefGoogle Scholar
  15. 15.
    Moore SR, Gresham LS, Bromberg MB, Kasarkis EJ, Smith RA. A self-report measure of affective lability. J Neurol Neurosurg Psychiatry. 1997;63:89–93.PubMedCrossRefGoogle Scholar
  16. 16.
    Smith RA, Berg JE, Pope LE, Callahan JD, Wynn D, Thisted RA. Validation of the CNS emotional lability scale for pseudobulbar affect (pathological laughing and crying) in multiple sclerosis patients. Mult Scler. 2004;10:1–7.CrossRefGoogle Scholar
  17. 17.
    Brooks BR, Thisted RA, Appel SH, et al; AVP-923 ALS Study Group. Treatment of pseudobulbar affect in ALS with dextromethorphan/quinidine: a randomized trial. Neurology. 2004;63:1364–1370.PubMedCrossRefGoogle Scholar
  18. 18.
    Panitch HS, Thisted RA, Smith RA, et al; Pseudobulbar Affect in Multiple Sclerosis Study Group. Randomized, controlled trial of dextromethorphan/ quinidine for pseudobulbar affect in multiple sclerosis. Ann Neurol. 2006;59:780–787.PubMedCrossRefGoogle Scholar
  19. 19.
    Pioro EP, Brooks BR, Cummings J, et al; Safety, Tolerability, and Efficacy Results Trial of AVP-923 in PBA Investigators. Dextromethorphan plus ultra low-dose quinidine reduces pseudobulbar affect. Ann Neurol. 2010;68:693–702.PubMedCrossRefGoogle Scholar
  20. 20.
    Faul M, Xu L, Wald MM, Coronado VG. Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths 2002–2006. Overview, page 13. Atlanta: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2010. Available at: Accessed Aug 8 2012.Google Scholar
  21. 21.
    Ware JE Jr., Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care. 1992;30:473–483.PubMedCrossRefGoogle Scholar
  22. 22.
    Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoeconomics. 1993;4:353–365.PubMedCrossRefGoogle Scholar
  23. 23.
    Vitaliano PP, Russo J, Young HM, Becker J, Maiuro RD. The screen for caregiver burden. Gerontologist. 1991;31:76–83.PubMedCrossRefGoogle Scholar
  24. 24.
    Andresen EM, Malmgren JA, Carter WB, Patrick DL. Screening for depression in well older adults: evaluation of a short form of the CES-D (Center for Epidemiologic Studies Depression Scale). Am J Prev Med. 1994;10:77–84.PubMedGoogle Scholar
  25. 25.
    Cedarbaum JM, Stambler N. Performance of the amyotrophic lateral sclerosis functional rating scale (ALSFRS) in multicenter clinical trials. J Neurol Sci. 1997;152:S1–S9.PubMedCrossRefGoogle Scholar
  26. 26.
    Schwab RS, England AC. Projection technique for evaluating surgery in Parkinson’s disease. In: Gillingham FJ, Donaldson IML, eds. Third Symposium on Parkinson’s Disease; May 20–22 1969, Edinburgh, UK.Google Scholar
  27. 27.
    Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist. 1969;9:179–186.PubMedCrossRefGoogle Scholar
  28. 28.
    Guajardo V, Souza BP, Henriques SG, et al. Loss of interest, depressed mood and impact on the quality of life: cross sectional survey. BMC Pub Health. 2011;11:826.CrossRefGoogle Scholar
  29. 29.
    House A, Dennis M, Molyneux A, Warlow C, Hawton K. Emotionalism after stroke. BMJ. 1989;298:991–994.PubMedCrossRefGoogle Scholar
  30. 30.
    Jenkinson C, Peto V, Fitzpatrick R, Greenhall R, Hyman N. Self-reported functioning and well-being in patients with Parkinson’s disease: comparison of the short-form Health Survey (SF-36) and the Parkinson’s Disease Questionnaire (PDQ-39). Age Ageing. 1995;24:505–509.PubMedCrossRefGoogle Scholar
  31. 31.
    Hagell P, Nygren C. The 39 item Parkinson’s disease questionnaire (PDQ-39) revisited: implications for evidence based medicine. J Neurol Neurosurg Psychiatry. 2007;78:1191–1198.PubMedCrossRefGoogle Scholar
  32. 32.
    Feinstein A, Feinstein K, Gray T, O’Connor P. Prevalence and neurobehavioral correlates of pathological laughing and crying in multiple sclerosis. Arch Neurol. 1997;54:1116–1121.PubMedCrossRefGoogle Scholar
  33. 33.
    Feinstein A, O’Connor P, Gray T, Feinstein K. Pathological laughing and crying in multiple sclerosis: a preliminary report suggesting a role for the prefrontal cortex. Mult Scler. 1999;5:69–73.PubMedGoogle Scholar
  34. 34.
    McCullagh S, Moore M, Gawel M, Feinstein A. Pathological laughing and crying in amyotrophic lateral sclerosis: an association with prefrontal cognitive dysfunction. J Neurol Sci. 1999;169:43–48.PubMedCrossRefGoogle Scholar
  35. 35.
    Edgley K, Sullivan MJ, Dehoux E. A survey of multiple sclerosis: part 2. Determinants of employment status. Can J Rehabil. 1991;4:127–132.Google Scholar
  36. 36.
    Julian LJ, Vella L, Vollmer T, Hadjimichael O, Mohr DC. Employment in multiple sclerosis: exiting and reentering the work force. J Neurol. 2008;255:1354–1360.PubMedCrossRefGoogle Scholar
  37. 37.
    Morrow SA, Drake A, Zivadinov R, Munschauer F, Weinstock-Guttman B, Benedict RH. Predicting loss of employment over three years in multiple sclerosis: clinically meaningful cognitive decline. Clin Neuropsychol. 2010;24:1131–1145.PubMedCrossRefGoogle Scholar
  38. 38.
    Ownsworth T, Shum D. Relationship between executive functions and productivity outcomes following stroke. Disabil Rehabil. 2008;30:531–540.PubMedCrossRefGoogle Scholar
  39. 39.
    Lantz MS. Pathologic laughing and crying in multiple sclerosis. Clin Geriatr. 2005;13:14–17.Google Scholar
  40. 40.
    Starr LB, Robinson RG, Price TR. Reliability, validity, and clinical utility of the social functioning exam in the assessment of stroke patients. Exp Aging Res. 1983;9:101–106.PubMedCrossRefGoogle Scholar
  41. 41.
    Phuong L, Garg S, Duda JE, Stern MB, Weintraub D. Involuntary emotional expression disorder (IEED) in Parkinson’s disease. Parkinsonism Relat Disord. 2009;15:511–515.PubMedCrossRefGoogle Scholar
  42. 42.
    Cummings JL, Arciniegas DB, Brooks BR, et al. Defining and diagnosing involuntary emotional expression disorder. CNS Spectrums. 2006;11:1–7.PubMedGoogle Scholar

Copyright information

© The Author(s) 2012

Authors and Affiliations

  • Jennifer Colamonico
    • 1
  • Andrea Formella
    • 2
    Email author
  • Walter Bradley
    • 3
  1. 1.Harris Interactive Inc.New YorkUSA
  2. 2.Avanir Pharmaceuticals, Inc.Aliso ViejoUSA
  3. 3.Miller School of MedicineUniversity of MiamiMiamiUSA

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