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Treating Involuntary Crying and Laughing

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The Difference Between Pseudobulbar Affect (PBA) and Depression

Medically Reviewed By Nicole Washington, DO, MPH

Crying episodes could be either depression or pseudobulbar affect. The difference is in how long they last.

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Sudden, uncontrollable episodes of crying, laughing, or other emotions that don’t have an obvious cause could be PBA.

Pseudobulbar affect involves bouts of intense emotional responses that occur after a brain injury, stroke, dementia, or Parkinson’s disease.

People often mistake PBA for depression because both cause crying episodes, but they aren’t the same. PBA generally develops after a disruption in the connections between parts of the brain responsible for controlling emotional expression.

Depression is a group of mental health conditions associated with sad, empty, or irritable moods that affect a person’s ability to function physically and mentally.

The two conditions sometimes overlap. Up to one-third Trusted Source PubMed Central Highly respected database from the National Institutes of Health Go to source  of people with PBA also have depression.

PBA can be uncomfortable and may have an adverse effect on your daily life. A diagnosis is essential so you can get started on the right treatment.

Knowing the difference between PBA and depression is helpful when you’re telling a doctor about your symptoms.

What causes PBA and depression?

PBA is caused by a disruption in communication between parts of your brain that control your emotional reactions, like the brainstem and frontal lobe. The condition gets its name from the bulb shape of the brainstem. 

People with PBA also experience changes to brain chemicals that control the expression of emotions. These changes are what make people with PBA cry or laugh uncontrollably without an apparent cause.

PBA affects people who have injuries or diseases of the brain, such as:

Between 5% and 50% Trusted Source PubMed Central Highly respected database from the National Institutes of Health Go to source  of people with these conditions develop PBA.

The causes of depression are more complex. The condition likely stems from a combination of several factors, including:

Depression is more common than PBA. About 21 million Trusted Source National Institute of Neurological Disorders and Stroke Governmental authority Go to source people in the United States, or more than 8% of the adult population, have experienced at least one episode of major depression in the past year. 

It’s hard to know exactly how many people have PBA because it’s so often misdiagnosed. Researchers estimate that from 2 million to 7 million Trusted Source PubMed Central Highly respected database from the National Institutes of Health Go to source  people in the United States live with the condition.

How are the symptoms different? 

PBA causes episodes of uncontrollable laughing, crying, or reactions of anger. The emotional responses are unusual for the situation. For example, someone with PBA might laugh at a funeral or cry during a humorous movie. 

Crying can be a symptom of depression, too. People with depression may also have symptoms like these:

  • feelings of guilt, worthlessness, or hopelessness
  • a lack of energy and fatigue
  • a loss of appetite or eating too much
  • restlessness or irritability
  • thoughts of death or suicide
  • trouble remembering, concentrating, or making decisions
  • trouble sleeping or sleeping too much

One difference between crying from PBA and from depression is how long it lasts. A PBA episode ends within a few seconds or minutes.

With depression, although crying may sometimes last only briefly, the sadness can last at least 2 weeks. Also, with depression, crying will accompany feelings of sadness or despair. With PBA, the crying won’t accompany these feelings. The person might feel fine, or even happy, despite crying.

Diagnosing PBA and depression

Healthcare professionals diagnose PBA and depression based on symptoms and how long they’ve lasted. Questionnaires such as the Center for Neurologic Study-Lability Scale (CNS-LS) and the Pathological Laughter and Crying Scale (PLACS) help healthcare professionals distinguish between PBA and depression. 

To receive a diagnosis of depression, your symptoms must have lasted at least 2 weeks and include a depressed mood or loss of interest in activities.

Treatments 

A drug that combines dextromethorphan hydrobromide and quinidine sulfate is the only medication specifically approved to treat PBA. It’s a capsule that you take once or twice a day. This medication changes levels of brain chemicals like glutamate and serotonin, which affect your emotional reactions.

A few techniques can also help you manage PBA episodes, including:

  • distracting yourself by counting or thinking of something else
  • taking slow, deep breaths
  • relaxing your muscles, especially the muscles in your face and shoulders
  • moving into a different position

Some of the same antidepressants that treat depression also help with PBA symptoms. These include selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. Doctors prescribe antidepressants at a lower dose for PBA than for depression.

Depression is also treated with other types of antidepressants, such as serotonin-norepinephrine reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors. Cognitive behavioral therapy (CBT) or “talk therapy” is another crucial part of treating depression. 

Summary

Pseudobulbar affect (PBA) impacts about one-third of people who have a stroke, multiple sclerosis (MS), or a traumatic brain injury. PBA is often misdiagnosed as depression because the two conditions have similar symptoms. Sometimes, the conditions overlap.

Contact a healthcare professional if you experience uncontrollable and unexpected bouts of laughing or crying. With the proper diagnosis, treatment can help reduce or stop these episodes.

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  2. Depression. (2021). https://www.nimh.nih.gov/health/publications/depression#part_6715
  3. Espiridion, ED. (2018). A major depressive disorder in a patient with pseudobulbar affect. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6388818/
  4. Highlights of prescribing information: Neudexta. (2010). https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021879s000lbl.pdf
  5. Kekere, V. (2022). Pseudobulbar affect mimicking depression: A case report. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9312808/
  6. Major depression. (2023). https://www.nimh.nih.gov/health/statistics/major-depression
  7. Pseudobulbar affect (PBA). (n.d.) https://www.biausa.org/brain-injury/about-brain-injury/pba
  8. Pseudobulbar affect (PBA). (2023). https://mymsaa.org/ms-information/symptoms/pba/
  9. Pseudobulbar affect (PBA). (2018). https://www.stroke.org/en/about-stroke/effects-of-stroke/emotional-effects-of-stroke/pseudobulbar-affect
  10. Turell, W. (2020). Living with the burden of pseudobulbar affect: A qualitative analysis of the effects of education on patient experience. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786644/
  11. What is depression? (2020). https://www.psychiatry.org/patients-families/depression/what-is-depression

Medical Reviewer: Nicole Washington, DO, MPH
Last Review Date: 2023 Nov 16
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