PBA and Depression

Actor portrayal of a patient with PseudoBulbar Affect (PBA) crying symptoms

Are your patients with depression also experiencing PBA?

Pseudobulbar affect (PBA) is commonly comorbid with depression or other mood and behavioral disorders. Screen for PBA when patients with neurologic conditions or brain injury are diagnosed with and treated for depression but are still experiencing involuntary, sudden, frequent laughing and/or crying episodes.1-4


In a clinical study, more than half of patients who were diagnosed with PBA had comorbid depression (N=367).5,a,b

70.8% of patients in the study were taking psychopharmacologic medications.

aPRISM II was a 90-day, open-label, single-arm, 74-site, US trial in adult patients with dementia, stroke, or TBI. All patients received a clinical diagnosis of PBA by their physician and had a Center for Neurologic Study-Lability Scale (CNS-LS) score ≥13 at baseline. CNS-LS is a 7-item self-report rating scale that measures perceived frequency and control over laughing and/or crying episodes. It was validated as a PBA screening tool in ALS and MS populations. CNS-LS ≥13 may suggest PBA but does not confer a PBA diagnosis.4-8

bBased on Patient Health Questionnaire-9 (PHQ-9), a 9-item assessment of depressive symptoms. Scores range from 0 to 27, with higher scores indicating increased depression severity.5

Nurse Practitioner Cathy Yaggi talks differentiating depression from PseudoBulbar Affect (PBA)
PBA and Depression: how to tell the difference
Nurse Practitioner Cathy explains how she differentiates between depression and PBA in her residents.

Differentiate PBA from depression by recognizing the characteristics of crying9

  • Matches how the patient feels
  • Mostly controllable; stops when mood changes
  • Onset and duration defined by mood
  • Disproportionate to or inconsistent with how the patient feels
  • Uncontrollable
  • Happens frequently, suddenly, and may be brief

These are not all the diagnostic features of depression.7 Formal diagnosis of depression or PBA can only be made by a qualified healthcare practitioner.

Various mood and behavioral disorders can affect patients with neurologic conditions or brain injury2

Depression is only one of many behavioral disorders that have symptoms similar to PBA. Crying or other outbursts are common among these disorders as well, which can complicate the diagnosis of PBA.1,3,4,9-11

Behavioral disorders with symptoms similar to PseudoBulbar Affect (PBA)

References: 1. Miller A, Pratt H, Schiffer RB. Pseudobulbar affect: the spectrum of clinical presentations, etiologies and treatments. Expert Rev Neurother. 2011;11(7):1077-1088. 2. Colamonico J, Formella A, Bradley W. Pseudobulbar affect: burden of illness in the USA. Adv Ther. 2012;29(9):775-798. 3. Parvizi J, Arciniegas DB, Bernardini GL, et al. Diagnosis and management of pathological laughter and crying. Mayo Clin Proc. 2006;81(11):1482-1486. 4. 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(8):e72232. 5. Hammond FM, Alexander DN, Cutler AJ, et al. 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. 6. Moore SR, Gresham LS, Bromberg MB, Kasarkis EJ, Smith RA. A self report measure of affective lability. J Neurol Neurosurg Psychiatry. 1997;63(1):89-93. 7. 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(6):679-685. 8. Smith RA, Berg JE, Pope LE, Thisted RA. Measuring pseudobulbar affect in ALS. Amyotroph Lateral Scler Other Motor Neuron Disord. 2004;5(suppl 1):99-102. 9. Cummings JL, Arciniegas DB, Brooks BR, et al. Deﬁning and diagnosing involuntary emotional expression disorder. CNS Spectr. 2006;11(S6):1-7. 10. Engelman WA, Hammond FM, Malec JF. Diagnosing pseudobulbar affect in traumatic brain injury. Neuropsychiatr Dis Treat. 2014;10:1903-1910. 11. Crumpacker DW, Engelman WA. Identifying pseudobulbar affect in Alzheimer’s disease and dementia. US Neurol. 2014;10(1):10-14.
















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