Behavioral Treatment of Pseudobulbar Affect: A Case Report

Post-stroke emotionalism: Diagnosis, pathophysiology, and treatment

BACKGROUND

Post-stroke emotionalism affects one in five stroke sufferers 6 months after their stroke, but despite its frequency remains a poorly understood stroke symptom. The literature is limited, especially compared to other frequently observed neurological conditions such as aphasia and visual neglect.

AIM AND METHODS

This narrative review presents a summary of the post-stroke emotionalism literature, to inform clinical practice and future research. We cover discussion of definitions, prevalence, neurobiology, predisposing and precipitating factors, and treatment.

RESULTS

Increasing evidence suggests that damage to specific areas functionally linked to emotion expression or regulation processes, disruption to structural pathways and those related to serotonin production and modulation individually or in concert give rise to emotionalism-type presentations. A range of emotionalism measurement tools have been used in research contexts making between study comparisons difficult. Testing for Emotionalism after Recent Stroke-Questionnaire (TEARS-Q) has recently been developed to allow standardized assessment. Treatment options are limited, and there have been few adequately powered treatment trials. Antidepressants may reduce severity, but more trial data are required. There have been no randomized-controlled trials of non-pharmacological interventions.

CONCLUSIONS

More research is needed to improve recognition and treatment of this common and disabling symptom. We conclude with research priorities and recommendations for the field.

Pseudobulbar Affect: An Overview

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.].

Post-stroke emotionalism: a qualitative investigation

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.

Recognizing and treating pseudobulbar affect

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.