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Chen L, Ye S, Murphy D, Wu J, Zhang H, Liu H, Zou B, Hou G, Zhang N, Yin T, Smith RA, Fan D. Chinese Translation and Validation of the Center for Neurologic Study Lability Scale. Neurol Ther 2024:10.1007/s40120-024-00605-w. [PMID: 38625649 DOI: 10.1007/s40120-024-00605-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/15/2024] [Indexed: 04/17/2024] Open
Abstract
INTRODUCTION Pseudobulbar palsy is a common symptom in patients with amyotrophic lateral sclerosis (ALS), but it is often underdiagnosed or misdiagnosed as other diseases. The Center for Neurologic Study Lability Scale (CNS-LS) is a self-report scale consisting of seven questions designed for evaluating pseudobulbar affect (PBA). The current study aimed to validate a Chinese version of the CNS-LS. METHODS The Chinese version of the CNS-LS was obtained through a standardized forward-backward translation and cultural adaptation. A total of 105 patients with ALS were recruited from the ALS database of Peking University Third Hospital in Beijing, China, to complete the CNS-LS. The reliability of the Chinese version was determined by the test-retest method, and receiver operating characteristic (ROC) analysis was performed for criterion validity. RESULTS Of 105 patients with ALS, 37 had symptoms of PBA and were diagnosed with that condition by neurologists. Forty-two patients completed the CNS-LS twice, and there was no statistically significant difference between the scores (Z = -0.896, p = 0.37). The Spearman correlation coefficient between the test and retest scores was 0.940 (p < 0.0005), and the Cronbach alpha coefficient was high (α = 0.905, n = 105). Scores of 12 or higher on the CNS-LS identified PBA with sensitivity of 0.919 and specificity of 0.882. The area under the ROC curve was 0.924. CONCLUSION The Chinese version of the CNS-LS demonstrated good sensitivity and specificity in the group of patients with ALS enrolled in this study. The CNS-LS should be a useful instrument for clinical and research purposes for patients in this language group.
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Affiliation(s)
- Lu Chen
- Department of Neurology, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
- Department of Neurology, Yan'an Hospital of Traditional Chinese Medicine, No. 26 Xuan Yuan Road, Bridge Ditch Street, Bao Ta District, Yan'an, 716000, Shaanxi Province, China
| | - Shan Ye
- Department of Neurology, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Davan Murphy
- Center for Neurological Study in La Jolla, 7590 Fay Avenue, Suite 517, La Jolla, CA, USA
| | - Jieying Wu
- Department of Neurology, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Hui Zhang
- Department of Neurology, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Hong Liu
- Department of Neurology, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Boliang Zou
- Department of Neurology, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Guanghao Hou
- Department of Neurology, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Nan Zhang
- Department of Neurology, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Tielun Yin
- Department of Neurology, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China
| | - Richard A Smith
- Center for Neurological Study in La Jolla, 7590 Fay Avenue, Suite 517, La Jolla, CA, USA.
| | - Dongsheng Fan
- Department of Neurology, Peking University Third Hospital, Haidian District, 49 North Garden Road, Beijing, 100191, China.
- Key Laboratory for Neuroscience, National Health Commission/Ministry of Education, Peking University, 38 Xueyuan Road, Haidian District, Beijing, 100191, China.
- Beijing Key Laboratory of Biomarker and Translational Research in Neurodegenerative Diseases, Beijing, 100191, China.
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Long RM, DuVal M, Mulvany-Robbins B, Wagner AN, Jickling GC. Emotional dysmetria after cerebellar-pontine stroke: a case report. J Med Case Rep 2023; 17:544. [PMID: 38098127 PMCID: PMC10722665 DOI: 10.1186/s13256-023-04294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/29/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Pseudobulbar affect, or emotional dysregulation, commonly occurs following stroke. However, it is frequently missed in cases involving the cerebellum, resulting in a lack of treatment, which can directly impact stroke rehabilitation. CASE PRESENTATION A 63-year-old Caucasian female with no history of mood disorders presented with gait instability, dysarthria, and right sided hemiplegia, secondary to cerebellar and pontine ischemic stroke from a basilar occlusion. She underwent endovascular therapy and her deficits gradually improved. However during recovery she began to develop uncontrollable tearfulness while retaining insight that her emotional expression was contextually inappropriate. She was treated with a selective serotonin reuptake inhibitor with reported improvements in her emotional regulation at one year follow up. CONCLUSION This case highlights cerebellar injury as a potential cause of poorly regulated emotions, or an emotional dysmetria. The recognition of this disorder in patients with cerebellar or pontine strokes is critical, as untreated pseudobulbar affect can impact future stroke rehabilitation.
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Affiliation(s)
- Rebecca M Long
- Cumming School of Medicine, University of Calgary, Calgary, Canada.
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
| | - Michèle DuVal
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada
| | | | - Amanda N Wagner
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada
| | - Glen C Jickling
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Trojsi F, Di Nardo F, D’Alvano G, Caiazzo G, Passaniti C, Mangione A, Sharbafshaaer M, Russo A, Silvestro M, Siciliano M, Cirillo M, Tedeschi G, Esposito F. Resting state fMRI analysis of pseudobulbar affect in Amyotrophic Lateral Sclerosis (ALS): motor dysfunction of emotional expression. Brain Imaging Behav 2023; 17:77-89. [PMID: 36370302 PMCID: PMC9922228 DOI: 10.1007/s11682-022-00744-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 11/13/2022]
Abstract
Pseudobulbar affect (PBA), referring to exaggerated or inappropriate episodes of laughing and/or crying without an apparent motivating stimulus, has been mainly attributed to bilateral degeneration of corticobulbar tracts. We aimed at exploring brain functional connectivity (FC) correlates of PBA in patients with amyotrophic lateral sclerosis (ALS), the most common motor neuron disease, frequently associated with PBA. Resting state functional MRI (RS-fMRI) independent component (ICA) and seed-based analyses and voxel-based morphometry (VBM) whole-brain analysis were performed on 27 ALS patients (13 with PBA; 14 without PBA) and 26 healthy controls (HC), for investigating functional and structural abnormalities in ALS patients compared to HC and in patients with PBA compared to patients without PBA. Between-patient analysis revealed different FC patterns, especially regarding decreased FC in several areas of cognitive (default mode, frontoparietal, salience) and sensory-motor networks in patients with PBA compared to those without PBA. However, no significant differences were found in gray matter atrophy. Seed-based analysis showed increased FC between middle cerebellar peduncles and posterior cingulate cortex and decreased FC between middle cerebellar peduncles and left middle frontal gyrus in patients with PBA compared to patients without PBA. Our findings suggest that some alterations of fronto-tempo-parietal-cerebellar circuits could be related to PBA in ALS. In particular, the abnormal FC between cerebellum and posterior cingulate cortex and left middle frontal gyrus in patients with PBA compared to patients without PBA highlights a crucial role of the cerebellum in regulating emotion expression in patients with ALS.
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Affiliation(s)
- Francesca Trojsi
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania "Luigi Vanvitelli", P.Zza Miraglia 2, 80138, Naples, Italy.
| | - Federica Di Nardo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Giulia D’Alvano
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Giuseppina Caiazzo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Carla Passaniti
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Antonella Mangione
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Minoo Sharbafshaaer
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Antonio Russo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Marcello Silvestro
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Mattia Siciliano
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Mario Cirillo
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Gioacchino Tedeschi
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
| | - Fabrizio Esposito
- Department of Advanced Medical and Surgical Sciences, MRI Research Center, Università degli Studi della Campania “Luigi Vanvitelli”, P.Zza Miraglia 2, 80138 Naples, Italy
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Sancho J, Ferrer S, Burés E, Luis Díaz J, Torrecilla T, Signes-Costa J, Servera E. Effect of one-year dextromethorphan/quinidine treatment on management of respiratory impairment in amyotrophic lateral sclerosis. Respir Med 2021; 186:106536. [PMID: 34260979 DOI: 10.1016/j.rmed.2021.106536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 11/26/2022]
Abstract
Treatment with Dextromethorphan/Quinidine (DM/Q) has demonstrated benefit on pseudobulbar affect and bulbar function in amyotrophic lateral sclerosis (ALS). The aim of this study was to assess whether DM/Q could provide long-term improvement in bulbar function and thereby prolong noninvasive respiratory management in ALS. MATERIALS AND METHODS This prospective, case-cohort study, recruited ALS patients with bulbar dysfunction. Subjects included were compared with cross-matched historical controls. Cases received DM/Q (20/10 mg twice daily) during one-year follow-up; bulbar dysfunction was evaluated with the Norris scale bulbar subscore (NBS) and bulbar subscale of AlSFRS-R (ALSFRSb). RESULTS In total, 21 cases and 20 controls were enrolled, of whom noninvasive respiratory muscle assistance failed in 6 (28.5%) patients in the DM/Q group, compared with 4 patients (20.0%) in the control group (p = 0.645). Time from study onset to failure of respiratory muscle aids was 5.50 + 1.31 months in the DM/Q group and 5.20 + 1.15 months in the control group (p = 0.663). The adjusted OR for the effect of treatment on failure of noninvasive respiratory muscle aids was 2.12 (95%CI 0.23-33.79, p = 0.592). In the DM/Q group an impairment in scores was found in NBS (F = 19.26, p = 0.000) and ALSFRS-Rb (F = 12.71, p = 0.001) across different months of the study. CONCLUSION Treatment with DM/Q in ALS is unable to prolong noninvasive respiratory management, and moreover, has no effect on long-term deterioration of bulbar function. Notwithstanding the results on bulbar function, DM/Q was found to improve pseudobulbar affect during one-year follow-up.
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Affiliation(s)
- Jesus Sancho
- Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; Research Group for Respiratory Problems in Neuromuscular Diseases, INCLIVA Health Research Institute, Spain.
| | - Santos Ferrer
- Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; Research Group for Respiratory Problems in Neuromuscular Diseases, INCLIVA Health Research Institute, Spain
| | - Enric Burés
- Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; Research Group for Respiratory Problems in Neuromuscular Diseases, INCLIVA Health Research Institute, Spain
| | - José Luis Díaz
- Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; Research Group for Respiratory Problems in Neuromuscular Diseases, INCLIVA Health Research Institute, Spain; International University of Valencia(VIU), Spain; Airliquide Healthcare Group, Spain
| | - Teresa Torrecilla
- Pharmacy Department, Hospital Clínico Universitario, Valencia, Spain
| | - Jaime Signes-Costa
- Respiratory Medicine Department, Hospital Clínico Universitario, Valencia, Spain; Research Group for Respiratory Problems in Neuromuscular Diseases, INCLIVA Health Research Institute, Spain
| | - Emilio Servera
- Research Group for Respiratory Problems in Neuromuscular Diseases, INCLIVA Health Research Institute, Spain
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Abstract
Neurological disease can impair emotional communication by several means: damaging the networks important in understanding the meaning of emotional stimuli (emotional semantics); damaging networks important in the perceptual recognition and production of emotional stimuli, and damaging the connections between networks supporting emotional semantics and recognition/production networks. Disorders of emotional expression, comprehension, and emotional semantics may improve with pharmacological or behavioral treatments. Pharmacological treatments can be used to redress naturally occurring or disease-related alterations in the computational properties of target neural systems. No drug treatment can replace a loss of cerebral knowledge related to the pathological loss of neural connectivity. Behavioral treatments that benefit either comprehension or expression of specific emotions may be of value if these emotions are particularly important in enabling human social interaction. However, behavioral treatments that achieve generalization, that is, improve performance with untrained exemplars and in daily life, are much to be preferred, even as they pose the greatest methodological challenges. This chapter will discuss possible mechanisms of generalization and then review what is known about the treatment of expressive and receptive affective aprosodia, deficits in recognition of facial emotions, and pseudobulbar affect. The final section of the chapter is devoted to a discussion of three disorders of emotional semantics, apathy, alexithymia, and impaired empathy.
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Affiliation(s)
- Stephen E Nadeau
- Research Service and the Brain Rehabilitation Research Center, Malcom Randall Veteran Affairs Medical Center, Gainesville, FL, United States; Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, United States.
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Young FG, Nguyen D. Treatment of pseudobulbar affect (PBA) in a patient with a history of traumatic brain injury, partial brain resection, and brainstem stroke: a case report. J Med Case Rep 2020; 14:235. [PMID: 33272325 PMCID: PMC7716484 DOI: 10.1186/s13256-020-02525-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 09/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pseudobulbar affect is a very distressing and underdiagnosed neuropsychiatric disorder that causes contextually inappropriate episodes of laughing and crying and general emotional incontinence. Although many proposed etiologies exist, the most widely accepted theory espouses the disruption of a corticopontine-cerebellar circuit that governs the modulation of emotional response. Pseudobulbar affect is commonly diagnosed secondary to primary neurological disorders such as amyotrophic lateral sclerosis, multiple sclerosis, and traumatic brain injury. Traditional pharmacological treatment of pseudobulbar affect is largely comprised of antidepressant therapy, including tricyclic antidepressants such as amitriptyline and selective serotonin reuptake inhibitors such as fluvoxamine. However, neither of these medication classes has been studied for the treatment of pseudobulbar affect in controlled trials, and their utility remains questionable. CASE PRESENTATION We describe a case of a 62-year-old Caucasian man with history of traumatic brain injury, ischemic brainstem stroke, and depression who developed intractable pseudobulbar affect. This patient's intensely distressing symptoms were not alleviated by amitriptyline. However, after being placed on fixed-dose 20 mg/10 mg dextromethorphan/quinidine (Nuedexta), our patient experienced complete resolution of his symptoms. He has experienced no deleterious side effects. CONCLUSIONS This case provides anecdotal evidence for the efficacy of dextromethorphan/quinidine in the treatment of pseudobulbar affect with remarkably swift and complete cessation of symptoms. As a secondary point, it is worth noting that our patient had experienced two devastating neurological traumas, both in anatomical areas that have been implicated in the corticopontine-cerebellar circuit thought to be responsible for pseudobulbar affect. However, only the second trauma, an acute left pontine infarction, produced symptoms of emotional disinhibition. The authors hope that reporting this case will provide both context for physicians managing this condition and hope for patients with this socially and psychiatrically damaging disease.
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Affiliation(s)
- Fletcher Graham Young
- University of Pikeville, Kentucky College of Osteopathic Medicine, The Medical Center, Bowling Green, KY, 42101, USA.
| | - Diep Nguyen
- University of Pikeville, Kentucky College of Osteopathic Medicine, The Medical Center, Bowling Green, KY, 42101, USA
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Villeneuve Y, Cruz-Santiago D, Masson H, Clerc D. Treatment of pseudobulbar affect in a mixed neurodegenerative disorder with compounded quinidine capsules and dextromethorphan cough syrup. SAGE Open Med Case Rep 2020; 8:2050313X20921076. [PMID: 32547756 PMCID: PMC7273619 DOI: 10.1177/2050313x20921076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 03/27/2020] [Indexed: 11/29/2022] Open
Abstract
An elderly woman admitted in our geriatric inpatient unit suffered from disturbing outbursts of crying and, less frequently, episodes of laughing. The patient was diagnosed with pseudobulbar affect related to a mixed neurodegenerative disorder. This condition is often underdiagnosed and undertreated, despite being relatively frequent in patients with neurodegenerative disorders. This case report describes the treatment of pseudobulbar affect in this patient. The only available treatment in Canada for this condition, antidepressants, was not effective for our patient. Dextromethorphan/quinidine is a good accepted alternative, but the combination is not marketed in Canada. To manage this problem, we used compounded quinidine capsules and dextromethorphan cough syrup. The crying of our patient improved significantly and rapidly after the initiation of this treatment. This case will help professionals to review their central role in treating this complex and disabling condition.
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Affiliation(s)
- Yannick Villeneuve
- Department of Pharmacy, Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, Canada
- Yannick Villeneuve, Department of Pharmacy, Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, H3W 1W5, Canada.
| | - Diana Cruz-Santiago
- Department of Geriatric Medicine, Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, Canada
- Department of Family and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Helene Masson
- Department of Neurosciences, Centre Hospitalier de l’Université de Montréal, Montreal, Quebec, Canada
| | - Doris Clerc
- Department of Geriatric Medicine, Institut Universitaire de Gériatrie de Montréal, Montreal, Quebec, Canada
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Alet M, Segamarchi C, Claverie S, Gonzálezy L, Lepera S, Rey R. [ Pseudobulbar affect in stroke patients in Argentina]. Vertex 2020; XXX:1-5. [PMID: 33890929 DOI: 10.53680/vertex.v30i148.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Pseudobulbar affect is defined by involuntary or exaggerated episodes of laughter or crying, subsequent to a specific disease. After-stroke pseudobulbar affect is reported in 11%-34% of patients. In our population is underdiagnosed. Our objective was to determine its frequency in a group of stroke patients. PATIENTS AND METHODS Prospective observational study from June/2017 to June/2018. Two populations were evaluated: chronic stroke (Group A) and acute stroke (Group B). Patients with severe psychiatric illness, cognitive impairment and/or aphasia were excluded. PLACS ("pathological laughing and crying scale") and CNS-LS ("lability scale for pseudobulbar affect") scales were performed. Pseudobulbar affect was defined with diagnostic criteria plus both positive scales. RESULTS Fifty patients were evaluated. Sixty-eight percent were men. Mean age: 65±12 years. Group A: 19 cases and group B: 31 cases. Positive PLACS: 21% group A and 29% group B. Positive CNS-LS: 58% group A and 26% group B. Both positive scales in 8 patients (2 in group A and 6 in group B). Three of them had associated depression. CONCLUSIONS Pseudobulbar affect should be screened after stroke. Post-stroke depression is frequent and differential diagnose with emotional lability attributable to pseudobulbar affect must be ruled out. The administration of a single scale would not be sufficient for diagnostic guidance.
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Affiliation(s)
- Matías Alet
- Sección de Enfermedades Cerebrovasculares, Servicio de Neurología. Hospital J.M. Ramos Mejía, Ciudad de Buenos Aires, Argentina. E-mail:
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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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Hassan I, Sahjpaul R, Tan JE, Moien Afshari F. Pseudobulbar Affect Due to Skull Base Meningioma Resolving After Temporal Lobectomy for Epilepsy. Can J Neurol Sci 2018; 45:485-6. [PMID: 29747704 DOI: 10.1017/cjn.2018.26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Wicks P, Lancashire L. No tears in heaven: did the media create the pseudo-phenomenon "altitude-adjusted lachrymosity syndrome (AALS)"? PeerJ 2018; 6:e4569. [PMID: 29632743 PMCID: PMC5888120 DOI: 10.7717/peerj.4569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/09/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE In the media, numerous public figures have reported involuntary emotional outbursts arising from watching films on planes, resembling neurological phenomena such as pseudobulbar affect. Putative risk factors put forward include altitude, mild hypoxia, or alcohol. Our objective was to determine whether watching a film on an airplane is really more likely to induce involuntary, uncontrollable, or surprising crying than watching one on the ground, described in some social media as "altitude-adjusted lachrymosity syndrome" (AALS), or whether this is a pseudo-phenomena. METHODS Amazon Mechanical Turk survey participants (N = 1,084) living in the United States who had watched a film on a plane in the past 12 months were invited to complete an online survey. The main outcome measures were likelihood of crying in a logistic regression model including location of viewing, age, gender, genre of film, subjective film rating, annual household income, watching a "guilty pleasure" film, drinking alcohol, feeling tired or jetlagged, or having a recent emotional life event. RESULTS About one in four films induced crying. Watching a film on a plane per se does not appear to induce involuntary crying. Significant predictors of crying included dramas or family films, a recent life event, watching a "guilty pleasure", high film ratings, and female gender. Medical conditions, age, income, alcohol use, and feeling tired or jetlagged were not significant. CONCLUSION People reporting the pseudo-phenomena of AALS are most likely experiencing "dramatically heightened exposure", watching as many films on a plane in a week's return trip as they would in a year at the cinema. Such perceptions are probably magnified by confirmation bias and further mentions in social media.
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Affiliation(s)
- Paul Wicks
- PatientsLikeMe, Cambridge, MA, United States of America
| | - Lee Lancashire
- Cohen Veterans Bioscience, Cambridge, MA, United States of America
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
Dextromethorphan (DM) has been used for more than 50years as an over-the-counter antitussive. Studies have revealed a complex pharmacology of DM with mechanisms beyond blockade of N-methyl-d-aspartate (NMDA) receptors and inhibition of glutamate excitotoxicity, likely contributing to its pharmacological activity and clinical potential. DM is rapidly metabolized to dextrorphan, which has hampered the exploration of DM therapy separate from its metabolites. Coadministration of DM with a low dose of quinidine inhibits DM metabolism, yields greater bioavailability and enables more specific testing of the therapeutic properties of DM apart from its metabolites. The development of the drug combination DM hydrobromide and quinidine sulfate (DM/Q), with subsequent approval by the US Food and Drug Administration for pseudobulbar affect, led to renewed interest in understanding DM pharmacology. This review summarizes the interactions of DM with brain receptors and transporters and also considers its metabolic and pharmacokinetic properties. To assess the potential clinical relevance of these interactions, we provide an analysis comparing DM activity from in vitro functional assays with the estimated free drug DM concentrations in the brain following oral DM/Q administration. The findings suggest that DM/Q likely inhibits serotonin and norepinephrine reuptake and also blocks NMDA receptors with rapid kinetics. Use of DM/Q may also antagonize nicotinic acetylcholine receptors, particularly those composed of α3β4 subunits, and cause agonist activity at sigma-1 receptors.
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Affiliation(s)
| | - Stephen F Traynelis
- Dept. of Pharmacology, Emory University School of Medicine, Atlanta, GA, USA
| | - Joao Siffert
- Avanir Pharmaceuticals, Inc., Aliso Viejo, CA, USA
| | - Laura E Pope
- Avanir Pharmaceuticals, Inc., Aliso Viejo, CA, USA
| | - Rae R Matsumoto
- College of Pharmacy, Touro University California, Vallejo, CA, USA
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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17
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Tortelli R, Copetti M, Arcuti S, Tursi M, Iurillo A, Barulli MR, Cortese R, Capozzo R, D'Errico E, Marin B, Simone IL, Logroscino G. Pseudobulbar affect (PBA) in an incident ALS cohort: results from the Apulia registry (SLAP). J Neurol 2016; 263:316-21. [PMID: 26588919 DOI: 10.1007/s00415-015-7981-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [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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18
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Abstract
The number of available symptomatic treatments has markedly enhanced the care of patients with amyotrophic lateral sclerosis (ALS). Once thought to be untreatable, patients with ALS today clearly benefit from multidisciplinary care. The impact of such care on the disease course, including rate of progression and mortality, has surpassed the treatment effects commonly sought in clinical drug trials. Unfortunately, there are few randomized controlled trials of medications or interventions addressing symptom management. In this review, the authors provide the level of evidence, when available, for each intervention that is currently considered standard of care by consensus opinion.
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Affiliation(s)
- Stacy Rudnicki
- University of Arkansas for Medical Sciences, 501 Jackson Stephens Drive, Room 769, Little Rock, Arkansas 72205-7199
| | - April L. McVey
- University of Kansas Medical Center, Dept. of Neurology, 3901 Rainbow Blvd, Mailstop 2012, Kansas City, KS 66160
| | - Carlayne E. Jackson
- University of Texas Health Science Center, 8300 Floyd Curl Drive, Mail Code 7883, San Antonio, TX 78229-3900
| | - Mazen M. Dimachkie
- University of Kansas Medical Center, Dept. of Neurology, 3901 Rainbow Blvd, Mailstop 2012, Kansas City, KS 66160
| | - Richard J. Barohn
- University of Kansas Medical Center, Dept. of Neurology, 3901 Rainbow Blvd, Mailstop 2012, Kansas City, KS 66160
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Abstract
Primary lateral sclerosis is characterized by insidious onset of progressive upper motor neuron dysfunction in the absence of clinical signs of lower motor neuron involvement. Patients experience stiffness; decreased balance and coordination; mild weakness; and, if the bulbar region is affected, difficulty speaking and swallowing, and emotional lability. The diagnosis is made based on clinical history, typical examination findings, and diagnostic testing negative for other causes of upper motor neuron dysfunction. Electromyogram is normal, or only shows mild neurogenic findings in a few muscles, not meeting El Escorial criteria. Treatment is largely supportive.
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Affiliation(s)
- Jeffrey M Statland
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 2012, Kansas City, KS 66160, USA.
| | - Richard J Barohn
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 2012, Kansas City, KS 66160, USA
| | - Mazen M Dimachkie
- Department of Neurology, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 2012, Kansas City, KS 66160, USA
| | - Mary Kay Floeter
- Human Spinal Physiology Unit, National Institute of Neurological Disorders and Stroke, Building 10, Room 7-5680, 10 Center Drive, Bethesda, MD 20892, USA
| | - Hiroshi Mitsumoto
- Department of Neurology, Columbia University Medical Center, 710 West 168th Street, New York City, NY 10032, USA
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20
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Chattha PK, Greene PE, Ramdhani RA. Pseudobulbar laughter as a levodopa off phenomenon exacerbated by subthalamic deep brain stimulation. J Clin Mov Disord 2015; 2:13. [PMID: 26788349 PMCID: PMC4711012 DOI: 10.1186/s40734-015-0023-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/27/2015] [Indexed: 11/10/2022]
Abstract
Pseudobulbar affect is a common symptom in neurodegenerative diseases and can also result from lesions in cortical, subcortical and brainstem regions. In Parkinson’s disease (PD), pseudobulbar affect (PBA) can occur as a wearing off phenomenon, manifested usually as crying without emotionality. In addition, subthalamic (STN) deep brain stimulation (DBS) has been reported to induce PBA in PD patients with no prior history of such episodes. We present a case of inappropriate laughter lacking mirth as a levodopa OFF phenomenon in a patient with PD, whose laughter also worsened with STN-DBS in his non-medicated state. Levodopa ameliorated his PBA both with and without stimulation. The case demonstrates pseudobulbar laughter as a levodopa OFF phenomenon that is also exacerbated by STN-DBS.
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Affiliation(s)
- P K Chattha
- Medical University of Lublin, Lublin, Poland
| | - P E Greene
- Department of Neurology Division of Movement Disorders, Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA
| | - Ritesh A Ramdhani
- Department of Neurology Division of Movement Disorders, Icahn School of Medicine at Mount Sinai, New York, NY 10029 USA ; Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, 5 East 98th St. First Floor, New York, NY 10029 USA
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21
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Assouad R, Louapre C, Tourbah A, Papeix C, Galanaud D, Lubetzki C, Stankoff B. Clinical and MRI characterization of MS patients with a pure and severe cognitive onset. Clin Neurol Neurosurg 2014; 126:55-63. [PMID: 25215443 DOI: 10.1016/j.clineuro.2014.08.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Revised: 07/21/2014] [Accepted: 08/01/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND OBJECTIVE Cognitive and behavioural symptoms are common in multiple sclerosis (MS), but they are rarely the inaugural and predominant manifestation of the disease. Our objective is to characterize the clinical and radiological features of cognitive-multiple sclerosis (cog-MS), defined as MS subjects who entered into the disease with cognitive symptoms, which subsequently remain the predominant manifestation. METHODS We describe the disease course, and clinical and radiological features of 18 subjects with a cognitive form of MS. RESULTS Memory loss and behavioural changes were the primary symptoms at disease onset. They remained prominent and led to severe cognitive impairment during disease course. The main associated manifestations were depression, pathological laughing and/or crying, urinary incontinence and gait disturbance suggestive of high-level gait disorder. Motor, sensory or cerebellar abnormalities were uncommon. During disease course, superimposed neurological relapses occurred in 61% of cases. Brain MRI revealed multiple periventricular lesions that were extensive and confluent in half of cases, and a severe atrophy measured as an increase in the third ventricular width compared to age-matched healthy controls. Gadolinium-enhancing lesions were common (72%). The mean diagnosis delay from disease onset was 2 years. A principal component analysis on the neuropsychological results revealed that verbal memory assessment is complementary to global cognitive functioning evaluation in these patients with severe cognitive deficit. Verbal memory deficit was associated with high EDSS. CONCLUSIONS cog-MS patients might represent a challenging diagnosis, which needs to be individualized for an early management.
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Affiliation(s)
- Rana Assouad
- AP-HP, Hôpital de la Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Celine Louapre
- AP-HP, Hôpital de la Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, and Inserm U 1127, and CNRS UMR 7225, and ICM, F-75013 Paris, France
| | - Ayman Tourbah
- AP-HP, Hôpital de la Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France; Centre Hospitalo-Universitaire de Reims, Université Champagne Ardennes Reims, France
| | - Caroline Papeix
- AP-HP, Hôpital de la Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France
| | - Damien Galanaud
- AP-HP, Hôpital de la Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, and Inserm U 1127, and CNRS UMR 7225, and ICM, F-75013 Paris, France
| | - Catherine Lubetzki
- AP-HP, Hôpital de la Salpêtrière, 47-83 boulevard de l'Hôpital, 75013 Paris, France; Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, and Inserm U 1127, and CNRS UMR 7225, and ICM, F-75013 Paris, France
| | - Bruno Stankoff
- Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, and Inserm U 1127, and CNRS UMR 7225, and ICM, F-75013 Paris, France; AP-HP, Hôpital Tenon, 4 rue de la Chine, 75020 Paris, France.
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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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24
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Johnson B, Nichols S. Crying and suicidal, but not depressed. Pseudobulbar affect in multiple sclerosis successfully treated with valproic acid: Case report and literature review. Palliat Support Care 2015; 13:1797-801. [PMID: 24916672 DOI: 10.1017/S1478951514000376] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Pseudobulbar affect/emotional incontinence is a potentially disabling condition characterized by expressions of affect or emotions out of context from the normal emotional basis for those expressions. This condition can result in diagnostic confusion and unrelieved suffering when clinicians interpret the emotional expressions at face value. In addition, the nomenclature, etiology, and treatment for this condition remain unclear in the medical literature. METHOD We report the case of a 60-year-old woman with multiple sclerosis who was referred to an inpatient psychiatry unit with complaints of worsening depression along with hopelessness, characterized by unrelenting crying. Our investigation showed that her symptoms were caused by pseudobulbar affect/emotional incontinence stemming from multiple sclerosis. RESULTS The patient's history of multiple sclerosis and the fact that she identified herself as depressed only because of her incessant crying suggested that her symptoms might be due to the multiple sclerosis rather than to a depressive disorder. Magnetic resonance imaging demonstrated a new plaque consistent with multiple sclerosis lateral to her corpus callosum. Her symptoms resolved completely within three days on valproic acid but returned after she was cross-tapered to dextromethorphan plus quinidine, which is the FDA-approved treatment for this condition. SIGNIFICANCE OF RESULTS This case provides important additional information to the current literature on pseudobulbar affect/emotional incontinence. The existing literature suggests a selective serotonin reuptake inhibitor (SSRI) and dextromethorphan/quinidine (Nuedexta) as first-line treatments; however, our patient was taking an SSRI at the time of presentation without appreciable benefit, and her symptoms responded to valproic acid but not to the dextromethorphan/quinidine. In addition, the case and the literature review suggest that the current nomenclature for this constellation of symptoms can be misleading.
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Zarowitz BJ, O'Shea T. Clinical, behavioral, and treatment differences in nursing facility residents with dementia, with and without pseudobulbar affect symptomatology. ACTA ACUST UNITED AC 2014; 28:713-22. [PMID: 24217191 DOI: 10.4140/tcp.n.2013.713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Characterize the prevalence and impact of crying and tearfulness as symptoms that may be suggestive of pseudobulbar affect (PBA) in residents of nursing facilities, including those with Alzheimer's disease (AD) and non-AD [non-AD-associated] associated dementia. DESIGN Data were extracted retrospectively from a large repository of de-identified and linked Minimum Data Set 2.0 (MDS) and prescription claims records for the period between October 1, 2009, and September 30, 2010. A score of 1 or 2 on MDS item E1m ("crying, tearfulness") was used to identify potential PBA. SETTING 19,000 nursing facilities in 48 states. PATIENTS/PARTICIPANTS Prescription and MDS records of nursing facility residents. MAIN OUTCOME MEASURES Comparison of concomitant diagnoses, MDS mood, and behavioral indicators, and psychopharmacologic medication use, in residents with crying/tearfulness to a control group matched for age, gender, diagnosis of AD or non-AD dementia, and diagnosis of depression. RESULTS A total of 137,829 residents underwent at least one MDS assessment during the study period. Of these, 12,595 (9.1%) had item E1m ("crying, tearfulness") scored as a 1 or 2 on their MDS assessments. Ten thousand residents were then randomly selected from this group and matched to 10,000 controls without "crying, tearfulness" (MDS E1m = 0) for analysis. A total of 4,786 (47.9%) unique residents with "crying, tearfulness" had a diagnosis of AD (8.8%), non-AD dementia (31.5%), or both (7.6%). All of the MDS mood indicators were at least twice as prevalent in this group compared with those without "crying, tearfulness" Additionally, mood symptoms such as anger, worried/pained facial expressions, and repetitive verbalizations; and behavioral symptoms such as verbal/physical abuse and socially inappropriate/disruptive behavior, were more than twice as frequent in the "crying, tearfulness" group. Antipsychotic medications were also used more often in this group (50% vs. 36.1%), as were antidepressants (59.1% vs. 49.8%). CONCLUSIONS In the absence of an International Classification of Diseases 9th edition, Clinical Modification code, the presence of "crying, tearfulness" on MDS 2.0 item E1m was used as a proxy to identify potential PBA. Nursing facility residents with "crying, tearfulness" had a higher prevalence of all mood and behavior indicators as well as psychopharmacological medication use, compared with matched controls without "crying, tearfulness." Similar results were seen in the subgroup of residents with an underlying diagnosis of AD and/or non-AD dementia. Further research should validate the actual prevalence of PBA in this population, and the corresponding impact on resident outcomes.
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Affiliation(s)
- Barbara J Zarowitz
- Omnicare, Inc., Livonia, Michigan College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
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Abstract
OBJECTIVE To evaluate the role of dextromethorphan/quinidine (DM/Q; Nuedexta™) in the treatment of pseudobulbar affect (PBA). DATA SOURCES A literature search of MEDLINE/PubMed (January 1966-June 2013) was conducted using search terms pseudobulbar affect, pathological laughing and/or crying, emotional lability, dextromethorphan, and quinidine. STUDY SELECTION AND DATA EXTRACTION English language clinical trials and case reports evaluating the safety and efficacy of DM/Q in PBA were included for review. Bibliographies of all relevant articles were reviewed for additional citations. DATA SYNTHESIS PBA, a poorly understood disorder, is characterized by involuntary crying and/or laughing. In the past, antidepressants and antiepileptics have been used off-label with mixed results. Four clinical trials have evaluated the use of DM/Q for the treatment of PBA. Although the therapeutic outcomes with DM/Q have been positive, interpretation of the published evidence is limited by small sample size and short treatment duration. CONCLUSIONS Based on the data available, DM/Q may be a viable, short-term treatment alternative for PBA. Long-term safety and efficacy data are lacking.
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Affiliation(s)
- Edna Patatanian
- College of Pharmacy, Southwestern Oklahoma State University, Weatherford, Oklahoma
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