The Neurologic Condition More People Need to Understand: PBA
Dr. Drew Falconer is a board-certified neurologist and movement disorders specialist at the Inova Medical Group. He specializes in advanced care of patients with Parkinson’s disease, essential tremor, dystonia, Huntington’s disease, tic disorders and other movement disorders. He has been awarded many honors for his exceptional work as both a doctor and teacher, is a member of the International Parkinson and Movement Disorder Society and serves on the medical advisory board for the Parkinson Foundation of the National Capital Area (PFNCA).
“I saw a patient crying uncontrollably in front of me, and they didn’t know why,” recalls Dr. Drew Falconer, board-certified neurologist and movement disorders specialist at the Inova Medical Group. This was the first time during his fellowship that he’d come across someone with PseudoBulbar Affect (PBA) — a largely unheard of neurologic condition that affects someone’s emotional expression, causing sudden, frequent and uncontrollable episodes of crying and/or laughing that don’t match how they feel and occur secondary to neurologic condition or injury. 
Because of these symptoms, and because PBA is prevalent in people with other neurological conditions like traumatic brain injury (TBI), stroke, multiple sclerosis (MS), ALS (Lou Gehrig’s disease), Alzheimer’s disease and Parkinson’s disease, many doctors assume the crying/laughing episodes are a result of depression stemming from their underlying neurologic condition. Despite PBA not being a well-known condition among all doctors, approximately 2 million people in the U.S. with neurologic conditions or traumatic brain injury have it. 
“It is a type of emotional incontinence,” Dr. Falconer elaborates. “It’s where that thermostat and control of emotional expression is not set right.” Patients can have episodes where they may cry and/or laugh in response to a situation in way that is not in line with their current mood. This can all lead to social isolation and alteration of a patient’s choices because they’re worried about embarrassing themselves in public or in the presence of loved ones. “It can bother the patients, it can bother the family… those that have experienced it have shared that it can make everybody uncomfortable,” Dr. Falconer notes. 
With that first PBA patient, Dr. Falconer said it was tough for him to take action because there was so little information available about the condition at that time. While Dr. Falconer is now familiar with PBA and has been able to help his PBA patients manage their condition, that is not the case with all doctors.
For patients to receive the support they need, doctors must have a basic understanding of the condition so that they can properly recognize and manage it.
“If you don’t know a condition exists, you can’t manage it,” Dr. Falconer said.
“Understanding of PBA is so limited,” he continued. “I didn’t hear about PBA until I was in my final leg of training, my fellowship. So, not only did I not learn about it when I started in medical school, but I didn’t hear about it in neurology residency after that either.” Dr. Falconer said that while he did see it in residency, PBA was not stressed as a condition to prioritize. With little awareness of the condition, PBA commonly goes misdiagnosed as depression, anxiety or another psychiatric diagnosis. 
“People don’t really talk about it, people don’t learn about it and people don’t bring it to the forefront to allow it to be managed,” says Dr. Falconer.
While PBA is an expression of emotion that includes laughing and/or crying, Dr. Falconer emphasized that it’s very different from the patient’s actual emotional feeling. It is a disconnect between feeling and expression. Dr. Falconer says doctors need to ask the right questions and know what to look for. Not every case is going to be “extreme.” In fact, many cases go undiagnosed. 
“Most people suffer in silence,” Dr. Falconer says.
Dr. Falconer diagnoses PBA through conversation with the patient or through screening. Screening consists of a brief test made up of seven questions that ask patients to rate their responses to statements on a scale of 1 to 5. Questions look something like: “There are times when I feel fine one minute and then I’ll become tearful the next over something small or for no reason at all.” Resulting scores of 13 or higher may suggest PBA in patients with a neurologic condition, such as Parkinson’s disease, according to Dr. Falconer.
If you suspect that you or a loved one might have PBA, there is a short online quiz that you can take and share with your doctor.
“For us, we want patients to know that they’re going to be okay and we can help them manage their condition,” Dr. Falconer said. “And all of a sudden you give them that ounce of hope that they need.”
 Miller A, Pratt H, Schiffer RB. Pseudobulbar affect: the spectrum of clinical presentations, etiologies and treatments. Expert Rev. Neurother. 11(7), 1077–1088 (2011).
 Work S, Colamonico JA, Bradley, WG, et al. Pseudobulbar affect: an underrecognized and undertreated neurological disorder. Adv Ther.2011;28:586-601