6 Signs Your Uncontrolled Crying Is Pseudobulbar Affect, Not Depression

People who have pseudobulbar affect (PBA) often experience episodes of sudden uncontrollable and inappropriate laughing or crying.

Because of the latter symptom, crying, PBA is often misdiagnosed as a mood disorder — typically depression or bipolar disorder.

“Unfortunately, PBA can be misdiagnosed, and it’s usually because people find that they’re crying out of context with anything [triggering],” says Richard D. Zorowitz, MD, a rehabilitation medicine specialist at MedStar National Rehabilitation Network in Washington, D.C., and a professor of clinical rehabilitation medicine at Georgetown University School of Medicine. “It’s important to remember that PBA is a neurological condition that occurs as a result of a condition or injury affecting the brain. That’s the key difference.”

Because undiagnosed or misdiagnosed PBA can mean that you’re not receiving the treatment that you need to manage the condition’s symptoms, it’s vital that you and your care team understand what makes it different from mood disorders such as depression. In addition, because people with PBA often experience depression along with PBA, they may need to be treated for both conditions.

The Problem of Missed or Undiagnosed PBA

The July 2011 issue of the journal Advances in Therapy included the results of a survey of people with a history of Alzheimer’s disease, amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), Parkinson’s disease, stroke, or traumatic brain injury — six of the most common conditions associated with PBA.

The survey found that while three-quarters of the respondents had reported episodes of inappropriate laughing or crying to their doctors, none of them were diagnosed with PBA. Instead, roughly one-third of them were given a diagnosis of depression, and 13 percent were said to have bipolar disorder.

Worse, because of this misdiagnosis of PBA, only 52 percent of respondents with the condition were receiving appropriate treatment at the time of the survey.

Because proper treatment can reduce the frequency and severity of PBA episodes, if people who have the condition are not diagnosed or are misdiagnosed, that can have a significant impact on their quality of life.

The Difference Between Depression and PBA

PBA is most commonly confused with depression, so it’s important to distinguish the two.

Depression is often described as a persistent feeling of sadness that affects how you feel, think, and behave. The condition may interfere with normal day-to-day activities, and may leave you feeling that life isn't worth living.

Symptoms of depression may include:

• Sadness, tearfulness, emptiness, or hopelessness
• Angry outbursts, irritability, or frustration
• Disinterest in most or all normal activities, such as sex or hobbies
• Insomnia or excessive sleep
• Fatigue and/or lack of energy
• Changes in appetite and weight gain or loss
• Anxiety, agitation, or restlessness
• Feelings of worthlessness or guilt
• Difficulty concentrating or making decisions
• Memory loss
• Suicidal thoughts
• Unexplained pain or headaches

If you have PBA, however, you typically experience emotions normally, although you may have unexplained outbursts of laughter and/or crying at inappropriate times. These episodes may be frequent, involuntary, and uncontrollable, and they may seem exaggerated and disconnected from your emotional state at the time.

Research suggests that unexplained crying is more common in PBA than laughter, which is why the condition is commonly misdiagnosed as depression. But PBA episodes tend to be short in duration, while the symptoms of depression are typically more chronic or persistent.

Also, if you have PBA, you may not experience the sleep disturbances and change in appetite that are commonly associated with depression.

Says Dr. Zorowitz, “People with PBA will tell us, ‘I’m really not depressed, but I cry frequently nonetheless.’”

Finally, because PBA is most often related to an underlying neurological condition, such as Alzheimer’s, ALS, or MS, a full neurological exam is usually required for diagnosis. A primary care physician, on the other hand, can often accurately diagnose depression.

“When the emotional display of crying occurs, it’s quite possible to think that the patient may be suffering from depression rather than PBA, unless a thorough evaluation is conducted to distinguish the two different syndromes,” explains Edward Lauterbach, MD, a neuropsychiatrist and professor emeritus of psychiatry and neurology at Mercer University School of Medicine in Macon, Georgia, who has specialized in treating people with these conditions]. “Statistically, depression is far more common than PBA, hence a reflexive tendency on the part of doctors to assume that the emotional display is due to depression. Still, if you have a known or suspected brain disease, PBA should be excluded first as a potential diagnosis.”

According to Zorowitz, these are some signs you may have PBA rather than depression:

1. You’ve experienced uncontrollable laughing in addition to crying.
2. You can’t control the crying episodes. People with depression can control their episodes of crying, at least to an extent, and “can modulate [their] intensity and duration,” Dr. Lauterbach says, whereas in PBA, crying can’t be modulated and “tends to be of similar or identical intensity and duration from episode to episode.”
3. You have a neurological condition like MS, Parkinson’s disease, ALS, Alzheimer’s disease, stroke, or brain injury.
4. You’ve had outbursts of laughing and/or crying at inappropriate times and places (that last no more than a few minutes).
5. Your emotional outbursts are short (lasting just a few minutes).
6. You haven’t experienced changes in appetite, weight, or sleep, or other symptoms related to depression.

Depression and PBA Together

Complicating the problem is research that suggests that depression is common among those who have PBA. A review published in November 2013 in Therapeutics and Clinical Risk Management suggests that as many as 35 percent of people with PBA are depressed.

This may be related to the feelings of embarrassment people with PBA have after an episode and their tendency to avoid social situations to keep others from seeing their outbursts—or because they’re dealing with depression simultaneously for reasons other than PBA.

So even if you’ve been diagnosed with PBA, it’s vital to talk to your doctor if you experience any symptoms of depression.

“PBA is always caused by a neurological condition, whereas depression can certainly develop in the context of a neurological condition — but it’s not requisite and is usually absent,” Lauterbach says. “Of course, some neurological patients have both PBA and depression, and [in these cases] both should be properly diagnosed and treated.”