Pseudobulbar Affect: Understanding the Neurological Condition Behind Uncontrollable Laughter and Crying

Published on: November 21, 2022
Updated on: November 21, 2025
Author: Kentucky Counseling Center

Pseudobulbar Affect (PBA) may not be a household term, but it’s a crucial concept to understand—especially if you or a loved one has a history of neurological conditions. If you’ve ever wondered why the fictional comic villain Joker can’t seem to stop laughing, PBA offers a revealing lens into such uncontrollable emotional outbursts. Although dramatized, his iconic laughter parallels the involuntary nature of this disorder.

Below, we’ll explore the pseudobulbar effect, its symptoms, possible causes, and treatment options. You’ll also learn how to distinguish PBA from other mood or affective disorders, as well as helpful strategies for coping with unexpected episodes of laughing or crying.

What Is Pseudobulbar Affect (PBA)?

The National Stroke Association defines pseudobulbar affect as uncontrollable crying or laughing that does not align with an individual’s actual emotional state. The key issue is the mismatch between emotional expression and the genuine emotional response. Though it is often classified alongside psychiatric or psychological conditions, PBA is primarily a neurological disorder.

A Closer Look at Involuntary Emotional Expression Disorder

Pseudobulbar effect is sometimes referred to by several other terms:

• Pathological laughing or crying
• Emotional lability
• Emotional incontinence
• Emotional dysregulation

These terms underscore the involuntary nature of emotional outbursts. Patients may experience exaggerated episodes of laughter or crying that appear incongruent with the context—sometimes triggered by minor stimuli or even random thoughts.

Common Neurological Conditions Associated With PBA

• Multiple sclerosis (MS)
• Parkinson’s disease
• Alzheimer’s disease
• Amyotrophic lateral sclerosis (ALS)
• Traumatic brain injury (TBI)

According to the Cleveland Clinic, PBA may affect 1 to 2 million individuals in the United States, though exact prevalence depends on the underlying neurological condition.

Signs and Symptoms of Pseudobulbar Affect

The hallmark symptoms of PBA, or emotional lability, are sudden outbursts of laughter and/or crying that are intense, inappropriate, and often short-lived compared to true mood disorders like major depression. Specifically:

1. Unpredictable Onset
   
   • Many describe these episodes as “seizure-like” in their abruptness.
2. Involuntary Emotional Displays
   
   • Laughter or crying outbursts that are disproportionate to the actual emotional state.
3. Incongruence with Reality
   
   • The emotional response may be incongruent with the situation, such as laughing when hearing sad news or crying over mildly funny remarks.
4. Little to No Control
   
   • Once an episode begins, it can be difficult to stop, leading to embarrassment or frustration.
5. Outbursts of Anger or Frustration
   
   • While crying and laughter are the most common symptoms, some patients also exhibit sudden irritability or anger.

Patients often find these episodes distressing and disabling, especially when cognitive functions are otherwise intact. Many fear social settings or feel alienated because they can’t predict when the next outburst will occur.

Causes of Pseudobulbar Affect

According to Psychiatric Times, scientists are still uncertain of the real reason why people develop Pseudobulbar affect. But some theories can explain that neurotransmitters and certain areas of the brain may be involved. Is it nature or nurture? Here’s what you need to know about the causes of PBA.

Neurological Damage and “Release Phenomenon”

PBA is often attributed to damage or lesions in the brain’s frontal lobe, which is involved in emotional regulation. The “release hypothesis” suggests that when the normal inhibitory pathways between the frontal lobe and the brainstem (where laughter and crying are generated) are damaged, uncontrolled emotional expressions occur.

Gate Control Theory

Some researchers propose that the mechanism regulating emotional expression—often referred to as an internal “gate”—is disrupted. Neurological damage, such as that caused by Alzheimer’s disease, stroke, or multiple sclerosis, impairs the brain’s ability to modulate emotional outbursts.

Neurotransmitter Imbalances

Another theory indicates that after a brain injury, neurotransmitters like dopamine, glutamate, serotonin, and sigma-1 may be dysregulated, altering how emotions are processed and expressed.

Traumatic Brain Injury (TBI) and PBA

The Brain Injury Association of America points out that pseudobulbar affect can follow a traumatic brain injury. Pathological laughter or crying could be the first significant sign of neurological damage. Because these episodes can mimic depression (intense crying) or mania (inappropriate laughter), PBA is frequently underdiagnosed.

Diagnosis of Pseudobulbar Affect

Clinical Evaluation and Symptom Reporting

If someone experiences excessive, uncontrollable episodes of laughter or crying unrelated to their true emotions, a thorough medical evaluation is crucial. Doctors will look for:

• Medical and psychiatric history
• Onset and duration of outbursts
• Neurological exams and imaging (e.g., brain scans)
• Blood tests to rule out other conditions

Standardized Rating Scales

Several screening tools help measure the frequency and severity of PBA:

1. Center for Neurologic Study – Lability Scale (CNS-LS)
   
   • A 7-item questionnaire scored from 1 to 5, gauging control over laughing and crying. A score of 13 or above often indicates a high likelihood of PBA.
2. Pathological Laughter and Crying Scale
   
   • An 18-item questionnaire assessing how often these episodes occur and their emotional impact. A score above 13 suggests potential PBA in stroke patients.

Initial criteria for diagnosing PBA date back to 1969 (Poeck) and have been updated since. Clinicians now focus on whether the emotional expression is out of proportion to stimuli, involuntary, not explained by another disorder, and does not offer emotional relief afterward.

Prognosis for Patients with PBA

The outlook depends largely on the underlying neurological condition. For instance, patients with multiple sclerosis or Parkinson’s disease may have varying prognoses, but managing the symptoms of PBA generally improves quality of life. While PBA is not considered curable in a strict sense, many patients see significant improvement in the frequency and intensity of outbursts with appropriate treatment.

Treatment of Pseudobulbar Affect

Medications

• Selective Serotonin Reuptake Inhibitors (SSRIs) and Tricyclic Antidepressants (TCAs)
  
  • Help modulate serotonin levels, reducing the severity and frequency of outbursts.
  • TCAs can have more side effects and pose higher toxicity risks, especially in older adults.
• Dextromethorphan-Quinidine (Nuedexta)
  
  • Approved by the FDA in 2010 specifically for PBA.
  • Dextromethorphan affects neurotransmitters involved in emotional expression, while quinidine helps maintain the therapeutic levels of dextromethorphan in the brain.

Distinguishing PBA From Depression

• Duration: Depression is a mood disorder that can last weeks or months, while PBA episodes last minutes.
• Triggers: PBA is triggered by neurological damage; depression arises from a broader set of causes (chemical imbalances, life events, etc.).
• Cognitive and Physical Symptoms: Depression includes sleep disturbances, appetite changes, and feelings of hopelessness—symptoms not inherent to PBA.

Multiple Sclerosis and PBA

For individuals with multiple sclerosis, PBA can manifest as the disease progresses. Studies suggest that 10% of MS patients may experience at least one episode of PBA. Impaired communication between the brain and body in MS can exacerbate emotional dysregulation. Timely diagnosis and targeted therapies can help manage both MS symptoms and PBA outbursts.

Living With Pseudobulbar Affect

PBA can be isolating and frustrating, but certain strategies make it more manageable:

1. Deep Breathing and Relaxation
   
   • Practicing yoga, meditation, or mindful breathing can help regain control when an outburst feels imminent.
2. Open Communication
   
   • Inform co-workers, friends, and family about your condition so they understand that outbursts are neurologically based, not intentional or mean-spirited.
3. Body Awareness
   
   • Adjust your posture and relax your muscles (especially the face and shoulders) to help quell escalating emotions.
4. Seek Support Groups
   
   • Joining communities—online or in-person—can alleviate feelings of isolation and provide new coping tips.

Prevention of Pseudobulbar Affect

While there is no definitive method to prevent PBA, lowering the risk of certain neurological events can help:

• Stroke Prevention: Maintain a healthy blood pressure, manage heart disease, and exercise regularly to reduce the risk of stroke—one of the most common underlying conditions leading to PBA.
• Early Intervention: If you experience mild symptoms following a head injury or if you have a degenerative neurological disorder, consult a healthcare professional early to minimize the severity of PBA episodes.

How to Take Care of Yourself During and After an Episode

1. Look for Distractions
   
   • Engage in a quick, absorbing activity—like reading, puzzles, or games—to divert your mind.
2. Practice Deep Breathing
   
   • Focus on slow, measured breaths. Use yoga or meditation techniques to calm your mind.
3. “Mood Reversal”
   
   • If you find yourself crying uncontrollably, try watching a comedy or reading something lighthearted.
4. Do Something You Enjoy
   
   • Counteract stress by immersing yourself in hobbies—spending time outdoors, cooking, or meeting friends.

Concluding Thoughts

Pseudobulbar Affect is a neurological condition, often triggered by damage to the frontal lobe or other parts of the brain responsible for modulating emotional expression. The rapid, involuntary outbursts of laughter or crying can be mistaken for depression or mood disorders—leading to frequent misdiagnoses.

Understanding and recognizing PBA symptoms is critical for getting appropriate care. Counseling, medication, and educational support play pivotal roles in mitigating the impact of this condition. Families and caregivers also benefit from knowledge about PBA, which can help them respond with compassion and awareness.

Here at Kentucky Counseling Center, we have a team of professionals specializing in counseling, psychiatry, and case management. We accept Medicaid and most major insurance plans. If you or someone you know struggles with Pseudobulbar Affect or any other mental health concern, contact Kentucky Counseling Center for professional support.