Do you know why “Joker” laughs so much? A comic book supervillain noted for his sick jokes and clown-like appearance, with that red paint plastered fixed in a creepy grin. Joker is Batman’s long-time foe and a popular villain admired by his DC comic fans for his iconic appearance and personality. But did you know that Joker’s creepy and uncontrollable laughing condition is due to a mental illness called Pseudobulbar affect?

National Stroke Association Defines PBA

The National Stroke Association defines Pseudobulbar affect as uncontrollable crying or laughing due to the disparity of an individual’s emotional expression and emotional response. It is mostly observed in patients with multiple sclerosis and other brain disorders.

What is Pseudobulbar affect? This article will tell you more about this psychological condition, its disease process, and its natural history. Disease knowledge is essential for the treatment of any kind of neurological condition.

A Type of An Involuntary Emotional Expression Disorder

Pseudobulbar affect (PBA) is more of a neurological condition than a psychological illness. It is also coined in different medical terms such as an involuntary emotional expression disorder, pathological laughing, emotional lability, emotional incontinence, and emotional dysregulation.

This type of neurological disorder is often misdiagnosed and often left untreated. It is usually characterized by uncontrollable episodes of laughter, crying, and other emotional displays that are incongruent and exaggerated with the underlying mood. Aside from multiple sclerosis, pseudobulbar affect also associated with Parkinson’s disease, Alzheimer’s disease, Amyotrophic Lateral Sclerosis, Traumatic Brain Injury, and other neurological disorders.

The pathological crying and laughing episodes can be caused by a triggering event such as a thought or an idea and can sometimes be difficult to restrain. The display of such exaggerated emotions can last longer and more intensely out of the ordinary.

Signs And Symptoms of Pseudobulbar Affect

The main symptoms of Pseudobulbar affect (PBA), or emotional lability, are sudden outbursts of laughing and crying that are usually intense and inappropriate. Another cardinal feature is the pathological lowering of the patient’s threshold for exhibiting emotional incontinence and behavioral response.

Patients with pseudobulbar affect have exaggerated emotional responses caused by stimuli congruent with the appropriate display of emotions. For example, a funny stimulus provokes inappropriate laughing episodes when the situation only calls for a smile or a giggle.

There are also other cases of Pseudobulbar Affect where the patient’s emotional display is incongruent to the emotional valence of the triggering stimulus. For example, the patient will cry as a response to happy news. Emotional displays may also switch from crying episodes to laughing in an instance or vice versa.

The symptoms of pseudobulbar affect can be persistent and severe. Other characteristics include:

  • Unpredictable and sudden onset, many patients described it as having a seizure
  • Involuntary and intense fits of laughter and crying in response to triggering stimuli with an emotion that is inappropriate to the event
  • Outbursts of anger and frustration
  • Lack of symptoms between emotional outbursts
  • The emotional responses are over-the-top or exaggerated for the situation.

When patients are clinically diagnosed with neurological disorders such as Parkinson’s disease or Bipolar disorder, true pseudobulbar affect can be unclear, opposing a grosser form of emotional dysregulation. Patients with intact cognitive functions will often describe the symptoms as disturbing.

Other patients would address their episodes as partially amenable to voluntary control unless there was a sudden change in mental status. The clinical effect of pseudobulbar can be disabling to patients and can also affect the patient’s family members and their everyday lives.

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.

Release Hypothesis

Our brain’s frontal lobe is responsible for our emotional responses’ conscious and semiconscious control. Pseudobulbar affect may be a result of prefrontal lobe damage. The frontal lobe has neurons that connect to the Medulla, the lower region of the brain that controls crying and laughter may be damaged.

Gate Control Theory

This theory suggests inhibition of the mechanism that regulates emotional expression. Neurological damage such as Alzheimer’s disease ought to be why the cortical structures’ activities are disrupted. The “gate control” mechanisms keep our emotional expressions in check. The neurological damages caused by brain diseases can disrupt the brain’s activities related to emotional processing and sensory motors.

Dysfunction of Neurotransmitters Theory

After a brain injury, this theory proposes that the neurotransmitters in the brain, such as dopamine, glutamate, serotonin, and sigma-1, are disrupted in different pathways and alter emotional expressions.

Traumatic Brain Injury and Pseudobulbar Affect

According to the Brain Injury Association of America, Pseudobulbar affect is a condition that can occur after a traumatic brain injury or a neurological disorder. PBA symptoms may range from mild to seizure-like episodes. Some people may confuse Pseudobulbar affect with depression since it involves excessive crying when the patient feels sad.

When underdiagnosed, pseudobulbar affect can be a distressing psychological disorder. Pathological laughter following a brain injury should be taken seriously, especially if it is accompanied by other PBA symptoms.

Person with pseudobulbar affect acting different emotions as oppose to what they truly feel.
Image from WikiMedia by Mark Harkin

How is the Pseudobulbar Affect Diagnosed?

If you know someone or a family member is laughing or crying a lot with no apparent reason, talk to a professional and seek proper medical help.

Most of the time, symptoms of the Pseudobulbar effect are overlooked, leading to misdiagnosis of this condition. The diagnosis is often made through the patient’s self-reported symptoms, medical observation, and clinical presentations.

Doctors, nowadays, have developed standardized rating scales to further screen and measure pseudobulbar affect more effectively. These scales include:

Center For Neurologic Study- Liability Scale (CNS-LS)

It is a self-administered, 7-item questionnaire about laughing and crying control. Each item scores from 1 to 5, and the total score ranges from 7 to 35, 7 being “no excess emotional liability” and 35 as to “severe excess emotional liability”. When a patient scores 13 and above, it predicts a clinical diagnosis of PBA in 82% of ALS patients than MS patients.

Pathological Laughter and Crying Scale

This scale is administered to measure sudden episodes of crying and laughing. It is an 18-item questionnaire that answers the question of how often the patient would have them and how does the symptoms made them feel. A score of more than 13 predicts a clinical diagnosis of pseudobulbar affect in stroke patients with high specificity. 

Pseudobulbar affect can also be diagnosed by a blood test or a brain scan. An initial criterion for pseudobulbar affect was established in 1969 by Poeck. These criteria include the appropriate response to situations, inability to control the severity and duration of the symptoms, affect is not congruent with the emotions, and emotional expression does not result in relief. 

These criteria were then expanded during 2006 and included a change with the emotional reactivity baseline, that the symptoms are not secondary to drug use, not due to another disorder, and the effect is not incongruent to the patient’s subjective emotions.

Prognosis For Patients with PBA

A patient’s pre-existing or underlying condition is the basis of prognosis. Some patients have neurological disorders like MS or Parkinson’s disease. The treatment aims to enhance the quality of life by reducing the frequency and intensity of the patient’s outbursts. PBA is not yet proven to be curable, but the signs and symptoms can be managed with medication.

How To Treat Pseudobulbar Affect

In treating PBA, disease knowledge is very important. Educating families, patients and caregiver is essential for treatment. This type of condition is easily underdiagnosed or misdiagnosed, and exaggerated laughing or crying can easily be interpreted as a symptom of depression or a mood disorder.

Pharmacotherapy aims to reduce the frequency and severity of the symptoms experienced. Common treatments target neurotransmitters such as glutamate and serotonin, which affect GABA release and motor function.

Selective Serotonin Reuptake Inhibitors and Tricyclic antidepressants are also used to treat PBA. These drugs can help increase serotonin levels in the cerebellar pathway. The SSRI has a narrow mechanism of action that aims to enhance serotonergic functions, while the TCA fixes much broader neurotransmitter functions.

Tricyclic antidepressants or TCA can be therapeutic because of their anticholinergic effect on Parkinson’s and ALS patients. However, the use of TCA as a treatment is limited due to its toxicity risk, drug-to-drug interactions, and side effect profiles. While the mechanism of action of SSRIs is directed to serotonergic neurotransmission, the side effect profile is less problematic compared to that of TCA.

Just last 2010, the first drug meant to treat PBA, Dextromethorphan (Nuedexta), was approved by the DFA. Clinicians use this medication for mood disorders and certain mental health conditions, like PBA. Nuedexta is consists of a capsule of Dextromethorphan and Quinidine taken once a week. Quinidine is an antiarrhythmic medication that can inhibit CYP2D that slows down the breakdown of Dextromethorphan and increase the brain’s exposure.

Depression and PBA

Depression is a mood disorder, while pseudobulbar affects an affective disorder. An effect is subjective and an outward expression, while the mood is experienced internally. Depression usually lasts for months, while symptoms of PBA usually last for a couple of minutes.

Patients with major depression usually know or can identify their triggers and can modulate their emotional response voluntarily, while with PBA, the response can be involuntary and uncontrollable. Diagnosis of depression includes changes in appetite, sleep disturbances, changes in energy, and feelings of hopelessness. These somatic symptoms are not associated with pseudobulbar affect.

Multiple Sclerosis And PBA

PBA is a nervous system condition, and multiple sclerosis is a neurological disorder. When a person is diagnosed with multiple sclerosis, their immune system is being attacked by their central nervous system. MS hinders the communication between the brain and body.

Studies show that 10% of patients with MS experience at least an episode of pseudobulbar affect. PBA is usually associated with the chronic progressive stage of the disease. MS patients who developed PBA tend to develop symptoms such as physical and neurological disability and intellectual deterioration.

Living with Pseudobulbar Affect

Living with PBA can be both isolating and frustrating. Some steps can help you and your family ease the stress and anxiety during an episode of PBA:

  • Breathe deeply and slowly until you feel that you are once again in control of your emotions.
  • Try talking to people around you, especially your co-workers and people whom you see every day. Talk to them about your condition and how it affects your family, so they won’t be alarmed or surprised during an episode.
  • Change the position of your body, try relaxing your shoulders, face, and other muscle groups during an episode.
  • Try to avoid social isolation and talk to others with the same condition. Try to learn from their experiences, and you might pick up tips along the way.

Prevention of Pseudobulbar Affect

Being diagnosed with PBA does not mean that you have to live with its symptoms for the best part of your life. PBA is associated with neurological conditions and brain injury, but experts are still uncertain why some people develop it, and others don’t. There are ways that one can do to reduce the risk of getting the disease.

Prevent PBA by reducing the risk of developing stroke, which is one of the underlying causes of PBA.

Pseudobulbar affect is reported as a post-stroke behavioral syndrome. Post-stroke patients most likely suffer depressive symptoms, triggering the weeping and wailing side of PBA symptoms. Reducing the risk of stroke by keeping your blood pressure within normal range, treating heart disease, and regular exercise can also prevent you from developing PBA.

How to Take Care of Yourself During and After an Episode

Look for a Distraction

Download an app on your mobile phone that could distract and hold your interest for a while or try to invest your time reading a book and keep your mind active and occupied. Try to find another hobby that can take your mind off the laughter and tears.


Try to practice deep breathing exercises. Yoga and meditations are great ways to promote inner calmness and relaxation. If you feel like you’re about to have another PBA episode, pause and practice deep breathing exercises. 

Place Your Emotions in Reverse

If you can’t stop crying, try to watch a happy movie or visit a comedy bar and get your dose of laughter. Sometimes, manipulating your mood can also avoid PBA episodes.

Do Something That You Enjoy

Pseudobulbar affect, and its underlying conditions can cause stress to the patient and their loved ones. Do something that you know you’ll enjoy and take your mind off the stress. Go out with your friends and family, go camping, fishing, or do anything worthwhile.

Concluding Thoughts

Pseudobulbar Affect is a neurological condition that occurs when triggered by damaged frontal lobes and other neurological underlying causes. The involuntary outbursts of signs and symptoms of PBS are sometimes mistaken as depression or a mood disorder.

Being educated and intellectually equipped with the disease process is essential in treating it. These types of conditions can affect a person’s physical and emotional well-being. Finding the right kind of mental health counselors could really help you get back on track.

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.

Search Posts


Leave a Reply

Your email address will not be published. Required fields are marked *

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Recent Posts

Introduction: In the bustling city of Lexington, KY, where the demands of daily life can take a toll on one’s mental health, it’s crucial to have access to professional counseling and psychiatry services. These
Ever wonder why you feel good after a good laugh? Why watching a comedy film with your family and laughing together instantly improve your mood? It’s because laughter is the best medicine. It’s not
Do you think you have the skills to read people’s emotions through their facial expressions? Yes, it is a skill that not everyone can do. But you don’t have to become a psychiatrist or