Pseudobulbar Affect – Not All Crying After Stroke Is Depression

Henry Hoffman
Friday, February 9th, 2018
Last modified on September 9th, 2022

Pseudobulbar Affect - Not All Crying After Stroke Is Depression

Among stroke survivors, feelings of depression and sadness are unfortunately common. The body has experienced acute changes both physically and mentally, and certain emotional responses may be triggered as a result. A survivor may find themselves dealing with bouts of anger, mood swings, and moments of intense crying or laughing, but these reactions do not necessarily indicate a typical case of depression.

Pseudobulbar affect (PBA) is an oft-overlooked condition. Health professionals may be quick to diagnose an individual showing signs of PBA with depression or similar disorder. This is a serious mistake because PBA and depression stem from different sources and therefore require different treatments.


By learning more about PBA, you can better understand what is happening to yourself or a loved one and take the appropriate steps toward successful recovery.

What Is Pseudobulbar Affect?

Also known as involuntary emotional expression disorder (IEED), pseudobulbar affect (PBA) involves frequent, sudden, and uncontrollable outbursts of emotion. These expressions may take the form of exaggerated or excessive laughing, crying, anger, or sadness. The defining characteristic of this disorder is that the outburst is not representative of how the person actually feels when the outburst occurs.

An emotional imbalance may stem from neurological damage in the brain’s prefrontal cortex, causing an individual to express random, strong emotions without an obvious trigger. PBA often is confused with depression because of similar behavioral patterns. It’s important to remember, however, that PBA is a neurological condition while depression is a psychological one. An overlap in symptoms can be misleading because PBA and depression are caused by different factors and should be approached with different solutions.

What Are The Differences Between PBA And Depression?

Aside from these two conditions originating in separate realms of the body, the major distinguishing difference is the cause of the emotion. A person suffering from depression may display behavior related to the feeling of negative emotions, resulting from being in a genuine prolonged depressive state. A person experiencing PBA does not necessarily have genuine feelings of prolonged sadness or happiness. Individuals with PBA can express extreme sadness or extreme joy, regardless of their true emotional state. The episodes are unpredictable and do not have particular triggers. Because these outbursts are unpredictable, many people with PBA try to cope by avoiding social situations, especially situations where they will be surrounded by those unaware of their diagnosis and their outbursts can lead to particularly embarrassing situations. Unfortunately, similar to depression, isolating oneself is one of the least helpful things one can do when attempting to combat a disorder.

There are other crucial differences in the experiences of living with PBA as opposed to depression. An episode related to PBA most likely will be short and intense, occurring for only a few seconds to a few minutes. Someone with PBA is unlikely to have other, more prolonged symptoms more commonly found in people with depression, such as a loss of appetite or immense feelings of guilt. The emotional expressions of depression last for a substantial amount of time, from several weeks or months, to even several years. Symptoms of depression also may appear milder on the surface, particularly because they can often be much more easily concealed than symptoms of PBA.

Keep in mind that it is possible for PBA and depression to co-exist, and they often do—but the illnesses are separate and need to be addressed as such. If you or a loved one is struggling to  distinguish between conditions, or if you think PBA and depression are both present, consult with a healthcare professional for a professional assessment. Your doctor may refer you to a specialist if needed.

Symptoms Of PBA

The symptoms of PBA may be difficult to pinpoint when they first surface. However, a discernible pattern will begin to arise as time passes and the condition progresses. You or a loved one may be experiencing PBA if you notice a combination of any of the following:

  • Episodes of uncontrollable laughing or crying
  • Reactions that are opposite of what’s expected in a given situation
  • Facial expressions that do not match actual emotions
  • Bouts of intense sadness, anger, or frustration
  • Anxiety in social situations due to a history of episodes of exaggerated and unexpected crying or laughing
  • Avoidance of social situations for fear of an involuntary outburst

Identifying these symptoms as pieces of a larger puzzle is half the battle. If you find they are present, an appropriate treatment plan can help alleviate the issue.

Treating PBA

Ultimately, the main objective of PBA treatment is to reduce the frequency and intensity of emotionally-inappropriate episodes.

Studies have shown that tricyclic antidepressants (TCAs) and certain selective serotonin reuptake inhibitors (SSRIs) reignite pathways of specific neurotransmitters—serotonin and glutamate—that can be disrupted by a neurological event, such as stroke. Without serotonin and glutamate working together, neurological signals cannot be sent and received properly.

The Food and Drug Administration also has recently approved another treatment combination of dextromethorphan (common cold medicine) and quinidine (antiarrhythmic agent). Quinidine increases the body’s absorption of dextromethorphan, which works to target receptors in regions of the brain that regulate emotional output. In clinical trials, the combination significantly improved the symptoms of PBA, thereby becoming a reliable alternative to TCAs and SSRIs.

In any case, it is important for a doctor or other healthcare professional to assess your unique case and make specific recommendations about which, if any, medications might be most beneficial.

You’re Not Alone In This Fight

You're not Alone in Dealing with PBA After Stroke

Not having control over your emotions and reactions can be terribly frustrating, but you should never feel like you’re alone in this fight. Estimates show that nearly 2 million people in the U.S. with neurological conditions or traumatic brain injuries have been diagnosed with PBA, while over 7 million people total have symptoms that may indicate PBA. These numbers could be deflated because PBA is often misdiagnosed as depression or another disorder.

Above all, it is essential to get the right diagnosis, and help is certainly available. If you or a loved one have any questions or concerns about PBA, consult with your doctor or other healthcare professional for support with diagnosis and treatment.

All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the Saebo website is solely at your own risk.

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