Ask the Expert – Pseudobulbar Affect (PBA)

Featuring Barry A. Hendin, MD 

Headshot of doctor Barry Hendin, chief medical officer for MSAA
Barry Hendin, MD

Question: Both pseudobulbar affect and bipolar disorder can have emotional highs and lows. Can you discuss the differences between the two conditions?  

 Answer: Pseudobulbar affect (PBA) refers to a condition characterized by episodes of sudden and uncontrollable laughing and/or crying. Bipolar disorder also has highs and lows, but these emotional states tend to last for weeks or months, rather than a sudden outburst that stops within minutes. PBA differs from depression as well but can be misdiagnosed and misinterpreted as depression when sudden crying predominates. The structural cause of PBA is a disruption of controlling or editing pathways that regulate emotions. This condition isn’t unique to MS and may occur in other neurological disorders, including traumatic brain injury, amyotrophic lateral sclerosis (ALS), and stroke. 

Depression and PBA are both more common in people with multiple sclerosis, but they also often occur independently of each other. PBA can be diagnosed clinically by its brief and explosive nature (laughing or crying). If there is no accompanying depression, the mood will be normal between outbursts. 

PBA can be embarrassing and anxiety-provoking for people who are affected. It can lead to social avoidance and even occupational challenges. Diagnosis is important and therapies are available. Nuedexta® (a combination of dextromethorphan hydrobromide and quinidine sulfate) is an FDA-approved therapy for PBA. Low-dosage antidepressants have also been used off-label. Behavioral therapies have been employed to mitigate the symptoms and help to cope with the psychological consequences of PBA. 

We are fortunate to live in a time when we have the wide availability of disease-modifying therapies, which reduce relapses and progression in MS. We are also fortunate to have more widely available symptomatic therapies for people with MS. This allows people with MS to look forward to an improved quality of life with less disease burden. 

MSAA’s Ask the Expert series received a Silver Award from the 24th Annual Digital Health Awards! 

Barry A. Hendin, MD, is a neurologist and Director of the Arizona Integrated Neurology MS Center. He is also Director of the Multiple Sclerosis Clinic at Banner University Medical Center and Clinical Professor of Neurology at the University of Arizona Medical School. 

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The Multiple Sclerosis Association of America (MSAA) is a national nonprofit organization and leading resource for the entire MS community, improving lives today through vital services and support. MSAA provides free programs and services, such as: a Helpline with trained specialists; award-winning publications, including, The Motivator; MSAA’s nationally recognized website, featuring educational videos, webinars, and research updates; a mobile phone app, My MS Manager™; safety and mobility equipment products; cooling accessories for heat-sensitive individuals; MRI funding; My MSAA Community, a peer-to-peer online support forum; MS Conversations blog; a clinical trial search tool; podcasts; and more. For additional information, please visit or call (800) 532-7667.

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