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Pseudobulbar affect (PBA) is a condition characterized by seemingly inappropriate display of emotion (or affect) by a person without an accompanying reason for the emotion. Overall, the trial showed a statistically significant benefit from taking a combination of dextromethorphan and quinidine, with both dosages being safe and well tolerated. If you do not want your question posted, please let us know. No doctor or clinic confirmed the data. Neuropsychiatr Dis Treat. A score of 13 or more predicted a clinical diagnosis of PBA in stroke patients with high sensitivity and specificity.1,5,15, The goals of pharmacotherapy are to reduce both the severity and frequency of PBA episodes. All rights reserved. Pathological laughing and crying following stroke: validation of a measurement scale and a double-blind treatment study. Causes significant distress or social/work/school impairment. 3. Acta Psychiatr Scand.  It is a symptom of ALS that many patients are unaware of and do not receive information about from their physician. Pseudobulbar affect (PBA) is a type of affect lability characterized by sudden, frequent, and uncontrollable episodes of crying and/or laughing. Inconsistent with or disproportionate to mood. 1. J Neurol Neurophysiol. The patient’s emotional response may be noted by healthcare professionals as disproportionate to the situation and can be wrongly attributed to poor coping, depression, or changes to the patient’s baseline neurocognitive disease and, therefore, may not be addressed. MS and related neurological damage are thought to be involved in disrupting activity in the cortical structures related to sensory, motor, and emotional processes, along with overactive motor cortical areas.10. A key consideration for pharmacists in supporting patients prescribed Neudexta is being able to understand the therapeutic moiety, dextromethorphan, and the requirement of CYP2D6 inhibition from quinidine sulfate in order to maintain therapeutic levels. Muller U, Murai T, Witmund T, von Cramon DY. The CNS-LS is a seven-item, self-administered questionnaire about the control of laughing (4 items) and crying (3 items).1,5,13,14 The scores for each question range from one to five; total scores range from seven (no excess emotional lability) to 35 (severe excess emotional lability).1,5,13,14 A score of 13 or more predicted a PBA clinical diagnosis by a neurologist in 82% of ALS patients.5,14 A score of 13 or more was less accurate in predicting a diagnosis of PBA for MS patients.5,14 Raising the score to 17 improved the specificity of a PBA diagnosis without affecting the sensitivity.5,14 The Pathological Laughter and Crying Scale) is a clinician-administered instrument that consists of 18 questions inquiring about sudden episodes of laughter and crying.1,5,15 The scores for each question range from zero (normal) to three (excessive emotional lability). Handbook of Clinical Neurology.  In Chapter VI, "Special Expressions of Man: Suffering and Weeping", Darwin discusses cultural variations in the acceptability of weeping and the wide differences in individual responses to suffering. II: Pathological laughing and crying. Diagnosis of pseudobulbar affect in traumatic brain injury. Polypharmacy is a significant issue for patients with PBA, which is why pharmacists’ thorough review of medication history, treatment plan, and nonprescription supplements is paramount to safeguarding care. Do you know of a review article? , Quinidine sulfate affects the way the heart beats, and is generally used in people with certain heart rhythm disorders.  PBA does not appear to be associated with duration of ALS. Dextromethorphan hydrobromide affects the signals in the brain that trigger the cough reflex. The Art of Autism accepts many art forms, including blog posts, art, poetry, video submissions and requests for book and film reviews.  The higher prevalence rates tend to be reported in stroke patients who are older or who have a history of prior stroke. Brain Inj. 1984;41(10):1095-1096.19. rare disease research! You may want to review these resources with a medical professional. Quinidine sulfate is added to the combination to inhibit CYP2D6, thereby blocking the metabolism of dextromethorphan to dextrorphan and resulting in increased and prolonged plasma concentrations of dextromethorphan.5,34 There are several contraindications to be aware of when it comes to Nuedexta. The chapter contains the following sentence: We must not, however, lay too much stress on the copious shedding of tears by the insane, as being due to the lack of all restraint; for certain brain-diseases, as hemiplegia, brain-wasting, and senile decay, have a special tendency to induce weeping.. 2013; 9: 483–489. Int J Geriatr Psychiatry. Pharmacists are able to address the gaps in care that may contribute to patient-safety risks in a treatment plan when multiple prescribers are involved in the care of a single patient. This variation ranges from poor metabolizer to ultra-rapid metabolizer, making pharmacokinetic and pharmacogenomic considerations an important factor when selecting treatment.36. The American Academy of Neurology guideline for Amyotrophic Lateral Sclerosis provides a Level B recommendation for DHQ stating “if side effects are acceptable, DHQ should be considered for symptoms of pseudobulbar affect in patients with ALS and is probably effective for pseudobulbar affect in ALS.”35 The American Academy of Neurology guidelines for Psychiatric Disorders in Multiple Sclerosis provides a Level C recommendation, describing DHQ “as possibly effective and safe and may be considered for treating individuals with MS with PBA.”20 Recognizing the limited options for management of complex patient pharmacotherapy is important in evaluating benefits and risks of treatment. (2006). Lancet. It appears to be a brain condition involving complex neurological abnormalities in brain pathways and neurochemicals, specifically disruptions involving serotonin and glutamate. Traditionally, antidepressants such as sertraline, fluoxetine, citalopram, nortriptyline and amitriptyline have been prescribed with some efficacy. Brain Inj. PBA has also been observed in association with a variety of other brain disorders, including brain tumors, Wilson's disease, syphilitic pseudobulbar palsy, and various encephalitides. It is used as a cough suppressant, although it can sometimes be used, medicinally, as a pain reliever, and is also used as a recreational drug. In the medical television show House, season 7, episode 8 (Small Sacrifices), the character Ramon Silva, played by Kuno Becker displays pseudobulbar affect, with uncontrollable incongruent laughter, while suffering from Marburg variety of Multiple sclerosis. In some cases, depressed mood and PBA may co-exist. Dr. John Grohol is the founder of Psych Central. " The conditions and results of that study are as follows: At one study site, a total of 326 participants received one of three dose options. Schiffer RB, Herndon RM, Rudick RA. For example, a … Self-selected computer-savvy patients in at-risk groups evaluated their own symptoms and submitted their self-diagnoses. A revised theory behind the release hypothesis suggests that cerebellar structures involved in laughing and crying are operating on incomplete information because of the lesions affecting this part of the brain.10, Gate Control Theory: The gate control theory proposes inhibition of the mechanism regulating emotional expression. The duration and severity of the episodes cannot be controlled by the person. Three double-blind, multicenter trials provided the efficacy data and basis for the FDA approval and use of DHQ in patients with PBA. Neurologic conditions compounded with PBA are complex to manage due to multiple factors, including the heterogeneity of neurologic conditions, comorbidities, care management by multiple prescribers, and consequential polypharmacy issues. Recognizing that Nuedexta is the only FDA-approved PBA treatment, pharmacists will need to be familiar with this product. Work SS, Colamonico JA, Bradley WG, Kaye RE. 2011;11(7):1077-1088.4. Pseudobulbar affect: an under-recognized and under-treated neurological disorder. Reproduction in whole or in part without permission is prohibited. Mack E, Peters H, Page SJ. J Basic Clin Physiol Pharmacol. For example, a patient may laugh in response to sad news or cry in response to stimuli with no emotional undertone, or, once provoked, the episodes may switch from laughing to crying or vice versa.. Handbook of Clinical Neurology.  PBA does not appear to be associated with duration of ALS.  PBA is generally associated with later stages of the disease (chronic progressive phase). The National Institutes of Health notes that scientific reviews of the literature in this area find that PBA is associated with widespread anatomical and neurophysiological abnormalities (Ahmed & Simmons, 2013). 1992;6(3):267-270.30. A lawyer with Aspergers – a review of Roman J. Israel, Esq. The Expression of the Emotions in Man and Animals by Charles Darwin was published in 1872. Not dependent on a stimulus, or are excessive relative to that stimulus. Ann Neurol. The Art of Autism, 855 S. Main Ave., Ste K. #313, Fallbrook, CA 92028, Why I am silent – an #autistic perspective, Understanding the spectrum – a comic strip explanation, 105 Favorite Quotes About Autism and Aspergers, How Satoshi Tajiri’s autism helped create Pokemon.
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