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Pseudobulbar Affect and Multiple Sclerosis

pseudobulbar affect and multiple sclerosis

Imagine breaking out into uncontrollable laughter or crying bouts for no apparent reason and in inappropriate settings. For about 10 percent of individuals who live with multiple sclerosis, this possibility is all too familiar.


These unpredictable episodes of emotion are called the pseudobulbar affect (PBA; also known as emotional incontinence). The cause of these puzzling and sometimes embarrassing situations is damage to areas of the brain involved with emotions; the corticobulbar tract and the prefrontal cortex have been named as probable culprits.

According to the National Stroke Association, more than 1 million people in the United States who have a nervous system condition such as stroke, Alzheimer’s disease, traumatic brain injury, Parkinson’s disease, or multiple sclerosis, can be affected by this condition. However, knowing that you are not the only one does not help much if you are the one experiencing these emotional outbursts.

So what can you do if you live with episodes of pseudobulbar affect?

How to deal with pseudobulbar affect

Nuedexta. The prescription drug Nuedexta (a combination of dextromethorphan and quinidine) is the first and only medication approved by the Food and Drug Administration for treatment of pseudobulbar affect in neurologic disorders. A new study published in Drugs noted that this drug combination at dosages of 20/10 mg or 30/10 mg twice a day reduced the rate of PBA events and improved their severity in a three-month, double-blind, placebo-controlled trial in adults with MS or ALS.

In a previous three-month study published in CNS Drugs, the researchers reported that the 20/10 mg dose of Nuedexta resulted in a 49 percent reduction in the number of pseudobulbar affect episodes when compared with placebo. In addition, 51 percent of individuals were in remission at three months compared with 29 percent of those who took placebo.

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According to the makers of Nuedexta (Avanir Pharmaceuticals), the most common side effects of this drug (occurring in 13% or less of users) are abnormal liver test results, cough, diarrhea, dizziness, flu-like symptoms, gas, swelling of the ankles and feet, urinary tract infection, and weakness. Nuedexta also may cause abnormal heart rhythm, so your doctor may not prescribe the drug if you have a history of heart problems.

Other drugs. Several other medications have been used to help manage pseudobulbar affect, but they have not been approved for this purpose. They include amitriptyline, desipramine, fluoxetine, fluvoxamine, and levodopa.

Explain. Talk to your family, friends, and coworkers about pseudobulbar affect. Explain that is a part of MS and that is something over which you do not have control, although there are some steps you can take that may help reduce the outbursts (see tips below).

Management tips. Some people with pseudobulbar affect find that one or more of the following tips can help them have a degree of control over their outbursts. Try these tips as soon as you feel the urge to cry or laugh.

  • Breathe slowly and deeply, and relax the muscles that tend to become tense when you experience an outburst.
  • Think about something else. Distract yourself by imagining a favorite vacation spot, a pleasant event, or anything else that is unrelated to the current situation
  • Change your posture or body position
  • Concentrate on doing progressive body relaxation, beginning with your toes and working your way up (or start with your head and go to your toes)
  • Practice meditation. This tip is different from the rest. The practice of meditation on a daily basis may help you better deal with these episodes when they occur

Other tips

  • Keep a diary of when your episodes occur, what you were doing at the time, and how long they last. The information may help you and your doctor better learn how to manage these events.
  • Seek support from others who experience these episodes. This may include support groups, either real or virtual, as well as forums and chat rooms. If no one in your MS support group has these episodes, you may find individuals in Parkinson’s disease or other support groups who do.

Also read about alternative treatments for multiple sclerosis

Garnock-Jones KP. Dextromethorphan/quinidine: in pseudobulbar affect. CNS Drugs 2011 May; 25(5): 435-45
Yang LP, Deek ED. Dextromethorphan/quinidine: a review of its use in adults with pseudobulbar affect. Drugs 2015 Jan; 75(1): 83-90