Treatment of pseudobulbar affect (PBA) in a patient with a history of traumatic brain injury, partial brain resection, and brainstem stroke: a case report

Abstract

Background Pseudobulbar affect is a very distressing and underdiagnosed neuropsychiatric disorder that causes contextually inappropriate episodes of laughing and crying and general emotional incontinence. Although many proposed etiologies exist, the most widely accepted theory espouses the disruption of a corticopontine–cerebellar circuit that governs the modulation of emotional response. Pseudobulbar affect is commonly diagnosed secondary to primary neurological disorders such as amyotrophic lateral sclerosis, multiple sclerosis, and traumatic brain injury. Traditional pharmacological treatment of pseudobulbar affect is largely comprised of antidepressant therapy, including tricyclic antidepressants such as amitriptyline and selective serotonin reuptake inhibitors such as fluvoxamine. However, neither of these medication classes has been studied for the treatment of pseudobulbar affect in controlled trials, and their utility remains questionable. Case presentation We describe a case of a 62-year-old Caucasian man with history of traumatic brain injury, ischemic brainstem stroke, and depression who developed intractable pseudobulbar affect. This patient’s intensely distressing symptoms were not alleviated by amitriptyline. However, after being placed on fixed-dose 20 mg/10 mg dextromethorphan/quinidine (Nuedexta), our patient experienced complete resolution of his symptoms. He has experienced no deleterious side effects. Conclusions This case provides anecdotal evidence for the efficacy of dextromethorphan/quinidine in the treatment of pseudobulbar affect with remarkably swift and complete cessation of symptoms. As a secondary point, it is worth noting that our patient had experienced two devastating neurological traumas, both in anatomical areas that have been implicated in the corticopontine–cerebellar circuit thought to be responsible for pseudobulbar affect. However, only the second trauma, an acute left pontine infarction, produced symptoms of emotional disinhibition. The authors hope that reporting this case will provide both context for physicians managing this condition and hope for patients with this socially and psychiatrically damaging disease.

Update on Neurodegenerative Diseases and Glutamate: A PMHNP Single Case Study Report of a Diagnostically Complex Adult Patient, Interventions, and Unexpected Outcomes

“…As in the case reported in this article, the results were both very effective and unexpected. The authors (Young & Nguyen, 2020) of this case study encourage practitioners to consider this type of treatment and point out that the types of presenting symptoms from PBA or other emotional outburst symptoms may vary widely.…”

Possible Effects of Acupuncture in Poststroke Aphasia

“…In a previous case report, a stroke patient treated with NMDA receptor antagonists for pseudobulbar affect was unexpectedly found to have significantly improved speech function and largely restored social ability. These findings suggest that inhibiting the excitotoxic effects of neurotransmitters and improving neural pathway signaling in the brain are of great significance for the recovery of speech function in patients with aphasia [ 127 ].…”

Gülmenin fizyolojisi: Beyin lezyonlarından gülme ile ilişkili yapıları anlama

“…Ancak iskeminin kısa süreli uyarıcı etkisi de dikkate alınmalıdır. 60 Patolojik gülmeyi içeren bozukluklar için kullanılan terimler, istemsiz gülme, pseudobulbar duygulanım 61,62 dysprosopeia 63 , sahte neşe 64 , uygunsuz, kontrol edilemez ve epileptik olmayan gülme ve duygusal inkontinans 65,66 gibi durumları kapsamaktadır. Seçici serotonin geri alım inhibitörleri 23,[67][68][69] ve levodopa 70 verilen hastalarda pozitif tedavi sonuçları rapor edildiğinden, patolojik kahkahaların serotonerjik ve dopaminerjik iletimden etkilendiğine dair kanıtlar vardır.…”