Abstract
Pseudobulbar affect (PBA) is an affective disorder of emotional expression characterized by frequent uncontrollable outbursts of laughing or crying. It is usually associated with stroke, traumatic brain injury, and other neurological conditions. This disorder can present a challenge to clinicians to distinguish this from mood disorders or to diagnose this disorder in the context of underlying mood disorders. In addition, the delay in the diagnosis can impact patients' quality of life.We describe a 48-year-old man who presented with frequent episodes of sudden, frequent, uncontrollable laughing two years after his recurrent stroke. The patient initially had his first stroke about three years ago and had a recurrent stroke eight months after his first stroke. A few days after getting discharged after his second stroke, the patient was admitted to the psychiatric unit after his family members reported aggressive behavior. The patient also reported symptoms of depression and was discharged on escitalopram for mood and divalproex for his aggressive behavior. Unfortunately, the patient was not compliant with these medications with no resolution of his symptoms. The patient was then treated with dextromethorphan-quinidine, escitalopram, and divalproex, resulting in significant improvement in his mood and aggressive behavior with a resolution of uncontrollable laughing spells. Clinicians are encouraged to inquire about symptoms of pseudobulbar affect in the context of stroke or other neurological disorders. Appropriate management of this condition can help improve patients' symptoms and positively affect their wellbeing.
Highlights
Pseudobulbar affect (PBA) is an affective disorder of emotional expression
PBA should be strongly considered in patients with stroke
We present a case of PBA with aggressive behavior in addition to uncontrollable laughing spells
Summary
Pseudobulbar affect (PBA) is an affective disorder of emotional expression. It is associated with stroke, traumatic brain injury, brain tumor, Alzheimer's dementia, Parkinson's disease, multiple sclerosis, and motor neuron disorders like amyotrophic lateral sclerosis [1,2,3]. Mr G exhibited inappropriate laughter during the second day of hospital admission, and pseudobulbar affect (PBA) was considered He was started on donepezil for possible vascular dementia; this was later discontinued. Mr G was brought to the emergency department multiple times between June 2020 to August 2020 with aggressive behaviors, punching his partner, and medication non-compliance He was recommended to be compliant with medications and advised to follow up with neurology; Mr G did not follow up as instructed. During one of the visits to the emergency department, he was prescribed divalproex 250 mg twice daily with a diagnosis of a major neurocognitive disorder, possibly due to vascular disease, with behavioral disturbance He was told to follow up in the psychiatry outpatient clinic; he did not follow up. He reported improvement in mood and aggressive behavior with a resolution of uncontrollable laughing spells with a combination of escitalopram 20 mg daily, divalproex 500 mg twice daily, and dextromethorphan/quinidine (20/10 mg) twice daily
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