Pseudobulbar affect and euphoria: Two very different MS symptoms

Imagine that you are in the middle of giving an important presentation at work and burst out laughing uncontrollably. What if you started sobbing while in a conference with your child’s teacher? Or doing either of these things in the middle of a grocery store, a movie theater or a fancy dinner party?
Pseudobulbar affect is a symptom of multiple sclerosis that is relatively uncommon, occurring in up to 10% of people with MS at some point in their lives. Also known as involuntary emotional expression disorder (IEED) or the less dignified, but nicely descriptive “emotional incontinence,” the simplest definition sums it up as “laughing without happiness and crying without sadness.”
Pseudobulbar affect is definitely due to physical changes in the brain as more than 75% of people who experience it have brain atrophy and a heavy lesion load.
The good news is that pseudobulbar affect can be treated. For many years it was treated with anti-depressant medications. There is also a medication on the market, Nuedexta (dextromethorphan hydrobromide and quinidine sulfate), that is specifically approved to treat pseudobulbar affect. One component of the drug, dextromethorphan, is a commonly-used cough medicine. Interestingly, the cough reflex and the ability to laugh and cry are controlled by the same part of the brain – by suppressing this area, laughing and crying are suppressed as well.
Pseudobulbar affect is often missed by physicians treating people with MS, because they assume the crying outbursts are a manifestation of depression, an extremely common symptom of MS. Indeed, many people with this symptom are confused, frustrated and angry about the problem leading to further difficulty communicating with their doctors about it.

While rare, keep IEED in mind if you experience episodes of laughing or crying that seem out of sync with your emotions at the time. Also, it may take a long time for someone to figure out that your laughing or crying is an MS symptom and it may be a good idea to explain IEED to those close to you to avoid hurt feelings and minimize awkwardness.

Help your doctor make the right diagnosis and differentiate your situation from depression by telling him or her if: your emotional expression doesn’t match how you are feeling and your crying (or laughing) comes on and ends very suddenly.  

Euphoria is an extremely rare symptom of MS, typically presenting only in people with very severe cognitive impairment.
In this disorder, people are described as having “a fixed state of mental wellbeing.” Occasionally, they are also disinhibited. As Dr. Anthony Feinstein described in his presentation on neuropsychological challenges in MS at ECTRIMS 2013, these severely disabled people are simply happy. For example, they tend to have extremely unrealistic expectations, often thinking that their MS is simply going to go away and that they will get better.
In the past, euphoria was often referred to as the “MS personality” and considered to be very common in people with MS. However, we now know there is no "MS personality" and that euphoria is associated with severe brain atrophy and heavy lesion load.
There is no treatment for euphoria. It is important for people with MS and their families to be educated about this condition as it can be very challenging and distressing for family members.
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Julie Stachowiak, PhD

Julie is the author of the Multiple Sclerosis Manifesto, the winner of the 2009 ForeWord Book of the Year Award in the Health Category. She is an epidemiologist who is also a person living with MS, Julie has an in-depth understanding about current research and scientific developments around MS. She also has first-hand knowledge of the frustrations and anxiety surrounding the disease, as she had MS for at least 15 years before receiving a diagnosis in 2003 and has had several relapses since her diagnosis.