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.

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  • LOMS   Oct 4, 2013 2:19 PM
    Actually, it was before diagnosis: I was laughing when I learned my brother committed suicide. Fortunately, no one was around (I'd already hung up the phone) and I figured it was just some nervous reaction. It was weird like some kind of Sadist
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    bjbecker43  Oct 4, 2013 3:53 PM
    I have cried for no reason whatsoever. I thought it was just a part of being female.
  • Sandy   Oct 4, 2013 7:12 PM
    Laughing uncontrollably and inappropriate verbal outbursts have been an issue for me for as long as I can remember. When it happens in public, I want to run & hide. Fortunately, my family has grown accustomed to it. Interestingly, I almost never cried until the past few years, even when most people would be in the fetal position, sobbing uncontrollably.
    I mentioned all this to my (former) MS specialist who is considered Thee MS guy in my tri-state area; the guy the rich & famous come to see, the "best," only to receive a slight nod of the head with no comment or follow up questions. He just blew me off.
    I don't want more meds, and certainly not meds that turn off emotion, so I'll continue with fits of laughter and shouting out random things that run through my head.
    Thanks for talking about something most people will never understand.
  • Barb   Oct 4, 2013 8:52 PM
    Had it years before I new I had M.S.. hmm
  • Mb   Oct 5, 2013 12:53 AM
    Yes, this has been a challenge for me for years and it seems to have progressed. I deal with it at work and have tried to educate my co-workers about PBA but I don't find that people 'remember' that is what is going on and they just treat you like you are an emotional wreck. I try to explain to them, My face is crying but I am not really. I have not had a laughing episode for many years but cry 3 days a week. It helped a lot when I got Dr. that told me that it was part of my MS then it made sense.
  • Rekha Naidu   Oct 5, 2013 2:15 AM
    I was diagnosed in 2002/2 with MS in Malaysia where incident is low, I was born in England 1959, graduated in 1981, BSc dietetic from Cardiff Wales . I started working July 1981 in England 1984 moved to Aberdeen Scotland worked as community dietitian, then England. Married 1988,left u.k. 1991 for Botswana. Worked for 7 month in Gaborone main government hospital. My 1st son was born September 1981, we left 1983 and moved to Malaysia,my husband's home. My 2nd son, born November 1993 then 1984, problems with eyes,sun glare, neurologist CT scan normal. Consultant for eyes, tests normal.
    Back to neurologist , drugs I was breast feeding so 'no', I would come back. A friend from Australia suggested I see her optometry ,thorough eye test, Rx sunglasses and eye exercise . I was fine until 2001, admitted into hospital 3-4 weeks,depressed referred to psychiatric doctor,trying different drugs etc. reviewed weekly. Jan 1997 my 3rd son born,I was taking care of my sons.breastfeeding and driving a car,some freelance work.
    2013 has been great as nov.dec. 2012 physio. 2-3 x week, 15 jan 2013 neurology ,Dr impressed as I had a smile + my arm+leg muscles stronger. The mitroxantron was working and now reached 40mls echo ultrasound normal. Sept.I went swimming after 7/8 years,so much easier. Check Malaysian MS society website
  • imdhreeves   Oct 9, 2013 7:12 PM
    I had inappropriate crying twice. Each time when I was having a glucose tolerance test. I thought it was related to blood sugar but since I do have MS that may have been the cause. It sure was strange to be crying without the usual emotions. I just wanted to hide.
  • Annette See   Oct 17, 2013 12:10 PM
    I didn't realize this was happening to others. It is hard when it happens when you are not with your family but now I know I am not alone.
  • RCM, male, 51, VA, USA, diagnosed RRMS 2006   Oct 17, 2013 12:12 PM
    Roughly concurrant with my diagnosis, i began to notice i am way more susceptible to getting choked up by emotional events. It can bring uncontrollable tears to my eyes if i think and/or talk about emotion-laden topics, and make it impossible for me to continue speaking. The trigger can be something as inocuous as a sappy movie, or saying a few words in front of the family over the Tgiving meal. NEVER had this problem prior to my diagnosis, so i have wondered for some time could it be i have a mild case of pseuodobulbar, or just coincidence.

    I am a very experienced public speaker and typically quite comfortable speaking in front of large groups, and no doubt i will be called upon to speak when my elderly mom passes away. I expect i won't be capable of saying what i would like to say.

    This is awkward and embarrassing for a male, at least in the society wherein i reside! I have a consistently positive outlook, am known as a very energetic,appreciative and outgoing person. Thankfully it has been a few years since my last relapse, but this sympton continues same as ever. I have never experienced anything like the euphoria side of pseudobulbar i read about, and i would not decribe the choking up and crying as the result of 'sadness'. Just unjustifiably chocked up over something too small to cause it.

    Any other diagnosed folks out there experience anything like this? Any experts have any thoughts on it?
  • Avatar
    mamaiguana  Oct 17, 2013 1:36 PM
    I frequently find that my eyes are leaking. I was a trial attorney and when I was working I used this to my advantage by pretending that I was emotionally affected by something when I wasn't. Now that I'm retired I sometimes have to explain what's happening to friends who haven't seen me do it before.
  • Anybeth   Oct 17, 2013 2:46 PM
    I've only had PBA(-like) symptoms a few times, never lasting long. I'm more familiar with the euphoria, though I'm better enough that it's very rare for me now. (Yes, I have a heavy lesion load; no, it doesn't always show.) Getting to that state, it's like your mind is trapped in a shrinking box with walls of thick plastic wrap. You can "see" what you want, but the harder your reach for it, the more resistance you encounter and you know you can never get there (kinda like anomia but more universal). What thinking you can manage is like walking through molasses. It gets more and more frustrating and distressing until... something changes, like one of those 3D (autostereogram) posters coming into focus. You can't even "see" those things you had been reaching for and there's no longer any struggle. You're still mentally trapped, but it's somewhere peaceful, beautiful, and more than a little magical (being there's so little you can understand) and you haven't the capacity to imagine anything else. Made me think of The Secret Garden. Like I said, I'm doing better now such that getting that bad is rarer and rarer. No, I don't miss it, but it's a mercy the euphoria's there just as the perceived mental limitations become too much to bear. So long as the one so limited keeps safe, it's a mercy. Btw, for me, distraction worked very well in such times. In such times, I couldn't understand if someone insisted something I wanted to do was dangerous, but I'd quickly forget about it all if my thoughts were led down a different path. Given something else to do, I'd also gladly do a loved one the favor of not doing the thing I couldn't understand was dangerous, so long as they hadn't been trying to convince me it was bad (which would lead me to think they don't know what they're talking about).
  • clare richards   Oct 17, 2013 3:21 PM
    I have had this MS now for over fourteen years but i cannot cry anymore! And i don't want to ever cry again COs i just end up laughing instead !
  • JESSICA   Oct 17, 2013 3:36 PM
    Well it sounds like this is more common symptom than the statistics show. I have been diagnosed for 25 years and have had this symptom on and off over the years. It is interesting because I don't have a heavy lesion load however I can't speak to my level of brain atrophy though I do have ongoing cognitive issues and a general slowing down overall. I would recommend that young people diagnosed with MS should get a baseline cognitive exam done just to have moving forward. I wish I had in my 20's because it would have been helpful now in my 40's. Thanks for the updated information.
  • Will   Oct 17, 2013 6:15 PM
    Is Lithium an appropriate medication to control this? I was diagnosed with bipolar at the same time I was diagnosed with ms. Hmmm
  • Jeffrey Paul   Aug 21, 2016 12:04 PM
    Years ago I had a traumatic brain injury during a motorcycle wreck. Many things did change, but very subtly. My sense of humor changed; my family noticed this. Behind closed doors and in my car I would cry, and I wasn’t a guy who cried prior to the accident. I was misdiagnosed with various depressions, bi-polar/manic, etc. Until one day I sobered up after self medicating for several years (alcohol, marijuana) and started seeing a doctor of psychiatry, a really good one, He’s from India, Dr. Shah; he diagnosed me with Pseudobulbar Affect, after I shamefully admitted how often I cried daily, and he made the connection; emotional incontinence, PBA. This explains my difficulties I had dealing with people, prior to my diagnosis and being medicated.
  • Bernice Golden   Nov 7, 2016 11:16 AM
    When I was about 10 or 11 my mother took me to friends funerals. When I looked in all the rooms with dead bodies i started to laugh . I out grew it but always had thoughts of my death. I am in good health with no other symptoms I am 84 and hope to live much longer.
  • meagan Smith   Feb 19, 2017 6:56 PM
    I laugh whenever I feel awkward.