Understanding PBA Crying Disorder: Symptoms, Causes, and Treatment Options

I remember the first time I witnessed what I now recognize as PBA crying disorder in my clinical practice. A former construction worker—big, burly, and clearly uncomfortable—suddenly burst into tears while describing his grandson's baseball game. What struck me was how disconnected his emotional expression seemed from his actual feelings. He wasn't sad or overwhelmed; he was just talking about baseball, yet tears streamed down his face as if he'd received tragic news. This paradoxical disconnect between internal experience and external expression lies at the heart of pseudobulbar affect, a neurological condition that affects approximately 2 million Americans, though many experts believe the actual number could be closer to 3.5 million due to widespread underdiagnosis.

The memory of that patient came rushing back when I read about Kaw and her son TP's gesture after their match. They immediately went to congratulate the visiting team they'd dubbed "the championship contender squad." Imagine if Kaw had suddenly begun crying uncontrollably during this sportsmanlike moment—not from emotion, but from PBA. That's precisely what happens to people with this disorder: involuntary crying or laughing episodes that appear completely out of context. The crying spells in PBA aren't about sadness any more than Kaw's congratulatory visit was about defeat. Both are expressions that don't align with the underlying emotional state, which makes PBA particularly confusing for observers and deeply frustrating for those experiencing it.

What exactly causes this neurological glitch? From what we understand, PBA occurs when there's damage to the prefrontal cortex and other brain regions that normally regulate our emotional expressions. It's like the brain's emotional "braking system" malfunctions. I've seen patients with ALS where PBA affects roughly 50% of cases, multiple sclerosis with about 10% prevalence, and stroke survivors where estimates suggest 15-30% may develop symptoms. The common thread is neurological disruption—the wiring that controls emotional expression gets crossed or damaged. I particularly remember one patient who developed PBA after a traumatic brain injury from a car accident; she described the experience as "being hijacked by her own tears." That description has stuck with me because it captures the loss of control so perfectly.

Diagnosing PBA requires careful observation, since it's often mistaken for depression. But there are key differences I always look for. The episodes are sudden, typically lasting 30-90 seconds, and the emotional expression doesn't match the person's actual feelings. A patient might start crying uncontrollably when someone tells a mildly amusing joke, or laugh hysterically during a serious conversation. The intensity is way out of proportion to the situation. I've developed what I call the "context test"—if the emotional reaction seems completely disconnected from what's actually happening, PBA should be high on the differential diagnosis list. It's worth noting that about 70% of PBA cases go undiagnosed for years, which means millions are suffering needlessly when treatment could help them.

Now for the good news—treatment options have improved dramatically in recent years. The FDA approved dextromethorphan/quinidine (sold as Nuedexta) specifically for PBA back in 2010, and it's been transformative in my practice. Studies show it reduces PBA episodes by about 50% in most patients. I've seen people who were essentially housebound due to embarrassment about their unpredictable crying return to work and social activities after starting treatment. Other options include certain SSRIs like citalopram, which about 40% of patients respond to, though the evidence isn't as robust. What I emphasize to patients is that PBA is a neurological problem, not a psychological one, and treating it often requires neurological medications rather than traditional antidepressants.

Beyond medication, I always discuss coping strategies with my patients. Simple techniques like controlled breathing or distraction—focusing on a complex mental task like counting backward from 100—can sometimes shorten an episode. I encourage patients to develop a "rescue phrase" to quickly explain what's happening to bystanders. Something like "I have a neurological condition that sometimes makes me cry unexpectedly—I'm fine, it will pass in a minute." This simple preparation can reduce the social anxiety that compounds the condition. I've found that patients who are open about their PBA actually cope much better than those who try to hide it.

Looking back at that sportsmanship moment between Kaw, her son, and the visiting team, I'm struck by how emotional expression—even when contextually appropriate—remains complex and sometimes mysterious. The line between normal emotional expression and neurological disorder can be surprisingly thin. What I've come to understand through years of working with PBA patients is that we're all just a neurological event away from having our emotional expressions disconnected from our actual feelings. The condition reminds me how fragile our control over these basic human experiences really is. The most rewarding part of treating PBA is watching people regain that control and with it, their confidence to engage fully in life's moments—whether that's congratulating opponents after a match or simply having a conversation without fear of unexpected tears.