Mary Beth, female patient with PBA in her 40s, talking to a doctor Mary Beth, female patient with PBA in her 40s, talking to a doctor

Diagnosing PBA

Ask the right question to
diagnose PBA1

Knowing what to ask your patients is important for reaching an accurate diagnosis. Start the conversation1

Mary Beth, patient living with PBA, and actor portrayal.

Three steps to help assess for PBA

Pseudobulbar Affect (PBA) can only be diagnosed following a complete assessment by a qualified healthcare provider.

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Ask a simple question like this one1:

“Do you ever cry or laugh but it feels odd because you’re not actually sad or amused?” 

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Differentiate between PBA and depression2-4

Crying in depression vs Crying in PBACrying in depression vs Crying in PBACrying in depression Crying in PBA How often and for how long? Onset and duration defined by mood Happens and may be brief frequentlyand suddenly Can they control it? Mostly ; stops when mood changes controllable Uncontrollable and involuntary Does it match their mood? Consistent with mood with or to mood Inconsistentdisproportionate
Crying in depression vs Crying in PBACrying in depression vs Crying in PBAHow often and for how long? Crying in depression Onset and duration defined by mood Crying in PBA Happens and and may be brief frequentlysuddenly Can they control it? Crying in depression Mostly ; stops when mood changes controllable Crying in PBA and involuntary Uncontrollable Does it match their mood? Crying in depression with mood Consistent Crying in PBA with or to mood Inconsistentdisproportionate
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Document your confirmed diagnosis with ICD-10 code F48.25*

Or for help identifying PBA symptoms, you can use the Center for Neurologic Study-Lability Scale (CNS-LS) screening tool.†

*ICD-10 diagnosis codes are provided for informational purposes only and do not guarantee that billing codes will be appropriate or that coverage and reimbursement will result. Providers should consult with their payers for all relevant coverage, coding, and reimbursement requirements. It is the sole responsibility of the provider to select proper codes and ensure the accuracy of all claims used in seeking reimbursement. This resource is not intended as legal advice or as a substitute for a provider’s independent professional judgment.

†CNS-LS is a self-administered questionnaire, designed to be completed by the patient with a 7-item rating scale that measures perceived frequency and severity of PBA episodes. It was validated as a screening tool in amyotrophic lateral sclerosis and multiple sclerosis populations.4,6 A CNS-LS score of ≥13 may suggest PBA symptoms, and a score of ≥21 may suggest more severe and frequent PBA symptoms.7

What is it like to experience a PBA episode?

View examples of patients experiencing crying and laughing episodes.

PBA episodes may:

Female patient experiencing a Pseudobulbar Affect (PBA) crying episode without tears
Appear with or without tears
Female patient experiencing a Pseudobulbar Affect (PBA) crying episode that is quiet
Sound noiseless or quiet

Female patient experiencing a Pseudobulbar Affect (PBA) crying episode that is noisy with increasing volume
Sound noisy with increasing volume
Male patient experiencing a Pseudobulbar Affect (PBA) crying episode that appears as a grimace
Appear with or without grimacing
Male patient experiencing a Pseudobulbar Affect (PBA) laughing episode
Appear as uncontrollable laughter
Male patient experiencing a Pseudobulbar Affect (PBA) crying episode that is brief and without tears
Appear only briefly

Nurses and other staff members may also describe your patient’s symptoms in different ways. Look for some of the following terms in patient charts that may suggest PBA3,4,8:

  • Emotional incontinence 
  • Emotional lability 
  • Inappropriate affect
  • Involuntary expression 
  • Mood incongruence 
  • Pathological laughing and crying
  • Sudden or emotional outbursts of laughing or crying

If you recognize these symptoms in your patient and confirm PBA, learn more about dosing and treatment with NUEDEXTA.

dosing & treatment

Identifying patients with PBA

Dr Nick Palladino and Dr Jennifer McVige provide insight into their experiences with patients who exhibited signs of PBA and the steps they took to make a PBA diagnosis.

Drs Palladino and McVige are paid consultants of Otsuka America Pharmaceutical, Inc.

Screenshot image of video titled “Identifying Patients with PBA” and actor portrayal of a female with Pseudobulbar Affect (PBA) at a grocery store
  • References: 1.

    Suavé WM. Recognizing and treating pseudobulbar affect. CNS Spectr. 2016;21(S1):34-44. doi:10.1017/‌S1092852916000791

  • 2.

    Kekere V, Qureshi D, Thanju A, Fouron P, Olupona T. Pseudobulbar affect mimicking depression: a case report. Cureus. 2022;14(6):e26235. doi:10.7759/‌cureus.26235

  • 3.

    Nuedexta. Package insert. Otsuka America Pharmaceutical, Inc.; 2022.

  • 4.

    Hammond FM, Alexander DN, Cutler AJ, et al. PRISM II: an open-label study to assess effectiveness of dextromethorphan/‌quinidine for pseudobulbar affect in patients with dementia, stroke or traumatic brain injury. BMC Neurol. 2016;16:89. doi:10.1186/‌s12883-016-0609-0

  • 5.

    Centers for Disease Control and Prevention. ICD-10-CM tabular list of diseases and injuries. Accessed June 12, 2024. https://ftp.cdc.gov/‌pub/‌health_statistics/‌nchs/‌publications/‌ICD10CM/‌2022/‌icd10cm-tabular-2022-April-1.pdf

  • 6.

    Pioro EP, Brooks BR, Cummings J, et al. Dextromethorphan plus ultra low-dose quinidine reduces pseudobulbar affect. Ann Neurol. 2010;68(5):693-702. doi:10.1002/‌ana.22093

  • 7.

    Brooks BR, Crumpacker D, Fellus J, Kantor D, Kaye RE. PRISM: a novel research tool to assess the prevalence of pseudobulbar affect symptoms across neurological conditions. PLoS One. 2013;8(8):e72232. doi:10.1371/‌journal.pone.0072232

  • 8.

    Miller A, Pratt H, Schiffer RB. Pseudobulbar affect: the spectrum of clinical presentations, etiologies and treatments. Expert Rev Neurother. 2011;11(7):1077-1088. doi:10.1586/‌ern.11.68

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IMPORTANT SAFETY INFORMATION and INDICATION for NUEDEXTA® (dextromethorphan HBr and quinidine sulfate)

IMPORTANT SAFETY INFORMATION

CONTRAINDICATIONS:

  • Quinidine and Related Drugs: NUEDEXTA contains quinidine and should not be used concomitantly with other drugs containing quinidine, quinine, or mefloquine.
  • Hypersensitivity: NUEDEXTA is contraindicated in patients with a history of NUEDEXTA-, quinine-, mefloquine-, or quinidine-induced thrombocytopenia, hepatitis, bone-marrow depression, lupus-like syndrome, or known hypersensitivity to dextromethorphan (e.g., rash, hives).
  • MAOIs: NUEDEXTA is contraindicated in patients taking monoamine oxidase inhibitors (MAOIs), or in patients who have taken MAOIs within the preceding 14 days, due to the risk of serious and possibly fatal drug interactions, including serotonin syndrome. Allow at least 14 days after stopping NUEDEXTA before starting an MAOI.
  • Cardiovascular: NUEDEXTA is contraindicated in patients with a prolonged QT interval, congenital long QT syndrome, history suggestive of torsades de pointes, heart failure, patients receiving drugs that both prolong QT interval and are metabolized by CYP2D6 (e.g., thioridazine and pimozide), patients with complete atrioventricular (AV) block without implanted pacemaker, or at high risk of complete AV block.

Thrombocytopenia and Other Hypersensitivity Reactions: Quinidine can cause immune-mediated thrombocytopenia that can be severe or fatal. Non-specific symptoms, such as lightheadedness, chills, fever, nausea, and vomiting, can precede or occur with thrombocytopenia. NUEDEXTA should be discontinued immediately if thrombocytopenia occurs.

Hepatotoxicity: Hepatitis, including granulomatous hepatitis, has been reported in patients receiving quinidine, generally during the first few weeks of therapy. Discontinue immediately if this occurs.

Cardiac Effects: NUEDEXTA causes dose-dependent QTc prolongation. QT prolongation can cause torsades de pointes-type ventricular tachycardia, with the risk increasing as the degree of prolongation increases. When initiating NUEDEXTA in patients at risk for QT prolongation and torsades de pointes, electrocardiographic (ECG) evaluation of QT interval should be conducted at baseline and 3 to 4 hours after the first dose. Some risk factors include use with CYP3A4 inhibitors or drugs that prolong QT interval, electrolyte abnormalities, bradycardia, or left ventricular hypertrophy or dysfunction. If patients taking NUEDEXTA experience symptoms that could indicate the occurrence of cardiac arrhythmias (e.g., syncope or palpitations), NUEDEXTA should be discontinued, and the patient further evaluated.

Concomitant Use of CYP2D6 Substrates: NUEDEXTA inhibits CYP2D6 and may interact with other drugs metabolized by CYP2D6. Adjust dose of CYP2D6 substrates as needed.

Dizziness: NUEDEXTA may cause dizziness. Take precautions to reduce the risk of falls.

Serotonin Syndrome: Use of NUEDEXTA with selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants increases the risk of “serotonin syndrome.”

Anticholinergic Effects of Quinidine: Monitor for worsening in myasthenia gravis.

Adverse Reactions: The most common adverse reactions (incidence of ≥3% and two-fold greater than placebo) in patients taking NUEDEXTA are diarrhea, dizziness, cough, vomiting, asthenia, peripheral edema, urinary tract infection, influenza, increased gamma-glutamyltransferase, and flatulence.

These are not all the risks for use of NUEDEXTA.

To report SUSPECTED ADVERSE REACTIONS, contact Otsuka America Pharmaceutical, Inc. at 1-800-438-9927 or FDA at 1-800-FDA-1088 (www.fda.gov/‌medwatch).

INDICATION

NUEDEXTA is indicated for the treatment of pseudobulbar affect (PBA).

PBA occurs secondary to a variety of otherwise unrelated neurologic conditions, and is characterized by involuntary, sudden, and frequent episodes of laughing and/or crying. PBA episodes typically occur out of proportion or incongruent to the underlying emotional state. PBA is a specific condition, distinct from other types of emotional lability that may occur in patients with neurologic disease or injury.

Please see FULL PRESCRIBING INFORMATION.