Strictly Clinical Create a healing environment for patients with pseudobulbar affect By Maude McGill, PhD, RN-BC, and Marzell McGill, BA, LPN tact their provider for prompt appropriate treatment. • Signs and symptoms include: Teach patients how to manage PBA • emotional responses (such as crying or laughing) for optimal quality of life. that don’t fit the situation • emotional episodes lasting longer than expected • sudden emotional outbursts (these outbursts can I just don’t understand why Mom is crying. When I include frustration, anger, laughter, or crying) walked in the room, she was happy and calm. Then, • moments of intense emotions that are out of the when I asked her about her day, her smile turned into patient’s control a frown and she started crying uncontrollably. I’ve nev - • facial expressions that don’t match the emotional er seen her cry like that. I’m concerned. response. EMOTIONS ARE NATURAL . We’ve all heard the cliché, “Emotions make us human.” People cry when they’re hurt and laugh when things are funny. However, mil - lions of people find that controlling their emotions is hard because of pseudobul - bar affect (PBA). PBA refers to inappropriate, involun - tary, or uncontrollable laughing or crying caused by the residual effects of a nervous system disorder. Al - though PBA is closely asso - ciated with post-stroke pa - tients, it can occur with any nervous system condition, including Alzheimer’s dis - ease, traumatic brain injury, and multiple sclerosis. Sci - entists have labeled PBA a disorder of emotional incon - tinence (patients can’t control their emotional respons - Navigating the new normal of PBA es). The patient understands how he or she should feel, After any neurological illness or injury, patients may but PBA limits the ability to display the correct emotion. have conditions that affect activities of daily living and can lead to complications if not addressed prop - Signs and symptoms erly. These conditions may be long-term or perma - Typically, the signs and symptoms of PBA are first recog - nent, so patients and family members must learn to nized by patients, caregivers, or family members. Teach manage them. According to a National Stroke Associ - patients with a nervous system disorder and their families ation Survey, about 53% of stroke survivor respon - about the signs and symptoms of PBA so they can con - dents reported PBA symptoms. However, only about American Nurse Today Volume 13, Number 4 AmericanNurseToday.com 24 Tips for living with PBA Share these tips with patients and fami - breathe to regain control and to contin - gy. The patient can try to release ten - lies to help them cope with the effects ue deep breathing until the episode sion from the forehead, neck, shoul - of pseudobulbar affect (PBA). passes. ders, jaw, and other muscle groups that might tense during a PBA episode. In Learn Distract addition, massage might be helpful in Help the patient and family understand In many cases, patients can sense an relaxing these muscles and reducing why this is happening. Clearly explain impending emotional outburst. Distrac - the overall stress of an episode. the condition in terms the patient can tion is a great way to decrease the oc - understand. Then encourage the pa - currence of episodes and diminish their Be patient tient and family to educate those around length. Teach the patient to focus on Patience is especially important for the them. The National Stroke Association something else; he or she can look out family and caregivers of PBA patients. surveyed patients living with PBA and the window, interact with a pet, or use Remember, PBA symptoms don’t match found that several identified the disor - mental imagery (such as thinking about the patient’s mood; they’re an involun - der as socially debilitating. To cope with a vacation or favorite family memory). tary response. The patient may need the embarrassment of emotional out - time to reshift his or her focus or for the bursts, patients were building their Change body positions emotional episode to dissipate. During lives around PBA and minimizing the Sometimes, changing the body’s posi - reactions. Most described the condition tion can help to distract and refocus this time, remain calm, be patient, and as isolating and hard for others to un - the mind. Teach the patient to change understand that this too shall pass. positions when he or she feels an on - derstand. The more the patient, family, Talk coming emotional outburst. A simple and surrounding support system un - The social stigma associated with PBA change from sitting to standing or derstand PBA, the better the responses should not affect the open and honest standing to walking can help decrease and reactions. approach patients and family members attention on the emotional episode. Inhale and exhale must have about the condition. Talking Taking deep breaths can decrease the Relax with their practitioner about PBA and impeding anxiety of an episode. Teach The PBA information website ( PBA.org ) other medically relevant options to pur - the patient how to slow down and suggests relaxation as a coping strate - sue is important. one third of the respondents with depressants or dextromethorphan symptoms were treated. and quinidine. PBA treatment includes cop - bout 53% of stroke ing strategies and pharmacologic Asurvivor respondents Creating a healing management. The concept of environment “navigating the new normal” reported PBA symptoms. PBA affects patients physically, bridges the gap between effec - socially, and emotionally. Increas - tively living with PBA and ineffectively coping with it. ing awareness and providing patients and families with PBA isn’t associated with mood; a patient who’s ways to manage the disorder are the first steps to creat - crying isn’t always sad. And when patients can’t ar - ing a healing environment that supports patients in ticulate their feelings in a manner that matches their their efforts to overcome the effects of PBA. expressions, they may become frustrated, leading to depression and social isolation. Depression occurs Maude McGill is the chief nursing administrator for the nursing program at Regent because the patient doesn’t understand why this is University in Virginia Beach, Virginia. Marzell McGill is a campus pastor for happening, and isolation occurs because the patient Elizabeth City State University in Elizabeth City, North Carolina. is afraid an episode might occur in public. In many Selected references cases, patients and families attempt to mask PBA Ahmed A, Simmons Z. Pseudobulbar affect: Prevalence and manage - symptoms by limiting social contact rather than being ment. Ther Clin Risk Manag . 2013;9:483-9. open and honest about the disorder and finding ef - Chang YD, Davis MP, Smith J, Gutgsell T. Pseudobulbar affect or de - fective ways to manage it. Depression and isolation pression in dementia? J Pain Symptom Manage . 2016;51(5):954-8. can lead to a prolonged healing process and poor Colamonico J, Formella A, Bradley W. Pseudobulbar affect: Burden of quality of life. As a nurse, you can teach patients illness in the USA. Adv Ther . 2012;29(9):775-98. how to navigate through the new normal of PBA and PBA Info. Life with PBA symptoms: Tips for PBA. pbainfo.org/pba-tips achieve the best possible quality of life. (See Tips for Perotti LP, Cummings LD, Mercado J. Behavioral treatment of pseudo - living with PBA .) bulbar affect: A case report. Perspect Psychiatr Care . 2016;52(2):82-7. If nonpharmacologic interventions don’t work, pa - Uhland V. Living with PBA. StrokeSmart. October 21, 2014. stroke tients may need to turn to medication, such as anti - smart.org/article?id=369 AmericanNurseToday.com April 2018 American Nurse Today 25.