Slurred speech, a weak grip, a lopsided smile, walking with a cane—these are visible signs of a stroke, but many people also experience lesser-known signs such as depression and pseudobulbar affect, a medical condition characterized by sudden and uncontrollable episodes of crying, laughing, or other emotional displays.
In my first year as an attending physician on the stroke service, I met a young man who had had a bleed on the surface of his brain, a subarachnoid hemorrhage, which was caused by an aneurysm (a small blood-filled, balloon-like bulge in the wall of a brain blood vessel). After undergoing a procedure that blocked the aneurysm using tiny platinum coils, he returned to his pre-stroke form, in terms of walking and talking. But he still faced two significant challenges: the happily married man of two young children was depressed and would frequently burst into tears.
Post-stroke Depression Is Common
Research suggests that as many as 25 to 80 percent of stroke survivors experience depression, a phenomenon that's associated with worse outcomes, more deaths, and longer stays in the hospital. The depression is understandable when you consider that most people's lives—and the lives of their families—are fundamentally altered after a stroke. Depression can also be a result of physiologic changes. For example, the specific location of a stroke in your brain can increase your risk of depression, and there is evidence that strokes can increase inflammation and alter brain chemistry, leading to mood changes.
Treating Post-stroke Depression
That's why we recommend that stroke survivors should be screened for depressive symptoms while in the hospital. Some evidence suggests that using an antidepressant early in the recovery period might not only improve mood but also improve other functional outcomes and motor skills. Once stroke survivors leave the hospital, their families and caregivers should watch for depressed mood three, six, and even 12 months after the stroke, especially if the person has a history of depression or other mood disorders. Other people who have a higher risk of depression after a stroke include women and those who were completely independent pre-stroke and are now totally dependent on others for basic tasks. Talk to your doctor about your concerns and pay attention—that grumpy mood might be more than just waking up on the wrong side of the bed. Your doctor may prescribe medication and recommend talk therapy, both of which can be helpful.
Episodes of Crying and Laughing
Pseudobulbar affect is associated with a variety of neurologic conditions in addition to stroke, including multiple sclerosis, Alzheimer's, dementia, amyotrophic lateral sclerosis, and traumatic brain injury. It is estimated to affect more than 1 million people in the United States. The condition can be distressing not only for the patient but also for friends and family, especially if it happens out of context or if the person doing the laughing and crying is someone who wasn't particularly emotional in the past. People may limit their interaction with others out of embarrassment or shame, given that their outward emotional expression may not match what they're feeling inside.
Treating Pseudobulbar
AffectIt's important to understand and recognize pseudobulbar affect and to support those experiencing it by showing compassion about their inability to control these episodes. Various medications are available to treat PBA, mainly antidepressants, but they are limited by their effectiveness and side effects. The US Food and Drug Administration approved the first drug specifically targeted for PBA—a combination of dextromethorphan and quinidine (Nuedexta) in 2010.
How did my patient do? With the help of antidepressants and counseling, he becomes more like the man he had been before his stroke, spending time with family and friends. Life after stroke may be different for him, but he's happier and more at ease with his new normal.
