Uncontrollable Laughter or Crying from Stroke Survivors

This article by David Wasielewski was posted in the September StrokeNet Newsletter the same time as Walt Kilcullen's article on "Dealing with Five Disabilities After Stroke" article in July 2014.

The StrokeNet site is an excellent source of information. 

Go to: www.strokenetwork.org

To contact David email to: newsletter@strokenetwork.org

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By David Wasielewski

Pseudo Bulbar Affect Disorder and Stroke Survivors

Many stroke survivors deal with the obvious challenges that stroke presents. Loosing physical use of one or more body parts, the ability to speak and or understand language. These losses are all readily apparent to caregivers and social contacts. But there are also a number of less obvious challenges that confront some survivors. One of those is Pseudo Bulbar Affect Disorder (PBA).

The symptoms of PBA are inappropriate outward or physical responses to emotions that the individual experiences. An affect is the physical manifestation of an emotion. The error in the affect defines the disorder. PBA has a range of effects and each survivor has their own experience. In its most severe case the survivor will display an affect that is opposite of the emotion experienced. A person hearing a funny joke may begin to cry, or a death in the family will bring the survivor to a hearty laugh.

In other cases the physical display varies in degree to what is appropriate or normal. The accidental breaking of a dinner plate might cause the survivor to cry uncontrollably or a slightly funny comment might cause prolonged loud laughter. The degree of the response is not appropriate. There is no difference between being slightly sad and uncontrollable crying. The response is always extreme. The inability to manage one’s emotional responses in day to day activities can be quite challenging for the survivor.

Not knowing what may cause an outbreak of crying or laughter may cause the survivor to isolate themselves to avoid embarrassment. In some extreme cases the survivor might even lack the personal insight to recognize that this is happening. It is also uncomfortable for caregivers and other social contacts. Others who do not fully understand the situation will tend to avoid the survivor in order to eliminate the uncomfortable situations. There is the perception that the survivor is mentally unbalanced. In any case, this invisible disability tends to isolate the survivor and make care and support more difficult than it already is.

I was stunned when I initially experienced this disorder. When I woke up in the hospital after my stroke I found myself crying uncontrollably when speaking to my family. As I expressed my concerns to the nurse she carefully explained that the overly emotional response was a result of the stroke. While this explained why I was so emotional she offered no advice as to how I might deal with the condition. I needed to develop some strategies on my own.

Over time (years) I have learned how to partially manage my reactions to events. If I’m aware that my emotional responses might be inappropriate in certain situations I will simply withdraw. I find myself leaving funerals when overcome. I often avoid telling funny stories or jokes as my laughter prevents me from completing the tale. If a situation is unavoidable I will try to explain the condition so others can understand.

The condition is particularly frustrating when I am involved in serious discussions. In situations where I should be mildly angry or upset my body reacts with laughter. This makes such discussions difficult for me, the person I’m dealing with and continuing on almost impossible. Often I need to withdraw instead of continuing on, leaving the topic unresolved.

So what is the survivor with PBA to do? Fortunately, there are some strategies to practice. When one feels an event coming on the survivor needs to find thoughts to distract him/herself from the topic. Imagining oneself in a calm place can be effective. Counting slowly to ten can distract the survivor from an emotional response. Deep, slow breathing often helps alleviate one’s reaction. Recently, several medications have come to the markets that are designed to manage PBA. Nuedexta is marketed for the condition. More information is available at: http://www.stroke.org/site/PageServer?pagename=PBA

It is most important for the survivor to identify the condition and explain it to friends, family and caregivers. This may not prevent the uncontrolled emotional response but it will allow others to recognize this somewhat unusual behavior as part of the effects of the stroke. Recognizing this as a condition and helping the survivor deal with it can help them overcome the stigma of PBA as they work to maintain their social relationships during their recovery.

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Emotions - Dealing with the Five Disabilities Resulting from Stroke Part II

In last week's article written by Walt Kilcullen you read about two more of the five disabilities caused by a stroke. This week's article concludes the series and deals with the remaining disability: emotion. Part 2 was originally posted in its entirety in the September issue of the StrokeNet Newsletter at:
http://www.strokenetwork.org/newsletter/articles/disability02.htm

If you wish to contact Walt, he may be reached at:
newsletter@strokenetwork.org

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by Walt Kilcullen

Part 2.

V. Problems with Emotion

V. Problems with Emotion: Many people experience a range of emotional changes after a stroke. These changes can cause the person’s personality to change and can be disruptive and problematic.

Depression is a common condition after a stroke. It can be mild or it can be all consuming. Although depression is a normal part of grief after a stroke, if it continues for the long run, professional help is
called for.

Anger is also common after a stroke. In my support group, once every two months we split into two groups; one for survivors and one for caregivers. Many times I have heard a caregiver complain about fits of anger from their loved one for no apparent reason.

Emotional Lability is a condition of the brain that causes sudden, uncontrollable crying or inappropriate laughter. Of course this can result in embarrassing situations for both the survivor and the caregiver.

Apathy is not the same as depression even though the behavior is similar. The survivor, who is apathetic, cannot seem to get motivated. He stays in bed too long, sits or lies on the couch for hours, and often will not leave the house.

Anxiety is an unpleasant feeling which often includes nervous behavior such as wringing the hands or pacing about. It is a feeling of fear or distress over something that is unlikely to occur such as a heart attack or car accident.

Treatment options for problems with emotion:

● Antidepressants, drugs that control mood, psychological counseling, and psychiatric therapy are treatments for depression, anxiety, and anger management.

● Apathy is more difficult to treat because there are no drugs available to treat it. However, therapists and counselors have had success by developing a routine for the patient to follow. This includes getting up every day at the same time and scheduling events or activities at certain times each day. The focus is on action which will later lead to motivation toward everyday life.

● I could not find any treatment for emotional lability, but fortunately after a few months, it usually (but not always) fades away.

I wrote an article in the September, 2012 issue of strokenetwork.org on anger and aggressive behavior. There are drugs that are sometimes successful in treating this problem, but there is much the caregiver can do to lessen anger.

● Remember that anger and aggressive behavior are a result of the stroke. Your loved one cannot always control this behavior.

● Stay calm. Do not over react to your loved one’s outbursts. Speak slowly and softly without raising your voice until your loved one calms down.

● Avoid arguing or confrontation with your loved one. Redirect her attention to something else.

● After you identify things that create anger in your loved one, avoid them as much as possible. For example, if you observe that being around a large group of people sets her off, avoid that environment.

● If you as a caregiver become angry or frustrated, back off and cool down. Chances are she will also calm down after you step back and remain calm.

● Stay safe. If your loved one becomes violent, back away keeping a safe distance, and seek help if need be. 
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