The Challenges of Diagnosing and Treating Pseudobulbar Affect
By H. Richard Adams, MD
This week we conclude our two part series about a distressing complication that may arise following a traumatic brain injury—pseudobulbar affect (PBA). Due to minimal awareness and knowledge of PBA in the medical community, PBA is often misdiagnosed as depression or part of the primary neurological disease when in fact, it’s a separate, treatable condition. Last week we described the condition and the complexity involved with distinguishing disorders of affect with disorders of mood.
The Challenge of Diagnosing Pseudobulbar Affect
In 1969, K. Poeck characterized four main features which he hoped would serve as criteria for diagnosing PBA:
(1) Episodes are inappropriate to the situation and can be precipitated by nonspecific stimulation, such as contraction of facial muscles, removal of bed covers, or the approach of someone toward the patient;
(2) There is not a close relationship between the emotional expression and how the patient is feeling;
(3) The episodes are relatively stereotyped, and it is very difficult for the patients to control the extent and duration of the episodes; and
(4) There are no episodic mood changes corresponding to the episodes, and there is no sense of relief as the emotions are expressed.
This last criteria tries to capture the fact that the episodes appear to come from nowhere and are out of context. Others have postulated Poeck’s criteria may exaggerate the dissociation and give the impression the evoking stimulus is never appropriate. This may not always be the case, especially in patients with aphasia or other forms of cognitive impairment.
Complications of Depression
Differentiating between PBA with crying episodes and crying due to depression may be difficult. The behavior of depressed individuals (e.g. crying) is congruent with the emotion, whereas this may not be the case in most instances for those with PBA. And when PBA is associated with depression, it makes the diagnosis even more difficult.
Some surveys of patients have found the emotions of labile anger and frustration to be present in more than half of those with underlying neurological disorders. These findings are consistent with previous epidemiological data suggesting episodes of anger and frustration, in addition to laughter and crying, are an important component of the emotional lability in PBA. Recent surveys of PBA report the mean prevalence to be at 10% minimally and up to 38% across the six most common underlying neurological conditions. Based onU. S.estimates for these neurological conditions (i.e. Alzheimer’s disease, ALS, MS, Parkinson’s disease, Stroke, and Traumatic brain injury) the total prevalence may be between 2-7 million people.
Although the cause and origin of PBA remains unclear, many consider it to be the result of brain lesions interfering with neural circuits and neural transmitters. These neural transmitters are involved in regular voluntary and perhaps over-learned involuntary emotional expressions. This has led many patients to report their symptoms have not been sufficiently controlled by medications primarily involving tricyclic antidepressants, selective serotonin-uptake inhibitors, other non-tricyclic antidepressants, and antipsychotics. Good news arrived in 2011 when the FDA approved the first treatment for PBA, Nuedexta (Avanir). This oral treatment is a fixed dose combination of the cough suppressant dextromethorphan hydrobromide and the anti-arrhythmic quinidine sulfate.
Seeking Treatment
The studies which support the effectiveness of Nuedexta were performed in patients with underlying ALS or MS. At this time, the drug has not been shown to be safe or effective in other types of emotional lability. The pharmacological action of the combination of this drug is felt to be the dextromethorphan that acts by inhibition of glutamate neurotransmission which has an excitatory effect on neurons, thereby decreasing behaviorals which occur at inappropriate times. The quinidine sulfate increases the bioavailability of dextromethorphan thereby extending its effectiveness. This medication has not been compared to other drugs used for PBA. The common adverse effects associated with the higher dosages of quinidine sulfate (used to suppress cardiac arrhythmias), including immune-mediated thrombocytopenia, lupus-like syndrome, granulomatous hepatitis, and QT prolongations, have not occurred with the much lower dose used in Nuedexta. The dextromethorphan may increase the risk of the life-threatening serotonin syndrome when used with other antidepressants. The initial dosage is one capsule once daily for seven days followed by one capsule twice daily thereafter. It does appear to be safe when used alone, but a negative could be the monthly cost of more than $500/month.
The Importance of Differentiation
In conclusion, it is important to differentiate pseudobulbar affect from disorders of mood. This requires clinicians to first define mood and affect on temporal grounds before characterizing the subjective and objective aspects of those domains of emotions. This is especially important in the context of many neurological disorders as PBA seems to occur more frequently than has been commonly recognized in general medical, neurological, rehabilitation and psychiatric practices.
Assessment scales, including the Pathological Laughing and Crying Scale, Emotional Lability Questionnaire, the Affective Lability Scale, and the Center for Neurologic Study Lability Scale, may help guide clinical evaluations. Not only will these scales assist clinicians with a diagnosis, but they may also help to measure the effects of treatments prescribed for this condition. It is hoped that this new agent, Nuedexta, may serve as a new category of neurotropic agents and lead to further medications being developed for this condition.
About the Author
H. Richard Adams, MD, is a practicing physician and brain injury specialist currently serving as staff physical medicine and rehabilitation specialist at Long Beach Memorial Medical Center in California. Dr. Adams is also a medical director of an adult neuro rehabilitation program and is an associate clinical professor at the University of California Medical Center in Irvine and Veterans Administration Hospital in Long Beach.
Paradigm is always ready to assist with the successful management of complex work-related injuries. Fill out our contact form if you have a case you would like to refer to us, and be sure to join us on Facebook and Linkedin.
The Importance of Differentiating Pseudobulbar Affect from Disorders of Mood
By H. Richard Adams, MD
This week we begin a two part series about a distressing complication that may arise following a traumatic brain injury—pseudobulbar affect (PBA). Due to minimal awareness and knowledge of PBA in the medical community, PBA is often misdiagnosed as depression or part of the primary neurological disease when in fact it’s a separate, treatable condition.
What is PBA?
Pseudobulbar affect, also known as pathological laughter and crying, or emotional lability, is characterized by involuntary, unexpected outbursts of inappropriate laughter or crying. The neurological condition is common in multiple sclerosis and amyotrophic lateral sclerosis, and may also occur in other neurological conditions including traumatic brain injury, stroke, and Alzheimer’s disease. It is a source of embarrassment and can be associated with a reduction in the patient’s quality of life. When compromised by injury or disease, this emotional dysregulation can have a substantial impact on the injured person, his or her family, and the larger community.
Affect Versus Mood
This disorder of emotion is thought to be predominantly dysregulation of affect versus mood. The American Journal of Geriatric Pharmacology has described “mood” as an emotional feeling stated by a patient and “affect” as the emotional appearance of the patient. Mood is often described as denoting an individual’s emotional state over a relatively long period of time (e.g. depression, anxiety and adjustment). Affect, on the other hand, refers to one’s emotional state over a relatively short duration (minutes to hours) that varies from moment to moment and can be superimposed on the prevailing mood.
The disorders of mood are described in considerable detail in the Diagnostic and Statistical Manual of Mental Disorders IV. This diagnostic-based system has, over time, facilitated improved identification and treatment of those disorders in many clinical settings. Unfortunately, the exclusive presentation of mood disorders in that system has unintentionally nearly eliminated the disorders of affect from the minds of many clinicians. Disorders of affect are characterized by impairment of the moment-to-moment regulation of emotion and the sustained/pervasive disturbances of mood are not necessary for the diagnosis and often times are absent. The prototype of an affective disorder is seen in Kluver-Bucy-like syndromes, which present with symptoms such as docility, hyperorality and visual agnosia.
Observing Pseudobulbar Affect
One of the earliest recorded references to what was probably pseudobulbar affect was made by Darwin, who observed in his writings on emotion that, “Certain brain diseases, as hemiplegia, brain-wasting, and senile decay have a special tendency to induce weeping.” The landmark medical description of the disorder was made in 1924 by S. A. Kinnear Wilson who described pseudobulbar affect as primarily secondary to strokes which enumerated the clinical features of laughter and crying and may evolve into its opposite.
Wilsonfurther pointed out the well-known fact that brain injury affecting descending motor pathways, from the cortex to the brainstem, can impair voluntary activation of facial musculature but leave involuntary facial expression, such as occurs in emotion, intact. This further led Wilson to propose that involuntary pathways allow stimuli with emotional contact to activate the brainstem facial respiratory control center into producing emotion and voluntary centers allowing regulation of brainstem facial respiratory center activation. Unfortunately, there has been little progress in verifyingWilson’s theory on the origins of PBA.
About the Author
H. Richard Adams, MD, is a practicing physician and brain injury specialist currently serving as staff physical medicine and rehabilitation specialist at Long Beach Memorial Medical Center in California. Dr. Adams is also a medical director of an adult neuro rehabilitation program and is an associate clinical professor at the University of California Medical Center in Irvine and Veterans Administration Hospital in Long Beach.
Paradigm is always ready to assist with the successful management of complex work-related injuries. Fill out our contact form if you have a case you would like to refer to us, and be sure to join us on Facebook and Linkedin.
A Paradigm Network Manager is far more than a typical nurse case manager (NCM). These field-based experts blend early, onsite intervention with specialized knowledge and act as an integral part of the medical care team. In contrast, most other NCMs are removed from onsite work and advise the patient telephonically. Paradigm’s Network Managers are backed with comprehensive data, tools and processes, and are a one-of-a-kind human resource that no other care management company offers.
The Role of the Network Manager
When managing a case, Paradigm immediately wraps a clinical team around each injured person to ensure the best level of care. The onsite Network Manager serves as the central hub and immediately starts supporting the patient and family, and communicating with the client, Paradigm team members, and treating medical staff. The Network Manager aligns all parties toward the outcome goal and remains involved with the case to collaborate with the medical team for the highest level of functional independence.
Special Qualifications
Each Paradigm Network Manager is a registered nurse with extensive experience in catastrophic injuries. When Paradigm hires Network Managers, “We look for a very specific skillset,” said Jo Carter, Associate Vice President of Network Services.
Before a candidate may be considered for the role, he or she must have a minimum of 5 years of clinical experience and 3-5 years of catastrophic injury management experience. The selection process involves an extensive application, a series of interviews and an industry-specific test. This evaluation helps Paradigm understand how the person practices—how they communicate, conduct assessments, resolve conflicts, and assist the injured person and family with making care decisions.
All Network Managers must have excellent verbal and written communication skills, as well as high levels of maturity and flexibility. These skills enable them to assess complex situations and make decisions in the best interest of the injured person. Paradigm’s Systematic Care ManagementSM process assists them with a methodical roadmap so no stones go unturned.
Paradigm’s Network Managers are:
Field-Based Advocates. Network Managers meet face to face with the injured worker, family, and all members of the treating medical team to assess the person’s situation and advocate for proper care throughout the recovery process.
Long Term Associates. A Network Manager with experience related to a patient’s particular needs is involved with the case from the initial hospitalization until they return to their community. “Catastrophic cases are usually open for about 24 months,” Carter said, and pain cases “at least 12 months.”
Highly Skilled Consultants. Every Network Manager is a registered nurse and 95% carry specialized certifications within their field, such as the Certified Case Manager credential.
Continually Educated Professionals. In addition to licensure and certification requirements, Paradigm requires 10 hours of internal continuing education per year, which is an elevated standard compared with state requirements. The additional training focuses on managing catastrophic conditions—education not available for generalist case managers.
Fully Supported Team Members. Paradigm supports each Network Manager with a clinical care team, access to data and a network of specialists.
Long-Term Employees. Paradigm has very low turnover rates among its Network Manager staff and a significant number stay with the organization for 10, 20 or more years.
“Our nurses are the heart and soul of what happens at Paradigm,” Carter said. “The standard of integrated care they uphold make Paradigm’s successful care management methods possible.”
Paradigm Management Services is always ready to assist with complex medical cases. For more information on our full service offerings, please feel free to contact us through our website or call (888) 621-6602. We also invite you to join our social communities on LinkedIn, Twitter, YouTube and Facebook.
Paradigm has been the leader in complex medical management for over 20 years, thanks to experts like Julie Fawson. As a Director of Clinical Services, Julie works hard to help improve the lives of catastrophically injured people. So let’s take a look at what she does to make a difference on a daily basis.
Julie coordinates the experts that make up the unique Paradigm model. She selects the right physicians, network managers and specialists to drive the best clinical outcomes for each case. She ensures each injured person’s needs, and the client’s expectations, are met in accordance with the highest standards.
And, thanks to her years of experience assisting injured people and working directly with our clients, she’s able to align goals and achieve superior results for all.
Directors of Clinical Services like Julie benefit our customers for many reasons. They lead the management process toward Paradigm’s guaranteed outcomes, pursue necessary, high-quality and effective courses of treatment, coordinate nationwide resources, and help everyone understand and plan for future medical needs.
Thanks to people like Julie, Paradigm is able to achieve return-to-work results that are 5 times better than the industry average, and help customers save 36% over the life of the claim.
This week, Dr. Richard Adams, Paradigm’s medical director and brain injury specialist, provides us with his insights and the evidence for “disorders of consciousness” or “slow to recover” programs seeking to address the brain injured patient with low level of functioning. It is critical to understand the evidence for and prognosis of brain injury patients in these programs.
Slow to recover brain injury programs, previously known as “coma stimulation,” play an important, and sometimes ignored, role in the functional recovery of injured patients. The overall goal of this type of neurorehabilitation program is to provide an environment which maximizes functional recovery through the use of neurostimulation techniques, and medical management to prevent complications which can prolong potential neurological recovery.
The need has evolved over the last 20 years as the number of severe brain injury survivors has increased due to improvements in critical care management and rehabilitation treatment. While many of these survivors will go on to achieve significant recovery of function, as many as 10-20% will remain in prolonged states of severely reduced consciousness for a period of time or permanently. These survivors do not meet the criteria for admission to an acute rehabilitation facility (e.g. active participation in therapy for 3 hours per day with specific goals for functional recovery) due to their low level of cognitive functioning.
This has led to the development and growth of specialized programs staffed by therapists and physicians trained in neurorehabilitation. The programs are usually located in a variety of settings, including long-term acute care hospitals (LTACs), subacute congregate residential homes, subacute skilled nursing facilities and acute hospital transitional units.
Slow to recover brain injury programs provide systematic structure and goal directed interventions/strategies including range of motion exercises, positioning protocols and schedules, bowel and bladder management, and treatment of abnormalities of muscle tone (e.g. spasticity); management of heterotopic ossification; management of autonomic dysfunction; tracheostomy protocols for removal; maintaining optimal skin condition; protocols for assessment to evaluate change in physical as well as cognitive status; treatments to alleviate pain and/or physiologic sequelae of procedures involving noxious stimuli or interventions; and family/surrogate education and training in clinical management.
At this time, due to lack of evidence-based medicine, guidelines are limited regarding length of stay. However, many rehabilitative experts empirically recommend a length of stay for 6-12 weeks with 10-15 hours of structured therapy per week. If the individual has not shown cognitive improvement indicating potential to meet the admission criteria for an acute rehabilitation facility, then it is appropriate to transition the individual into a long-term environment. This does not mean there will not be further recovery, but it is unlikely the recovery would be to a level of functioning qualifying the individual for acute rehabilitation. Rehabilitative re-evaluations should take place at 6, 9 and 12 months before determining permanency.
The natural history and long term outcome of “slow to recovery” individuals has not yet been adequately investigated but clinical experience suggests that many of these individuals will recover to a level of meaningful activity which may not occur if not placed in the appropriate stimulating environment.
These programs continue to provide an enriching environment to maintain comfort, eliminate complications and optimize functional recovery. We need to move away from warehousing individuals who initially are at a low level of functioning until a sufficient amount of time has passed to allow for further recovery.
How do you measure the return on investment of medical case management effectiveness particularly for catastrophic and complex workers’ compensation injuries?
It’s a question all claims departments ask and one all case management providers will say they’ve answered.
But here’s the real proof:
Milliman, an independent consulting firm, examined a database consisting of more than sixty thousand acute catastrophic claims to evaluate how the workers’ compensation industry performs.
They concluded that the best case management efforts can significantly reduce lifetime costs and improve outcomes such as Release to Return to Work, Return to Work, and Return to Work Full Duty. For more about what Paradigm can offer, please view the video above or feel free to contact us.
Medically complex cases, including catastrophic injuries with post-acute medical needs, account for a very large portion of workers’ compensation claims costs. However, when claims managers seek to control volatility by helping the injured worker reach the highest possible recovery, they in turn reduce the risk of complications and lower long term medical care costs.
There are several factors responsible for driving the high costs in catastrophic and complex cases. First, there are the numerous ongoing risks that are inherent with these types of cases. Second, there is a considerable amount of medical care involved–significantly more than in other cases. Third, there are complications due to the increased number of settings in which care takes place and the increased number of providers and specialists that deliver care. These factors all increase the likelihood of errors that lead to increased expenses.
One example of this is the high incidence of complications associated with a traumatic brain injury. Figure A, below, represents the dramatic volatility that is inherent in these catastrophic injuries over time. Some of the more frequent complications driving increased medical need and costs include skin breakdown, hydrocephalus, seizure disorder, spasticity/contracture, impulsivity, pneumonia, meningitis, chronic pain, and the inability to live independently in the long term residential setting.
Figure A
Each risk is case-dependent and all can greatly increase the ultimate costs of the case. Poor management in the acute period can lead to a host of significant and expensive long-term complications, even when the initial costs appear to decline.
The trajectories for Paradigm-managed cases are quite different when it comes to costs for all types of medically complex cases because we prevent or mitigate the medical complications commonly responsible for poor outcomes and high costs.
Figure B (below) represents cumulative medical expenses for all types of catastrophic injuries.
Three simple actions can help claims professionals and treating medical achieve the highest possible clinical outcomes, reduce the risk for outbound volatility and control the overall claim costs:
Figure B
1) Engage top tier medical specialists to consult with claims staff and treating physicians
2) Map a detailed care path to the best-case recovery
3) Closely manage the case according to the care plan
Paradigm Management Services uses Systematic Care Management to integrate and coordinate healthcare services to achieve better medical outcomes. For more information, please call 800-942-1725 or feel free to contact us.
When addressing catastrophic and complex cases, workers’ compensation claims professionals seek a win-win: the maximum recovery possible with controlled medical costs. Fortunately, these seemingly disparate interests can align when a comprehensive team is involved to ensure the best quality care and support for the injured worker and his or her family. This approach translates into better medical outcomes for the injured person which leads to earlier release to return to work, and a reduction of medical and indemnity costs.
It’s no secret in workers’ compensation that expert medical case management is the best method for achieving these goals. The difficulty lies in utilizing the proper components for catastrophic injuries and complex medical conditions due to the inherent volatility driven by the complexity of the injury and complications that can occur. These cases require specialized, targeted intervention. With the right type of case management, better outcomes and lower overall costs can be achieved.
Catastrophic and complex cases require highly active, onsite engagement with the injured worker, his or her family, and the treating care team. Telephonic case management may be effective with more common and less serious conditions, but it is ineffective in these situations. There are many complexities and a broad range of clinical conditions that must be understood and managed onsite.
An expert nurse case manager with specialized training in catastrophic injuries is best suited to perform this role. The nurse immediately wraps a comprehensive team around the injured worker to ensure the best care is provided. Their experience managing cases that are rare for most leads to better medical outcomes and better informed injured workers and their families. This lowers the risk for medical complications, improves transitions between treatment teams, and helps motivate the injured worker toward his or her recovery.
It is critical to remain outcome focused rather than assignment focused. Developing a comprehensive care plan at the beginning of the case that includes specific, functional recovery goals is essential for catastrophic and complex case management. However, this is only the first step. Successfully implementing the plan requires a goal oriented focus, delivering the best care in support of these goals and managing the case until the defined outcomes are achieved.
In addition to using an onsite case manager, it is critical to involve a consulting physician, or medical director, who has deep expertise in the specific injury and who remains on the case from beginning to end. As a collaborator with the attending physician, the medical director helps align goals and develop comprehensive care plans to mitigate risks and resolve clinical issues.
Tightly managed, these strategies can dramatically reduce costs and maximize medical outcomes on catastrophic and complex workers’ compensation claims. Employing the same approach that serves high volume injuries (e.g. slips, strains and falls) is unfortunately inadequate for addressing catastrophic and complex injuries.
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