April 2011 - The ALS Association Greater Sacramento

Ask the Doc Q & A with Edward Kasarskis, MD, PhD
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Edward Kasarskis, M.D., Ph.D. is Director of the multidisciplinary ALS Center at the University of Kentucky
Neuroscience Center in Lexington, Kentucky, professor in the Department of Neurology at the
University of Kentucky, and Chief of Neurology at the VA Medical Center in Lexington KY.
Q: I find that I sometimes overreact to something I hear, read, or see on TV. Occasionally I start crying;
other times I seem to laugh uncontrollably. Is this something other people with ALS experience,
or might I have another medical problem? Is there anything I can do about this?
A: It’s perfectly normal to experience happy or sad feelings when you have ALS, of course. But if you
find yourself laughing or crying excessively, or if your family or friends feel you are over-reacting to Dr. Kasarskis
situations with more emotion than you typically did, that could suggest a problem. It’s not uncommon for people with
ALS to have what is called “pseudo bulbar affect” (PBA), which is the proper medical term for this set of symptoms.
PBA can occur in people with many different neurologic conditions and is recognized by involuntary, sudden, and frequent
episodes of laughing and/or crying far in excess of situation which may have provoked it. The outbursts can
cause embarrassment and anxiety, particularly when you’re with others. People with PBA may find it difficult to hold
down a job or interact in social situations, and may isolate themselves as a result. One ALS patient of mine with PBA
found that he couldn't discipline his child because he burst out laughing at his son's mischievous antics.
It’s common for people with PBA to wonder how the problem can possibly be related to ALS, but it is. The PBA appearances
are nothing more than exaggerated reflexes, and are yet another hyperactive reflex that reflects the "Upper Motor
Neuron" involvement in ALS. Not surprisingly, people with other conditions, such as multiple sclerosis, stroke, traumatic
brain injury, and other neurologic problems can also exhibit PBA.
For years, people with PBA have been treated with a variety of anti-depressants, with only limited success. There is,
however, a new drug, just approved by the FDA, called Nuedextra® -- a fixed dose combination of dextromethorphan
hydrobromide and quinidine (not quinine) sulfate -- that is effective in reducing PBA symptoms. (In the spirit of full
disclosure, the University of Kentucky participated in the evaluation of the drug as a clinical trial study site, but there is
no other potential conflict of interest). Neudextra may be a useful medication for people who find their episodes of
laughing or crying interfering with their activities of daily living and quality of life.
I suggest you discuss your own personal situation with your physician. He or she will help you decide whether your
symptoms are significant enough to warrant taking the medication (which is given twice a day), and if the potential
benefits make the drug worthwhile for you.
If you would like to submit questions for a future Q & A, please send your questions to Amber Walters at awalters@alsa-national.org.
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