Everyone has at least a little bit of firsthand experience with inappropriate emotional reactions — cracking up at bad news, for example, or having one of those aggressive “so cute I could eat it up” moments. That’s fine. That’s normal. You’re not perfect, and sometimes, there’s going to be an imperfect match between your emotions and the emotions that the moment calls for.
But in a recent column in Scientific American, psychiatrist Daniel Shalev described a case of this phenomenon taken to an extreme: An elderly woman who cried at anything and everything and couldn’t seem to stop. She’d suffered a stroke a few days earlier; now, in the aftermath, the tears just kept on coming.
The problem: The woman, identified as “Maddie” (a pseudonym), had emerged from her stroke relatively unscathed except for the crying — but the crying was a pretty whopping exception. “Maddie cried when her husband came in and when he left. She cried during therapy meetings and medical updates. She cried through eating and bathing,” Shalev wrote. “The only time she did not weep was while she slept.” In the stroke unit of the hospital, her doctors had assumed her tears were a normal response to a scary situation; once she was transferred into rehab, though, it became clear that they were something more.
The diagnosis: Maddie had a history of depression, Shalev noted, but wasn’t currently showing any of the other signs of the condition: She was sleeping and eating normally, her concentration wasn’t off, she had energy. In fact, her lone symptom — “extreme, uncontrollable expressions of sadness without the accompanying emotion” — seemed like “the opposite of depression, in which a person may feel despair within but appear blank or detached.”
Instead, Shalev determined that Maddie was suffering from something called pseudobulbar affect, or PBA — a “vastly underdiagnosed” condition in which patients experience “involuntary bursts of emotional expression”:
PBA is caused by the disruption of an emotional expression circuit spanning several brain regions. Cortical structures responsible for higher emotional-intellectual function, such as the frontal lobe, produce the emotional context for expression and send it to the brain stem and cerebellum. The cerebellum acts as a gatekeeper, inhibiting or allowing the impulses to pass to the pons, where they are executed as laughter or tears.
Often, it’s mistaken for depression or another condition; in one study, only half of patients with PBA had gotten any treatment for their symptoms, and even then, many of them were receiving treatment for the wrong thing.
In some cases, though, that can end up working out: A class of depressants called serotonin reuptake inhibitors (SSRIs), Shalev noted, can also effectively treat PBA. That’s what happened with Maddie, who began taking SSRIs in addition to her regular antidepressant. In less than a week, her tears had stopped almost completely. Or rather, as Shalev wrote, they’d dropped down to a level that matched the situation — she still had crying bouts, but so soon after a medical emergency, she was entitled to them.