Crying and PBA
After a brain injury, the tears may become loose or they may flow more quickly down the cheeks. People with brain injuries may also struggle to control emotional outbursts. Crying is not always an expression of sadness. Many people with brain damage call themselves 'emotionally incontinent', which is often experienced as a nuisance. Sometimes it is an expression of a small emotion. Sometimes the emotion doesn't match the tears. The braking function of emotions may be reduced.
NB! There are many people with brain damage who are no longer able to cry.
That can be a major obstacle in life. People can feel the emotion, but the tears, which can provide relief from this emotion, do not flow.
That is a consequence of the brain injury.
Many causes of increased emotionality and crying as a result of brain injury
There are many causes of 'crying' in brain injuries, it is important to recognize the cause because medication can provide relief for some causes.
controlling crying reflex or crying reflex broken
As children we learn to control outbursts of emotion and control the crying reflexes. For most adults, crying is the moment that other people see their emotion.
In a healthy person, the neurotransmitters that stimulate and inhibit emotion are in balance. They interact with a complex of nerve pathways that control emotion and with nerve pathways that show emotion. This may have been damaged due to brain injury. This is a neurological consequence of brain damage.
In the acute phase after brain damage, crying is entirely consistent with the shock and sadness surrounding the new situation. In many cases, people with brain damage continue to cry or tears quickly run down their cheeks. This can sometimes be completely unexpected, due to an unimportant incident or a small emotion.
The expressed emotion is then, as with many brain injury victims, not congruent with the felt emotion. Seeing something beautiful can also be a reason to cry. The crying reflex can no longer be consciously inhibited.
Crying fits can be intense and completely contradictory to the feeling someone has at that moment. It may seem disproportionate.
Crying does not have to be an expression of sadness. It cannot be prevented by doing pleasant things and cannot be treated by talking to a psychologist.
Crying can also be a normal reaction to the loss. New situations can cause new losses. Chronic loss can become more intense over time.
It is therefore important to distinguish the different ways of crying or tears.
A distinction can be made between eight causes and multiple forms can occur simultaneously.
- forced crying (Pseudobulbar effect/PBA) A person has involuntary or uncontrollable seizures cry or laugh. This is a condition related to the location of the brain injury in the brain. Medicines can provide relief. See our special compulsive crying/compulsive laughing page.
- overstimulation crying A person has received too many sensory or cognitive stimuli to process; it can lead to crying fits that do not provide relief.
- tiredness crying A person may be too tired and overloaded from the brain injury and may be unable to do anything other than cry. If the crying spell leads to falling asleep it can provide relief, otherwise not. NB! Overstimulation crying and fatigue crying can coincide.
- no longer being able to control the tear reflex A small emotion of happiness, beauty, slight sadness, slight disappointment or slight stress can bring someone to tears. She or he cannot stop that. Situations that cause (mild or severe) tension can easily cause tears to flow.
- experience the emotion magnified Enjoying music becomes intensely enjoying music that makes tears flow.
- crying is the only expression of emotion Every emotion; scared, angry, happy, sad can lead to tears.
- sadness and depression The feelings of sadness or melancholy loneliness can cause tears to flow. Living with a brain injury is chronic living loss. Crying can be a normal reaction to the loss. New situations can cause new losses. Chronic loss can become more intense over time. The risk of depression is increased after brain injury. Depression can occur in 20-50% of people who have a stroke in the first year after the injury. No figures are known for the other causes. Depression causes a lot of psychological suffering. But physical functioning also deteriorates.
- post traumatic stress disorder, PTTS Brain injury can have a traumatic cause or can be such a powerful confrontation with near death that it can lead to PTSD. Our advice is to seek professional help.
How to deal with the tears?
When the cause is known, bystanders can respond more appropriately than when the cause is unknown.
As a bystander you can ask what caused the tears, or what the emotion is. The person with brain injury can then choose to ask not to pay attention to it because it is part of the injury, or because he/she is very sad now.
If someone suffers from uncontrollable attacks of crying and/or laughing (PBA or compulsive crying), it is important to ask further questions. The difference between PBA and real grief is sometimes difficult to tell. Medicines can help with PBA.
Medicines can also provide relief from depression. However, this does not apply to all forms of depression.
Brain injury explanation from the neurology/neuropsychology team
Parvizi J, Archiniegas DB, Bernardini GL, Hoffman MW, et al. (2006). "Diagnosis and management of pathological laughter and crying". Mayo Clinic Proceedings. 81(11):1482–1486. doi:10.4065/81.11.1482.PMID 17120404.
Dark FL, McGrath JJ, Ron MA; McGrath; Ron (1996). "Pathological laughing and crying". Australian and New Zealand Journal of Psychiatry. 30(4):472–479. doi:10.3109/00048679609065020. PMID 8887697.
Apopleksi – sygdom, treatment og organization, Munksgaard, 2012 https://www.pbainfo.org/