Evaluation and Management of Crying Spells
Begin with a focused history and physical examination to determine if the crying represents pathological crying (involuntary, excessive, stereotyped outbursts) versus psychiatric symptoms, as this distinction fundamentally changes management.
Initial Assessment Framework
The evaluation depends critically on patient age and clinical context:
For Infants (<1 year old)
Perform a systematic physical examination looking for occult injury or illness, as 61% of infants presenting with unexplained excessive crying have serious underlying conditions 1. The physical exam is diagnostic in 41% of cases and provides clues in another 13% 1.
Essential examination components include:
- Complete skin inspection under all clothing (looking for hair tourniquets, bruising)
- Palpation of all long bones (occult fractures)
- Corneal fluorescein staining (corneal abrasion)
- Eyelid eversion (foreign body)
- Rectal examination
- Retinal examination
- Thorough neurologic assessment 1
For afebrile infants in the first few months of life, obtain urinalysis and urine culture 2. Among infants <1 month, urine cultures are positive in 10% of cases 2. Other laboratory testing should be driven by clinical findings, as "screening" tests beyond urinalysis are of little help 1.
Key clinical predictor: Infants who continue crying excessively after initial examination are more likely to have serious pathology, while those who stop crying during assessment are unlikely to have serious causes 1.
For Adults and Adolescents with Mental Health Presentations
Determine medical stability through focused assessment rather than routine laboratory screening 3. The goal is identifying whether behavioral symptoms are caused or exacerbated by underlying medical conditions requiring acute treatment.
Critical assessment elements include:
- Abnormal vital signs
- Neurologic examination (looking for stroke, CNS lesions, seizures)
- Cardiac and respiratory systems
- History of recent stroke or neurologic illness 3
Medical conditions that can present as psychiatric symptoms include:
- Neurologic: stroke, hemorrhage, CNS infections, seizures, tumors
- Metabolic/endocrine: hypoglycemia, hyponatremia, hypocalcemia, thyroid disorders
- Infectious: meningitis, encephalitis, HIV, syphilis 3
Routine laboratory testing (including urine toxicology) has minimal utility unless clinically indicated 3. In one study, routine toxicology screens were positive in only 5% of cases with no changes in management 3.
Management of Pathological Crying
If the crying represents pathological laughing and crying (PLC)—involuntary, uncontrollable paroxysms often triggered by non-sentimental stimuli and excessive relative to any emotional stimulus—this is a distinct neurologic syndrome requiring specific treatment.
First-line treatment: Selective serotonin reuptake inhibitors (SSRIs) 4. SSRIs are efficacious, safe, and well-tolerated for pathological crying and are recommended as the primary treatment 4.
Alternative treatments if SSRIs are ineffective or poorly tolerated:
- Tricyclic antidepressants (documented efficacy in controlled studies) 5
- Dextromethorphan/quinidine
- Dopaminergic agents 4
The rationale for serotonergic treatment is that post-stroke pathological crying may result from stroke-induced destruction of serotonergic raphe nuclei in the brainstem or their ascending projections 5.
Critical Pitfalls to Avoid
Do not misdiagnose pathological crying as depression or mania. PLC does not bear a predictable relationship to the patient's prevailing mood, and episodes do not produce sustained mood disturbance 4. The crying is variably accompanied by episode-congruent emotional feelings and may even occur with contradictory feelings (feeling happy while crying).
Do not assume psychiatric etiology without medical clearance. History and physical examination provide the diagnosis or clues in 54-74% of cases across age groups 1, 2. Missing occult medical causes can have significant morbidity implications.
For infants, do not rely on parental reassurance alone. Parents cannot identify the cause in the majority of serious conditions 1.