Crying Spells: Definition and Clinical Context
Crying spells refer to paroxysms of involuntary, uncontrollable crying that can occur in two distinct clinical contexts: pathological crying due to neurological disease, or as a symptom in neonatal drug withdrawal and certain psychiatric conditions. 1
Pathological Crying (Neurological Origin)
Pathological crying represents paroxysms of involuntary and uncontrollable crying resulting from neurologic illnesses, where the crying episodes are often provoked by nonsentimental stimuli or are excessive relative to the inciting stimulus. 2
Key Clinical Features
The crying episodes are stereotyped outbursts that are excessive to an appropriate emotional response and can be triggered by almost any emotional stimulus (happiness, excitement, sadness, being looked at or talked to, sight of a doctor) or even occur without obvious external or internal stimulus. 3
The crying may be variably accompanied by episode-congruent subjective emotional feelings, but critically, does not bear a predictable relationship to the patient's prevailing mood. 1, 2
In unusual cases, episode-related feelings may be of contradictory valence (feeling happy while crying). 1
The occurrence of these episodes does not produce a sustained mood disturbance, so patients must not be misunderstood as "depressed" solely on the basis of frequent episodic crying. 2
Associated Neurological Conditions
Pathological crying occurs after stroke with a 1-year incidence of 20%, though it often goes unrecognized because patients and relatives rarely complain spontaneously. 3
The condition is associated with various brain stem, cortical hemispheric, cerebellar, and thalamic lesions. 4
The pathophysiology may involve stroke-induced partial destruction of serotonergic raphe nuclei in the brainstem or their ascending projections to the hemispheres. 3
Treatment Approach
SSRIs are efficacious, safe, and well-tolerated first-line treatments for pathological crying. 5, 2
Tricyclic antidepressants, dextromethorphan/quinidine, or dopaminergic agents may serve as alternative treatments when SSRIs are ineffective or poorly tolerated. 5
Three controlled studies have documented effective treatment with tricyclic antidepressants and the selective serotonin reuptake inhibitor citalopram. 3
Crying Spells in Neonatal Drug Withdrawal
Neonates exposed to SSRIs or other drugs late in the third trimester develop crying as part of a withdrawal or toxicity syndrome requiring prolonged hospitalization. 1
Clinical Presentation
Reported clinical findings include continuous crying, irritability, jitteriness, restlessness, tremors, hypertonia, feeding difficulty, sleep disturbance, hypoglycemia, and seizures. 1
The onset of these signs ranges from several hours to several days after birth and usually resolves within 1 to 2 weeks, though in one infant exposed to paroxetine, signs persisted through 4 weeks of age. 1
These features are consistent with either a direct toxic effect of SSRIs or a drug discontinuation syndrome, and in some cases the clinical picture is consistent with serotonin syndrome. 1, 6, 7
Specific Drug Considerations
With fluoxetine exposure, one case report documented an infant who developed crying, sleep disturbance, vomiting, and watery stools, with plasma drug levels of 340 ng/mL fluoxetine and 208 ng/mL norfluoxetine on the second day of feeding. 6
Sertraline exposure during late pregnancy results in neonates with complications including constant crying as part of the withdrawal syndrome. 7
Crying Spells in Other Clinical Contexts
Cultural Syndromes
Uncontrollable crying and/or screaming may be prominent during panic attacks in Caribbean Latinos experiencing ataque de nervios (attack of nerves), where the cultural syndrome links loss of control episodes precipitated by severe stressors. 1
Pediatric Considerations
Crying is a common trigger for child abuse and the most common trigger of abusive head trauma, with crying generally beginning in the first month of life and peaking between 2 and 4 months of age. 1
In one study, almost 6% of parents of 6-month-old infants admitted they had smothered, slapped, or shaken their infant at least once because of crying. 1
Breath-holding spells in children represent a unique form of syncope: cyanotic breath-holding spells occur from age 6 months to 5 years due to forced expiration during crying, while pallid breath-holding spells occur in the first 1 to 2 years and may be an early form of vasovagal syncope. 1
Vaccine-Related Considerations
Persistent, inconsolable crying lasting ≥3 hours occurring within 48 hours after DTP vaccination is considered a precaution rather than contraindication, as follow-up has indicated this reaction is without long-term sequelae. 1
- Inconsolable crying occurs most frequently following the first dose and is less frequently reported following subsequent doses, though crying for >30 minutes can predict increased likelihood of recurrence. 1
Important Clinical Distinctions
Clinicians must distinguish between "functional" crying (where the relationship with mood is inconsistent) and "organic" crying (associated with neurological lesions), as these represent clinically distinct types with different implications for treatment. 8
In rare circumstances, pathological crying may be the presenting symptom of a neurological illness, requiring prompt diagnostic evaluation before initiating treatment. 5
Education and supportive therapy help patients and families mitigate the social isolation and embarrassment that crying episodes frequently produce. 5