No Crying in Baseball (and John Boehner)

The short YouTube clip from the movie A League of Their Own illustrates a common (but exaggerated) response to outbursts of tears in inappropriate situations.  Tom Hanks is managing a womens replacement baseball during World War II.  He becomes upset when one player starts to cry and shouts out a memorable line: "There's no crying in baseball".  The tearful display of emotions of the new Speaker of the House John Boehner has prompted discussion of the appropriateness and meaning of tearfulness.  Certainly crying is a normal human emotion, but the question here is context--when and where is appropriate to become tearful.

There is significant normal variability in frequency of crying and laughter in humans.  Some normal individuals cry much more frequently than others.  Cultures vary in the acceptance of public displays of tearfulness.  But there is also the potential for clinical neuroscience disorders to disrupt the regulation of emotional expression.  When the threshold for crying becomes too low, or occurs  in inappropriate situations it may be a signal of a pathological condition impairing emotional regulation.

A review article by Parvizi and colleagues from the Department of Neurology at UCLA summarizes some of the key clinical issues in pathological crying and laughter (PLC).  They note that mood disorders such as depression commonly produce lowered thresholds for crying.  This however, occurs in the context of a pervasive low mood.  Frequent crying in depression needs to be differentiated from frequent crying without a pervasive low mood. This type of emotional display can occur in a variety of brain disorders.  They summarize the types of clinical conditions and prevalence rates for pathological crying or laughter:

• Amyotrophic lateral sclerosis (Lou Gehrig's disease) 49%
• Cerebellar multiple system atrophy (MSA) 37% 
• Stroke 11-34%
• Alzheimer's disease (non-depressed) 30%
• Traumatic brain injury 5-11%
• Multiple sclerosis 10%
• Parkinson's disease 5%

As you can see, there are a variety of disorders than can produce pathological crying or laughing.  Pathological crying or laughing is not commonly a presenting sign of these conditions.  But PLC can produce significant distress and cause concern in family members and friends of those affected by this condition.

The good news is that many who have PLC can be successfully treatment with medication.  Patients with PLC often experience significant improvement with antidepressant medications such as amitriptyline (Elavil) or selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac).  The effect occurs even if the patients do not have clinical depression.  This effect suggests that serotonin may be involved in emotional regulation independent of the effect in mood disorders.

A interesting recent development in the treatment PLC has been work with the cough suppressant dextromethorphan.  A recent randomized clinical trial was conducted using dextromethorphan (combined with quinidine that raises serum dextromethorphan levels) in over 300 patients with ALS or multiple sclerosis.  This trial found superiority for dextromethorphan over placebo with approximately a 50% reduction in the symptoms of PLC.

Patients with PLC due to an underlying clinical neuroscience disorder may benefit from one of these types of treatments.  Effective treatment may significant reduce their distress and embarrassment due to emotions that get out of control. 

Parvizi J, Arciniegas DB, Bernardini GL, Hoffmann MW, Mohr JP, Rapoport MJ, Schmahmann JD, Silver JM, & Tuhrim S (2006). Diagnosis and management of pathological laughter and crying. Mayo Clinic proceedings. Mayo Clinic, 81 (11), 1482-6 PMID: 17120404


Pioro EP, Brooks BR, Cummings J, Schiffer R, Thisted RA, Wynn D, Hepner A, Kaye R, & Safety, Tolerability, and Efficacy Results Trial of AVP-923 in PBA Investigators (2010). Dextromethorphan plus ultra low-dose quinidine reduces pseudobulbar affect. Annals of neurology, 68 (5), 693-702 PMID: 20839238