Crying

[zenman]

Would any neuro red flags go off with a 69 yr old patient who breaks into tears every time he talks about management monetary waste, welfare, unions, and bullies in the workplace? It just doesn't seem the same as someone crying over a lost pet, for example. I'll be talking with his spouse tomorrow and PCP. He did ok on cognitive impairment testing. Just doesn't feel right.

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[Bartelby]

Maybe frontotemporal dementia? Is his MMSE score good?

Or maybe he's just an odd guy who gets too worked up about political and social issues, maybe with a strong history of victimization himself. I wonder what kind of role money and work has played in his problems. I'm interested to see what people come up with on the differential.

 

[IAmAUser]

,

 

[OldPsychDoc]

boehner syndrome?

You're going to Hell for that, you know...

 

[billypilgrim37]

You're going to Hell for that, you know...

Don't worry, he'll get the cell down the hall from us.

 

[nitemagi]

Pseudobulbar palsy? I'm pulling from step 1/2 for that one...

 

[zenman]

boehner syndrome?

Good one, but he has a lifetime of crying about almost anything, not a sudden event. Forgot to add this patient had MI and CABG 9 yrs ago.

 

[whopper]

Ask him why those topics seem so touchy for him.

 

[notdeadyet]

Good one, but he has a lifetime of crying about almost anything, not a sudden event. Forgot to add this patient had MI and CABG 9 yrs ago.

Do you get an Axis II vibe off of him?

 

[kumar28]

sounds like pseudobulbar affect. Any hx of head trauma when he was young (since this has been since he could remember). Tx usually is a very low dose of SSRI. Maybe you could try that..like 5mg of prozac and see if this helps.

 

[strangeglove]

I would recommend a neuro exam, and then a cognitive exam that includes some executive functioning measures, such as the MOCA. The life-long history argues against PBA. Nonetheless, if the symptoms are impairing his functioning (another important question before any treatment), then I concur with the low-dose SSRI. Of course, there is also Nuedexta. Does he have a cough?

I also wonder whether he is using repression-based defences, such as displacement, to avoid affect related to his attachments. What's his life like? How is the quality of his relationships? This could give you some insight into his personality.

 

[billypilgrim37]

I just started tearing up a little bit when I was reading the formal announcement from Borders about their closing.

So when you figure out what this guy has, let me know, so I can get treated too.

 

[IT514]

Given this guys history w/ vascular stuff and the CABG, I'd second a more in depth cognitive/neuropsych eval. I'd be curious if there were memory problems beyond what screeners could pick up, as a guy like this, esp. at his age, could ace the MMSE and the MOCA and do terribly on a measure that goes beyond the 7+/-2 attention bufffer.

Vascular dementia with PBA and prior hx of depression is not uncommon. Did you give any depression screens? With the wife or PCP, I'd look for the history of onset/offset of symptoms to tell you a lot (and make darn sure to ask about his driving!). Any TIAs recently?

 

[OldPsychDoc]

I just started tearing up a little bit when I was reading the formal announcement from Borders about their closing.

So when you figure out what this guy has, let me know, so I can get treated too.

Maybe you should try some of that Nuedexta stuff.
Or just make yourself a Robitussin & tonic...

 

[Mattchiavelli]

As far as pseudobulbar affect, at least what would build a case for it based on what I've seen in behavioral neuro clinic-
-also has a propensity for lability the other direction as far as intense laughter from things only mildly funny or with no apparent humorous cause
-has insight into this being inappropriately intense of an emotional reaction/ego dystonic
-this crying/laughing happens even without any kind of stimulus, some patients describe it as coming over them kind of like a seizure

It's be pretty uncommon to see PBA be the presenting sx of a neurological disease but not impossible. Much more likely to be emotional lability associated with depression. Other things to consider if you're thinking FTD include language difficulty (word finding difficulty, shrinking vocabulary, up to frank aphasia/mutism), executive dysfunction, and other emotional issues like problems matching emotional states or blunting.

If this is really a lifetime thing then I think vascular etiology is really off the table. With his CAD it does make him higher risk for stroke but he would have a clear onset if that were the case and it wouldn't be something lifelong.

 

[IT514]

I think while PBA is less likely than just depression here, I dont think vascular contribution is off the table b/c of prior history, as long as you can establish that hes more weepy now than before, and has the "crying storm" quality to it. As everyone here is saying, the answer is in the history. I'm curious what brought him to the attention of the OP in the first place. Is this a therapy case?

Edit: Again, my concern here is hes doing fine on screeners and is walking around with memory and executive problems. How did the collateral interview go?

 

[dianamd]

Would any neuro red flags go off with a 69 yr old patient who breaks into tears every time he talks about management monetary waste, welfare, unions, and bullies in the workplace? It just doesn't seem the same as someone crying over a lost pet, for example. I'll be talking with his spouse tomorrow and PCP. He did ok on cognitive impairment testing. Just doesn't feel right.

Along with pseudobulbar, don't forget to r/o ALS. Saw a very similar case two years ago and noticed fasciculations on the forearm during my interview. (Just search "pathological crying.")