Roy J. Mathew, MD

DOCTOR, PLEASE DON’T CRY

The patient was clearly startled; it was written all over her face. That morning she insisted that because of her past traumatic experiences with a man she had decided not to have any more relationships with men. After having had a painful experience one can either adopt a defensive approach of avoidance or maintain a positive attitude and use lessons of the past to avoid similar disasters in future. Avoidance of risks for fear of a negative outcome, I argued, would produce a safe but colorless existence. It will grant the silence of a desert, peace of a grave yard, or security of a salve. To illustrate the point I told her about my German Shepherd, Davy.

Some 20 years ago when I was playing ball with him, Davy was run over by a speeding car. I was devastated by his death. The trauma was so substantial and protracted that I decided not to have pets anymore. However, upon further reflection I realized that the pain of his loss was so deep because Davy was so near and dear to me. He enriched my life so substantially. My decision not to have more pets would have deprived me of that happiness. I decided not to be intimidated by the one negative experience. Twenty years later and after six dogs, I am glad I did not stay with my initial decision not to have pets.

The resurrection of my memories of Davy touched a sore note I did not know existed. I thought that I had resolved Davy’s death and had come to terms with it. In the depths of my mind unbeknown to me, the wound was still raw. A flood of tears crossed the span of 20 years and burst forth through my eyes. I could not control myself. I could hardly speak. The patient was shocked and she did not know what to do and how to react. Finally, I told her to wait outside while I pulled myself together.

Why did I shed tears? Why was I embarrassed by my tears and more importantly, why should my tears startle the patient?

Crying betokens weakness. Crying is believed to be an infantile behavior.. It is unprofessional and un-adult like behavior. Yet it is an important component of human emotional landscape.

It is tempting to rationalize tearfulness as a distress signal. All animals have distress signals that beckon other members of the pack to come to their rescue. Distress signals vary widely across the species. However it is not clear if any other animal uses tearfulness. Various pet owners claim that their dogs and cats do cry but there is very little scientific literature on the subject. Some limited studies indicate that elephants and gorillas also shed tears. Animals produce tears to lubricate their eyes and to remove irritants. I am not sure if they shed tears when they are upset. Surely distress tears cannot appear in humans for the first time, out of nowhere. There has to be some precedence in our immediate animal ancestors. When deprived of their bananas monkeys do not shed tears. How did this unique form of human behavior evolve?

Shedding of tears is linked to elimination. The elimination function is mediated by the parasympathetic nervous system. Tears are manufactured by the lachrymal gland tucked away in the upper, outer part of the orbital cavity. Phylogenically the tear gland is related to the salivary gland. Both salivary glands and the lachrymal gland are innervated by the parasympathetic fibers. The facial nerve carries parasympathetic fibers both to the lachrymal gland and the parotid salivary gland. Crocodile exemplifies the link between salivation and lachymation. It is said that when devouring its prey the animal becomes tearful. This tearfulness that is linked to swallowing does not represent remorse and guilt and hence the term, crocodile tears. In psychiatry crocodile tears are not so uncommon. Recently Hillary Clinton was accused of shedding crocodile tears for political gain.

The primary function of the lachrymal gland is not expression of emotions. Normally a modest amount of tears is constantly produced to lubricate the eye. The tears thus produced (basal tears) wash across the eye and are drained through the superior and inferior puncta situated in the lower, inner quadrant of the orbit via the superior and inferior lachrymal canals into the lachrymal sac and the nasolachrymal duct. The nasolachrymal duct, as the name implies, empties into the nose. Blinking facilitates the passage of tears across the conjunctival sac. Irritants in the eye stimulate additional tear production (reflex tears). Tear production is augmented during both sadness and happiness (emotional tears). When the tear production is in excess of what can be drained out, it overflows on to the face.

In composition the three types of tears: basal, reflex and emotional, differ. Tears are water-based; it is said that 98% of the tears consist of water. It also contains several electrolytes and trace amounts of some 45 proteins and immunoglobulins. There is no clear explanation for the biochemical differences between the three types of tears.

Physiologically tear production is an excretory/secretory function but as we have seen it also is linked to emotion. This association is not limited to tears. Anxiety is associated with increased frequency of urination and bowel movement. Acid secretion in the stomach, another parasympathetic function, is also tied to anxiety. Sweating, another excretory function, is a manifestation of anxiety. However, over and above the other emotion-related excretory functions, tear production seems to have acquired special significance.

Stimulation of lachrymal glands by the parasympathetic fibers is not an isolated phenomenon. Parasympathetic fibers also supply the mucous membrane of the nose and pharynx. When the emotional output is powerful, tear production is accompanied by production of mucus-rich secretions in the nose and the throat. Voice becomes husky. When the emotional turmoil is even higher, sympathetic fibers also come into play. The heartbeat increases and so does the respiratory rate and blood pressure along with heightened palmar perspiration. In extreme cases, additional facial nerve activation contracts a unique set of facial muscles, producing an unattractive but characteristic distortion of facial features. This is accompanied by a wailing sound and spasms of irregular breathing: sobbing. Babies thrash around with their arms and legs; fortunately such a display is not often seen in adults.

In the human infant, the production of tears, emission of the wailing sound, and thrashing of arms and legs broadcast a powerful signal. The signal invariably elicits supportive responses always from the mother, usually from the father, and occasionally even from the irate audience. The distress signal has considerable survival value for the human baby. Unlike many other species, at birth the human infant is totally dependant on others for all its needs. It is totally incapable of locomotion. When confronted by a predator its survival depends exclusively upon an adult who may carry it to safety. The infant also relies on others for several vital needs including nutrition. The dependency continues well into the teens. Maturity takes the longest time in humans. Most mammals reach maturity at 30% of their final body weight. Humans on the other hand arrive at puberty only when their body weight is 60 to 70% complete. This lag in human maturity is most obvious in brain development. Thus, for the human who takes forever to reach self sufficiency the importance of crying in his/her survival cannot be overestimated. A function i.e. crying, that serves the organism so very well for such a long time cannot and will not be discarded easily.

Humans in particular, are known to retain a multitude of behaviors from our infantile days. Human brain is said to be “neotenic”. Neoteny implies the persistence of infantile anatomical and physiological characteristics into adulthood. Pedomorphism or the preservation of infant features in adults is also well known to occur in humans. Behaviors and phenomenan that served the human infant and are carried into adulthood with minimal or no change. Crying is one such behavior.

Vikram Patel of Maudsley Hospital in London used MRI to study brain mechanisms that produce crying and also the brain mechanisms underlying the observer’s responses. The cingulate gyrus was activated at the time of tear production. The mother who witnessed the crying spell also activated her cingulate gyrus. Although crying may be initiated by a cortical command, tear production and the related phenomena involve lower brain structures like the hypothalamus. The cingulate is known to link the cortical and the subcortical components of behavior. In his 1937 epoch-making article on the brain mechanisms that mediate emotion, Papez wrote,”The cingulate region endows visceral sensations with conscious awareness.”

Richard Davidson identified right prefrontal activation during uncontrollable crying. The prefrontal cortex represents brain development unique to humans. Thus crying that is predominantly a human phenomenon being located there makes sense. The conscious mind that initiates volitional behavior is represented by the dominant left hemisphere. Crying is by and large involuntary as my embarrassing behavior demonstrated. Involvement of the non-dominant right hemisphere would seem to be a perfect fit. The dominant hemisphere is associated with positive emotions while such negative emotions as sadness are linked to the non-dominant right hemisphere.

Crying betokens helplessness that characterizes the infant. It behooves the observer to come to the crier’s aid. When a physician, especially a psychiatrist starts crying, it forces a drastic role reversal. The psychiatrist who is supposed to be the consoler, all of a sudden, starts putting out signals of distress and helplessness. The patient who is supposed to be the recipient of sympathy and support is forced to supply help and assistance to the psychiatrist. This accounted for my discomfort and the patient’s confusion.

I regained control in a few minutes and asked the patient to come back to the consulting room. I apologized to her for my weakness and we resumed our regular psychiatrist-patient roles and relationship. I had my mask back on and I was consoling her and she was accepting my assistance and support.

After the display of her crocodile tears people felt Hillary Clinton was more human and her popularity went up.

The next time my patient came, she told me that she felt closer to me. She felt I was more human than before. She felt so close to me that she would never leave me to go to another psychiatrist. Somehow, my tears opened a new dimension in our relationship. Perhaps I triggered the maternal instinct in her by my baby-like behavior. Perhaps by exposing my weakness and vulnerability I came down from the podium to where she could reach me. More than anything else, it was clear that we needed each other and that there was not such a great deal of difference between giving and receiving. After all, we belong to the same pack.

Disclaimer: The facts presented in this article and the views expressed are solely those of the author(s) and do not necessarily reflect the views of the Board of Directors or other members of West Texas Physicians Alliance.