SJOGREN'S SYNDROME AND THE INABILITY TO CRY

THE ABILITY TO CRY

I have Sjogren's Syndrome, pronounced“SHOW-grins”. It is an autoimmune disease that affects the body's ability to produce tears as well as affecting the exocrine (moisture) glands all over the body.

Over the last few years, something that people take for granted has become increasingly difficult for me. I can't cry, or at least not to the degree that I used to be able to or when I ordinarily would have. It really bothered me when my husband died a few years ago. Not only did I not have the release, but I worried that others would think I was cold and uncaring. I loved my husband deeply.

I used to think it was related to depression and due to things that have happened in my life that cause me to dissociate. But it turns out there is more of a physiological reason.

WHAT HAPPENS WHEN YOU SHED TEARS

To begin with, the surface of your eye is made mostly of water. And your tears are divided into two categories: Lacriminization and crying. You have lacrimal glands that are between your eyelids and your eyeball. When the gland on the outer corner of your eye, near the temple, produces a tear, you will blink and that will spread the tear across your eyeball. This takes about ¼ of a second.

Then the tear goes to the lacrimal punctum. Wikipedia describes it as follows: “ There are two lacrimal puncta in the medial (inside) portion of each eyelid. Together, they function to collect tears produced by the lacrimal glands. The fluid is conveyed through the lacrimal canaliculi to the lacrimal sac, and thence via the nasolacrimal duct to the inferior nasal meatus of the nasal passage.”

That is just a complicated way of saying there is a natural drain in your eye and from there it goes into your nasal passages and out your nose. This is why your nose also runs when you cry. Who knew?

 lacrimal drainage

During periods of high tear production, like a highly emotional state or severe irritation, the drainage system can't keep up and the tears run down your face. OR at least they are supposed to.

DIFFERENT TYPES OF TEARS

Under normal circumstances, your body has three different types of tears that it can produce. They are basal, reflex and psychic tears. Basal tears serve the purpose of keeping your corneas lubricated so that your eyes don't dry out. Reflex tears form as a response to irritation like when something gets in your eyes or when you are exposed to the noxious vapors of an onion, or you open a bottle of ammonia.

And last but not least, there are the psychic tears. These are the ones you make when you are experiencing a strong emotion, like sadness or happiness, or anger or physical pain. Some people actually feel better after a good cry due to a pain-killing neurotransmitter produced by your body called leucine enkephalin. These emotional tears also contain more protein than the ones produced in response to an irritation.

YOUR AUTONOMIC NERVOUS SYSTEM AND TEARS

But how does this factor into your emotions? Within your brain, there is an area called the limbic system, and within it is an area called the hypothalamus. This is part of your autonomic nervous system. Your autonomic nervous system or ANS controls the things that you don't, such as tears, sweat, heart rate, breathing, etc. One of the neurotransmitters involved in the ANS is acetylcholine. It affects the lacrimal or tear-producing system.

Under normal circumstances, you feel a strong emotion, and this causes your ANS to signal tear-production.

When you cry, there are other things going on within your ANS. Part of your ANS called the sympathetic nervous system which controls the fight or flight response will also cause you to sweat, and your breathing will slow down, and you will also get what is called the globus pharyngis. That's the feeling of having a lump in your throat. When your ANS isn't working properly it is called dysautonomia.

THE PSYCHOLOGICAL AND SOCIAL RESULTS

Researchers Jonathan Rottenberg and Lauren M. Bylsma from the University of South Florida found that there are benefits to crying. Crying helps your body control breathing when it has been aroused in a negative way. https://www.livescience.com/5238-hate-cry.html

When a person experiences overwhelming stress and arousal, his or her heart rate increases and the body begins to sweat. But as a person cries, his or her breathing slows, rendering a calming effect, according to Rottenberg. 

The reason some people find having a good cry pleasant is that the calming effect of crying lasts longer than whatever stressor caused them to cry in the first place.

There are major areas of your life that can be affected when you can't cry. There is more going on here than a response to a stimulus. Evolution has given you this means of crying out in a non-verbal manner to others around you. It allows them to see that you need emotional help. When you receive social input from others it strengthens your emotional bonds with them because they share in your experience. When others say, “I can see that you are sad. I am sorry you are feeling this way. How can I help? Here is a big hug.” You will feel better. And they, in turn, feel empathy and sympathy. These responses are very important when babies cry. They can't speak and therefore need to be able to communicate so that their needs are met. They cry because they are hungry or in pain or are angry. And then their parents respond to them and this causes bonding.

When you cry it can show that you are submissive or vulnerable. This can cause potential attackers to perceive you as weak and underestimate you, or feel empathy toward you, thereby avoiding an attack. In a relationship, it might cause the other person to change their behavior in many ways.

In other social situations, crying can show trust a need for affection, and this results in bonding.

There have been studies that show women actually do cry more than men. However, men cry over the most of the same things as women do, like, death, homesickness or a romantic breakup. Women cry more over small things, but men cry more in response to happiness. The differences between the sexes can be attributed to several things. Culture, male testosterone levels( which inhibit crying) and their work environments.

When you can't produce tears, how do others know that you feel grief, despair, frustration, helplessness, powerlessness, pain, happiness, anger and empathy, pride, longing, anger, frustration sadness or love? If you are able to produce the sobbing sounds of crying, people might not feel empathy toward you if they don't have the visual cue of tears and then assume you are faking the emotion. If they don't see them signaled by the shedding of tears, then we lose out on the social interaction and response that we should get. The result is that we can be isolated socially. Tears are as important as facial expressions. “research provided further evidence for the facilitating effect of tears on processing emotion recognition and social judgments. Their function seems to surpass the connection with merely enhancing sadness recognition. Rather, tears seem to play a significant role as a visual signal in terms of promoting (pro)social behavior.” Emotional Tears Facilitate the Recognition of Sadness and the Perceived Need for Social Support

Age-Related Changes in the Signal Value of Tears http://journals.sagepub.com/doi/full/10.1177/147470491100900304

Studies have found that people feel better when they are with another person when they cry, which indicates that crying helps us to bond and get emotional support from other people. Dry eyes aren't just a medical issue.

WHAT PEOPLE THINK WHEN THEY SEE RED IRRITATED EYES

Humans are also the only primates with the sclerae(the white outer layer of the eye) allowing both the color of the eye and how red the conjunctiva is to show up. Scleral redness shows important biological and social information about you. Other people make judgements about your sadness, healthiness, and attractiveness based on their perception of the redness of your eyes.

When your eyes are red it is mostly caused by blood vessels in your conjunctiva becoming dilated. The conjunctiva is the transparent membrane that covers the sclera or white part of your eye. When your eyes are red, others perceive you to be sadder, older, less healthy, and thereby, less attractive. On an evolutionary level, you don't appear to be biologically fit to a prospective mate. Binocular Symmetry/Asymmetry of Scleral Redness as a Cue for Sadness, Healthiness, and Attractiveness in Humans

People who have Sjogren's Syndrome and eye irritation can become isolated because of other people's perception of them.

EMOTIONAL BLUNTING 

Something worse than all of this is that another problem can be overlooked. There is a condition or symptom of depression and almost suicidal depression. Sometimes it is called emotional blunting and other times it is called a flat affect. The Inability to Cry Medical Definition of Flat affect

I had an experience with this once. I was put on an antidepressant. It caused me to feel this way. It was one of the scariest things I have ever experienced. I couldn't react to things in a normal way. I have a great sense of humor and I would be watching television and see something funny. I would think wow I know that is hilarious. But I couldn't laugh. It was like I could logically understand that it was fun and feel it but I couldn't express it. And it was similar with anger. I could see how a person might say, “that should make me angry, so I should react in a certain way.” Sadness was very strange too. Because not only couldn't I shed tears, now I couldn't even express sadness verbally. I think this is pretty close to what people on lithium feel. You can feel but you can't express. After that, I have this fear of ending up in a nursing home after a stroke, unable to speak and unable to cry, locked in my own misery.

If you have Sjogren's Syndrome and you are on SSRI's you might want to pay attention to how you experience emotions. Nienke van Leeuwen, a Ph.D. candidate in health psychology at Utrecht University in the Netherlands, found that 22 percent of patients with the Sjogren's Syndrome had "significantly more difficulty" identifying their own feelings than control participants did (Clinical and Experimental Rheumatology, 2012).

This condition doesn't need an antidepressant to cause it. You can read here all of the things that can cause it. Reduced affect display Emotional Detachment

A Dutch study of 300 people showed that 22% of the patients with Sjogren's Syndrome were clinically 'alexithymic'. This means they were having difficulty identifying and describing emotions. This was compared to only 12% of healthy controls. Other studies showed that those with higher levels of alexithymia had worse mental well being, proving a link between the two.

THE PHYSICAL BENEFITS OF CRYING

Tears can be a great relief for emotional stress and can get rid of pent up emotions. They actually reduce stress hormones. They also contain antibodies that fight of pathogens. After you cry, your breathing and heart rate decrease and you are calmer. Antibodies in human tears during and after infection. Effects of laughing and weeping on mood and heart rate variability

Dr. William Frey, a biochemist at the Ramsey Medical Center in Minneapolis discovered that emotional tears contain stress hormones that are being excreted through crying. When you cry, your body also produces endorphins. Endorphins are the hormones that make us feel good and are also pain relieving. Two of these are the endorphin leucine-enkephalin and prolactin. Another is adrenocorticotrophic hormone (ACTH), which is an indicator of stress in your body. Your body is getting rid of these hormones and toxins caused by stress. Emotional tears have a 24% higher albumin protein concentration that regular tears caused by irritation. Dr. Jerry Bergman writes, “Suppressing tears increases stress levels, and contributes to diseases aggravated by stress, such as high blood pressure, heart problems, and peptic ulcers.

Crying can also lower your manganese level. Elevated manganese can cause anxiety, nervousness, irritability, fatigue, aggression, and emotional problems. Manganese Induced Oxidative Stress

When you can't produce tears, even light and air can be irritating and painful and lead a person to avoid going outside. The result is yet another way to become isolated. People with dry eyes can also end up with complications like infections and ulcers.

As you can see, tears serve more of a purpose than just keeping foreign bodies out of our eyes. And the ability to cry or not cry shouldn't be taken for granted. We are the only primates that can do it and this ability is a profound influence on our lives. I pray that someday soon there will be an answer for people like me. I know that God intended for us to be able to express a whole range of emotions and although I  often can't cry about it, I am still sad. 

Ecclesiastes 3:4 says that there is an appointed time for everything, “A time to weep and a time to laugh; A time to mourn and a time to dance”. Romans 12:15 says we are supposed to “Rejoice with those who rejoice, and weep with those who weep”. The shortest and one of the most profound verses in the Bible is John 11:35, “Jesus wept”.

Crying: The Mystery of Tears by William H. Frey

The Miracle of Tears by Dr. Jerry Bergman

Emotional Expression and Health: Advances in Theory, Assessment and Clinical Applications

Ivan Nyklícek, Lydia Temoshok, Ad Vingerhoets

Routledge, 2004

Adult Crying: A Biopsychosocial Approach

A. J. J. M. Vingerhoets, Randolph R. Cornelius

Psychology Press, 2001

American Psychological Association (http://www.apa.org/monitor/2014/02/cry.aspx)

Emotional Tears as Biological Signals

Why we cry-New research is opening eyes to the psychology of tears.

Inability to cry in patients with Sjogren's syndrome affect emotional and mental well-being

Another Crossover Illness with POTS--Sjogren's Syndrome

Sjogren's Syndrome-- Is an autoimmune disease named for Henrik Sjögren, a Swedish ophthalmologist. It is mostly known for causing extremely dry eyes and mouth. But it affects MANY other parts of the body because it affects the exocrine glands. The exocrine glands secrete their products to the outside of the body. These glands include the lacrimal and salivary glands and also glands in the stomach, intestines, respiratory tract, the skin, vagina as well as the pancreas and prostate. If their function is impaired it will affect the corresponding organs.

There are three types of Sjögren's syndrome. Primary Sjögren's syndrome occurs by itself, with no other associated disorders. Secondary Sjögren's syndrome occurs along with other autoimmune disorders, like systemic lupus erythematosus, rheumatoid arthritis, scleroderma, vasculitis, or polymyositis. If  the disorder only involves the eyes, it is called sicca complex.

About nine times as many women as men suffer from Sjögren's syndrome. Although most patients are diagnosed when they are between 40 and 55, SS affects all age groups. Thirty percent of people with other autoimmune diseases like Systemic Lupus Erythematosus and rheumatoid arthritis, also have SS. And a large percentage of SS patients also have POTS, and/or OT.

 Between 0.1% and 3% of the population in the United States have SS and it is reflected in all ethnicities. According to the American College of Rheumatology, between 1 million and 4 million Americans have Sjögren's syndrome.

Exactly what causes Sjogren's syndrome has not been determined. There are several possibilities. It runs in some families, indicating a genetic factor. The fact that more women than men have it points toward hormonal influences. And there are also viral factors. The immune system may be activated when the patient contracts a virus and then it becomes overactive and  mistakes areas of the body that produce moisture. In 2004 a group of Greek researchers presented evidence that a coxsackievirus may be the disease organism that triggers SS.

Most frequently SS causes dryness in the salivary glands, causing an extremely dry mouth. This is called xerostomia. This leads to difficulty swallowing and speaking. Because there is a reduction of saliva to help keep the teeth clean,  cavities and gum disease are also a prominent result. Saliva is produced mostly by the parotid glands. They lie over the jaw bones and behind the cheeks and in front of the ears. They frequently become enlarged in patients with SS.

The extremely dry eyes found in SS is caused by the lacrimal glands which produce tears, being slowly destroyed. This results in itching, burning, redness, sensitivity to light and thickened secretions that gather at the corners of the eyes. In some cases, the cornea develops ulcerations.
Other moisture producing glands in other areas of the body can cause many other symptoms. In the respiratory tract, dry mucous membranes in the nose can cause sinus infections and nosebleeds, not to mention discomfort. There can also be hoarseness, bronchitis, pneumonia, and ear infections. It can also cause inflammation and damage to alveoli(air sacs) in the lungs, resulting in scarring and breathing difficulty.  Patients can have very uncomfortable vaginal dryness resulting in yeast  infections and urinary symptoms.

I found out the hard way that the pancreas and gallbladder can be involved. This is due to slowed production of digestive enzymes and the pancreas itself works similarly to salivary glands and in conjunction with them. When you chew food a digestive enzyme is released in your mouth and another one is released by your pancreas. But if you think about it, it makes perfect sense. They are liquid. If they aren't functioning, then there can be problems digesting food  and absorbing nutrients like B12 which causes pernicious anemia. If you also have something like lupus, you are already at risk of anemia because of increased cell apoptosis.The role of apoptosis in systemic lupus erythematosus My gallbladder was necrotic and the cystic duct was gangrenous and the cystic artery was thrombosed. During my surgery, I lost 10 ml of blood. If I had lost anymore they would have had to do a blood transfusion. The whole thing ended up causing pancreatitis.

Liver diseases have been found in about a quarter of patients with Sjögren's syndrome. These can include Primary sclerosing cholangitis (PSC), a chronic, or long-term, disease that slowly damages the bile ducts, Primary biliary cirrhosis (PBC),autoimmune liver disease,  and in some areas of the world, Hepatitis C. 


There are also problems with the esophagus and the rest of the digestive tract due to decreased secretions. One very obvious problem with SS and digestion is constipation. If there aren't enough secretions in the intestines and not enough moisture, you are going to be constipated. Medications to reduce reflux are frequently prescribed and many patients have strictures and other problems with the esophagus and swallowing called dysphagia. I have had strictures, and esophagheal spasms, GERD and I have Barrett's Esophagus.  Esophageal motor function in primary Sjögren's syndrome: correlation with dysphagia and xerostomia  Dysphagia and other manifestations of oesophageal involvement in the musculoskeletal diseases Mayo Clinic: Dysphagia  You can also have abnormal liver function tests, chronic active autoimmune hepatitis and primary biliary cirrhosis.

Here are a few other links for some of the digestive problems with SS. gastrointestinal-effects-of-sjogrens   Sjögren's syndrome - information for patients and professionals by Dr. Joop P van de Merwe

 Kidney problems such as glomerulonephritis(inflammation of the glomerulus filters in the kidney) are also not unusual. This will cause, edema or swelling, blood in the urine and reduced urine output. Again this makes perfect sense because your kidneys are what maintain the balance of fluids in your entire body. Patients also have symptoms that have nothing to do with their glands including, fatigue, muscle aches and pains, fevers and joint pain.  Sixty-one percent  of patients with primary Sjögren's syndrome have severe urological symptoms compared with 40% of control patients
with osteoarthritis.  One of these problems is bladder irritability associated with urinary urgency and overactive bladder.  The overactive bladder associated with Sjögren's syndrome is an autoantibody-mediated disorder of the autonomic nervous system,which may be part of a wider spectrum of cholinergic hyperresponsiveness. This is basically the autonomic nervous system or in other words, dysautonomia. Patients  can also have interstitial cystitis.  This is inflammation in the interstitium of the bladder. Symptoms include pain, pressure or discomfort in or around the bladder, a persistent urge to urinate and frequent urination both in the daytime and at night. When the bladder is full, the pain is worse. There isn't any urinary tract infection, though. There are other names for it such as painful bladder syndrome(PBS) and hypersensitive bladder. Kidney stones are a problem as well, and those are quite painful and urinary tract infections are frequent as well. I am plagued with both. 
SS patients also have skin problems such as dry patches or overall dry skin, vasculitis. Cutaneous B-cell lymphoma(generally easier to think of as just lymphoma) is something that SS patients are at increased risk of. 

 As previously mentioned, Sjogren's can affect the bladder due to dysautonomia. Sjogren's syndrome can also cause damage to the nervous system which causes peripheral neuropathy, which is damage to the nerves in the arms and legs. This results in pain, numbness, and weakness. When it causes cranial neuropathy, it can cause headaches  and loss of taste and smell. And the parasympathetic system can be affected, which causes POTS and OT. Dysautonomia International: Underlying Causes of Dysautonomia It can also cause digestive motility problems because those are part of the autonomic nervous system via the parasympathetic nervous system. It results in yet another reason for difficulty swallowing, nausea, vomiting, and constipation. This can be exacerbated by inflammation. Diarrhea can also be a problem. If your pancreas isn't working properly and releasing digestive enzymes, then you won't be able to absorb fats and will have oily diarrhea.
 About 1/3 of Sjogen's patients have some form of thyroid disorder.An underactive thyroid gland can cause constipation and fatigue.  Thyroid problems can be treated, but they are often underdiagnosed. 

The all over pain and fatigue that often accompanies SS can be very debilitating as if you have the flu and it won't go away. 

And all of this can be secondary to other autoimmune diseases and the symptoms that go along with them. Antiphospholipid Syndrome is an autoimmune disease that causes bleeding and clotting problems, and apart from the problems this can cause the patient themselves, it can also put them at risk during pregnancies and cause miscarriage. Babies born to mothers with SS can have a condition called fetal heart block. Because of the association with these other conditions, such as lupus and rheumatoid arthritis, those patients will also be at risk for developing POTS and OT. 

Sjogren's syndrome has no cure. The symptoms can be treated in order to relieve some of the discomforts and try to avoid complications. Artificial tears are available over the counter and there are also prescription eye drops but those have an increased risk of malignancy. Some patients need to use these every 30 minutes or so. There is also a procedure called punctal occlusions, where they seal off your tear ducts so you maintain more tears in your eyes. Keeping something, especially water close at hand in order to take frequent sips of will help some with dry mouth. Sugarless gum and other lozenges can also be helpful. There are also mouthwashes for dry mouth. Pilocarpine(Salagen) and cevimeline(Evoxac) are prescription medications to increase saliva and tears. In order to avoid tooth decay and gum disease, special attention to dental hygiene is necessary. There are gel lubricants to treat vaginal dryness. Humidifiers and avoiding cigarette smoke are a good idea. Over the counter lotions and moisturizers help the dry skin. Other complications of Sjogren's can be helped with steroids. And an anti-malarial drug called Hydroxychloroquine(Plaquenil) is also frequently prescribed. 

Diagnosis is made through tests of your eyes to see how much tears you produce as well as biopsies of the salivary glands and blood tests for specific autoimmune antigens. You can read here about how it is diagnosed. http://www.sjogrens.org/home/about-sjogrens/diagnosis

Recently, attention has been brought to the condition in the media because Venus Williams has it.

After you watch the Sjogren's Syndrome videos, don't forget to watch the POTS videos at the bottom of the blog. You have to scroll down for them.

Sjögren's Syndrome - CRASH! Medical Review Series

Sjogren's: A Place to Begin - Part 1: What is Sjogren's Syndrome?

Sjogren's: A Place to Begin - Part 2: Management & Treatment of 
Sjogren's

Sjogren's: A Place to Begin - Part 3: Personal Experience: Estrella

Sjogren's: A Place to Begin - Part 4: Personal Experience: Cathy

Tips for Sjogren's Syndrome- Now With Captions!

Let's Talk About Pain: Sjogren's Syndrome & Rhumatoid Arthritis