Emotional lability

Emotional lability refers to rapid, often exaggerated changes in mood, where strong emotions or feelings (uncontrollable laughing or crying, or heightened irritability or temper) occur. Emotional lability is a distinct emotional process characterized by frequent, excessively rapid, and intense changes in emotions resulting in an inability to maintain a consistent emotional state over time ¹. These very strong emotions are sometimes expressed in a way that is greater than the person’s emotions. When a person is emotionally labile, emotions can be out of proportion to the situation or environment the person is in. For example, a person may cry, even when they are not unhappy – they may cry just in response to strong emotions or feelings, or it may happen “out of the blue” without warning. A person may have little control over the expression of these strong emotions, and they may not be connected to any specific event or person.

Emotional lability is seen or reported in various conditions including borderline personality disorder ², histrionic personality disorder ³, hypomanic or manic episodes of bipolar disorder ⁴ and neurological disorders or brain injury (where it is termed pseudobulbar affect), such as after a stroke ⁵. Emotional lability has sometimes been found to have been a harbinger, or early warning, of certain forms of thyroid disease. Emotional lability also results from intoxication with certain substances, such as alcohol and benzodiazepines ⁶. Emotional lability can also be an associated feature of ADHD ⁷.

Children who display a high degree of emotional lability generally have low frustration tolerance and frequent crying spells or tantrums ⁸. During preschool, ADHD with emotional lability is associated with increased impairment and may be a sign of internalizing problems or multiple comorbid disorders ⁹. Children who are neglected are more likely to experience emotional dysregulation, including emotional lability ¹⁰.

Potential triggers of emotional lability may be: excessive tiredness, stress or anxiety, over-stimulated senses (too much noise, being in large crowds, etc.), being around others exhibiting strong emotions, very sad or funny situations (such as jokes, movies, certain stories or books), death of a loved one, or other situations that elicit stress or strong emotions.

Emotional lability causes

Emotional lability is seen or reported in various conditions including borderline personality disorder ², histrionic personality disorder ³, hypomanic or manic episodes of bipolar disorder ⁴ and neurological disorders or brain injury (where it is termed pseudobulbar affect), such as after a stroke ⁵. Emotional lability has sometimes been found to have been a harbinger, or early warning, of certain forms of thyroid disease. Emotional lability also results from intoxication with certain substances, such as alcohol and benzodiazepines ⁶. Emotional lability can also be an associated feature of ADHD ⁷.

In brain injury, emotional lability occurs because of damage to parts of the brain that control:

• Awareness of emotions (yours and others)
• Ability to control how emotions are expressed – so ability to inhibit or stop emotions coming out
• Stronger emotional responses

Following brain injury an individual may also lose emotional awareness and sensitivity to their own and other’s emotions, and therefore their capacity to control their emotional behavior may also be reduced. They may overreact to people or events around them, conversations about particular topics, sad or funny movies or stories. Weaker emotional control and lower frustration tolerance, particularly with fatigue and stress can also result in more extreme changes in emotional responses.

The person may express their emotions in situations where previously they would have been able to been restrained or in control (in quiet situations, in church, listening to a concert, the library).
These behaviors can be confusing, embarrassing, and difficult to understand for the person with brain injury and for others.

Emotional lability treatment

Emotional lability treatment involves treating the underlying cause.

Coping with emotional lability

Become aware of triggers for emotional lability and try to avoid these when you can. Triggers can include:

• excessive fatigue or tiredness
• stress, worry or anxiety
• high stimulation (too demanding, too noisy, too many people) – too much pressure
• strong emotions or demands from others
• very sad or funny situations (such as jokes, movies, certain stories or books)
• discussing certain topics e.g. driving, loss of job, relationships, death of a family member
• speaking on the telephone or in front of a group or where a person feels under pressure

Have a break

Have a short break away from the situation so the person can regain control of emotions, and to give the opportunity for emotions to settle.

Sometimes a break of a few minutes or a longer period is enough to regain control of emotions – taking a short walk, doing a different activity all can help to cope with these strong emotions.

Ignore the behavior

Try to ignore the emotional lability as much as is possible. Try to get others to ignore it too and continue on with the conversation or task. Focussing on the emotional lability or giving the person too much attention when it is happening can reinforce and increase the problem. It is important that other people don’t laugh too, as this will also reinforce and increase the behavior.

Change the topic or task

Changing the topic or activity (redirection and distraction) can reduce stimulation or stress (particularly if the topic was a trigger). Try to distract or divert the person’s attention by engaging them in a different activity or task.

Provide information and education

Uncontrolled crying or laughing can be upsetting, frightening or confusing for other people if they don’t understand.

• Encourage the person to provide simple explanations or information to other people about the lability, for example, “I cry a lot since I had my stroke … don’t worry about it” or “Sometimes when I am nervous I get the giggles”.
• Let people what they can do, for example “Just ignore me and it will stop”.

Plan ahead

When there is severe emotional lability, one-to-one, brief and fun activities in a quiet environment will be better.

• Try to avoid putting the person in stressful situations or environments e.g. noisy, busy, high levels of activity or that are too demanding.
• Plan activities that are within the person’s ability.
• Plan more demanding activities or appointments after rests, or when the person has the most energy.
• Plan for rests between activities.

Use cognitive techniques

Some simple cognitive strategies can also assist in managing emotional lability:

• Relaxation and breathing exercises to reduce tension and stress
• Using distractions – thinking of something else, imagining a peaceful image or picture, counting
• Doing an activity (going for a walk), having a cold drink
• Cognitive and behavioral strategies such as thought stopping could be discussed with a psychologist.

Counseling and support

If there are other emotional adjustment and coping issues, referral to a counselor such as a psychologist, social worker or psychiatrist may be helpful. Families (parents, siblings, children), friends or carers may also benefit from support and care to help them understand and to cope with these changes.

References

1. Leaberry K.D., Walerius D.M., Rosen P.J., Fogleman N.D. (2017) Emotional Lability. In: Zeigler-Hill V., Shackelford T. (eds) Encyclopedia of Personality and Individual Differences. Springer, Cham. https://doi.org/10.1007/978-3-319-28099-8
2. Paris, Joel (1993). Borderline Personality Disorder: Etiology and Treatment. American Psychiatric Pub. p. 106. ISBN 978-0-88048-408-4
3. Kernberg, Otto F. (27 September 1995). Aggression in Personality Disorders and Perversions. Yale University Press. p. 58. ISBN 978-0-300-06508-4
4. Fortinash, Katherine M.; Worret, Patricia A. Holoday (13 June 2014). Psychiatric Mental Health Nursing. Elsevier Health Sciences. p. 230. ISBN 978-0-323-29327-3
5. Kim, Jong S. (2016-09-30). “Post-stroke Mood and Emotional Disturbances: Pharmacological Therapy Based on Mechanisms”. Journal of Stroke. Korean Stroke Society. 18 (3): 244–255. doi:10.5853/jos.2016.01144
6. Stark, Margaret M.; Payne-James, J. Jason (30 April 2009). Symptoms and Signs of Substance Misuse. Cambridge University Press. p. 22. ISBN 978-0-521-13727-0
7. Posner J, Kass E, Hulvershorn L. Using stimulants to treat ADHD-related emotional lability. Curr Psychiatry Rep. 2014;16(10):478. doi:10.1007/s11920-014-0478-4
8. Posner, Jonathan; Kass, Erica; Hulvershorn, Leslie (2014-08-19). “Using Stimulants to Treat ADHD-Related Emotional Lability”. Current Psychiatry Reports. Springer Nature. 16 (10): 478. doi:10.1007/s11920-014-0478-4
9. Maire, Jenna; Galéra, Cédric; Meyer, Eric; Salla, Julie; Michel, Grégory (June 2016). “Is emotional lability a marker for attention deficit hyperactivity disorder, anxiety and aggression symptoms in preschoolers?”. Child and Adolescent Mental Health. 22 (2): 77–83. doi:10.1111/camh.12168
10. Maguire, S. A.; Williams, B.; Naughton, A. M.; Cowley, L. E.; Tempest, V.; Mann, M. K.; Teague, M.; Kemp, A. M. (2015-03-03). “A systematic review of the emotional, behavioural and cognitive features exhibited by school-aged children experiencing neglect or emotional abuse”. Child: Care, Health and Development. Wiley. 41 (5): 641–653. doi:10.1111/cch.12227