Emotional and behavioural changes after stroke Flashcards
Thoughts/ behaviours/ feeling are related
Left or right hemisphere?
thoughts = what we think
behaviours = what we do
feelings = how we feel
(these 3 things should be viewed collectively)
the brain mediates and integrates all cognitive activities, emotional experiences, feelings and behaviours
- after a stroke individuals may experience fear, anxiety, frustration, anger and sadness and a sense of loss for the changes they have experienced = natural response to stroke
- -> this will effect how people interact with the external world
Right hemisphere associated with more emotional deficits (Eslinger) = less emotional expressivity
Post-stroke depression
2 reasons why someone may develop PSD?
Anosognosia
quite common, affects 1/3 individuals
- combination of factors can cause it. The sudden nature of the stroke can have a life-changing impact
-damage to brain after stroke, genetics and social factors can also contribute to depression
- v. underdiagnosed and focus of therapy is usually on other deficits
-2 reasons why someone may develop depression:
1) damage to key cortical and subcortical regions
responsible for emotional processing eg. those responsible for monoamine circuitory (frontal lobe/ basal ganglia), serotonin rich nuclei (araf nuclei in brain stem)
-changes in serotonin and noradrenalin activity (subcortical region damage)
2) Reactive psychological conditions resulting from the impact of stroke
eg. changes to perception of self, loss of independence/ support
Anosognosia - partial or complete unawareness of deficit. Can coexist with depression
PSD and cognitive deficits
having to deal with both cognitive impairment and PSD can be severely debilitating
- there’s a bidirectional relationship between functional deficits and depression
- functional deficits can increase the risk of depression
- depression can have a negative impact on functional recovery
Post-stroke depression (PSD) assessment
4 assessments
physical/ verbal difficulty?
symptoms
clinicians use a number of assessment measures:
1) Beck’s depression inventory: used to rate mood (21 items) - self administered questionnaire
2) CES-D: depression screening (20 items to assess symptoms over past week) - interview/ self-administration
3) Zung scale: assesses affective/ psychological and somatic depressive symptoms (20 items: 10 negative, 10 positive statements) - self-administration/ telephone interview
4) emotional and behavioural index: behaviour index form rating emotional reaction to acute stroke (item ratings)–> examiner rated index
(telephone assessment needed if person can’t physically make it to assessment centre)
problem with communication = can ask family/friends/ caregivers to look out for any post-stroke changes= highlights importance of social support
- some of these symptoms may overlap with cognitive deficits, therefore, it’s important for the clinician to be able to differentiate this; this can be challenging
symptoms:
- persistent sadness, anxiety, empty feelings
- sleep disturbances
- changes in appetite
- feelings of helplessness. worthlessness, hopelessness
- social withdrawal
- fatigue
- difficulty concentrating or remembering details
PSD treatments
- pharmacological treatment: anti-depressants (ssris) - shown to reduce dependence/ disability due to their mood improvement ( = improves quality of life)
- psychological therapy = CBT, counselling - can help with negative thoughts/ cognition and feelings of hopelessness (improve self concept)
- other therapies = tackling cognitive deficits
(increase cognitive abilities = feel better about self = lower depression)
PSD management
- communication with others helps
- improve nutrition
- stroke support group
- set realistic goals and prioritise
- practice stress/ anxiety management
- be positive
- stay as active as possible
- get out into community
Predictors of PSD
more favourable outcomes likely by using?
previous depression
small vessel disease
stroke severity and associated disability
social isolation
anxiety
poor coping skills
= all can lead to unfavourable outcome for stroke - associated depression eg. death
more favourable outcomes likely by using:
- SSRIs
- psychotherapy
- other antidepressants
- good coping skills
Pseudobulbar affect (aka emotionalism)
=uncontrollable episodes of laughing or crying that is out of context for what the person is feeling
- result of an underlying neurological problem most likely (as it’s also seen in dementia and parkinsons)
- sometimes stroke can affect areas of emotion processing and expression. the stroke leads to a disconnection of these in the brain which triggers episodes of crying and laughing -> no specific link between PBA and lesions location (any damage in this area can lead to problems in emotion expression)
- the underlying mechanism of PBA appears to be a lack of voluntary control
mood = how we feel emotionally on the inside
affect = how we display/express our emotion and how we feel to the outside world
–> for stroke survivors with PBA = disconnect here
- the inability to control specific emotions can be frustrating and disruptive
(can be embarrassing to react inappropriately in public)
- psychological consequences and impact on social interaction can be substantial
PBA diagnosis
Difference to depression?
- brief episodes (seconds to minutes)
- episodes are sudden/ abrupt
- uncontrollable
- exaggerated reaction
- does not match internal mood
Depression:
- episodes last from weeks-months
- ongoing sadness
- expression of emotion can be controlled
- emotional reaction matches their internal state
PBA treatment
efficacy?
-SSRIs
-TCA
- antidepressants used for treatment. Efficacy explained:
1) onset of action may occur within a few days, which is faster than for depression. For depression it takes at least 2 weeks
2) doses are lower than those used for depression
(underlying mechanisms for how these drugs work in PBA is not well documented)
PBA management
- be open about the problem so people aren’t surprised/ confused when you have an episode
(increased awareness) - distract yourself when you feel episode coming on
- take slow deep breaths until you’re in control
-change body position
it is a condition that is:
1) underrecognised
2) under diagnosed
3) under treated
Stroke and personality changes
- stroke is associated with a decrease in the personality trait under the positive pole
- tend to move more towards negative pole of spectrum
- a stroke can completely change a personality
- more severe the stroke the greater the personality change (Ferro, Caeiro + Figueira)
Apathetic personality disorder
assessment
treatment
apathy = a disorder of motivation characterised by decreased mental and physical ability and emotional interference
- decreased initiative in carrying out activities but are able to if given instructions
-frontal lobe area of the brain is associated with personality –> damage to this area = changes
-more common in individuals with cognitive problems or depression
Characteristic symptoms:
- lack of interest in previous activities/ hobbies
- preference for passive activities where they don’t have to express feeling/ respond
- emotionally indifferent
ASSESSMENT:
- personality scale
- neuropsychiatric inventory
(most often the individual might not realise anything has changed –> usually a family member or friend)
TREATMENT
- v little research
-behavioural interventions looked at:
1) coping strategy training - help them manage impact of their disability
2) problem-solving therapy - based on CBT and involves developing an action plan, very much goal-orientated
- patients generally show little improvement over time
- apathy interferes with rehabilitation, and reduces quality of life
Aggressive personality change
characteristics ?
Assessment?
Treatment?
damage to prefrontal cortex could lead to aggressive behaviour, due to impairment in inhibition of aggressive responses
- failure in inhibitory control is probably primary cause of ASB
-external environment can contribute to development of agg behaviour
- fMRI studies have implicate ventromedial, prefrontal and orbitofrontal cortices in anger
characterisitcs:
- can behave aggressively without feeling angry
-can use aggression to react to other deficits: cognitive problems, depression etc.
- aggression can be secondary to the loss of empathy
- loss of empathy - reduced understanding of how other people feel
ASSESSMENT:
same kind of assessment used
MANAGEMENT AND TREATMENT:
- no studies which have evaluated specific interventions for treating or managing aggressive behaviour following stroke
- SSRIs - underlying mechanism is no understood
-counselling recommended to help manage
- strategies for caregivers on how to manage agg patients
Examples of other deficits?
mania
Kluver-Bucy syndrome
Anosoagnosia
