Emotional and Behavioural Changes Following a Stroke

Question 1

What can occur following a stroke?

Answer 1

Post-stroke depression

Pseudobulbar Affect (PBA)

Personality Changes (Apathy and Aggression)

Question 2

Factors that may influence post-stroke depression

Answer 2

Family support

How severe the impairments are

Thinking style of the person

Feelings of hopelessness

Depression prior to the stroke

Small vessel disease

Anxiety

Social isolation

Poor coping skills

Question 3

How many people does post stroke depression affect?

Answer 3

1/3 of stroke patients

Question 4

What may cause post-stroke depression

Answer 4

Damage to cortical and subcortical regions responsible for emotional processing

Reactive psychological conditions resulting from the impact of the stroke

Question 5

PSD and cognitive deficits

Answer 5

Might not be able to do the things they could do before

This can have an effect on how people feel about themselves

PSD can affect cognitive deficits as they may not want to engage in therapies that may help them to recover

Question 6

What is Pseudobulbar Affect?

Answer 6

A condition which results in sudden, uncontrollable episodes of laughing or crying

Not within the context of how the person is feeling

Incongruence with how they feel and what they express

Often inappropriate to the situation

Question 7

What is Pseudobulbar Affect also known as?

Answer 7

Emotional incontinence

Question 8

What other diseases can show Pseudobulbar Affect?

Answer 8

Other neurological diseases

Parkinsons

Dementia

Question 9

What does the fact that PBA affects other conditions tell us?

Answer 9

That there is an underlying neurological problem

Question 10

What is thought to cause PBA?

Answer 10

A disconnect between the brainstem, cerebellum and the cortex

A lack of inhibitory control (the uncontrollable nature of the condition)

Question 11

What part of the brain causes personality changes in stroke?

Answer 11

Frontal lobe

Question 12

Apathy changes

Answer 12

Disorder of motivation

Question 13

Characteristics of apathy changes in stroke

Answer 13

Lack of interest in hobbies

Emotionally indifferent

Preference for passive activities

Question 14

Characteristics of aggression changes in stroke

Answer 14

Behaving aggressively without feeling angry

Reaction to other deficits of the stroke

Loss of empathy

Question 15

PSD assessment

Answer 15

Beck’s Depression Inventory

Centre for Epidemiological Studies Depression Scale (CES-D)

Zung Scale

Emotional and Behavioural Index

Question 16

Beck’s Depression Inventory

Answer 16

21 item scale

Used to rate mood

Self-administered questionnaire

Question 17

CES-D

Answer 17

Depression screening

20 items assess current symptoms over the past week

Interview

Self-Administration

Question 18

Zung Scale

Answer 18

Assesses affective, psychological and somatic depressive symptoms

20 items: 10 negative statements and 10 positive statements

Self-administration

Telephone interview

Question 19

Emotional and Behavioural Index

Answer 19

Behaviour index form rating emotional reaction to acute stroke

Item ratings

Examiner-rated index

Question 20

What symptoms of depression is it important to encourage family members to look out for?

Answer 20

Persistent sadness, anxious or empty feelings

Sleep disturbances

Changes in appetite

Feelings of helplessness, worthlessness or hopelessness

Social withdrawal

Fatigue

Difficulty concentrating or remembering details

Question 21

Why is post-stroke depression hard to diagnose?

Answer 21

It is hard to distinguish which symptoms are depression and which are due to cognitive deficits

Question 22

PBA Assessment

Answer 22

Look for symptoms

• Brief episodes (seconds to minutes)
• Episodes are sudden/abrupt
• Uncontrollable
• Exaggerated reaction
• Does not match internal state

Question 23

Personality Change Assessment - Apathetic Personality Change

Answer 23

Personality scales

Neuropsychiatric inventory

Question 24

PSD Therapies

Answer 24

Pharmacological treatments
- Anti-depressants

Psychological therapies

• Counselling
• CBT

Other therapies
- Tackling cognitive deficits

Question 25

PSD management

Answer 25

Communication
- Talk to someone about feelings

Improve nutrition

Stroke Support Group

• Can relate to other people
• Make them feel less alone and reassured that other people are going through the same thing

Set realistic goals and priorities

Practice stress/anxiety management

Be patient

Stay as active as possible

Get out into the community
- Gives a sense of belonging

Question 26

PBA Treatments

Answer 26

Antidepressants

• SSRIs
• TCA
• Improvement in PBA patients can be seen within a few days as opposed to depression which takes a few weeks
• Need lower does of ADs in PBS

Clearly a different mechanism than depression

Question 27

PBA management

Answer 27

Communication
- Being open about the problem so people aren’t surprised and it decreases an uncomfortable situation

Distraction
- When feeling an episode coming on you can sometimes disrupt the mechanism by distracting yourself

Breathing
- Can control and reduce the length of an episode

Changing body position
- Potentially due to the cerebellum being involved and so disrupts the network

Question 28

Apathetic personality change management

Answer 28

Coping strategy training

Problem solving therapy

• Developing action plans
• Identify the problem and see if they can tackle it

Question 29

Aggressive personality change treatment/management

Answer 29

Pharmacological treatments
- SSRIs

Counselling