L9 Emotional and Behavioural Change Post Stroke

Question 1

The brain mediates and integrates all cognitive

activities, emotional experiences and behaviours. Following a stroke, these interactions can change…

Answer 1

…

Question 2

What is Post Stroke Depression (PSD)

Answer 2

PSD is a persistent and server negative affective change following a stroke, characterised by depression. Broadly speaking, it can be caused by two things;

1. Reactive depression to loss of normal abilities
2. Result of damage to cortical areas (PFC)

Seems to be a clear link between CI and PSD. This has problems because research has shown that with depression comes less willingness and engagement in treatments and therapies, so can have a doubly damaging effect

Question 3

How can PSD be assessed?

Answer 3

using normal Depression scales;

1. Becks Depression Scale (BDI) - is a 21 item scale which is used to assess an individual’s feelings concerning traits associated with depression, eg hopelessness, feelings of worthlessness, sadness, suicidal thoughts etc. participants pick a sentence which describes how they have been feeling in the past two weeks best, scored out of 4 depending on the degree to which they indicate presence of that particular depressive trait. scores added for all items and can range from 0-64. different cut-offs form groups. anything above 27 is classed as clinically significant levels of depressive traits.

This measure is good because its widely used, easy to administer and costs little. can be done without training and calculated easily. a good indicator. however, confounded by the level of CI, some may not be able to comprehend or complete the questionnaire.

2. Emotional and Behavioural Observational Index (EBOI) - is an observational method which requires a clinical professional to observe a patient for signs of depression.

Takes a while, costly, sensitive, useful for those whos CI prevent using BDI

Question 4

Describe some treatments for PSD

Answer 4

1. Antidepressants - tricyclic antidepressants like SSRIs can improve depression by increasing levels of serotonin in the brain which can improve mood. easy and appropriate for most patients
2. Acceptance and Commitment Therapy (ACT) - acceptance and commitment therapy is a form of counselling and a branch of clinical behaviour analysis. It is an empirically-based psychological intervention that uses acceptance and mindfulness strategies mixed in different ways with commitment and behaviour-change strategies, to increase psychological flexibility. Designed to help the patient accept their new condition.

Another way to treat this depression can be to help improve a person’s CI.

3. Speech and Language therapy
4. rTMS for Aphasias, Apraxias,

Another thing that is important is to minimise factors which reduce outcomes, one of the biggest isolation.

Question 5

What is Psudobullar affect

Answer 5

Sudden uncontrollable episodes of laughing or crying. Do not reflect persons true feelings. in other words, is a disconnect between mood (inner emotion) and affect (expression of emotion). Tend to present at inappropriate times eg laugh at a funeral. Is seen in some forms of dementia suggesting its due to change in neurology. Due to a complex interaction between cortex (emotional centre), Cerebellum (motor) and the brainstem (the connection between them)

Question 6

How is PBA assessed?

Answer 6

The doctor has to rule out PSD. usually, diagnose based on extended behavioural observations of the patient, and if possible, the patient can tell the doctors. assessed to see whether its PBA or PSD based on;

• duration of episodes
• context of episodes
• emotional control patient has
• match/mismatch between patient mood and affect.

Question 7

How is PBA treated?

Answer 7

1. Antidepressants - SSRIs and TCAs seem to work to help reduce episodes of PBA, although are needed in much smaller doses and work differently to how they work for depression. we know this because effects for depression take up to 4weeks, whereas effects for PBA take a few days.

Management techniques are also employed.

1. Making others aware - it can be a very confusing condition for others to encounter, informing others can be an effective way to minimise the social effects of this condition
2. Distraction techniques - some with PBA have learned that they can feel an episode coming on, and before this happens, they quickly change what they are doing. for example, they can change their context, go to another room, try and remember things which are a cognitive distractor eg phone number.
3. Changing body position - this seems to also work, possibly because it disrupts the messages coming from the cerebellum.

Question 8

What does Personality changes post-stroke refer to?

Answer 8

refers to a change in an individuals personality. find that typically, patients shift towards the more negative personality pole; negative affect, antagonistic, disinhibition
psychoticism, detachment, introversion

Apathy - is a loss of motivation and intrest in previously enjoyed activities. prefer sameness and are indifferent (neither positive or negative). due to damage to PFC

Question 9

How are Personality changes assessed?

Answer 9

1. Personality scales - BFI

Unless an individual has completed a comprehensive personality test pre-stroke, it is hard to quantitatively assess changes in personality. The best way is qualitative techniques;

1. Ask family members about the experienced change

Question 10

Are there any treatments for Personality changes?

Answer 10

In short, no. Treatments focus on helping manage it.

Question 11

Describe Carota et al (2002)’s paper

Answer 11

Carata et al (2002) - did a summary review of the literature exploring common and rare emotional and behavioural changes post-stroke.

Broccas and wernicas aphasias can lead to frustration and depression. linked with losing social ties which are linked to poor outcomes for emotions living with the changes chronically.

Kluver-bucy syndrome - is a rare behavioural impairment characterized by inappropriate sexual behaviours and mouthing of objects. Rare because it follows on from a very rare and specific type of stroke, in which incomplete bi-temporal lesions are formed.

Anxiety - at 1 year, 25-50% of stroke survivors suffer acute anxiety. this drops at 1 year. is linked to prior anxiety, with those showing predisposition more likely to experience chronic anxiety

Changes in sex drive - A decrease in sexual ability, coital frequency, libido, vaginal lubrication and orgasm in women, and poor or failed erection and ejaculation in men are a common complaint after stroke. Linked to PSD and a left hemispheral leison. whereas the association between reduced libido and emotionalism suggests a serotonin dysfunction. Many other factors are certainly involved (drugs, vascular diseases, diabetes). The relevant psychological factors are a reduced attitude towards sexuality, the fear of impotence, the inability to discuss sexuality, an unwillingness to participate in sexual activity, and the degree of functional disability.