Lecture 9 Emotional and Behavioural Changes Following Stroke

Question 1

Which triad interacts with each other?

Answer 1

Thoughts, feelings and behaviour all interact with each other and affect how an individual interacts with the world

Question 2

Which factors may influence the development of PSD?

Answer 2

A loss of independence, feeling of hopelessness, changes to self-perception, lack of emotional support

Question 3

What is the prevalence of PSD?

Answer 3

Very common, seen in about a third of individuals but is often blinded by physical symptoms and under-diagnosed

Question 4

What are some proposed causal factors?

Answer 4

Damage to key cortical and subcortical regions which are responsible for emotional processing e.g. regions that are rich in monoamine circuitry and serotonin activity
Could also be a reactive psychological condition resulting from the impact of the stroke

Question 5

How do PSD and cognitive deficits interact?

Answer 5

If individuals are feeling depressed, less likely to engage in the therapies, support plans and management –> makes overcoming cognitive challenges difficult
Should be a primary focus, so they can engage with treatment properly

Unsolved Q whether depression negatively influences the cognitive impairment outcome or whether cognitive impairment leads to depression - probably bi-directional

Question 6

What are some examples of PSD assessment?

Answer 6

Beck’s Depression Inventory
CES-D
Zung Scale
Emotional and Behavioural Index

But individuals may have communication issues, making it difficult to assess but is often recognised by a family member

Question 7

What are some PSD treatments?

Answer 7

Pharmacological: anti-depressants (SSRIs)
Psychological: counselling, CBT
Other therapies: tackling cognitive deficits

Question 8

What are some methods of PSD management?

Answer 8

Communicate how they are feeling,
Improve nutrition
Stroke support groups
Practice stress/anxiety management
Stay active and keep motivated

Question 9

What is Pseudo-bulbar Affect (PBA)?

Answer 9

Sudden uncontrollable episodes of laughing or crying, not within the context of how the individual is feeling - some mismatch
Often inappropriate to the situation
Massively under-diagnosed, clear underlying neurological problem
Sometimes mistaken for depression

Question 10

What is the cortical mechanism behind PBA?

Answer 10

PBA is a disconnect between the cortex, cerebellum and brainstem, which are associated with emotional processing
The lack of inhibitory control is the primary mechanism

Question 11

What treatment is there for PBA?

Answer 11

Pharmacological treatment: SSRIs and TCA (tri-cyclic anti-depressants)
Mechanisms that make SSRIs work are not fully understood but thought to be different to depression
Need lower doses for PBA compared to depression

Question 12

What can be used in management of PBA?

Answer 12

Telling people about it & raising awareness
Distracting yourself - cognitive shift
Focusing on breathing - can reduce episode length
Change in body position - potentially due to involvement of cerebellum

Question 13

What is the relationship between stroke and personality changes?

Answer 13

Stroke is associated with a decrease in personality traits in the positive pole e.g. extraversion, agreeableness, emotional stability
And an increase in the negative pole e.g. antagonism, detachment, psychoticism
There is a relationship between stroke severity and degree of personality change

Question 14

What is apathetic personality change?

Answer 14

Due to damage in the frontal lobe, a disorder of motivation, characterised by a decrease in physical & mental activity and an emotional indifference
Lack of interest in hobbies
Preference for passive activities

Question 15

How is apathetic personality change assessed?

Answer 15

Personality Scales

Neuropsychiatric inventory

Question 16

How is apathetic personality change treated/managed?

Answer 16

Coping Strategy Training

Problem Solving Therapy - based on CBT, goal oriented

Question 17

What is aggressive personality change?

Answer 17

Due to frontal lobe damage, behaving aggressively without feeling angry, a reaction to other deficits and loss of empathy

Question 18

How is aggressive personality change assessed?

Answer 18

Personality Scales

Neuropsychiatric inventory

Question 19

How is aggressive personality change treated/managed?

Answer 19

Pharmacological treatment (SSRIs)
Counselling

Important for the family to be involved so they know how to manage these outbursts of aggression

Question 20

How is family support involved?

Answer 20

In a study, the levels of emotional support from their family was significantly correlated with the patient’s functional status, psychological status and social status during the first 6 months post stroke

Question 21

What are the most common sites which affect emotion-related processing?

Answer 21

In cerebrovascular disease, the right hemisphere and frontal lobe affect emotion-related processing

Question 22

What are the critical sites of damage for empathetic changes?

Answer 22

The prefrontal cortex and right posterior cortices have been identified as critical sites of damage leading to significant empathetic changes
Leads to impairments in theory of mind tasks and understanding sarcasm

Question 23

What are the emotions like in aphasia?

Answer 23

Patients with Broca’s aphasia show intense emotional behaviours, often with a depressive content. Aphasia increases the risk of developing depression
In Wernicke’s aphasia, patients attribute their aggressiveness to the assumption that the examiner was deliberately speaking in an incomprehensible way

Question 24

What is affective dysprosody?

Answer 24

Refers to the impairment of both the production and comprehension of language components that allow the translation of internal states in speech

Question 25

What is Klüver-Bucy Syndrome?

Answer 25

Characterised by inappropriate sexual behaviours
Tameness with loss of fear and anxiety
Hyper-orality
Hypermetamorphis - excessive exploration of environment

A very rare syndrome in stroke because of its peculiar lesion topography

Question 26

How is psychosis related to stroke?

Answer 26

Psychosis has generally been reported with right hemispheral stroke. Old age, pre-existing degenerative disease or cerebral atrophy increase the risk

Question 27

How is catastrophic reaction related to stroke?

Answer 27

Catastrophic reaction manifests as a disruptive emotional behaviour when the patient is confronted with an insolvable task

Only patients with left hemispheral lesion manifested catastrophic behaviours - loss of the modulatory amygdala effect?