Lecture 9 - Emotional And Behavioural Changes Following Stroke

Question 1

What factors influence the development of post-stroke depression (PSD)?

Answer 1

Motivation, quality of care, support network, lack of independence, personal relationship dynamics, loss of identity, loss of control.

Question 2

What is post-stroke depression and why might it occur?

Answer 2

There are 2 reasons why someone might get depression after a stroke:
1. Damage to key cortical and subcortical regions responsible for emotional processing e.g. frontal lobe, impairment to neurotransmitter activity.
2. Reactive psychological conditions resulting from the impact of the stroke - the reaction of the stroke.
If someone had depression before the stroke, they are more likely to get it after.
There is a bidirectional relationship between functional deficits and depression.

Question 3

What are the symptoms of PSD?

Answer 3

Persistent sadness, anxious or empty feelings, sleep disturbances, changes in appetite, feelings of helplessness/worthlessness, social withdrawal, fatigue, difficulty concentrating or remembering details.

Question 4

How is PSD assessed?

Answer 4

Clinicians may use a number of assessment measures or just one. There are a range of scales used and clinicians will usually decide which is most appropriate based on patients needs’. Methods include becks depression inventory, CES-D, zung scale and emotional and behavioural index.

Question 5

What is Becks Depression Inventory?

Answer 5

It is a self-administered questionnaire that is used to rate mood.

Question 6

What is CES-D?

Answer 6

It is done through an interview or it could be self-administered. It is a depression screening.

Question 7

What is Zung Scale?

Answer 7

It can either be self-administered or a telephone interview. It assesses affective, psychological and somatic depressive symptoms.

Question 8

What is Emotional and Behavioural Index?

Answer 8

It is an examiner-rated index that rates emotional reaction to acute stroke.

Question 9

What are the treatments for PSD?

Answer 9

Pharmacological treatments such as anti-depressants e.g. SSRIs - there is evidence it leads to improved outcomes.
Psychological therapies such as counselling or CBT - may be helpful if patient is already taking a lot of medication.
Other therapies involve tackling the cognitive deficits which is useful for those who may not be able to engage in therapies.

Question 10

How is PSD easier managed?

Answer 10

If treatments are not successful then the focus will be shifted to management:
- Communicate with others through writing or speaking.
- Improve nutrition.
- Support groups - understand what you are going through.
- Set goals to think about future without feeling overwhelmed.
- Anxiety management e.g. breathing exercises.
- Be patient.
- Stay active - will prevent another stroke so helpful in term of prevention.
- Community activity e.g choir. Hobbies may change after a stroke so helpful to fin other hobbies they can still do.

Question 11

What is pseudobulbar affect (PBA)?

Answer 11

It is a condition that results in sudden and uncontrollable episodes of laughing or crying that is out of context with what the person is feeling.
Often happens when a stroke affects the areas of the brain that control normal expression of emotion and emotion processing - leads to a disconnect of these areas.
It is not widely known so it often goes undiagnosed.
The cortex is responsible for cognitive and affective processing - seems to occur due to an affected pathway between the cortex, brainstem and cerebellum.
Also thought it has something to do with inhibitory control.
In PBA the mood and affect are disconnected.

Question 12

What are the symptoms of PBA and how do they differ with depression?

Answer 12

The episodes are brief (seconds/minutes) and are sudden and uncontrollable. There is often an exaggerated reaction with PBA and the affect does not match the internal mood.
This differs from depression as episodes last weeks to months and it is ongoing sadness, the expression of these emotions match internal state and can be controlled.

Question 13

What are the treatments for PBA?

Answer 13

Pharmacological treatments are based on antidepressant medication. The underlying mechanisms for how these work for PBA is not well understood but it is different to depression because the onset of action occurs quicker (within a few days) and the doses are lower. The mode of action also differs. Examples used are SSRI’s.
Also use dextromethorphan (a cough suppressant) to increase serotonin and noradrenaline in the synaptic cleft and decreases glutamatergic activity.

Question 14

How is PBA easier managed?

Answer 14

Some drug treatments might not work or be acceptable so there are other ways to help the individual manage PBA:
- Be open about the problem so people are not confused/surprised when you have an episode.
- Distract yourself when you feel an episode coming on by focusing on something else.
- Take slow deep breaths until you’re in control.
- Change your body position.

Question 15

How does personality change following a stroke?

Answer 15

A stroke is associated with a decrease i personality traits in the positive pole - it is a shift to the negative pole.
Studies have found the more severe the stroke, the greater the personality changes (Ferro et al., 2016).
The 2 most researched personality changes are apathy and anger.

Question 16

What are apathetic personality changes?

Answer 16

Apathy is characterised by decreased mental and physical activity and emotional indifference - decrease in initiative to carry out activities.
The frontal lobe area is associated with personality so damage to this area can lead to the personality changes.
Suggested the indifference is due to a frontal cortex deactivation (Carota et al., 2002).

Question 17

What treatment/management is used for apathetic personality changes?

Answer 17

Coping strategy training and problem solving therapy.

Question 18

What assessments are used for personality changes?

Answer 18

Personality scales and neuropsychiatric inventory.

Question 19

What are aggressive personality changes?

Answer 19

Characterised by behaving aggressively without feeling angry and lack of empathy. It is often a reaction to other deficits.
The prefrontal cortex is associated with personality so damage to this area may lead to aggression due to impairment in the inhibition of aggressive responses.
Failure of inhibitory control is probably the primary cause of aggressive behaviour.
fMRI studies have implicated the ventromedial, prefrontal and orbitofrontal cortices involved in anger. Any damage to these circuits can lead to aggressive behaviour.

Question 20

What did Eslinger et al. (2002) suggest impacted emotional recovery following stroke?

Answer 20

The level of emotional support the patient has correlated with function, psychological and social status first 6 months after stroke, the influence of spouses is also a significant factor affecting recovery.

Question 21

How does empathy change following a stroke?

Answer 21

Over half of patients generate empathy scores more than 2 SDs below the mean (Eslinger et al., 2002).
Associated with lesions in prefrontal cortex and right posterior cortices.

Question 22

What is Kluver-Bucy Syndrome?

Answer 22

It is a rare neuropsychiatric disorder of a stroke and can occur due to lesions affecting bilateral temporal lobes, especially the hippocampus and amygdala. 3 of the following symptoms is needed for diagnosis:
- Tameness with loss of fear or anxiety.
- Dietary changes.
- Deviant sexual behaviours.
- Hypermetamorphosis (excessive attentiveness to visual stimuli).
- Hyperorality (excessive preoccupation with oral sensations and behaviours).
- ‘Psychic blindness’.
Carota et al. (2002).

Question 23

What other emotional changes can occur following a stroke?

Answer 23

Carota et al. (2002):
Anxiety (25-50% get it).
Mania (1% - most associated with right hemisphere infarcts).
Psychosis.
OCD.
Hyposexuality (decrease).
Catastrophic reaction (disruptive emotional behaviour when patient is confronted with an unsolvable task - only in patients with left hemispheral lesions).