Stroke Survivors: Unpredictable Behavior Explained

A stroke is a life-threatening medical emergency that occurs when there is an issue with blood flow to the brain. It can cause physical, cognitive, and emotional changes, including erratic and aggressive behaviours. The location and severity of the stroke determine the types of personality changes experienced by the survivor. For instance, damage to the frontal lobe of the brain can result in impulsivity and aggression due to its role in self-control. Behavioural changes can also be caused by emotional problems, such as dealing with the shock of the stroke and the resulting lifestyle changes. These changes can be difficult for both survivors and their loved ones, but effective treatments and support groups are available to help manage and cope with these challenges.

Emotional lability

The cause of emotional lability is a neurological disconnect between the brain's nerve connections and chemistry, which interferes with accurate emotional expression. It is often associated with damage to the frontal lobe, which contributes to self-control and decision-making processes. This can result in depressive symptoms, apathy, or sudden lashing out.

There are several strategies that can help manage emotional lability:

• Identifying triggers and trying to avoid or minimise them.
• Being open about the condition with others so they are not caught off guard.
• Distracting oneself by counting objects or thinking about something unrelated when feeling an episode coming on.
• Practising slow, deep breathing to regain control.
• Relaxing the forehead, shoulders, and other muscle groups that tense up during an episode.
• Changing body position, as certain postures may be associated with emotional responses.

While these strategies can help manage emotional lability, it is important to seek professional help. A doctor can provide a proper diagnosis and recommend treatment options, which may include medication or therapy. Cognitive behavioural therapy, for example, can help individuals identify and change unhelpful thought patterns, leading to a more positive and problem-solving approach. Antidepressants may also be prescribed to manage depression or anxiety, which are common after a stroke and can contribute to emotional lability.

Aggression

Aggressive behaviour is a common symptom of a stroke, with studies showing that between 11-35% of stroke survivors experience anger or aggression during the acute stage of recovery, while 19-32% experience anger in the first 3-12 months. Aggression is often the result of damage to the frontal lobe, which can cause a loss of self-control. Aggressive behaviour can also be caused by pseudobulbar affect (PBA), which is characterised by intense and often inappropriate displays of emotion. PBA affects around half of all stroke survivors and can cause patients to laugh when someone is injured or cry in response to a joke.

There are many triggers for anger and aggression in stroke patients, including a perceived lack of control, difficulty performing tasks, fatigue, confusion, insensitive comments from others, anxiety, and overstimulation.

Anger and aggression in stroke patients can be managed through medication, such as selective serotonin reuptake inhibitors (SSRIs), and by avoiding triggers. It is also recommended that survivors recognise the situations that trigger anger and take a break from frustrating tasks. Relaxing music, meditation, and journaling are also suggested as ways to cope with anger.

Inappropriate behaviour

A stroke can cause erratic behaviour due to the damage it inflicts on the brain. This can manifest in many ways, including inappropriate behaviour.

Treatment

There are several ways to manage inappropriate behaviour:

• Cognitive Behavioural Therapy (CBT): This type of talking therapy focuses on the connection between thoughts, feelings, and behaviours. It can help stroke survivors understand how their thoughts and behaviours are linked and learn to manage their actions.
• Antidepressants: Medication can be helpful if depression or anxiety is contributing to inappropriate behaviour.
• Support groups: Stroke support groups can provide a non-judgmental setting for survivors to share their experiences and learn from others.
• Talking to loved ones: Open communication with family and friends can help manage inappropriate behaviour. It is important to explain what is acceptable behaviour and what is not. Consistency in how inappropriate behaviour is addressed is also crucial.

Apathy

A stroke can cause erratic behaviours, including apathy. Apathy is a common neuropsychiatric symptom that can occur after a stroke, with 15.2-71% of patients demonstrating apathy in the acute phase of a stroke. Three to six months after a stroke, the incidence of apathy has been reported to be 26.7% compared to 5.4% in control groups.

There are several risk factors associated with post-stroke apathy, including a history of cerebrovascular disease, low HbA1c levels, and lower scores on the Mattis Dementia Rating Scale Initiation/Perseveration subset (MDRS I/P). Additionally, cognitive dysfunction has been found to be related to apathy, although the relationship is complex and not all patients with cognitive dysfunction will experience apathy.

Treating apathy after a stroke is important as it can increase the burden on caregivers, lead to longer hospital stays, and cause patients to participate less in rehabilitation. Effective treatments for apathy include cognitive behavioural therapy, antidepressants, and positive psychology.

Cognitive behavioural therapy

A stroke can cause erratic behaviour in survivors due to changes in the brain, specifically, damage to the frontal lobe. This can result in a loss of self-control and impulsive behaviour. In addition, a stroke survivor's sense of personality and identity may be impacted as they may no longer be able to participate in their usual activities and relationships. This can lead to altered personality traits and behaviours.

• Psychoeducation: Help the survivor understand the nature of their emotions and how they are related to their stroke.
• Relaxation training: Teach relaxation techniques such as progressive muscle relaxation or autogenic relaxation.
• Cognitive disputation: Identify and challenge negative thoughts and predictions associated with certain activities.
• Cognitive rehabilitation: Focus on strategies such as paraphrasing to slow down conversations and improve information acquisition.
• Relapse prevention: Help the survivor to identify and plan for future challenges, and maintain their current level of social activity.

Some modifications to traditional CBT approaches may be necessary to address cognitive and communication disabilities that may be present after a stroke. For example, in the case study mentioned, the therapist wrote things down and slowed the pace of conversations to aid understanding. Carer involvement in treatment may also be important.

Frequently asked questions