Stroke's Emotional Impact: Anger And Its Causes

Stroke survivors often experience a range of emotional and behavioural changes. This is because a stroke impacts the brain, and the brain controls our behaviour and emotions. Changes in emotional regulation after a stroke may occur due to altered brain chemistry or as a result of damage to specific areas of the brain.

Anger after a stroke can manifest in many ways, including aggressive behaviours such as hitting, kicking, biting, and throwing objects. Verbal behaviours can include screaming, refusal of treatment, and muttering of unkind or hostile words.

Studies have shown that anger can be a risk factor for stroke, and that acute anger and other emotional upsets can play a role in triggering stroke. According to a large international study published in 2021, one in 11 stroke survivors felt angry or upset in the hour before their stroke symptoms began. The study also found that anger or emotional upset was linked to an approximately 30% higher risk of having a stroke within one hour of experiencing those emotions.

While anger after a stroke can be distressing for both survivors and their loved ones, there is hope for recovery. Many episodes of post-stroke anger and aggressive behaviour decline in frequency and intensity as time passes. There are also various treatment options available, including psychotherapy and medications such as selective serotonin reuptake inhibitors (SSRIs).

Post-stroke anger can be caused by damage to the frontal lobe, lenticulocapsular, or pontine base areas of the brain

The frontal lobe plays a crucial role in impulse control, and damage to this area can result in difficulty managing anger and aggression. The lenticulocapsular area is also involved in emotional regulation, and damage to this area can lead to irritability, impulsivity, and hostility. The pontine base area is part of the brainstem, which is involved in several essential functions, including controlling automatic processes and relaying information between the brain and the body. Damage to this area can disrupt these functions and contribute to post-stroke anger.

Post-stroke anger can manifest in various ways, ranging from overt aggressive behaviors such as hitting or hurting others to more subtle signs such as irritability, impulsivity, and hostility towards family members. It is important to recognize and address post-stroke anger as it can cause distress for both the survivor and their loved ones. Treatment options include pharmacological interventions, such as selective serotonin reuptake inhibitors (SSRIs), and psychotherapy to help identify and manage triggers and improve emotional regulation.

Anger after a stroke can be caused by neurochemical changes in the brain

Research has shown that neurochemical dysfunction due to brain injury can contribute to post-stroke anger. Specifically, damage to the brain after a stroke may inhibit the brain's serotonin system, leading to increased anger or aggressive behavior. Serotonin is an important neurotransmitter that carries signals between neurons in the brain. Disruption of the brain's serotonin system can be treated with selective serotonin reuptake inhibitors (SSRIs), which are commonly prescribed antidepressants that work by increasing serotonin levels in the brain. Studies have shown that SSRIs can be effective in reducing the severity of post-stroke anger and improving quality of life.

In addition to neurochemical changes, other factors that may contribute to post-stroke anger include cognitive changes, physical effects, and emotional disorders. Cognitive changes after a stroke can include a lack of empathy or increased impulsivity, which can lead to frequent feelings of anger. Physical effects, such as motor impairments and pain, can make it difficult to perform daily tasks, leading to frustration and anger. Emotional disorders, such as pseudobulbar affect, can also cause involuntary and uncontrollable outbursts of anger.

Anger can be a risk factor for having a stroke

The hazardous effects of anger on cardiovascular health may be mediated by other risk factors, including hypertension or diabetes mellitus. Anger can lead to increased physiological activation, particularly sympathetic activation, which can cause endothelial damage, increased vascular rigidity, and elevated blood pressure. It can also result in increased cortisol release, which can disrupt vulnerable plaques, and increased inflammatory and pro-thrombotic responses, leading to increased platelet aggregation and plasma viscosity.

Additionally, anger can be a triggering factor for stroke. A case-crossover study found that the odds of having a stroke were 14 times higher during a 2-hour hazard period of anger compared to a 2-hour control period. Another study of 13,462 patients from 32 countries found that anger or emotional upset in the hour before stroke symptom onset was associated with a higher risk of all stroke types, including ischemic stroke and intracerebral hemorrhage.

It is important to recognize and address anger as a risk factor for stroke, as strategic management of anger may help prevent stroke occurrence and improve an individual's quality of life.

Aggressive behaviour after a stroke can be a temporary phase

The acute phase of stroke usually ranges from the first 24 hours to several weeks after the onset of stroke. During this acute phase, the focus of treatment is minimising damage to the brain and stabilising the individual by addressing urgent medical complications. Aggressive behaviour after a stroke has been found to occur frequently in the acute stage of recovery. In a study of 202 acute stroke patients, anger was present in 35% of patients, with 37% of those patients experiencing severe anger.

Jong S. Kim, MD, explains that aggressive behaviour after a stroke is more likely a symptom of brain injury rather than reactive behaviour. When a stroke affects the frontal lobe, lenticulocapsular, or pontine base areas, emotional incontinence (the inability to control emotion) is more likely to be a side effect. This is because the frontal lobe in particular plays a role in reasoning, problem-solving, and controlling basic impulses like anger. When the frontal lobe is damaged, it can affect emotional regulation and lead to aggressive or combative behaviour after a stroke.

Additionally, recent research performed by Kim suggests anger and aggressive behaviour after a stroke can be triggered by neurochemical dysfunction as well as unfavourable environments. For example, damage to the brain after a stroke may inhibit the brain's serotonin system, increasing the prevalence of angry or aggressive behaviour. Furthermore, noxious (negative) stimulation from the environment can contribute to combative and aggressive behaviour after a stroke.

It is important to ask your neurologist about the location of your stroke. The area of the brain affected by a stroke has significant implications for the secondary effects you may experience, such as anger or aggressive behaviour. Learning more about your specific injury can help you and your caregiver understand your unique symptoms.

Combative or aggressive behaviour after a stroke will often resolve as the survivor transitions out of the acute phase. Some cases do persist, however, depending on the area of the brain affected. While it’s unknown how long aggressive behaviour after a stroke may last, there is hope for recovery. Long-term personality changes can improve with time and appropriate treatment.

Aggressive behaviour after a stroke can be treated with medication

It is important to note that medication may be used in conjunction with other anger management techniques for enhanced benefits. Additionally, as with all medications, there may be side effects that can negate potential benefits. For example, some side effects of SSRIs include anxiety, confusion, and difficulty falling asleep, which can trigger anger. It is crucial to work closely with a doctor to monitor health and adjust medication as needed.

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