Stroke's Impact: Altered Personalities And Changed Lives

A stroke can have a profound impact on a person's personality, and it's not uncommon for stroke survivors to experience changes in their emotions and behaviour. These changes can be challenging for both the survivor and their loved ones, as they may feel like they've lost themselves or the person they knew. While some personality alterations may disappear over time, others might require medication or therapy. Understanding the underlying causes of these shifts, whether they stem from brain damage, physical limitations, or psychological factors, can help guide the most effective approach to managing them.

Emotional instability

A stroke can cause emotional instability, which can manifest in various ways. One common effect is emotional lability or pseudobulbar affect (PBA), where individuals experience disproportionate or mismatched emotional responses, such as uncontrollable laughter or crying. PBA affects about 20% of stroke survivors and can be managed through medication and cognitive behavioural therapy.

Additionally, strokes can lead to impulsiveness, particularly in individuals with right-side or front lobe damage. This impulsiveness is characterised by the inability to think ahead or understand the consequences of one's actions. It can result in unsafe or inappropriate behaviour.

Another consequence of a stroke can be apathy, where individuals exhibit a lack of interest, drive, or motivation to engage in any activities. While this is not the same as depression, it can significantly impact a person's quality of life. Encouraging social participation and seeking professional guidance from a neuropsychologist may help address apathy.

Furthermore, strokes can induce or exacerbate anxiety, with one in four survivors experiencing it within the first five years. Anxiety can manifest as difficulty concentrating, trembling, feeling sick, or having "butterflies" in the stomach. It can lead to sleeping problems, tiredness, and muscle tension, as well as avoidance of social situations and activities. Cognitive behavioural therapy and medication are effective treatments for anxiety.

Depression is also a common emotional challenge after a stroke, affecting one in three survivors within the first year. Signs of depression include persistent feelings of sadness, worthlessness, hopelessness, anxiety, loss of interest in previously enjoyed activities, lack of energy, sleeping disturbances, and changes in appetite or sex drive. Depression can be addressed through medication and cognitive behavioural therapy, with the latter helping to identify and modify unhelpful thought patterns.

It is important to recognise and address these emotional challenges to support the recovery and well-being of stroke survivors. Treatment options are available, and seeking help from a healthcare team or mental health professional can improve quality of life.

Loss of cognitive skills

A stroke can cause a loss of cognitive skills, which can be distressing for the survivor and their loved ones. This may include trouble with language, problem-solving, reading, and simple mathematical calculations. Survivors may become forgetful, losing things, forgetting names, or neglecting important tasks. Memory issues can improve over time, and medication for other issues, such as sleeping problems, can sometimes help with memory.

There are several ways to help manage memory loss and confusion:

• Designating specific places for frequently used items, such as keys and coats.
• Using memory cues to aid recollection, such as associating a name with a song.
• Keeping a notebook with important information, organised into sections such as phone numbers, medications, and directions.
• Breaking down complex tasks into simple steps.
• Practising conversations in a quiet, distraction-free environment, gradually expanding to include more people.

Cognitive deficits can also cause confusion and make it difficult to understand concepts that were previously familiar. This loss of cognitive skills can occur after a stroke in almost any region of the brain but is most common following strokes that affect the frontal lobe, parietal lobe, or temporal lobe.

Aggression

Aggressive behaviour after a stroke is a common secondary effect, particularly in the acute stage of recovery. This can be temporary or, in some cases, long-lasting and indicative of damage to specific areas of the brain. Aggression is often a result of both the emotional feelings about the stroke and the stroke-induced brain injury.

Acute Stage of Recovery

The acute phase of a stroke usually ranges from the first 24 hours to several weeks after its onset, during which the brain is still swollen. Aggressive behaviour is likely to occur during this time. A study of 202 acute stroke patients found that anger was present in 35% of patients, with 37% of those patients experiencing severe anger.

Aggressive behaviour can be physical, including hitting, kicking, biting, and throwing objects. It can also be verbal, such as screaming, refusing treatment, and muttering hostile words. These behaviours can be distressing for both the survivor and their caregiver or family.

Causes of Aggression

Research suggests that aggression after a stroke is due to a combination of factors. When a stroke affects the frontal lobe, lenticulocapsular, or pontine base areas, emotional incontinence (the inability to control emotion) is more likely. The frontal lobe plays a role in reasoning, problem-solving, and controlling basic impulses like anger. Damage to this area can affect emotional regulation and lead to aggressive behaviour.

Recent research suggests that anger and aggression can also be triggered by neurochemical dysfunction and 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. Additionally, negative stimulation from the environment can contribute to combative and aggressive behaviour.

Overcoming Aggressive Behaviour

While some side effects from the acute stage of a stroke go away on their own through spontaneous recovery, there are other ways to treat aggressive behaviour to improve quality of life and maximise safety for both the survivor and their caregiver. Working with a therapist or counsellor can help identify and manage aggressive behaviours.

Medication can also help treat aggressive behaviour. For example, selective serotonin reuptake inhibitors (SSRIs) can help treat anger, aggression, or combative behaviour by increasing levels of serotonin in the brain. Fluoxetine (Prozac) has been shown to improve "post-stroke anger proneness" and "post-stroke emotional incontinence".

Coping strategies for combative behaviour include understanding triggers, such as overstimulation, confusion, disruption of routine, and lack of control over the environment or physical functions. It is important to seek help from a licensed therapist if post-stroke aggression persists beyond the acute phase.

Self-centred attitude

A stroke survivor may exhibit self-centred behaviour, which can be challenging for caregivers to navigate. This behaviour is often a result of the stroke's neurological impact, specifically damage to areas of the brain responsible for empathy, such as the right supramarginal gyrus and the anterior insula. It is important to remember that this behaviour is not a result of vanity or selfishness but rather a consequence of the brain injury.

Self-centred behaviour after a stroke can manifest in several ways. Stroke survivors may become primarily concerned with their own interests and may lack empathy for others' feelings. They may also exhibit childlike behaviour and have difficulty regulating their emotions. This can lead to aggressive, dismissive, or demanding behaviour. It is important for caregivers to understand that this behaviour is not intentional and is a result of the stroke's impact on the brain.

While some stroke survivors may not be aware of their self-centred behaviour, others may struggle with feeling frustrated or angry due to their inability to control their emotions effectively. This can lead to further challenges in social situations and relationships. It is crucial for caregivers to provide support and understanding while also setting boundaries and practising self-care to avoid burnout.

To cope with self-centred behaviour in stroke survivors, caregivers can employ several strategies. Firstly, gently bringing up the behaviour and explaining that personality changes are common after a stroke can help increase awareness and encourage the survivor to be more mindful. Additionally, seeking psychological care, such as cognitive behavioural therapy, can help survivors regain empathy skills. The support and involvement of loved ones can also aid in the recovery process.

It is important to remember that not all strokes cause self-centred behaviour, and the effects can vary widely between survivors. Some changes may disappear on their own through spontaneous recovery, while others may require targeted interventions. Recovery is a continuous process, and improvements in self-centred behaviour may take time.

Loss of social inhibitions

A stroke can cause a loss of social inhibitions, leading to socially inappropriate behaviour. This can include taking food from a stranger's plate, insulting people, undressing or urinating in public, or making inappropriate comments. Those affected by a stroke may also become more impulsive, self-centred, and refuse to do anything unless it brings immediate results. This loss of inhibition can also affect sexual behaviour, with an increase in physical intimacy cravings.

These behaviours are often associated with a stroke in the frontal lobe, which is responsible for making predictions and adjusting behaviour. The loss of inhibition can be better controlled when the person is comfortable and in a familiar, stress-free environment.

If you are caring for someone who has lost their social inhibitions due to a stroke, it is important to be aware that their behaviour is not intentional. Consistent reminders about appropriate behaviour can help, as can interventions such as using a lap belt on a chair if the person keeps jumping out of it.

It is common for behaviour to change after a stroke, and these changes can be challenging for both the survivor and their loved ones. However, it is important to remember that these changes are not permanent and can be addressed with the help of a healthcare team.

Frequently asked questions