Stroke-Induced Personality Changes: Understanding The Unexpected Shift

can strokes cause personality change

Strokes can cause significant personality changes, which can be distressing for both survivors and their loved ones. These changes are often due to damage to the brain, specifically the frontal and temporal lobes, which regulate emotional responses, decision-making, and judgement abilities. As a result, survivors may experience depression, apathy, anger, irritability, aggression, and a loss of empathy. They may also develop inappropriate behaviours, such as a loss of social inhibitions, and a condition called pseudobulbar affect, characterised by uncontrollable expressions of emotion. While some changes may be long-term, there is hope for recovery through treatments such as cognitive behavioural therapy, medication, and support groups.

Characteristics Values
Emotional instability Uncontrollable laughing or crying, depression, anxiety, anger, aggression, irritability, apathy, impulsiveness, and loss of empathy
Inappropriate behaviour Inability to read social situations, loss of inhibitions, tactless remarks, interrupting, loss of social skills, and violent behaviour
Cognitive changes Loss of cognitive skills, confusion, memory loss, difficulty understanding concepts, and difficulty with language, problem-solving, reading, and mathematical calculations
Pseudobulbar Affect (PBA) Intense and inappropriate displays of emotions, such as laughing at a funeral or crying at a joke
Delirium Intense onset of altered consciousness with fluctuations in orientation, memory, thought, or behaviour

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Emotional lability and pseudobulbar affect

Emotional lability, or pseudobulbar affect (PBA), is a common consequence of stroke. PBA is a neurological condition that occurs when the parts of the brain that control emotions are injured. It is characterised by involuntary bouts of crying, laughter, or anger that are uncontrollable and can occur without an emotional trigger. The outburst may be out of proportion to the trigger, or there may be a rapid switch between laughing and crying. Those experiencing PBA are often aware that their emotional response does not match their feelings. This condition affects approximately 1 in 5 stroke survivors in the first six months, and 1 in 8 survivors beyond six months post-stroke.

The cause of PBA is a neurological disconnect between the brain's nerve connections and chemistry, which interferes with accurate emotional expression. PBA can result from injury or dysfunction anywhere along the cortico-ponto-cerebellar pathway. While PBA is commonly associated with damage to the cortex and limbic system, it can also occur with ischemic stroke of the cerebellum and pons.

PBA can be treated, and the first step is to get an accurate diagnosis. Educating caregivers and family members is also important. Some coping techniques for PBA include being open about the problem with those around you, and trying to distract yourself when you think you're about to have an episode. Taking slow deep breaths and relaxing your muscles during an episode can also help.

PBA is distinct from depression, although the two conditions can be confused as people with PBA may cry a lot. PBA has been treated with anti-depressants in the past, but these may only be moderately successful.

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Apathy and depression

Prevalence

Apathy occurs in about one-third of stroke patients, with symptoms beginning as early as four days post-stroke. The prevalence of apathy increases by around 10% five years after a stroke. Depression, on the other hand, affects about 15-20% of stroke survivors.

Risk Factors and Causes

The exact causes of apathy and depression after a stroke are not well understood, but several risk factors have been identified:

  • A history of cerebrovascular disease
  • Low HbA1c levels
  • Lower scores on the Mattis Dementia Rating Scale Initiation/Perseveration subset (MDRS I/P)
  • Age
  • Education level
  • Frontal lobe lesions
  • Right-side or front lobe stroke
  • Low mini-mental state examination (MMSE) scores
  • Low Montreal Cognitive Assessment (MoCA) scores

Treatment

While there is no definitive treatment for post-stroke apathy, several approaches can be considered:

  • Pharmacological approaches: Antidepressants such as selective serotonin reuptake inhibitors (SSRIs) have been prescribed, but evidence for their effectiveness is limited. Other drugs such as nefiracetam and acetylcholinesterase inhibitors have shown some promise in small studies.
  • Behavioural approaches: Neuropsychological advice, goal setting, problem-solving therapy, and cognitive-behavioural therapy can help patients re-engage in goal-directed activities.
  • Other approaches: Repetitive transcranial magnetic stimulation (rTMS) has shown some effectiveness in treating post-stroke apathy in small studies.

Impact

  • Increased burden on caregivers
  • Longer hospitalizations
  • Reduced participation in rehabilitation
  • Negative impact on quality of life
  • Slower recovery of functional abilities
  • Increased risk of future vascular events, dementia, and mortality

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Aggression and anger

These behaviours can be distressing for both the survivor and their caregiver, and are likely to be caused by a combination of factors. Research suggests that when a stroke affects the frontal lobe, lenticulocapsular, or pontine base areas, emotional incontinence (the inability to control emotion) is a likely side effect. This is because the frontal lobe 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.

Other factors that can cause anger after a stroke include:

  • Cognitive changes, such as a lack of empathy or increased impulsivity
  • Physical effects, such as motor impairments and pain
  • Emotional disorders, such as pseudobulbar affect, or post-stroke depression

There are a number of strategies that can help manage anger after a stroke:

  • Recognising and understanding triggers
  • Taking a break when feeling frustrated or confused
  • Practising self-compassion, and anger coping mechanisms, such as listening to relaxing music, meditation, or expressing emotions through journaling or artwork
  • Medication, such as selective serotonin reuptake inhibitors (SSRIs)

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Inappropriate behaviour

A stroke can cause immediate and drastic changes in behaviour, including inappropriate behaviour. This can be caused by damage to the brain, or be linked to emotional problems.

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Cognitive behavioural therapy

Experiencing a stroke can lead to emotional, behavioural, and cognitive changes, which can vary in severity depending on the area of the brain affected and the intensity of the injury. These changes can be challenging for both the survivor and their caregivers, and they often negatively influence the survivor's quality of life. However, rehabilitation and therapy can help improve recovery.

CBT can be particularly helpful in managing post-stroke conditions such as anxiety, depression, and pseudobulbar affect (PBA), also known as emotional incontinence. PBA is characterised by sudden and unpredictable episodes of crying or laughing, often in socially inappropriate situations, due to a mismatch or exaggeration of feelings and expressions.

During CBT sessions, individuals can learn to identify and understand their thoughts and emotions, and develop strategies to manage and change unhelpful thought patterns. This can lead to a more positive and problem-solving approach to dealing with the challenges posed by post-stroke personality changes.

In addition to CBT, other therapeutic approaches that can be beneficial include Solution-Focused Therapy, Problem-Solving Therapy, Acceptance and Commitment Therapy, Interpersonal Therapy, and Mindfulness-based interventions. Each of these therapies offers a unique perspective and set of tools to help individuals cope with the emotional, behavioural, and cognitive changes that can occur after a stroke.

Frequently asked questions

Yes, strokes can cause personality changes. This is due to the damage to the brain caused by the stroke, or it could be linked to emotional problems. Changes in personality and mood after a stroke are common, and can include impulsiveness, apathy, anger, frustration, and depression.

It's important to acknowledge that these changes are happening and seek help. Talk to your loved one's doctor about any personality changes or behavioural issues you've noticed. They can help you understand what to expect and work with you on treatment.

Treatment options include medication such as antidepressants, and therapy such as cognitive behavioural therapy. Support groups can also be beneficial, providing a space to share experiences and learn from others.

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