The Complex Link Between Strokes And Aggression

Experiencing anger and aggression after a stroke is common, with studies showing that between 11-35% of stroke survivors experience anger or aggressive behaviours during the acute stage of recovery, while 19-32% experience anger during the first 3-12 months following a stroke.

There are several factors that can cause anger after a stroke, including:

- Cognitive changes, such as a lack of empathy or increased impulsivity

- Physical effects, such as motor impairments and pain, that make it difficult to engage in daily tasks

- Emotional disorders, such as pseudobulbar affect, which involves involuntary and uncontrollable outbursts of emotion

- Genetic predisposition

- Changes in brain chemistry

- Unwanted lifestyle changes, such as losing a job due to stroke-related impairments

Anger after a stroke can be distressing for both survivors and their loved ones, and it is important to address this issue to improve quality of life and relationships. There are several strategies that can help manage anger after a stroke, including:

- Identifying triggers and learning how to avoid or manage them

- Practicing relaxation techniques, such as deep breathing, meditation, and yoga

- Using communication strategies, such as visual aids or simple language, to reduce frustration

- Engaging in physical activity to promote relaxation and enhance mood

- Medication, such as selective serotonin reuptake inhibitors (SSRIs), to balance moods and reduce instances of anger

Brain injury and emotional instability

Overview

Emotional instability is a common occurrence after a stroke, with aggressive behaviour frequently observed in survivors, especially during the acute stage of recovery. This can be a temporary phase, or it may be long-lasting and indicative of damage to specific areas of the brain.

Causes of Emotional Instability

Changes in the brain can cause a stroke, and these changes can lead to emotional instability. This includes alterations in empathy and impulsivity, resulting in anger. Physical limitations brought about by the stroke can also cause frustration and anger, as the individual may no longer be able to perform tasks that were once effortless.

Pseudobulbar Affect

A stroke may also affect the emotional centre of the brain, causing a disorder called pseudobulbar affect. This condition results in unintentional and uncontrollable fits of crying, laughing, or anger, which are usually disproportionate to the events that trigger them.

Triggers of Emotional Instability

There are several factors that can trigger emotional instability and aggressive behaviour in stroke survivors:

• Inability to complete tasks
• Communication difficulties
• Fear of another stroke
• Exhaustion or disorientation
• Reactions to others' actions
• Nervousness and sensory overload
• Obstacles to achieving goals

Management of Emotional Instability

Some strategies to manage emotional instability and aggressive behaviour include:

• Identifying triggers
• Practising relaxation techniques
• Communication strategies
• Physical activity
• Medication

Physical limitations

The physical effects of a stroke can also impact a person's ability to participate in their cherished hobbies or activities, which can be a significant source of anger and frustration. Mobility is often one of the biggest challenges faced by stroke victims, and the inability to move around freely can lead to feelings of anger and frustration.

In addition to motor impairments, stroke victims may also experience cognitive changes that affect their ability to process information and understand others. This can include a lack of empathy or increased impulsivity, which can lead to frequent feelings of anger.

The physical limitations imposed by a stroke can also contribute to feelings of anger and frustration. For example, stroke victims may experience fatigue, confusion, or disorientation, which can lower their threshold for frustration and anger. They may also struggle with communication difficulties, such as aphasia, making it difficult to express themselves clearly or understand others.

Overall, the physical limitations imposed by a stroke can have a significant impact on a person's life, leading to feelings of anger and frustration. It is important to address these emotions and seek help if needed to manage them effectively.

Pseudobulbar affect

The cardinal feature of the disorder is a pathologically lowered threshold for exhibiting the behavioural response of laughter, crying, or anger. An individual with PBA may exhibit episodes of these behaviours without an apparent stimulus or in response to stimuli that would not typically elicit such a response. The symptoms of PBA can be severe, with persistent and unremitting episodes. The onset can be sudden and unpredictable, and outbursts may happen several times a day, lasting from a few seconds to several minutes.

PBA is thought to result from disruptions of neural networks that control the generation and regulation of motor output of emotions. PBA is most commonly observed in people with neurological injuries such as traumatic brain injury (TBI) and stroke, and neurological diseases such as Alzheimer's disease, attention deficit hyperactivity disorder (ADHD), multiple sclerosis (MS), amyotrophic lateral sclerosis (ALS), and Parkinson's disease (PD). PBA has also been observed in association with physiological disorders, including hyperthyroidism, Graves' disease, and hypothyroidism.

PBA is often misdiagnosed as depression or bipolar disorder. However, PBA episodes are sudden and episodic, while crying in depression is more sustained and closely related to the underlying mood state. The level of control that one has over the emotional displays in PBA is minimal or non-existent, whereas for those with depression, the emotional expression can be modulated by the situation.

Medications may help treat PBA. Antidepressants such as tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs) may help reduce the frequency and severity of PBA episodes. Dextromethorphan hydrobromide and quinidine sulfate (Nuedexta) is a medication specifically designed to treat PBA and is approved by the Food and Drug Administration (FDA).

Triggers and coping strategies

Triggers

Anger after a stroke can be caused by a combination of factors, including changes in the brain, physical limitations, and emotional instability. Here are some common triggers for anger in stroke victims:

• Perceived lack of control: Navigating institutions like therapy centres, insurance coverage, and government-funded disability programs can be challenging and may lead to feelings of anger.
• Difficulty performing tasks: Motor and/or cognitive impairments can make daily activities challenging, leading to frustration and anger.
• Fatigue or confusion: Post-stroke fatigue and cognitive difficulties can heighten emotional reactions like anger.
• Other people's behaviour: Stroke survivors may encounter insensitive comments and other challenges that can trigger anger.
• Anxiety and overstimulation: The brain's heightened anxiety and the possibility of overstimulation during recovery can be overwhelming and trigger anger.
• Barriers to goals or routines: Stroke recovery can be slow, and having to change daily routines or modify goals due to persistent impairments can be upsetting.

Coping Strategies

• Identify triggers: Recognising and understanding the situations that trigger anger can help survivors manage their moods and reduce or avoid them.
• Take breaks: Many anger triggers involve frustration from unrealistic expectations or overexertion. Taking a break can help prevent these feelings from intensifying into anger.
• Practice self-compassion: Stroke recovery is challenging, and survivors should practice self-compassion by stepping back from frustrating situations and using anger coping mechanisms like listening to relaxing music, meditation, prayer, or expressing emotions through journaling or artwork.
• Consider medications: If anger is reducing quality of life or damaging relationships, selective serotonin reuptake inhibitors (SSRIs) are often considered first-line medications. However, be aware of potential side effects, such as anxiety, confusion, and difficulty sleeping, which can trigger anger.
• Strategies for loved ones: Loved ones can help reduce triggers and minimise frustration by practising empathy and compassion, validating feelings of hurt or frustration, and responding gently and compassionately.

Treatment options

Aggressive behaviour in stroke victims can be treated or prevented using various methods, including pharmacological therapies. Here are some treatment options for stroke victims experiencing aggression:

Medication

Selective serotonin reuptake inhibitors (SSRIs) are commonly prescribed antidepressants that work by increasing serotonin levels in the brain. They can help treat behavioural changes after a stroke, such as anger, aggression, or combative behaviour. Fluoxetine (Prozac) is an SSRI that has been shown to improve "post-stroke anger proneness" even three months after discontinuation of treatment. It significantly improved post-stroke anger proneness and post-stroke emotional incontinence but did not help with post-stroke depression in one study.

Beta-adrenergic antagonists and lithium may also reduce aggressiveness in patients with brain injuries. However, there is limited clinical evidence for their effectiveness in stroke patients.

Therapy

Therapy can help stroke victims learn to identify and manage aggressive behaviours. Cognitive behavioural therapy (CBT) is a type of talking therapy that focuses on thinking and behaviour and how they are connected. It may help patients learn to think through their actions and understand their effects on others.

Identify and Avoid Triggers

Understanding the triggers of aggressive behaviour can be a valuable first step in managing it. Common triggers include overstimulation, confusion, disruption of routine, and lack of control over the environment or physical functions.

Develop a Strategy

Agree on a word, phrase, or sign with family and friends to indicate when the patient is acting aggressively. Alternatively, agree that they will walk away and leave the patient alone for a short period.

Frequently asked questions