Psychological effects of

STROKE HELPLINE 0845 3033 100 FACTSHEET 10

Stroke can cause many different effects. Most people recognise there can be physical effects such as weakness or speech problems, but stroke can also cause psychological changes. These changes can be expressed in the way people feel or think about things, or in the way they behave. This factsheet explains the different psychological effects that can happen after stroke and the help that is available.

What causes psychological angry or bewildered. All these are changes? common and, although they usually fade with time, they may persist in some people. The emotional, psychological and behavioural changes that take place The most common psychological changes following a stroke are, in part, caused by that can happen after stroke are: physical damage to the brain. When ; ; emotional lability; brain cells are damaged, the sensations and personality changes. and parts of the body controlled by these cells no longer function properly. Depression

Each stroke is different and, to a large Depression is extremely common in people extent, the psychological problems that who have had a stroke – it is probably the someone may experience will vary most common psychological effect after depending on the part of the brain affected stroke. In fact, it is estimated that around and the extent of the damage. For example, half of those who survive a stroke suffer impulsive behaviour is associated with significant depression within the first year. damage to the right half of the brain, while Depression after stroke can anyone tearfulness and outbursts of are regardless of their age, sex, background, more common in those with damage to the or the severity of their stroke. It can left half of the brain. develop immediately after the stroke Apart from the psychological effects caused happens, or weeks or months later. by damage to the brain, having a serious Many people are not routinely assessed for illness such as a stroke, being in hospital, depression after stroke, and only a minority or facing up to the reality of having to live are properly diagnosed and treated. with any lasting disabilities can affect Being assessed and receiving the right help emotional health. Someone may feel is crucial as managing depression can anxious or depressed, be frustrated, really make a difference.

The Stroke Association (October 2006) 1 FACTSHEET 10 Psychological effects of stroke

What causes depression? What are the symptoms of depression? Having a stroke can be a frightening experience. Stroke happens very suddenly There are a number of symptoms of and it can take some time to come to terms depression to be aware of. The most with the shock of what has happened. common include: Many people feel frightened, anxious, • sad, blue or down in the dumps frustrated or angry about what has happened to them. These feelings are •A loss of in every day activities normal and usually fade over time, but in • Feelings of worthlessness, some people they develop into depression. hopelessness or despair Depression often sets in once the initial • Inability to concentrate or difficulty period of recovery is over, and the person making decisions becomes aware of how their lasting disability may affect their everyday life. • or The person who has had a stroke may • Changes in sleeping pattern or appetite have to come to terms with the loss of many of their and plans for the • Loss of energy future, as well as having to adapt to a • Suicidal feelings changed role in the family, and possibly the loss of a career. • Low self esteem. As many of us value ourselves through Depression after stroke can range from everyday activities, the impact of a stroke mild to severe, and last for anything from a can result in loss of and few months to more than a year. The lowered feelings of self-worth. Sometimes most obvious symptom is low mood, the stroke directly damages the part of the although occasionally symptoms such as brain which generates and controls how anxiety or are prominent. we think, feel and behave. It may also be Sometimes the emotional symptom is better the result of the emotional impact of described as a sort of flatness or inability a serious illness. to feel . There can also be underlying physical Depression can also cause changes in causes for the depression. For example, thinking, such as trouble concentrating chronic affects many people after or memory difficulties. Sometimes this a stroke and is a common cause of negative thinking becomes severe, and the depression. Being isolated can cause person may develop feelings of or low mood, so having somebody to talk suicidal thoughts. to is important in reducing the likelihood of depression.

The Stroke Association (October 2006) 2 FACTSHEET 10 Psychological effects of stroke

What are the treatments be helpful knowing that apathy is not the for depression? individual ‘giving up’ but more often is the result of damage to the brain. If you are concerned that you or someone do not be afraid you know is depressed, What causes apathy? to talk about it and mention any symptoms to the doctor. Depression Post-stroke apathy, like all mood changes is best treated when it is diagnosed after , is caused by a combination and treated early. The most effective of psychological, biological and other treatment is psychological intervention or factors. In general, apathy is the result of counselling, combined, if appropriate, with either post-stroke depression or is a medication. There are symptom of changes in the brain. also a number of things you can do yourself Many people experience depression to help ease depression. See the Help after stroke and may develop emotional available section at the end of this factsheet symptoms, such as or for details. hopelessness, and physical symptoms, lethargy insomnia Apathy such as or . They may not be confident of their abilities and be What is apathy? unable to feel pleasure. Not surprisingly, they may become apathetic and Apathy is a lack of motivation or uninterested in mundane concerns or . Someone with apathy may unwilling to initiate actions. appear listless, passive, lacking Secondly, post-stroke apathy can be spontaneity and motivation, and may not unrelated to depressive episodes, but due show the variety of expression that they to brain changes in critical structures that usually display. They are often indifferent to regulate emotional reactivity. Certain areas everyday occurrences and unmoved by of the brain are involved in emotional emotional events that would normally arouse control. A stroke in those brain areas can strong feelings. Often there is a loss of produce an emotional disorder. interest in things going on around them, such as socialising or previous hobbies. The frontal area is important for such emotional experiences as energy, This can be difficult for friends and family enthusiasm, productivity, and initiative. who may become confused or frustrated. A stroke in this area may produce an The carer or partner may feel hurt or apathetic state in the way described. neglected, as the person with apathy may Damage in the frontal lobes could be a show less interest in them. This can be biological cause of apathy. particularly frustrating if the individual was previously active. People with apathy need support and encouragement, and it may

The Stroke Association (October 2006) 3 FACTSHEET 10 Psychological effects of stroke

Managing apathy For other people the symptoms can be more exaggerated, and some people find Many people with apathy will take part in that they cry for little or no reason. Less tasks and activities as long as they are commonly, people laugh rather than cry, prompted and encouraged to do so. but again the is out of place This can put additional strain onto carers and does not match how they are feeling and therefore if you are caring for someone at the time. with apathy, it is important you have support These usually come and go for yourself as well. You may find that joining very quickly, unlike when someone feels and attending a stroke club together is upset and is crying. Some people may even helpful. Meeting other people in a similar swing from crying to laughing. Although situation can be beneficial. the individual realises that their crying or As with many of the after effects of stroke, laughter doesn’t fit the situation, they feelings of apathy often begin to disappear cannot control it and this can be with time. This can be through the recovery very upsetting. process or as the depression begins to These episodes of crying can often be lift. If however the apathy is linked to misinterpreted as depression. depression and shows no sign of lifting, then Sometimes people with emotional lability antidepressant drugs and counselling have depression as well, but crying may help. because of emotional lability is not Emotional lability necessarily a sign of depression. If there are about whether or not the individual mental health What is emotional lability? has depression, a professional might be able to help by Emotional lability is the term used when assessing and advising on treatments. someone is more emotional and/or has difficulty controlling their emotions. What causes emotional lability? It can happen with many neurological Emotional lability is caused by the damage conditions and often happens after a done by the stroke. Frequently, difficulties stroke. Some people describe the feeling as with swallowing and tongue movements though all their emotions are “much nearer coincide with emotional lability. If this is the surface” or stronger after their stroke. the case, a speech and language For example some people may become therapist may help to accurately identify upset more easily, or cry at things they emotional lability. would not have cried at before their stroke. Their emotional response is in line with The exact process by which emotional their feelings, but is much greater than lability occurs is not fully understood but it before the stroke. is thought that damage to the cortex in the brain is responsible. Crying is a reflex that we

The Stroke Association (October 2006) 4 FACTSHEET 10 Psychological effects of stroke

can normally control, but it can become • Distraction – by changing the subject of uncontrollable when the cortex is damaged. conversation, or trying some deep Consequently the crying reflex can be breathing can help some people. caused even when the person does not have • Some people find it harder to control their normal triggers that would usually make emotions when other people are very them cry (in a similar way that your leg jerks emotional around them, so it may help to when the doctor uses a hammer to hit your be aware of this. knee to check your reflexes). • Don’t ignore the person, or leave, unless What can be done to help? they say that is what they want.

Emotional lability is often distressing and • Treat it like a minor inconvenience and embarrassing for the individual and their continue the conversation as if it will go friends and family. Understanding that the away. It usually does. exaggerated (and often uncontrollable) • Touch can be helpful – a touch on the emotional reaction is due to the stroke, arm or hand or a hug as is appropriate to may help others to accept and adjust to the relationship. This may increase the the differences in behaviour. crying, but that may be preferred. It’s OK Emotional lability is often worse soon after to cry, and sometimes it helps people to the stroke happens, but usually lessens or feel better. goes away with time as the person • With genuine crying, or crying full of recovers. If this doesn’t happen, the GP may emotion, and understanding be able to help. Some medications that are are usually helpful. also used to treat depression can help with control of emotions the even if the person Personality changes is not depressed. Strokes can cause changes in someone’s Tips for helping someone with behaviour or personality. They may emotional lability become impatient and irritable or withdrawn introspective Ask and . Sometimes the person affected how they would like previous character traits can be to be treated when they have an episode of reversed, with a mild-mannered person crying. Some ideas are: becoming aggressive, a difficult person • Remember being so emotional often becoming more passive, or a once sociable causes people to feel upset or and lively person becoming less sociable and embarrassed. Don’t tell the person not withdrawn. More commonly, however, to cry, this will not help. existing traits are exaggerated.

The Stroke Association (October 2006) 5 FACTSHEET 10 Psychological effects of stroke

become aware Managing personality changes Helping the stroke survivor of their actions and the effect it is having on Family and friends of stroke survivors who are you may help them change their behaviour. affected in this way often find changes to It may be that relationship counselling can behaviour and personality hard to deal with. offer support to both of you. The Stroke People can be upset by the things their Association’s Family and Carer Support relative says to them and may find them very Co-ordinators (formerly Family Support difficult to live with or to be around. Organisers) also support families affected by stroke. Joining a stroke club may also help This is especially true if the stroke survivor as socialising with other people who have becomes aggressive. If your partner, friend experienced strokes may be beneficial in or family member becomes aggressive (in a gaining a deeper understanding of strokes, way that you find threatening), it is important for you and your partner. See the Useful to remember that, despite the stroke, it can organisations section at the end of this be quite frightening. If you find yourself in factsheet for more information. this situation, then there are organisations that can help. These are listed at the end Everybody needs to find their own way of of this factsheet. coping with these changes and often things take time. As the brain goes through Some people find that the challenging the healing process, the changes that behaviour is aimed only at them and have occurred may begin to feel more that the person affected by the stroke is manageable for all concerned. reasonable with other people. This is really consistent people’s behaviour quite with Help available generally. Most of us are more able to get cross with the people we are actually Sorting out the psychological changes closest to, as we feel safe in the knowledge that may occur after a stroke can be that they will probably forgive us and still complicated. Not only can some people want to see us. suffer a range of problems, but it may be difficult to pin down the exact cause of a Some stroke survivors seem unable to specific problem. If you or your family or carer recognise or understand that their notice changes that are affecting you, behaviour or personality has altered, discuss this with your doctor. Ask to have and feel that there is nothing wrong with a proper examination so that any them so they have no reason to try and underlying causes can be correctly change. This kind of situation is harder to diagnosed and treated, if possible. manage so it is important to try and get It may be that professionals such as support from other members of your family psychologists and psychiatrists can as well. You may also find it helpful to avoid help you find appropriate solutions or confrontational situations and to walk coping strategies. away if a situation is becoming too difficult to manage.

The Stroke Association (October 2006) 6 FACTSHEET 10 Psychological effects of stroke

It is important that you are helped to find Many people benefit from talking through some way to make your future life as their difficulties, but if your stroke has left meaningful and fulfilled as possible. you with problems communicating or Keeping up your morale is a crucial aspect of understanding others, it may not be your psychological well-being. Those around the best option, or you may require the you can contribute greatly to this. They specialist skills of a speech and should ensure that they understand the language therapist. reasons for any changes in your behaviour Your GP may be able to refer you to a local or emotions after a stroke, so they can NHS psychology or counselling service. make sense of what has happened and help Often GPs have a counsellor as part of their as much as possible. practice. There are also community adult It may help you to talk to others who have mental health, and older adult mental had similar experiences to yours, for instance health teams to which you can be referred. in a stroke club or self-help group. By However, these services may not be available sharing your feelings, and listening to in all areas, and there may be a waiting list. theirs, you may be able to help them – as Therapy is also available privately (the cost well as yourself. varies between therapists but can be quite local Counselling expensive). There may also be organisations which offer counselling, Acknowledging what has happened, and sometimes at a reduced cost, so it is worth accepting how life has changed is an checking in your telephone directory or at important step in the recovery process and your local library for more local contacts. talking treatments can help with this. Medication Psychological and counselling services aim to encourage you to talk about your Antidepressant medication is usually thoughts and feelings and help you to prescribed to treat depression but is come to terms with what has happened to occasionally used if someone has apathy or you. With the guidance of your psychologist emotional lability. It works by acting or counsellor, you will have the opportunity to on the chemicals in the brain. Many look at how the stroke has affected your are very effective and about life and discover ways of moving forward. two thirds of people who take them benefit. Having the space to talk things through at As antidepressants take at least two weeks your own pace can be very helpful. You will to work properly, it is worth persevering gain a clearer picture of what lies ahead with them, even if you do not feel better and help you feel more in control of life immediately. However, as with any by working out and trying to find solutions medication, there can be side effects, such to problems. as fatigue or a dry mouth, so you may need to try more than one type of antidepressant before you find one that is effective.

The Stroke Association (October 2006) 7 FACTSHEET 10 Psychological effects of stroke

Helping yourself are unable to do things as well as you could before the stroke. Many activities can There are also many things you can do be adapted to enable you to carry on yourself to improve your psychological enjoying them. well-being. Not all of these suggestions will suit everyone, but most people find at least • Exercise: Recent research shows that one or two helpful. exercise is very beneficial in treating and preventing depression. Doing any physical • Keep informed: A lack of knowledge activity regularly, however gentle, can help. about stroke can lead to uncertainty, and misunderstandings can arise that can add • Healthy diet: People who are depressed to worries. Having information about often lose their appetite, and a poor diet stroke can be reassuring and if there is can make you feel tired and run down. Try something you are not sure about, or you to eat regular meals with fresh fruit and do not understand, don’t be afraid to ask vegetables every day. your doctor or carer to explain. The • There are many self-help books available Stroke Association can also help with with further information on living with information about stroke and its effects. conditions such as stroke, and depression. • Social contact: Meeting people regularly, They are available from most bookshops every day if possible, is an important and libraries. source of well-being. Talking to others can be a big help. If you are able to, keep Useful organisations talking to family and friends, and try not The Stroke Association provides to push people away or assume you are information about stroke and its effects, and a burden. has details of support groups and our Family • Support groups: Many people find and Carer Support Service (formerly known support groups useful. They provide a as Family Support Service). You can call our chance to meet people who have been Helpline on 0845 3033 100 or email us at through a similar experience, and many [email protected] arrange social activities. Stroke clubs are British Association for Counselling and support groups for people affected by Psychotherapy (BACP) stroke. Contact us for details of a group near you. 15 St John’s Business Park, Lutterworth LE17 4HB • Hobbies and interests: Returning to Tel: 0870 443 5252 hobbies and interests is an important part Email: [email protected] of the rehabilitation process after stroke. Website: www.bacp.co.uk You could even look at trying new things. Publish the Counselling & Psychotherapy Try not to be put off by thoughts that you Resources Directory. This lists organisations,

The Stroke Association (October 2006) 8 FACTSHEET 10 Psychological effects of stroke

counsellors and psychotherapists in the UK. Depression Alliance Some counsellors operate a sliding scale of 212 Spitfire Studios, 63–71 Collier St, charges according to income. London N1 9BE British Psychological Society (BPS) Tel: 0845 123 2320 Email: [email protected] St Andrews House, 48 Princess Road East, Website: www.depressionalliance.org Leicester LE1 7DR Has publications and information and Tel: 0116 254 9568 also coordinates a national network of Email: [email protected] self-help groups. Website: www.bps.org.uk Holds lists of counselling psychologists. Different Strokes Carers UK 9 Canon Harnett Court, Wolverton Mill, Milton Keynes MK12 5NF 20–25 Glasshouse Yard, London EC1A 4JT Tel: 0845 130 7172 Carersline: 0808 808 7777 Email: [email protected] (open Wed & Thur 10–12pm & 2–4pm) Website: www.differentstrokes.co.uk Email: [email protected] A charity for people under 55 affected Website: www.carersuk.org by stroke. They are developing a national Provides information and support to carers. referrals network of professionally CONNECT qualified counsellors. 16–18 Marshalsea Road. London SE1 1HL Medical Advisory Service Tel: 020 7367 0840 PO Box 3087, London W4 4ZP Email: [email protected] Tel: 020 8994 9874 (Mon–Fri 6pm–8pm) Website: www.ukconnect.org Email: [email protected] Has counsellors with personal experience of Website: www.medicaladvisoryservice.org.uk aphasia who are trained to help counsel A registered charity you can contact people with communication problems. regarding medical problems. Gives Cruse Bereavement Care information and advice on health PO Box 800, Richmond, services, charities, self-help groups and Surrey TW9 1RG general counselling. Tel: 0844 477 9400 MIND Email: [email protected] 15–19 Broadway, London E15 4BQ Website: www.cruse.org.uk Tel: 0845 766 0163 Provides support, information and advice to Email: [email protected] anyone who has been bereaved. Website: www.mind.org.uk Mind is a national mental health charity offering a range of publications and information on local services and support groups.

The Stroke Association (October 2006) 9 FACTSHEET 10 Psychological effects of stroke

National Phobics Society Zion Community Resource Centre, 339 Stretford Road Hulme, Manchester M15 4ZY Tel: 0870 122 2325 Email: [email protected] Website: www.phobics-society.org.uk A national charity for people suffering from anxiety disorders. Provides counselling services, email support and details of self-help groups. RELATE Herbert Gray College, Little Church Street, Rugby, Warwickshire CV21 3AP Tel: 0845 456 1310 Email: [email protected] Website: www.relate.org.uk Relate has local branches and provides counselling for couples and individuals with relationship problems. Womens Aid Head Office, PO Box 391, Bristol BS99 7WS Tel: 0808 2000 247 (Freephone 24 Hour National Domestic Violence Helpline run in partnership between Women’s Aid and Refuge) Email: [email protected] Website: www.womensaid.org.uk Information and support for women experiencing domestic abuse or friends/relatives/professionals seeking information on their behalf.

For further information, phone the Stroke Helpline on 0845 3033 100, email [email protected] or visit our website www.stroke.org.uk F10 Psychological effects of strokeF10 Psychological effects Charity No. 211015. Association October 2006. Registered © The Stroke The Stroke Association (October 2006) 10