Psychosocial Aspects of Recovery from Stroke
Associate Professor,Departments of Community Health Sciences and Psychiatry,University of Calgary, Population Health Investigator,The Alberta Heritage Foundation for Medical Research,Calgary, AB.
Stroke has the potential to disrupt several facets of a person's life including communication, emotional regulation, cognitive function and coping skills.1 Furthermore, stroke does not just impact on the individual but also on his or her family members and other social networks of which he or she is a part Stroke has been regarded as form of "double-jeopardy"1 in the sense that the condition creates many new problems and challenges for those afflicted, and simultaneously detracts from the afflicted persons' capacity to cope with those challenges. It can also lead to disruptions in those same social connections that would normally support adaptation to loss.
, http://www.100md.com
Understanding the role of psychosocial factors in recovery from stroke requires adopting a conceptual viewpoint that transcends the traditional biomedical perspective. A suitable framework is provided by the World Health Organization's International Classification of Impairments, Disabilities and Handicaps (WHO-ICIDH). The WHO system differentiates among impairment, disability and handicap. According to the WHO, impairment is defined as any loss or abnormality of structure or function. In essence, impairment refers to the impact of stroke at a neurological level, which can be evaluated by clincical means. However, of itself, impairment has very little specific social or personal significance.
, 百拇医药
The WHO defines disability as a restriction or lack of ability to perform an activity or task in a manner considered normal. This concept helps us understand the impact of a stroke from the point of view of the person who has had a stroke-for instance, what tasks is this person able or unable to perform? An assessment of disability can range from an evaluation of activities of daily living (ADL) to an occupational assessment.
Finally, the WHO's concept of handicap refers to a social dimension--can the person fulfill a role that is normal for that person? The term handicap thus reflects an interaction between individuals and their social environment.
, 百拇医药
Inherent in the WHO Classification is a great degree of optimism. First, the brain is probably much more plastic than was previously believed,2 and rehabilitative efforts may affect fundamental aspects of neural recovery. Second, even in the presence of neurological deficits, disabilities can often be overcome and handicaps can be effectively addressed. If impairment leads to difficulty in completing a task, household modifications and various aids to daily living can be used, in order to maximize functiioning. By a process of psychosocial adaptation, persons who have had a stroke can learn to adapt to
, 百拇医药
the new reality in their life--albeit one that may include some impairments. They can adopt new roles and develop new interests. As such, it should not be considered inevitable that neurological impairments must translate into a poorquality of life. The Framingham study confirmed that extent of impairment was related to outcome (the dependent variable in this study was institutionalization), but also identified an important role for psychosocial factors. In men, marital status was more strongly related to institutionalization than was extent of impairment; however, this was not true for women.
, http://www.100md.com
In the acute stages of a stroke, the emphasis tends to be on medical treatment and assessment. Once the condition has stabilized, a decision is made on whether to proceed with rehabilitation. Often, the initial goal of rehabilitation is regaining physical function with psychosocial factors becoming more important over time. However, this delay in psychosocial intervention may affect outcome; those trials of psychosocial interventions that have been implemented many months post-stroke have generally reported disappointing results, whereas support provided in the first six months has been strongly associated with favourable outcomes. Therefore, an assessment of important psychosocial variables should be performed during the early stages of rehabilitation.
, http://www.100md.com
Psychosocial assessment should be individualized, but must include certain elements. The asse- sment should allow a differentiation between the self-limited distress associated with psychological adaptation (as occurs in adjustment disorders) and the signs and symptoms of psychiatric disorders that require treatment. In order to make such distinctions, a clinical interview focusing on the severity and persistence of symptoms is essential, but should be supplemented by information provided by significant others and observations by members of the health care team. The risk of suicide is elevated post-stroke, and inquiries should be made regarding suicidal ideation. More broadly-based assess-
, 百拇医药
ment of the psychosocial and physical environment of the afflicted individual is also essential. These are areas where family meetings, home visits and occupational therapy assessment can be very helpful. Neuropsychological assessment can contribute to the assessment by identifying deficits, and can
also uncover cognitive deficits that might otherwise act as subtle sources of frustration and poor communication. Psychosocial assessment need not entirely be oriented towards identifying deficits: the pursuit of happiness is a universal human objective, and one that can be facilitated by recreational and social opportunities.
, http://www.100md.com
Certainly, professionals should recognize that their way of interacting with stroke survivors helps to lay the foundation for improved outcomes. In addressing such considerations, it is useful to consider the psychological concept of self-efficacy. Self-efficacy refers to the belief in one'scapabilities to cope with specific situations and is related to quality of life after a stroke (and inversely to depressive symptom levels). Rehabilitation nurses, physicians and therapists can promote self-efficacy by negotiating
, 百拇医药
with patients about setting goals and by providing feedback during the treatment and rehabilitation process. Interactions using a collaborative style and language are likely to assist with the patient's pre-
servation of dignity, autonomy and sense of control.1 Professionals must also recognize that the normal process of adaptation to loss is characterized by a plurality of emotions and not just sadness. Grieving the losses associated with stroke (loss of independence, mobility, social roles,etc.) can involve
, http://www.100md.com
expressions of frustration or anger and these should generally be regarded as normal rather than causing defensive anger. Another important need, related to the concept of self-efficacy,is the need of in-
formation. Knowledge about stroke can offer a sense of greater control and autonomy to the stroke survivor.
Particularly important during the post-stroke period is surveillance for depressive disorders. For example, it has been shown that remission of post-stroke major depression is associated with improved recovery of ADL.7 Depressive disorders impair quality of life in psychological and social domains, and perhaps even in the domains of physical function. Depression, always a destructive entity in its clinical forms, is especially destructive after a stroke when optimism, enthusiasm and motivation are so valuable for rehabilitation and psychological adaptation. When depression is severe, the most minor of life's challenges can seem insurmountable. Even persons without any neurological limitations m-
, 百拇医药
ay struggle with the day to day demands of functioning (hygiene, housekeeping etc.) when they are severely depressed, making it easy to understand the ways in which depression can undermine a person's capacity to face the many challenges of the post-stroke period. The literature concerned with lesion location and depression has been inconsistent. However, recent advances in brain imaging
techniques may lead to better recognition of those lesions most likely to cause depression.
, 百拇医药
In diagnosing post-stroke depression, DSM-IV recommends that symptoms directly attributable to the stroke not be counted towards the diagnosis, reflecting concern that inclusion of physical symptoms may render the diagnostic criteria non-specific. However, these issues may have been over-emphasized in the past. It has been shown that the psychological and physical symptoms that characterize post-stroke depressive disorders are typical of those seen in major depression.These symptoms include depressed mood, loss of interest, psychomotor changes (agitation or retardation), sleep and appetite disturbance, fatigue, problems with memory and concentration, a negative thinking style (e.g. low self esteem, pessimism, guilt), and thoughts of suicide or death. Because the patient may experience aphasia, communicating symptoms may present a problem even greater than that of discerning the origin of symptoms.
, 百拇医药
Recently, a randomized placebo-controlled clinical trial of nortriptyline versus fluoxetine found a higher rate of remission (over 12 weeks of treatment) with nortriptyline. However, in this specific study, neither drug impacted upon recovery of cognitive or social functioning, and the response to
fluoxetine did not differ from placebo. In another randomized-controlled trial, one SSRI antidepressant, citalopram, was shown to be more effective than placebo. The trial reported a high rate of spontaneous remission (and no superiority for the antidepressant over placebo in this group) for patients
, 百拇医药
who experienced onset of depressive symptoms within seven weeks of the stroke. However, in sujects whose depression had its onset seven or more weeks post-stroke, the rate of spontaneous remission was low and the impact of the medication was significant. Observational studies have generally confirmed the effectiveness of antidepressant treatment in the "real world" setting.
Unfortunately, the results of randomized-controlled trials (RCTs) of non-pharmacological interventions for psychosocial problems have been disappointing. A variety of interventions have been evaluated, with most of these focusing on the mobilization of community resources, family and social support and education. A recent review of such RCTs was conducted by Knapp et al.;13 the results were
, 百拇医药
largely negative. At best, weak effects have been reported. These sentiments were echoed by Glass etal.,who have also designed a family-based intervention that is currently under evaluation in the clinical trial called the Families in Recovery from Stroke Trial (FIRST).
While RCTs of psychosocial interventions have so far been disappointing, this does not alter the fact that human beings are psychological and social beings as well as biological ones. After a stroke, cherished social roles may no longer exist for a disabled person. This most obviously applies to occupational functioning, but more subtly defined social roles may be cherished to the same extent as careers--for example, family and recreational roles. Direct intervention is often needed to help families and individuals adapt to the new reality of their situation. Continued progress within the public policy
, 百拇医药
sphere is also needed in order to ensure that post-stroke impairments do not lead to undue isolation and immobility for stroke victims. Social support is important for at least two reasons--because the stroke survivor may direct physical assistance with specific tasks and because of the need for
emotional support that tends to occur at times of stress and loss. When family support is unavailable or families are dysfunctional, additional social support may be mobilized through programs that encourage socialization (e.g. recreational programs for seniors), through supportive individual counseling and/or peer support groups.
, 百拇医药
Inherent in these many clinical challenges are tremendous opportunities to improve the lives of stroke victims. Clinicians can make a tremendous impact when they approach psychosocial problems with interest, enthusiasm and optimism.
References
1.Glass TA, Dym B, Greenberg S, et al. Psychosocial intervention in stroke: Families in recovery from stroke trial (FIRST). Am J Orthopsychiat 2000; 70:169-81.
, 百拇医药
2.Robertson IH. Compensations for brain deficits. Br J Psychiatry 2001; 176:412-3.
3.Kelly-Hayes M, Wolf PA, Kannel WB, et al. Factors influencing survival following stroke: the Framingham study. Arch Phys Med Rehabil 1988; 69:415-18.
4.Kelly-Hayes M, Paige C. Assessment and psychologic factors in stroke rehabilitation. Neurology 1995; 45(Suppl 1):s29-s32.
5.Glass TA, Matchar DB, Belyea M, Feussner JR. Impact of social support on outcome in first stroke. Stroke 1993; 24:64-70.
, 百拇医药
6.Robinson-Smith G, Johnston MV, Allen J. Self-care self-efficacy, quality of life, and depression after stroke. Stroke 2000; 81:460-4.
7.Chemerinski E, Robinson RG, Kosier JT. Improved recovery in activities of daily living associated with remission of poststroke depression. Stroke 2001; 32:113-7.
8.Kathol RG, Noyes R, Williams J, Mutgi A, Carrol B, Perry P. Diagnosing depression in patients with medical illness. Psychosomatics 1990; 436:434-40.
, http://www.100md.com
9.Paradiso S, Ohkubo T, Robinson RG. Vegetative and psychological symptoms associated with depressed mood over the first two years after stroke. Int J Psychiatry Med 1997; 27(2):137-57.
10.Robinson RG, Schultz SK, Castillo C, et al. Nortriptyline versus fluoxetine in the treatment of depression and in short-term recovery after stroke: a placebo-controlled, double-blind study. Am J Psychiatry 2000; 157:351-9.
11.Andersen G, Vestergaard K, Lauritzen L. Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram. Stroke 1994; 25:1099-104.
12.Finklestein SP, Weintraub RJ, Karmouz C, et al. Antidepressant drug treatment for poststroke depression: retrospective study. Arch Phys Med Rehabil 1987; 68:772-6.
13.Knapp P, Young J, Forster A. Non-drug strategies to resolve psychosocial difficulties after stroke. Age Aging 2000; 29:23-30., 百拇医药(Scott B. Patten, MD, PhD)
Stroke has the potential to disrupt several facets of a person's life including communication, emotional regulation, cognitive function and coping skills.1 Furthermore, stroke does not just impact on the individual but also on his or her family members and other social networks of which he or she is a part Stroke has been regarded as form of "double-jeopardy"1 in the sense that the condition creates many new problems and challenges for those afflicted, and simultaneously detracts from the afflicted persons' capacity to cope with those challenges. It can also lead to disruptions in those same social connections that would normally support adaptation to loss.
, http://www.100md.com
Understanding the role of psychosocial factors in recovery from stroke requires adopting a conceptual viewpoint that transcends the traditional biomedical perspective. A suitable framework is provided by the World Health Organization's International Classification of Impairments, Disabilities and Handicaps (WHO-ICIDH). The WHO system differentiates among impairment, disability and handicap. According to the WHO, impairment is defined as any loss or abnormality of structure or function. In essence, impairment refers to the impact of stroke at a neurological level, which can be evaluated by clincical means. However, of itself, impairment has very little specific social or personal significance.
, 百拇医药
The WHO defines disability as a restriction or lack of ability to perform an activity or task in a manner considered normal. This concept helps us understand the impact of a stroke from the point of view of the person who has had a stroke-for instance, what tasks is this person able or unable to perform? An assessment of disability can range from an evaluation of activities of daily living (ADL) to an occupational assessment.
Finally, the WHO's concept of handicap refers to a social dimension--can the person fulfill a role that is normal for that person? The term handicap thus reflects an interaction between individuals and their social environment.
, 百拇医药
Inherent in the WHO Classification is a great degree of optimism. First, the brain is probably much more plastic than was previously believed,2 and rehabilitative efforts may affect fundamental aspects of neural recovery. Second, even in the presence of neurological deficits, disabilities can often be overcome and handicaps can be effectively addressed. If impairment leads to difficulty in completing a task, household modifications and various aids to daily living can be used, in order to maximize functiioning. By a process of psychosocial adaptation, persons who have had a stroke can learn to adapt to
, 百拇医药
the new reality in their life--albeit one that may include some impairments. They can adopt new roles and develop new interests. As such, it should not be considered inevitable that neurological impairments must translate into a poorquality of life. The Framingham study confirmed that extent of impairment was related to outcome (the dependent variable in this study was institutionalization), but also identified an important role for psychosocial factors. In men, marital status was more strongly related to institutionalization than was extent of impairment; however, this was not true for women.
, http://www.100md.com
In the acute stages of a stroke, the emphasis tends to be on medical treatment and assessment. Once the condition has stabilized, a decision is made on whether to proceed with rehabilitation. Often, the initial goal of rehabilitation is regaining physical function with psychosocial factors becoming more important over time. However, this delay in psychosocial intervention may affect outcome; those trials of psychosocial interventions that have been implemented many months post-stroke have generally reported disappointing results, whereas support provided in the first six months has been strongly associated with favourable outcomes. Therefore, an assessment of important psychosocial variables should be performed during the early stages of rehabilitation.
, http://www.100md.com
Psychosocial assessment should be individualized, but must include certain elements. The asse- sment should allow a differentiation between the self-limited distress associated with psychological adaptation (as occurs in adjustment disorders) and the signs and symptoms of psychiatric disorders that require treatment. In order to make such distinctions, a clinical interview focusing on the severity and persistence of symptoms is essential, but should be supplemented by information provided by significant others and observations by members of the health care team. The risk of suicide is elevated post-stroke, and inquiries should be made regarding suicidal ideation. More broadly-based assess-
, 百拇医药
ment of the psychosocial and physical environment of the afflicted individual is also essential. These are areas where family meetings, home visits and occupational therapy assessment can be very helpful. Neuropsychological assessment can contribute to the assessment by identifying deficits, and can
also uncover cognitive deficits that might otherwise act as subtle sources of frustration and poor communication. Psychosocial assessment need not entirely be oriented towards identifying deficits: the pursuit of happiness is a universal human objective, and one that can be facilitated by recreational and social opportunities.
, http://www.100md.com
Certainly, professionals should recognize that their way of interacting with stroke survivors helps to lay the foundation for improved outcomes. In addressing such considerations, it is useful to consider the psychological concept of self-efficacy. Self-efficacy refers to the belief in one'scapabilities to cope with specific situations and is related to quality of life after a stroke (and inversely to depressive symptom levels). Rehabilitation nurses, physicians and therapists can promote self-efficacy by negotiating
, 百拇医药
with patients about setting goals and by providing feedback during the treatment and rehabilitation process. Interactions using a collaborative style and language are likely to assist with the patient's pre-
servation of dignity, autonomy and sense of control.1 Professionals must also recognize that the normal process of adaptation to loss is characterized by a plurality of emotions and not just sadness. Grieving the losses associated with stroke (loss of independence, mobility, social roles,etc.) can involve
, http://www.100md.com
expressions of frustration or anger and these should generally be regarded as normal rather than causing defensive anger. Another important need, related to the concept of self-efficacy,is the need of in-
formation. Knowledge about stroke can offer a sense of greater control and autonomy to the stroke survivor.
Particularly important during the post-stroke period is surveillance for depressive disorders. For example, it has been shown that remission of post-stroke major depression is associated with improved recovery of ADL.7 Depressive disorders impair quality of life in psychological and social domains, and perhaps even in the domains of physical function. Depression, always a destructive entity in its clinical forms, is especially destructive after a stroke when optimism, enthusiasm and motivation are so valuable for rehabilitation and psychological adaptation. When depression is severe, the most minor of life's challenges can seem insurmountable. Even persons without any neurological limitations m-
, 百拇医药
ay struggle with the day to day demands of functioning (hygiene, housekeeping etc.) when they are severely depressed, making it easy to understand the ways in which depression can undermine a person's capacity to face the many challenges of the post-stroke period. The literature concerned with lesion location and depression has been inconsistent. However, recent advances in brain imaging
techniques may lead to better recognition of those lesions most likely to cause depression.
, 百拇医药
In diagnosing post-stroke depression, DSM-IV recommends that symptoms directly attributable to the stroke not be counted towards the diagnosis, reflecting concern that inclusion of physical symptoms may render the diagnostic criteria non-specific. However, these issues may have been over-emphasized in the past. It has been shown that the psychological and physical symptoms that characterize post-stroke depressive disorders are typical of those seen in major depression.These symptoms include depressed mood, loss of interest, psychomotor changes (agitation or retardation), sleep and appetite disturbance, fatigue, problems with memory and concentration, a negative thinking style (e.g. low self esteem, pessimism, guilt), and thoughts of suicide or death. Because the patient may experience aphasia, communicating symptoms may present a problem even greater than that of discerning the origin of symptoms.
, 百拇医药
Recently, a randomized placebo-controlled clinical trial of nortriptyline versus fluoxetine found a higher rate of remission (over 12 weeks of treatment) with nortriptyline. However, in this specific study, neither drug impacted upon recovery of cognitive or social functioning, and the response to
fluoxetine did not differ from placebo. In another randomized-controlled trial, one SSRI antidepressant, citalopram, was shown to be more effective than placebo. The trial reported a high rate of spontaneous remission (and no superiority for the antidepressant over placebo in this group) for patients
, 百拇医药
who experienced onset of depressive symptoms within seven weeks of the stroke. However, in sujects whose depression had its onset seven or more weeks post-stroke, the rate of spontaneous remission was low and the impact of the medication was significant. Observational studies have generally confirmed the effectiveness of antidepressant treatment in the "real world" setting.
Unfortunately, the results of randomized-controlled trials (RCTs) of non-pharmacological interventions for psychosocial problems have been disappointing. A variety of interventions have been evaluated, with most of these focusing on the mobilization of community resources, family and social support and education. A recent review of such RCTs was conducted by Knapp et al.;13 the results were
, 百拇医药
largely negative. At best, weak effects have been reported. These sentiments were echoed by Glass etal.,who have also designed a family-based intervention that is currently under evaluation in the clinical trial called the Families in Recovery from Stroke Trial (FIRST).
While RCTs of psychosocial interventions have so far been disappointing, this does not alter the fact that human beings are psychological and social beings as well as biological ones. After a stroke, cherished social roles may no longer exist for a disabled person. This most obviously applies to occupational functioning, but more subtly defined social roles may be cherished to the same extent as careers--for example, family and recreational roles. Direct intervention is often needed to help families and individuals adapt to the new reality of their situation. Continued progress within the public policy
, 百拇医药
sphere is also needed in order to ensure that post-stroke impairments do not lead to undue isolation and immobility for stroke victims. Social support is important for at least two reasons--because the stroke survivor may direct physical assistance with specific tasks and because of the need for
emotional support that tends to occur at times of stress and loss. When family support is unavailable or families are dysfunctional, additional social support may be mobilized through programs that encourage socialization (e.g. recreational programs for seniors), through supportive individual counseling and/or peer support groups.
, 百拇医药
Inherent in these many clinical challenges are tremendous opportunities to improve the lives of stroke victims. Clinicians can make a tremendous impact when they approach psychosocial problems with interest, enthusiasm and optimism.
References
1.Glass TA, Dym B, Greenberg S, et al. Psychosocial intervention in stroke: Families in recovery from stroke trial (FIRST). Am J Orthopsychiat 2000; 70:169-81.
, 百拇医药
2.Robertson IH. Compensations for brain deficits. Br J Psychiatry 2001; 176:412-3.
3.Kelly-Hayes M, Wolf PA, Kannel WB, et al. Factors influencing survival following stroke: the Framingham study. Arch Phys Med Rehabil 1988; 69:415-18.
4.Kelly-Hayes M, Paige C. Assessment and psychologic factors in stroke rehabilitation. Neurology 1995; 45(Suppl 1):s29-s32.
5.Glass TA, Matchar DB, Belyea M, Feussner JR. Impact of social support on outcome in first stroke. Stroke 1993; 24:64-70.
, 百拇医药
6.Robinson-Smith G, Johnston MV, Allen J. Self-care self-efficacy, quality of life, and depression after stroke. Stroke 2000; 81:460-4.
7.Chemerinski E, Robinson RG, Kosier JT. Improved recovery in activities of daily living associated with remission of poststroke depression. Stroke 2001; 32:113-7.
8.Kathol RG, Noyes R, Williams J, Mutgi A, Carrol B, Perry P. Diagnosing depression in patients with medical illness. Psychosomatics 1990; 436:434-40.
, http://www.100md.com
9.Paradiso S, Ohkubo T, Robinson RG. Vegetative and psychological symptoms associated with depressed mood over the first two years after stroke. Int J Psychiatry Med 1997; 27(2):137-57.
10.Robinson RG, Schultz SK, Castillo C, et al. Nortriptyline versus fluoxetine in the treatment of depression and in short-term recovery after stroke: a placebo-controlled, double-blind study. Am J Psychiatry 2000; 157:351-9.
11.Andersen G, Vestergaard K, Lauritzen L. Effective treatment of poststroke depression with the selective serotonin reuptake inhibitor citalopram. Stroke 1994; 25:1099-104.
12.Finklestein SP, Weintraub RJ, Karmouz C, et al. Antidepressant drug treatment for poststroke depression: retrospective study. Arch Phys Med Rehabil 1987; 68:772-6.
13.Knapp P, Young J, Forster A. Non-drug strategies to resolve psychosocial difficulties after stroke. Age Aging 2000; 29:23-30., 百拇医药(Scott B. Patten, MD, PhD)