Catastrophic reaction after cerebrovascular lesions: frequency, correlates, and validation of a scale

Spectrum of neuropsychiatric symptoms in chronic post-stroke aphasia

BACKGROUND

Neuropsychiatric symptoms (NPS) have been insufficiently examined in persons with aphasia (PWA) because most previous studies exclude participants with language and communication disorders.

AIM

To report a two-part study consisting of a literature review and an observational study on NPS in post-stroke aphasia.

METHODS

Study 1 reviewed articles obtained from PubMed, PsycINFO, Google Scholar and Cochrane databases after cross-referencing key words of post-stroke aphasia to NPS and disorders. Study 2 examined language deficits and activities of daily living in 20 PWA (median age: 58, range: 28-65 years; 13 men) with the Western Aphasia Battery-Revised and the Barthel Index, respectively. Informants of these 20 PWA were proxy-evaluated with the Neuropsychiatric Inventory and domain-specific scales, including the Stroke Aphasia Depression Questionnaire-10 item version and the Starkstein Apathy Scale. In addition, an adapted version of the Hospital Anxiety and Depression Scale was directly administered to the PWA themselves. This observational study is based on the baseline assessment of an intervention clinical trial (EudraCT: 2017-002858-36; ClinicalTrials.gov identifier: NCT04134416).

RESULTS

The literature review revealed a broad spectrum of NPS in PWA, including depression, anxiety, apathy, agitation/aggression, eating and sleep disorders, psychosis, and hypomania/mania. These findings alert to the need for improving assessment and treatment approaches of NPS taking into consideration their frequent occurrence in PWA. Study 2 showed that the 20 participants had mild- to-moderate aphasia severity and were functionally independent. A wide range of comorbid NPS was found in the post-stroke aphasic population (median number of NPS: 5, range: 1-8). The majority of PWA (75%) had depressive symptoms, followed by agitation/aggression (70%), irritability (70%), anxiety (65%) and appetite/eating symptoms (65%). Half of them also presented symptoms of apathy, whereas euphoria and psychotic symptoms were rare (5%). Domain-specific scales revealed that 45% of participants had apathy and 30% were diagnosed with depression and anxiety.

CONCLUSION

Concurrent NPS are frequent in the chronic period of post-stroke aphasia. Therefore, further research on reliable and valid assessment tools and treatment for this aphasic population is strongly warranted.

Language as a Threat: Multimodal Evaluation and Interventions for Overwhelming Linguistic Anxiety in Severe Aphasia

Linguistic anxiety (LA) is an abnormal stress response induced by situations that require the use of verbal behavior, and it is accentuated during language testing in persons with aphasia (PWA). The presence of LA in PWA may jeopardize the interpretation of cognitive evaluations, leading to biased conclusions about the severity of the language alteration and the effectiveness of the treatments. In the present study, we report the case of a woman (Mrs. A) with severe chronic mixed transcortical aphasia due to left frontal and parietal hemorrhages that partially spared the perisylvian area. Mrs. A was treated with the dopamine agonist Rotigotine alone and combined with Intensive Language-Action Therapy (ILAT). Complementary evaluations included autonomic reactivity during the performance of different language tasks, resting state functional magnetic resonance imaging (rs-fMRI) and [18F]-fluorodeoxyglucose positron emission tomography (18F-FDG-PET). We found that formal language testing in a clinical setting triggered a dramatic increase of automatic echolalia, perseverations and frustration, making the task completion difficult. The treatment improved aphasia, but gains were more robust when evaluation was performed by Mrs. A's husband at home than by clinicians. Autonomic evaluation under Rotigotine revealed higher reactivity during tasks tapping an impaired function in comparison with a task evaluating a preserved function (verbal repetition). Baseline 18F-FDG-PET analysis showed decreased metabolic activity in left limbic-paralimbic areas, whereas rs-fMRI revealed compensatory activity in the right hemisphere. We also analyzed the different factors (e.g., premorbid personality traits, task difficulty) that may have contributed to LA in Mrs. A during language testing. Our findings emphasize the usefulness of implicating adequately trained laypersons in the evaluation and treatment of PWA showing LA. Further studies using multidimensional evaluations are needed to disentangle the interplay between anxiety and abnormal language as well as the neural mechanisms underpinning LA in PWA.

The long-term development of non-motor problems after STN-DBS

OBJECTIVES

Stimulation of the subthalamic nucleus (STN-DBS) is an established treatment with long-term beneficial effects on motor symptoms in patients with Parkinson's disease (PD). The long-term development of non-motor problems after STN-DBS is not fully understood. In this study, we have studied how non-motor problems develop in patients with and without STN-DBS.

MATERIALS AND METHODS

We collected data from a prospectively followed cohort of patients that had been operated with STN-DBS 6-9 years before final examination and compared our findings to the longitudinal development of non-motor problems in a non-operated, comparable reference population.

RESULTS

In general, the non-motor problems of advanced PD seem to develop independently of treatment with STN-DBS. We found that depressions do not worsen after STN-DBS, and the Montgomery and Aasberg Depression Rating Scale score in operated patients was substantially reduced from pre-operatively to post-operatively. Further, fatigue may represent an important unrecognized side effect of long-term stimulation, as fatigue was found to increase rapidly in operated patients already a year after surgery and continued to increase trough the 6- to 9-year follow-up.

CONCLUSIONS

The non-motor problems of advanced PD seem to develop independently of treatment with STN-DBS. This may influence the strategy for choice of when to perform this therapy for eligible patients.

Language as a Stressor in Aphasia

BACKGROUND: Persons with aphasia often report feeling anxious when using language while communicating. While many patients, caregivers, clinicians and researchers would agree that language may be a stressor for persons with aphasia, systematic empirical studies of stress and/or anxiety in aphasia remain scarce. AIM: The aim of this paper is to review the existing literature discussing language as a stressor in aphasia, identify key issues, highlight important gaps, and propose a program for future study. In doing so, we hope to underscore the importance of understanding aspects of the emotional aftermath of aphasia, which plays a critical role in the process of recovery and rehabilitation. MAIN CONTRIBUTION: Post stroke emotional dysregulation in persons with chronic aphasia clearly has adverse effects for language performance and prospects of recovery. However, the specific role anxiety might play in aphasia has yet to be determined. As a starting point, we propose to view language in aphasia as a stressor, linked to an emotional state we term "linguistic anxiety." Specifically, a person with linguistic anxiety is one in whom the deliberate, effortful production of language involves anticipation of an error, with the imminence of linguistic failure serving as the threat. Since anticipation is psychologically linked to anxiety and also plays an important role in the allostatic system, we suggest that examining physiologic stress responses in persons with aphasia when they are asked to perform a linguistic task would be a productive tool for assessing the potential relation of stress to "linguistic anxiety." CONCLUSION: Exploring the putative relationship between anxiety and language in aphasia, through the study of physiologic stress responses, could establish a platform for investigating language changes in the brain in other clinical populations, such as in individuals with Alzheimer's disease or persons with post traumatic stress disorder, or even with healthy aging persons, in whom "linguistic anxiety" might be at work when they have trouble finding words.

Perception of motor strength and stimulus magnitude are correlated in stroke patients

The authors examined whether perception of contralateral limb strength is altered and whether perception of strength correlates with perception of stimulus intensity (magnitude) in a prospective sample of patients with unilateral right (RHL: n = 13) and left (LHL: n = 6) hemisphere lesions due to stroke. Patients with RHL tended to overestimate strength and patients with LHL tended to underestimate strength; both patterns were highly correlated with altered perception of stimulus magnitude.

Anger, hostility and aggression in the first days of acute stroke

In acute stroke patients, anger can disturb management and rehabilitation and creates a stressful situation for family, health-care providers and other patients. We aim to describe the presence of anger and its association with demographic, clinical, psychiatric, lesion variables and functional outcome in acute stroke patients. We screened anger prospectively in 202 consecutive acute stroke patients (< or =4 days) using eight items from three psychiatric scales (Catastrophic Reaction Scale, Mania Rating Scale and Comprehensive Psychopathological Rating Scale). Anger was present if the patient scored in at least one item. Anger was detected in 71 (35%) patients and 26 of these were severely angry (> or =4 points). There was no association between anger and the considered variables. Analysis of the items extracted two factors: (i) the emotional-cognitive and (ii) the behavioural components of anger. These components were independent of each other in 26 patients. In 38 patients we found a dissociation between clinical observation and patients' subjective expression. Anger was frequent in acute stroke patients. Anger was probably triggered by the brain lesion, which interfered with the emotional control. The lack of an association with clinical and imaging variables suggests a contribution of psychological/psychosocial dimensions.

Emotional Behavior in Acute Stroke

OBJECTIVE

To study emotional behaviors in an acute stroke population.

BACKGROUND

Alterations in emotional behavior after stroke have been recently recognized, but little attention has been paid to these changes in the very acute phase of stroke.

METHODS

Adult patients presenting with acute stroke were prospectively recruited and studied. We validated the Emotional Behavior Index (EBI), a 38-item scale designed to evaluate behavioral aspects of sadness, aggressiveness, disinhibition, adaptation, passivity, indifference, and denial. Clinical, historical, and imaging (computed tomography/magnetic resonance imaging) data were obtained on each subject through our Stroke Registry. Statistical analysis was performed with both univariate and multivariate tests.

RESULTS

Of the 254 patients, 40% showed sadness, 49% passivity, 17% aggressiveness, 53% indifference, 76% disinhibition, 18% lack of adaptation, and 44% denial reactions. Several significant correlations were identified. Sadness was correlated with a personal history of alcohol abuse (r = P < 0.037), female gender (r = P < 0.028), and hemorrhagic nature of the stroke (r = P < 0.063). Aggressiveness was correlated with a personal history of depression (r = P < 0.046) and hemorrhage (r = P < 0.06). Denial was correlated with male gender (r = P < 0.035) and hemorrhagic lesions (r = P < 0.05). Emotional behavior did not correlate with either neurologic impairment or lesion localization, but there was an association between hemorrhage and aggressive behavior (P < 0.001), lack of adaptation (r = P < 0.015), indifference (r = P < 0.018), and denial (r = P < 0.045).

CONCLUSIONS

Systematic observations of acute emotional behaviors after stroke suggest that emotional alterations are independent of mood and physical status and should be considered as a separate consequence of stroke.

Poststroke depression: prevalence, diagnosis, treatment, and disease progression

In recent years, poststroke depression has attracted worldwide interest. This review focuses on the major research themes that have emerged. Pooled data from studies conducted throughout the world have found prevalence rates for major depression of 19.3% among hospitalized patients and 23.3% among outpatient samples. The diagnosis of poststroke depression is most appropriately based on a structured mental state exam and DSM-IV criteria for depression due to stroke with major depressive-like episode or depressive features. Rarely, poststroke patients may also develop bipolar mood disorder. The treatment of poststroke depression has been examined in several placebo-controlled randomized clinical trials with both nortriptyline and citalopram showing efficacy. The progression of recovery following stroke can be altered by treating depression, which has been shown to improve recovery in activities of daily living and cognitive impairment and to decrease mortality. In addition, two studies have demonstrated that poststroke depression can be prevented using antidepressant medication, which also decreases the frequency of associated physical illness. Furthermore, two studies have shown that premorbid depression can significantly increase the risk of stroke over the subsequent 10-15 years. The mechanisms underlying the association of cerebrovascular diseases and mood disorder are important areas for future investigation.

Pharmakotherapie emotionaler Störungen bei Patienten mit erworbener Hirnschädigung

Zusammenfassung: Emotionale Störungen sind häufige und klinisch bedeutsame Folgeerscheinungen nach erworbener Hirnschädigung. In den letzten Jahren sind zahlreiche Original- und Übersichtsarbeiten zu epidemiologischen, pathophysiologischen und therapeutischen Aspekten neuro-psychiatrischer Störungen erschienen. Ausgehend von diagnostischen Überlegungen gibt die vorliegende Arbeit eine aktuelle Übersicht zur Pharmakotherapie von Depressionen, emotionaler Instabilität (pathologisches Weinen), organischer Manie (bipolarer Störung), Angststörungen und Antriebsstörungen (Apathie). Patienten mit Schlaganfall und traumatischer Hirnschädigung stehen im Mittelpunkt, so wie in der Forschungs- und Lehrbuch-Literatur. Psychische Störungen bei neurodegenerativen und systemischen Erkrankungen des Gehirns werden nur am Rande erwähnt. Ausführlich werden differentielle Indikationen und Nebenwirkungen neuartiger Antidepressiva diskutiert. Ausblickend werden innovative Therapiestrategien wie CRH-Antagonisten und die präventive Behandlung mit Antidepressiva vorgestellt.

Poststroke depression: an examination of the literature

OBJECTIVE

To examine literature on poststroke depression (PSD).

DATA SOURCES

More than 200 articles related to stroke and depression were selected from a computer-based search spanning 1985 to 1995.

STUDY SELECTION

All relevant articles on PSD. Articles in foreign languages, case studies, anecdotal reports, book chapters, and reviews were excluded.

DATA EXTRACTION

Summary findings were independently reviewed by the authors.

DATA SYNTHESIS

PSD remains a frequent sequela of stroke; its prevalence remains uncertain because of continued methodologic problems in defining subject groupings and in utilizing psychiatrically normed assessment tools with neurologically impaired individuals, and because of the poor specificity/sensitivity of neuroendocrine markers in determining a diagnosis. The etiology of PSD appears to be complex and not fully understood. Although there has been much research on PSD, this review highlights the sparsity of available literature on its treatment.

CONCLUSION

The review points out the further need for more carefully designed studies of PSD that examine both assessment and treatment.

Self-reported aggressive behavior in patients with stroke

This study represents a first attempt to identify some of the clinical and pathoanatomical correlates of violent outbursts in patients with cerebrovascular accident. Subjects were selected from a population of patients hospitalized with acute stroke. Although we did not have behavioral measures of violent behavior, patients who reported having had violent outbursts were identified based on clinical ratings on a structured interview. Subjects were asked if they had experienced episodes of anger accompanied by behaviors ranging from shouting to violence during the time since their stroke. These patients were compared with controls matched for demographic variables. Violent patients had higher total Present State Exam and Hamilton-D scores. The percentage of patients with cognitive impairment in the angry outburst group (66%) was greater than the control group (22%). Outburst patients had a higher frequency of left-hemisphere lesions (46.7%) compared with controls (29.4%). When lesion volumes were statistically equated, proximity of lesion to the frontal pole was one of the factors related to the self-reported irritable/violent behavior. To determine whether depression explained our findings, we carried out two-way analyses of variance with angry outburst and major depression group membership as factors. Effects of left anterior lesion location and cognitive impairment on violence remained present. These findings suggest that the potential for anger and violence in patients with stroke has multiple clinical and neuropathological correlates, including greater cognitive impairment and left anterior hemisphere lesions.

Factors complicating the diagnosis of depression in cerebrovascular disease, Part I--Phenomenological and nosological issues

Depression is frequently associated with cerebrovascular disease. Early detection and intervention in depression may enhance rehabilitation potential. Difficulties encountered by clinicians in identifying depression in patients with cerebrovascular disease are numerous. This two part review focuses on issues related to the diagnosis of depression with emphasis on recognition of depressive symptoms and their relevance to the diagnosis of depressive syndromes in the presence of vascular lesions and associated neurological deficits. Furthermore, the value of diagnostic instruments and biological markers in identifying depression following stroke has been critically evaluated. In this first part of this two part paper, phenomenological and nosological aspects are considered with an emphasis on symptom profile, significance of vegetative symptoms and other related emotional responses such as catastrophic reaction, emotionalism and apathy in the diagnosis of depression following stroke. The applicability of diagnostic subcategories to define depressive syndromes associated with cerebrovascular disease and its clinical relevance is also discussed. The authors stress that knowledge on phenomenology of depression and other emotional responses related to cerebrovascular disease will facilitate better understanding of its clinical presentation and may improve diagnostic acumen.