Psychological Reactions to Changes in Function
PTHER 524
Lecture 4-2
September 21, 2010
Stroke
• Leading cause of disability in Western cultures
• 50 000 new strokes each year in Canada;
Incidence expected to double by 2020
What is lost?
• Brain tissue
• Communication (aphasia)
• Cognition
• Swallowing (dysphagia)
• Sexual function
• Motor function
– Hemiplegia
– Hemiparesis
– Spasticity
– Rigidity
What does this mean?
• Stroke patients and families rarely define their loss in terms of body structure/function, but in everyday
activities they are no longer able to do
– Walking, driving, toileting, etc
Think, Pair, Share Identity
• Many people define themselves by what they do
– Athlete, breadwinner, traveler
• “I’m more dependent on than being depended on.”
50 yr old stroke survivor
• “A stroke is a small death. It comes on suddenly,
often hitting someone who is quite well for his
age, and leads to obvious physical loss. The
victim is rendered helpless „at a stroke‟, and is
robbed of his dignity and independence.”
» Wade et al. 1985
Loss and Grief
• Loss: when you no longer have something or have less of something
• Loss….
– Of function
– Of health status
– Of role capacity
– Of life
• Grief: very great sadness, especially at the death of someone
• Cambridge Dictionaries on-line
Adjustment to Loss
• Shock and disbelief
– Numb, confused, anxious
• Treatment stage
– High expectations of recovery; deny permanent disability; grief
• Developing awareness
– “starting to sink in”; anger, frustration, depression
• Restitution – “anything to make it up” (bargaining)
• Resolving the loss
– “coming to terms”; Intellectual and emotional acceptance; adjustments; social-reinvestments
Adjusting to loss
• Adjustment depends on many factors
– Effects of pathological process or injury
– Personality
– Stage in life
– Personal meaning of disability
– Use of defence and coping mechanisms
• Accepting the loss of identities that were previously crucial to one‟s sense of self and inventing new
ones that provide satisfaction and fulfillment are key to adjustment
Whirlpool of Loss
Emotions Roles and expectations Adjustment to new situation Reactions of others Personality
What you can do for your client
• Allow people to “be”
– Express fear/anger/other emotions
– Talk about the loss
• Understand how client is adjusting to stroke and help them adjust
• Set client-oriented goals
– How to resume or re-define roles
– Confidence in themselves and abilities
– Maximize client‟s participation in decision-making process
Psychological Reaction to Stroke and Loss of Function
• Depression
• Apathy
• Anxiety
• Emotionalism
• Cognition
• Social Disruption
Depression
• Sad mood and loss of pleasure in activities that were previously enjoyable, hopelessness,
worthlessness (DSM IV)
• 20-60% of stroke survivors; peaks 1-3 mos
– Variations due to different structured interviews, population, selection criteria, time, etc.
• Consequences:
– Related to mortality
– Related to morbidity
– Related to poor functional recovery
– Related to low quality of life scores
Causes of post-stroke depression
• Stroke location
– Inconclusive evidence: left hemisphere, frontal lobe?
• Neurotransmitters
– Decreased serotonin, norepinephrine
• Inflammatory molecules
• Genetics
• Social and psychological stressors
– Social isolation, feeling of being a burden, decreased autonomy
– “You‟d be depressed too…..”
Treating Depression • Antidepressants
– Effective in treating post-stroke depression (EBRSR, Teasell)
– Early treatment of depressed and non-depressed stroke patients
• Psychothera
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