Besides the weakened or paralyzed muscles, the difficulty walking and the communication challenges a stroke survivor faces, there are often stroke-related personality changes.
Personality is that quality made up of all the things that define who we are, to our family, friends and the outside world. It is our ways of thinking, feeling and behaving. It’s who we are.
The impact of Strokes on a person and the ensuing stroke-related personality changes can be devastating and difficult, not only for the survivors, who suddenly cannot make themselves understood but also for their family and friends.
It often requires they completely change the way they interact with the stroke survivor, and it can be very disruptive.
Think of a stroke as something that destabilizes parts of the brain. The changes that take place are determined by which parts are affected.
- Some survivors are not affected by an impact on the limbic system, which are the emotion-related parts of the brain. For them, there may be relatively lesser changes in terms of their emotions and personality.
A little better understanding of the makeup of the brain might be helpful for understanding stroke-related personality changes.
- On top (beneath the skull) is the wrinkly cortex, which controls higher thinking, reasoning, organization, and language.
- Underneath that, is the sub-cortical layer, which has to do with memory and sensory processing, as well as some motor control.
- The next layer is the limbic system, which controls our emotional reactions — although they may be modified by the higher levels.
- Then, below that, are the brain stem and other parts of the brain that control our autonomic processes such as breathing, heart rate, temperature and some types of movement.
According to Dr. Christine Salinas, (a Neuropsychologist and Director of Space Coast Neuropsychology Center in Florida), in addition to the site of the stroke, the following also determine the seriousness of the stroke-related personality changes:
- The type of stroke, blood clot or bleeding
- The size of the lesion
- The patient’s risk factors such as hypertension and diabetes.
- Age, gender, ethnicity, and education
Usually, the smaller the infarction (the tissue death due to the inadequate blood supply to the affected area), or the smaller the extent of the brain damage, the fewer cognitive or behavioral consequences.
However, someone could have a small infarct (tissue death) in a deep part of the brain (such as the thalamus, hippocampus, white matter or brain stem) that leads to cognitive deficits as severe as those seen with a large stroke.
One example is that a right-handed stroke survivor who has a stroke on the left side of the brain usually suffers from right-sided weakness or right-sided neglect, not even realizing he/she has a right side.
But the stroke-related personality changes are unpredictable
- Some survivors become much less emotional.
This is called having a “flat affect,” meaning they express and respond to emotions in a flat (almost deadpan) way.
- Some people become irritable and angry
- Some become impulsive or child-like
- Some stroke survivors become intensely emotional
- Others become depressed
Depression is the most common of the stroke-related personality changes, affecting up to one-third of survivors at some point in their recovery.
The effects of depression can also run from flat affect to upset, from sad to angry.
- Reactive depression develops in response to the many losses that result from a stroke.
- Physiological depression causes the person to perceive things in a more negative manner. It’s hard for these people to experience pleasure.
Depression also affects motivation, which impacts all areas of recovery and the reason why it is very important to get it assessed and treated early — usually with a combination of medication and psychotherapy.
- Being around family, friends, and others through support groups also helps.
Occasionally we hear about stroke survivors who lash out, usually by being verbally abusive.
- This reaction usually stems from depression, because the person is upset and frustrated about their situation.
Often stroke survivors are unable to dress, drive, or even feed themselves. They react to that with anger, as well as depression.
For most survivors, however, this is temporary and improves as they adjust to their new circumstances.
- As they get better and function at a higher level, they feel better about themselves and the future.
In a small group of stroke patients, depending on where in the brain the stroke occurred, there is a release of aggressive behavior.
- In addition, the person’s personality before the stroke, such as having a short temper, can play a part.
An unfortunate and painful aspect of this behavior is that it’s often directed at caregivers. This is especially true if there’ s a frontal lobe injury, which is associated with loss of empathy and impulse control.
- This group has less capacity for curbing their impulses than the rest. It will be important for them to have a medical evaluation and intervention from a neurologist, psychiatrist or neuropsychiatrist.
It’s possible to work to decrease this behavior with medication; particularly those that help people gain control over their impulses as well as with antidepressants.
Medical intervention is the key to improving the caregiver’s situation.
Sexuality often changes after a stroke. Although occasionally a survivor’s sexuality increases, the more typical reaction is diminished sexual expression.
- Intimacy is complex, and depression impacts that as well. Stroke can have a dramatic effect, especially if caregiving is involved.
In addition, other medical issues like diabetes and vascular disease affect sexual dysfunction. Even older medications, such as beta-blockers, used to treat high blood pressure, (hypertension) have an impact on sexuality.
Regarding the opposite, hyper-sexuality is rare. It seems to be associated with strokes on the part of the brain called the temporal lobe.
- In some stroke survivors, the ability to regulate their emotions is affected, and their judgment is off. They don’t know what’s okay and what’s not.
They may think that it’s okay to act on their sexual feelings. Their inhibitions are released and their self-control is reduced. So, the person experiences different emotional drives and emotion-related behaviors.
However, it’s not specifically sexual. It’s just that they are uninhibited.
As with the other effects, interventions that focus on changing behavior may be necessary in cases of hyper-sexuality.
PTSD is typically the result of a life-threatening or traumatic experience to which a person has developed an intense emotional reaction.
- They are afraid it will happen again
- They have nightmares about it
- They experience flashbacks as well as overwhelming physical reactions when exposed to any reminders of the experience
One of the most common effects of stroke-related personality changes is anxiety.
- After a stroke, people often worry about getting around or driving, finances, family, his or her future, especially if he or she is having cognitive issues.
Other potential sources of anxiety after stroke are fear of falling because of balance deficits or being anxious about speaking because of aphasia (an inability to understand and formulate language because of damage to specific regions of the brain).
Lack of Awareness
Another type of the stroke-related personality changes in survivors of right hemisphere strokes is a profound lack of awareness of problems that the stroke caused.
- They might have no idea that one leg doesn’t work or that they have terrible trouble with memory or can’t see half of their visual field.
The fancy term for this is “anosognosia.” It’s a profound personality change in their ability to monitor themselves. It doesn’t always happen with right hemisphere strokes, but we know it’s something to look out for after one.
The awareness deficit is difficult to treat because the part of the brain in charge of awareness is broken.
Family members often mistake this for denial. They believe that the survivor is in denial about the effects of their stroke. But it’s not denial.
This is a brain-based issue. When families accept that the broken part can’t work, it really reduces the tension.
Fortunately, many times after a stroke, the lack of awareness improves over time, if the brain heals. But it’s a huge burden on the caregiver.
For stroke survivors experiencing changes in emotions, the best thing is to schedule time with their stroke professional — a neurologist, neuropsychologist or physiatrist (one who deals with physical medicine and rehabilitation). This will assist them to determine what’s physical, what’s reactive and what might be the result of some demands from family members that the patient really can’t fulfill in that moment.
In all likelihood, it will get better over time. We now know that the brain is very plastic and malleable, and if you spend time working on a particular skill, you create changes in the brain at the cellular level.
That process occurs whether you’re practicing using a limb that’s not working as well as it should or practicing your speech, you always have the opportunity to improve over time.
Exercise Provides Enormous Benefits (as it does in every aspect of health)
- Neurologists frequently urge their patients to be physically active regularly. There are a number of benefits.
- When you put exercise head to head with antidepressant medicines, exercise tends to work as well but without the side effects.
One reason exercise is so good at improving mood is that when we exercise, the frontal lobe, which regulates emotions, immediately starts to work faster, better and stronger.
Exercise releases neurotrophins, a family of proteins that cause the development, survival and the function of nerve cells and helps with cell repair.
- Post-stroke exercise can be challenging. It can be hard for survivors to go back to their old form of exercise (if any), but I strongly recommend that they work with their physical therapist to develop a way that they can get aerobic exercise every day.
There’s usually a way that you can move some part of your body to get your heart rate up.
Our understanding of the location of stroke injury and the behaviors they affect is progressing, thanks to MRI’s.
- This imaging process allows a physician to literally ask someone to feel an emotion and, in real time, track what parts of their brain are more active.
In addition, our research methods are becoming more sophisticated, and after decades of research, we have a kind of roadmap. But it’s not perfect yet.
The same injury in the same place on two different people may still produce different results…but we’re working on it.
And that’s good news for stroke survivors and their loved ones.