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Emotionalism after stroke is common, occurring in 10%–20% of a community sample.1 Psychological factors in its cause or maintenance have not been studied; research has tended to concentrate instead on location of the stroke lesion. We suspect that one reason for this neglect of psychological aspects of emotionalism is that most people do not make a distinction between emotionalism, and pathological crying and laughing. As a result all disorders of emotionality after stroke are stereotyped as being related to brain damage and therefore psychologically meaningless.
None the less, many patients with emotionalism describe their crying as provoked by emotionally congruent experiences, which makes the tearfulness seem understandable.1 In two previous studies1 2 we have shown that stroke patients with emotionalism have more symptoms of psychological disorder than do patients without emotionalism. In the present study, we explored further the psychological characteristics of stroke patients with emotionalism. Our aim was to determine whether they differed from patients without emotionalism in their psychological reactions to stroke, or in the coping strategies they reported.
Post-traumatic stress disorder is also characterised by recurrent episodes of intrusive and uncontrollable emotion, and we were therefore interested in whether patients with emotionalism also experienced the intrusive thoughts typical of post-traumatic stress disorder. Because emotionalism is often described as uncontrollable, we were interested in the possibility that patients were more generally helpless, passive, or avoidant in their responses to stroke. Again, because of the reported uncontrollability of emotionalism, we postulated that patients with emotionalism would report a more external locus of control3 than those without emotionalism
Participants were adults admitted to local general hospitals after stroke, and were interviewed within 1 month of admission. Exclusions were due to poor physical health, cognitive impairment, communication difficulties, or lack of consent. Approval for the study was obtained from the local research ethics committees.
All participants completed a standardised measure of distress—the general health questionnaire, GHQ-124; a widely used measure of intrusive thoughts of the sort encountered in post-traumatic stress disorder—the impact of events rating scale5; a measure of cognitive coping—the mental adjustment to stroke scale (O’Rourke S, Dennis M, MacHale S, Slattery J. The development of the mental adjustment to stroke scale: reliability, patient outcome and associations with mood and social activity, manuscript in preparation); and a measure of beliefs about responsibility for recovery from illness—the recovery locus of control scale.3 All the measures are self report questionnaires.
A total of 177 stroke patients were screened, of whom 112 were excluded. The 65 participants (29 men, 36 women) had a mean age of 71.8 years (range 43 to 88 years). Nineteen (29.2%) patients met our criterion for emotionalism,1 a rate similar to that found in other studies. Their scores on the study measures are compared with the scores of patients without emotionalism in the table.
It might be that these associations with emotionalism were accounted for by the greater general levels of distress experienced by those with emotionalism. We therefore undertook analysis of covariance with GHQ- 12 and presence of emotionalism as the covariates, and each of the other test items in turn as the independent variable. The results showed an association, after adjustment for GHQ-12 score, between emotionalism and the impact of events subscales intrusion (F=15.33, p<0.001), and avoidance (F=11.84, p=0.001); the mental adjustment to stroke scale subscales helplessness/hopelessness (F=11.7 1, p=0.00 1) and anxious preoccupation (F=8.05, p=0.006). The associations with fatalism (F=14.79, p=0.052) and avoidance (F=0.06, p=0.80) on the mental adjustment to stroke scale were no longer significant after adjustment for GHQ-12 score.
This study confirms earlier work by showing that stroke survivors with emotionalism have more other mood symptoms (here rated by the GHQ-12) than do those without emotionalism. It goes further however, in showing that they also have intrusive thoughts about their stroke, of a sort similar to those reported by people with post-traumatic stress disorder. This unpleasant remembering is probably responsible for their higher ratings on anxious preoccupation. It is compatible with our finding in a previous study2 that irritability is associated with emotionalism, as irritability is a common response to threatening intrusive memories of the sort encountered in post-traumatic stress disorder. It may not be that emotionalism is a direct manifestation of post-traumatic stress disorder, although that condition has been described after stroke,6 but the analogy raises the possibility that an abnormality in processing emotionally important stimuli may be one of the causes of emotionalism. If correct it suggests possible treatment strategies along the lines of those used in post-traumatic stress disorder.
A corollary is our finding of increased feelings of helplessness and hopelessness, coupled with avoidance—at least as a cognitive coping strategy reported on one of our measures. Avoidant coping may perpetuate the symptom of emotionalism, by preventing habituation to the social stimuli which provoke it. Alternatively it may lead to a reduction in social support, exacerbating coexistent mood disturbance. Thus, it may be that avoidant coping is not an integral part of emotionalism, but rather that it is an important maintaining factor.
We predicted that patients with emotionalism would have more “external” scores on the locus of control measure, reflecting their sense of lack of personal control over crying. They did not, perhaps because the emotional expression, although not apparently controllable by internal resources, is none the less perceived as having psychological meaning, so that responsibility for it it cannot readily be devolved to others.
Our study used a relatively weak between- groups design, the number of patients was not large, and we cannot be sure that all confounders were dealt with. None the less, our results suggest that future research into emotionalism could profitably concentrate not just on seeking its biological correlates, but should also explore the psychological factors which might contribute to its cause or continuation.
We thank those patients who participated in the study and the staff of local hospitals and the Leeds Stroke Database for their invaluable help. We also thank Dr Louise Dye for her statistical advice. This study was completed as part of work for the degree of DClinPsychol at Leeds University (SE).