MONTAGUE ULLMAN, M.D.
The occurrence of a stroke is a sudden, dramatic, and at times irreversible reminder that life is finite, a fact which in our culture is subject to insistent denial. This illness often precipitates an array of behavioral reactions designed to protect the individual from the distress and anxiety that would otherwise arise in connection with the realization of serious disability, helplessness, dependency, and, in the case of survival, the close call with death.
Because of an age incidence predominantly involving people in the sixth decade of life and later and the frequent occurrence of severe and enduring neurological deficits, the stroke tends to be a disorganizing experience for the patient and his family. A variety of defensive operations may become manifest as the patient moves from the period of initial crisis, through the convalescent stage with recovery or stabilization of deficits, to the rehabilitation period where efforts are directed to the restoration or improvement of function.
The more important reactions occurring following strokes will be briefly considered in an effort to better orient the physician and other concerned parties to their meaning and importance. The main categories of response include the idiosyncratic defensive attitudes characteristic of the individual and evoked by the initial impact of the illness, the development of depressive and paranoid reactions, and the problems associated with denial of illness and anosognosia (the latter term refers to unawareness of illness or deficit associated with brain damage).
The initial subjective reactions of the patient are organized on the basis of two dynamic principles. He is at one and the same time attempting to define for himself the nature of what it is that is happening to him and he is attempting to do it in a way that will do the least damage to his sense of physical intactness, his personal value system, and his sense of social relatedness. In most instances, in situations where the patient is faced with the stress of an illness that may be the harbinger of disability, dependency, or even death, these initial defensive operations often take the form, implicitly or explicitly, of minimizing the experience.
Under these circumstances rationalizations emerge, linking the initial symptoms to earlier and more benign forms of illness or disability. Activity is engaged in designed to further the illusion that nothing serious has occurred. One patient with an incipient hemiplegia continued to drive a cab. Another bought a cane in order to walk to the hospital. At the time that President Eisenhower suffered a transient and mild cerebrovascular accident, several patients with more massive brain damage and severe hemiplegia euphemistically referred to their illness as “Eisenhower s disease.” Stoical attitudes often betray an underlying sense of personal inviolability.
The term depression is used here to encompass reactions varying from mild and transient states of unhappiness to full-blown neurotic or psychotic states. The seriousness of the illness and the frequent residue of paralysis, with or without speech disturbances, almost inevitably precipitate an initial depressive response. In many ways this resembles the grief associated with the loss of a love object. Analogously, the transformation and dissipation of this feeling is a function of time, degree of recovery, and, in favorable circumstances, the possibilities of favorable restitution of the life situation.
This type of reaction closely parallels the progress of the disease. The feelings are those of unhappiness and resignation but characteristically lack the self-deprecation, the guilt, the intrusions of concepts of sin and punishment, and the intense projection of hopelessness that betray the underpinnings of the more serious forms of depression. In the neurotic depression, the patient is responding to the symbolic meaning of the stroke rather than to the actual deficit or material impairment in his life situation.
In one patient, a middle-aged woman, separated and living alone, the occurrence of a stroke resulted in the resurgence of guilt and self-deprecation based on her concern that the present illness was the result of a syphilitic infection innocently acquired some 30 years before. The stroke itself was simply a vehicle for the symbolic expression of unresolved guilt and anxiety in connection with her earlier marriage and subsequent withdrawal from heterosexual contacts.
In the psychotic depression, the history of antecedent episodes as well as the psychotic proportions of the symptomatology establish the diagnosis.
The management of neurotic and psychotic depressions generally requires the services of a psychiatrist to explore, in the case of the former, the way in which the current episode is linked to the patient’s past and, in the latter, to have recourse to the various somatic therapies.
The management of what might be called the more normal grief reaction devolves upon the members of the rehabilitation team and is a function of their degree of success in nurturing the motivational potential of the patient. This reaction is characterized by what in effect is a period of mourning for the functional loss of the involved limb. The patient reflects a mood of sadness which under these circumstances is genuine, appropriate, and inevitable. The response is proportional to the severity of the enduring physical deficit. Relief comes only when new avenues of functional usefulness and mastery are established.
This is highlighted in the case of the aphasic patient whose sense of self-esteem has been closely linked with intellectual achievement and verbal communication. In one such patient it was possible to tap latent creative talents so that effective self-expression was achieved through painting.
A not infrequent response masking or perhaps preventing an underlying depression is that of negativism, belligerence, irritability, and the general tendency to project blame and responsibility externally. Personnel in attendance are often the chief victims of what in essence is u kind of paranoid barrage arising as a consequence of the patient’s inability to come to grips with the effects of his illness. In the more elderly patient with associated features of cerebral arteriosclerosis this may take the form of an organized paranoid delusional system. The following is an example taken from an interview with a 75-year-old woman with a left hemiparesis:
I can go in the washroom but they won’t let me, these colored girls'. They’re terrible. It’s not the hospital it used to be. They think they can rule the hospital. Oh no, not yet! There’s too much girl-friend and boy-friend business going on. They brought all of Harlem here. The hospital isn’t clean the way it used to be. .
In this instance the stroke, in conjunction with generalized cerebro-arteriosclerosis, lowered the cortical controls touching off earlier sexual conflicts. These in turn were handled through the mechanism of projection resulting in feelings of persecution at the hands of the Negro personnel in the ward.
Certain problems arise in connection with the attitude of stroke patients toward a residual hemiplegia. Babinski in 1918 noted the tendency of a stroke patient to remain unaware of an existing paralysis and to maintain this unawareness despite efforts to call it to his attention. In the intervening time a number of neurologically oriented explanations have been preferred, based on damage to specific underlying neural structures, e.g., parietal lobe with resultant impaired sensory integration (an example is Denny-Brown’s concept that unawareness of a hemiplegic limb is the result of the defective perception of the spatial aspects of all forms of sensation), and damage to structures responsible for the intactness of the body image (e.g., the work of Head and Holmes linking parietal lobe damage to disturbance in the three-dimensional representation in the mind of the “body scheme”).
More recently Weinstein and Kahn in a series of papers and a monograph [Weinstein, Edwin A., M.D., and Kahn, Robert L., Ph.D., “Denial of Illness,” Springfield, 111.: Charles C. Thomas, 1955] developed a radically different point of view. They explained the behavior of the patient in terms of characteristic patterns of defensive operations intrinsically related to the premorbid personality but now becoming manifest under altered states of brain function. Hence the behavior, while expressing characteristic attitudes, does so by means of different symbolic elements because of the factor of cerebral dysfunction.
The patient whose premorbid personality revealed denial patterns in relation to illness would tend to show an anosognosic response. Those who tended to withdraw in relation to stress might react with apathy and mutism. Such phenomena as paraphasia, confabulation, disorientation for time, place, or person, and reduplication were explained on the basis of idiosyncratic motivational needs of the individual patient. The authors felt that in one way or another the behavior expresses the effort to identify with those values which, in terms of the patient’s past experience, represent health and continued relatedness with his own cultural milieu.
This contribution represented a significant step forward in integrating dynamic personality concepts with the neurological point of view concerning the behavior of brain damaged patients.
The final behavioral response, the one of concern to the rehabilitation team, is the resultant of all the factors influencing the patient’s capacity to perform, as well as his motivation to perform. In the presence of local brain dysfunction certain specific sensory and motor effects occur which influence the capacity of the patient to respond appropriately. If the stroke involves diffuse brain dysfunction, we meet with profound difficulties in abstract thought, an occurrence which radically alters the patient’s response capacity.
True anosognosia is associated with the occurrence of a local deficit such as a hemiplegia in conjunction with diffuse brain damage and difficulty in engaging in abstract thought. This difficulty prevents the patient from adequately conceptualizing and realistically integrating the nature of his illness and the residual motor deficit. Motivation, with its roots in the premorbid personality and current life situation, interacts with capacity and the final behavioral response is determined by this interaction. When the impaired capacity dominates the situation an anosognosic response occurs.
With less impairment, motivational patterns emerge more clearly, and these move either in the direction of denial of illness or toward a more normally integrated response.
The role of the psychiatrist will, of course, vary considerably in relation to individual patients as well as the setting in which treatment and rehabilitation is carried out. In a general hospital setting one of the initial tasks is to orient the house staff to the meaning of a stroke to a patient in the fifth decade of life or older.
The age difference between the young physician and the older patient, as well as the former’s more active orientation to more esoteric problems, makes for a certain emotional distance and perfunctoriness in the management of the stroke patient—both of which are not only contraindicated but unnecessary.
When the physician becomes patient-oriented rather than organ pathology-oriented, he becomes sensitive and responsive to the drama that is set into motion by the occurrence of a stroke. The sudden disruptive effect upon the life situation of the patient, the many anxieties relating to death and disability, the occurrence of the illness at a time in life when physical and personal resources may be on the wane, .taxes the adaptive capacities to the extreme and creates the need for new sources of support, reassurance, and guidance.
There are a number of problems occurring during the period of convalescence and rehabilitation as well as following the discharge of the patient that may require the special services of the psychiatrist. These involve the management of depressive reactions, the occasional psychotic episodes following the stroke, and problems of disposition when severe brain syndromes are present. The first two involve the use of psychotherapy and, when indicated, antidepressive medication and tranquilizers. Severe brain syndromes are best managed within an institutional setting.
In most instances the psychiatrist can function as a useful member of the rehabilitation team in orienting the other members to the defensive operations (e.g., denial, withdrawal, projection) of the patient, the specific areas of vulnerability in task performances (e.g., the intellectual residue of brain damage in the form of limited attention span, defective carry-over, and perceptual impairment based on the existence of sensory deficits), the meaning of success and failure in terms of the patient’s motivation (e.g., to what extent is the task meaningful and important to the patient), and the influence of the patient’s total life situation and personality on his behavior in the rehabilitation setting.
The problems arising following discharge involving family, work, and social relationships may also require specific psychotherapeutic intervention.JOURNAL OF REHABILITATION, November-December, 1963, Vol. XXIX, No. 6, pp. 39-40