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This article is reproduced from strokeconnection.strokeassociation.org. Next week will be a follow up of this one. Six potential personality changes will be presented.
Something's Different: Personality Changes After Stroke
BY JON CASWELL
Strokes change many things for those who survive them. Muscles weakened or paralyzed; walking affected; fingers unresponsive; communication challenged; cognition impaired; emotions that run the gamut. It can leave someone with any one of those or all of them or some combination, and it can span a wide spectrum of intensity and rehab-ability. Stroke can also change a survivor’s personality — that ineffable quality made up of all the attributes that define who we are to our family, friends and the outside world. “Personalities are individual patterns of thinking, feeling and behaving,” said clinical neuropsychologist Karen Postal, who teaches at Harvard Medical School and is president of the American Academy of Clinical Neuropsychology. As an example, she posits the glass half full or half empty question: “The glass-half-full person perceives things optimistically; they are positive. Someone who sees the world as a glass half empty tends to look at the negative and be suspicious of motivation. That’s an example of a constant way of perceiving and interacting with the world, which is really what personality is. Mood is something that’s overlaid on that.
“Stroke has an unpredictable impact on the basic constant personality, and that change can be really devastating and difficult for the survivor, but also for their loved ones because personality is really what we connect with,” Postal said. “Personality makes you you. And when something fundamental about that personality changes, it requires loved ones to change fundamentally the way that they act with the survivor. If our relationships are like a dance, when personality changes, when someone fundamentally changes their dance steps, that requires other family members to change their dance steps as well. It can be very disruptive.”
One can think of a stroke as something that destabilizes parts of the brain. Neuropsychologist Andrew Borson of Crozer-Chester Medical Center in Pennsylvania notes that the changes that occur are determined by which parts are affected. “You have some survivors where there was not that much impact on the limbic system, the emotion-related parts of the brain, and for them, there may be relatively lesser change in terms of their emotions and personality,” he said.
Understanding a little more about the makeup of the brain might be helpful here. Borson described the brain as a series of layers: 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 — though they may be modified by the higher levels. And below that are the brain stem and other parts of the brain that control our autonomic processes — breathing, heart rate, temperature, some types of motion.
In addition to the location, Christine Salinas, neuropsychologist and director of Space Coast Neuropsychology Center in Florida, points out that the type of stroke — clot or bleed — the size of the lesion and vascular risk factors such as hypertension and diabetes also determine the severity of cognitive deficits. Age, gender, ethnicity and education also play a role. “Typically, the smaller the infarct or brain damage, the fewer cognitive or behavioral consequences,” Salinas said. “But someone could have a small infarct in a deep part of the brain (i.e., thalamus, hippocampus, white matter, brain stem) that leads to as severe cognitive deficits as a large hemispheric stroke. In addition, a person’s personality and thinking style before a stroke may be exaggerated afterward.”
“Of course, it also matters whether it’s a right- or left-hemispheric stroke,” Borson said. “Overall, I think changes in how someone responds emotionally are pretty common after stroke.” Those changes run the gamut: Some people become irritable and angry, others depressed; some become impulsive or child-like. Some survivors become intensely emotional, while others become much less emotional — almost flat.
“A broad generalization is that right-handed survivors of left-brain stroke, which typically affects language more and causes right-sided weakness or right-sided neglect, those people tend to be more prone to flattening of their emotions, showing less emotional responsivity. I don’t think we really have a great explanation of why that occurs in terms of the brain anatomy,” said Borson.
Neuroscientific understanding of injury location and behavioral consequences is progressing thanks to neuroimaging. “Now we have functional magnetic resonance imaging where we can literally ask someone to experience emotion, and we can, in real time, track what parts of their brain are more active,” Postal said. “Our research methods are becoming more sophisticated, and after decades of research, we have a kind of road map. We know a lot about likely potholes when we have lesions in certain areas, but our map is just a schematic. It can give us a heads up that something might occur, but it does not tell us for sure that something will occur or has occurred.”
In other words, the same injury in the same place on two people may produce different results.