Abstract
Anger is a frequent neuropsychiatric symptom after stroke, which can disrupt treatment and recovery, in particular by affecting adherence behaviour to treatment and health care education. This study aimed to follow-up a cohort of stroke patients 12 months after their stroke to describe the presence of anger, compare levels and profile of acute and post-acute anger and analyse its impact on the adherence to treatment and beliefs about stroke. We followed (13.3 months mean follow-up) 91 stroke patients with a standardized protocol, using State-Trait Anger Expression Inventory-2 (STAXI-2) to assess the frequency and profile of anger and its components and one questionnaire to measure adherence to treatment and health education (meaning on the treatment) (Adh-T). We used as explanatory variables socio-demographic, clinical, stroke type and location information collected during the acute phase. Anger-state was detected in 15 (17%) patients, while anger-trait was present in 7 (8%) patients. The best regression model revealed that trait-anger, stroke location (posterior infarcts), and impact of stroke sequels were independent predictive factors for anger (R 2 = 43%). Patients with higher levels of anger expression had lower adherence rates, independently of the adherence dimension. In the chronic phase after stroke anger was related with posterior lesions, the impact of stroke consequences and anger as a personality trait. The detection and monitoring of anger could eventually prevent the negative impact of anger in care, especially in adherence to rehabilitation and secondary prevention.
Similar content being viewed by others
Abbreviations
- IS:
-
Ischemic stroke
- ICH:
-
Intracerebral haemorrhage
- STAXI-2:
-
State-Trait Anger Expression Inventory-2
- S-Ang:
-
State-anger
- S-Ang/F:
-
Feeling angry
- S-Ang/V:
-
Feel like expressing anger verbally
- S-Ang/P:
-
Feel like expressing anger physically
- T-Ang:
-
Trait-anger
- T-Ang/T:
-
Angry temperament
- T-Ang/R:
-
Angry reaction
- AX-O:
-
Anger expression-out
- AX-I:
-
Anger expression-in
- AC-O:
-
Anger control-out
- AC-I:
-
Anger control-in
- AX:
-
Anger expression
- AC:
-
Anger control
- AX-Index:
-
Anger expression index
- MMSE:
-
Mini-Mental State Examination
- HADS:
-
Hospital Anxiety Depression Scale
- SASC-19:
-
Satisfaction with Stroke-Care Questionnaire
- Adh-T:
-
Meaning on the treatment
- Mean-D:
-
Meaning on the disease
- TACI:
-
Total anterior circulation infarct
- PACI:
-
Partial anterior circulation infarct
- POCI:
-
Posterior circulation infarct
- LACI:
-
Lacunar infarct
- mRS:
-
Modified Rankin Scale
- SPSS:
-
Statistical Package for Social Sciences
- χ2 :
-
Chi-square
- SD:
-
Standard deviation
- Z :
-
Wilcoxon signed ranks test
- OR:
-
Odds ratio
- 95% CI:
-
95% confidence interval
- U :
-
Mann–Whitney test
- ROC curve:
-
Receiver operating characteristic curve
- SD:
-
Standard deviation
References
Bushnell C, Olson D, Zhao X, Pan W (2011) Secondary preventive medication persistence and adherence 1 year after stroke. Neurology 77:1182–1190
Phillips L, Diefenbach M (2015) Stroke and TIA survivors’ cognitive beliefs and affective responses regarding treatment and future stroke risk differentially predict medication adherence and categorised stroke risk. Psychol Health 30:218–232
O’Carroll R, Whittaker J, Hamilton B (2011) Predictors of adherence to secondary preventive medication in stroke patients. Ann Behav Med 41:383–390
Haynes R, Taylor D, Sackett D (1979) Compliance in health care. Johns Hopkins University Press, Baltimore
Meichenbaum D, Turk D (1987) Treatment adherence: terminology, incidence and conceptualization. In: Meichenbaum D, Turk D (eds) Facilitating treatment adherence. Plenum Press, New York, pp 19–39
Luger S, Hohmann C, Niemann D, Kraft P (2015) Adherence to oral anticoagulant therapy in secondary stroke prevention—impact of the novel oral anticoagulants. Patient Prefer Adherence 9:1695
Sauer R, Sauer E, Bobinger T (2015) Adherence to oral anticoagulation in secondary stroke prevention—the first year of direct oral anticoagulants. J Stroke Cerebrovasc Dis 24:78–82
Hohmann C, Neumann-Haefelin T (2013) Adherence to hospital discharge medication in patients with ischemic stroke. Stroke 44:522–524
Gupta A, Deepika S, Taly AB et al (2008) Quality of life and psychological problems in patients undergoing neurological rehabilitation. Ann Indian Acad Neurol 11:225–230
Meroni R, Beghi E, Beghi M, Brambilla G (2013) Psychiatric disorders in patients suffering from an acute cerebrovascular accident or traumatic injury, and their effects on rehabilitation: an observational study. Eur J Phys Rehabil Med 49:31–39
Kim JS, Choi S, Kwon SU, Seo YS (2002) Inability to control anger or aggression after stroke. Neurology 58:1106–1108. doi:10.1212/WNL.58.7.1106
Martin R, Watson D, Wan C (2000) A three factor model of trait anger: dimensions of affect, behavior, and cognition. J Pers 68:869–897
Cox DE, Harrison DW (2008) Models of anger: contributions from psychophysiology, neuropsychology and the cognitive behavioral perspective. Brain Struct Funct 212:371–385. doi:10.1007/s00429-007-0168-7
Santos CO, Caeiro L, Ferro JM et al (2006) Anger, hostility and aggression in the first days of acute stroke. Eur J Neurol 13:351–358
Ramos-Perdigués S, Mané-Santacana A, Pintor-Pérez L (2015) Revisión sistemática de la prevalencia y factores asociados a la ira tras un ictus. Rev Neurol 60:481–489
Kim JS, Choi-Kwon S, Kwon SU et al (2005) Fluoxetine improves the post-stroke quality of life in patients with emotional disturbances: a double-blind placebo-controlled study. J Neurol Sci 238 (suppl):S70
Angelelli P, Paolucci S, Bivona U (2004) Development of neuropsychiatric symptoms in poststroke patients: a cross-sectional study. Acta Psychiatr Scand 110:55–63
Choi-Kwon S, Han SW, Kwon SU et al (2006) Fluoxetine treatment in poststroke depression, emotional incontinence, and anger proneness a double-blind, placebo-controlled study. Stroke 37:156–161. doi:10.1161/01.STR.0000190892.93663.e2
Redfern J, McKevitt C, Dundas R et al (2000) Behavioral risk factor prevalence and lifestyle change after stroke a prospective study. Stroke 31:1877–1881
Chan K-L, Campayo A, Moser DJ et al (2006) Aggressive behavior in patients with stroke: association with psychopathology and results of antidepressant treatment on aggression. Arch Phys Med Rehabil 87:793–798. doi:10.1016/j.apmr.2006.02.016
Chang K, Zhang H, Xia Y, Chen C (2011) Testing the effectiveness of knowledge and behavior therapy in patients of hemiplegic stroke. Top Stroke Rehabil 18:525–535. doi:10.1310/tsr1805-525
Brott T, Adams HP, Olinger CP, Marler JR, Barsan WG, Biller J, Spilker J, Holleran R, Eberle R, Hertzberg V, Rorick M, Moomaw CJWM (1989) Measurements of acute cerebral infarction: a clinical examination scale. Stroke 20:864–870
Jennett B, Teasdale G (1977) Aspects of coma after severe head injury. Lancet 23:878–881
Tatemichi T, Foulkes M, Mohr J, Hewitt J (1990) Dementia in stroke survivors in the Stroke Data Bank cohort. Prevalence, incidence, risk factors, and computed tomographic findings. Stroke 21:858–866
Bamford J, Sandercock P, Dennis M et al (1991) Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 337:1521–1526
Folstein M, Folstein S, McHugh P (1975) “Mini-mental state”: a practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12:189–198
Guerreiro MS, Botelho MA, Leitão O, Castro-Caldas A, Garcia C (1994) Adaptação à população portuguesa da tradução do Mini Mental State Examination (MMSE). Rev Port Neurol 1:9–10
Morgado J, Rocha C, Maruta C (2009) Novos valores normativos do mini-mental state examination. Sinapse 9:10–16
Zigmond A, Snaith R (1983) The hospital anxiety and depression scale. Acta Psychiatr Scand 67:361–370
Pais-Ribeiro J, Silva I, Ferreira T et al (2007) Validation study of a Portuguese version of the Hospital Anxiety and Depression Scale. Psychol Heal Med 12:225–227. doi:10.1080/13548500500524088
Rankin J (1957) Cerebrovascular accidents in particular in patients over the age of 60. Scott Med J 2:200–215
Bamford J, Sandercock P, Warlow C, Slattery J (1989) Interobserver agreement for the assessment of handicap in stroke patients. Stroke 20:828
Spielberger C (1999) Staxi-2: state-trait anger expression inventory-2; professional manual. Psychological Assessment Resources Inc, Lutz
Marques M, Mendes A, De Sousa L (2007) Adaptação para português do inventário da expressão da ira estado-traço (STAXI-2) de Spielberger. Psychologica 46:85–104
Boter H, De Haan RJ, Rinkel GJE (2003) Clinimetric evaluation of a Satisfaction-with-Stroke-Care questionnaire. J Neurol 250:534–541. doi:10.1007/s00415-003-1031-2
Pamplona A (1997) Estudo da adesão ao tratamento com pacientes de 12 especialidades médicas em regime ambulatório. Universidade de Lisboa, Lisboa
Minati L, Jones CL, Gray M et al (2009) Emotional modulation of visual cortex activity: a functional near-infrared spectroscopy study. NeuroReport 20:1344–1350. doi:10.1097/WNR.0b013e328330c751
Herrmann MJ, Huter T, Plichta MM et al (2008) Enhancement of activity of the primary visual cortex during processing of emotional stimuli as measured with event-related functional near-infrared spectroscopy and event-related potentials. Hum Brain Mapp 29:28–35. doi:10.1002/hbm.20368
Lang PJ, Bradley MM, Fitzsimmons JR et al (1998) Emotional arousal and activation of the visual cortex: an fMRI analysis. Psychophysiology 35:199–210. doi:10.1111/1469-8986.3520199
Geday J, Gjedde A, Boldsen AS, Kupers R (2003) Emotional valence modulates activity in the posterior fusiform gyrus and inferior medial prefrontal cortex in social perception. Neuroimage 18:675–684. doi:10.1016/S1053-8119(02)00038-1
LeDoux JE (2000) Emotion circuits in the brain. Annu Rev Neurosci 23:155–184. doi:10.1146/annurev.neuro.23.1.155
Davis M, Whalen PJ (2001) The amygdala: vigilance and emotion. Mol Psychiatry 6:13–34. doi:10.1038/sj.mp.4000812
Murphy FC, Ninmo-Smith I, Lawrence AD (2003) Functional neuroanatomy of emotions: a meta-analysis. Cogn Affect Behav Neurosci 3:207–233. doi:10.3758/CABN.3.3.207
Toscano M, Viganò A, Puledda F, Verzina A, Rocco A, Lenzi GL, Di Piero V (2014) Serotonergic correlation with anger and aggressive behavior in acute stroke patients: an intensity dependence of auditory evoked potentials (IDAP) study. Eur Neurol 72:186–192
Mostofsky E, Penner EA, Mittleman MA (2014) Outbursts of anger as a trigger of acute cardiovascular events: a systematic review and meta-analysis. Eur Heart J 35:1404–1410. doi:10.1093/eurheartj/ehu033
Sharma A, Prasad K, Padma MV (2015) Prevalence of triggering factors in acute stroke: Hospital-based observational cross-sectional study. J Stroke Cerebrovasc Dis 24:337–347
Everson-Rose SA, Roetker NS, Lutsey PL et al (2014) Chronic stress, depressive symptoms, anger, hostility, and risk of stroke and transient ischemic attack in the multi-ethnic study of atherosclerosis. Stroke 45:2318–2323. doi:10.1161/STROKEAHA.114.004815
Everson S, Kaplan G, Goldberg DE et al (1999) Anger expression and incident stroke: prospective evidence from the Kuopio ischemic heart disease study. Stroke 30:523–528. doi:10.1161/01.STR.30.3.523
Williams J, Nieto F, Sanford C et al (2002) The association between trait anger and incident stroke risk the atherosclerosis risk in communities (ARIC) study. Stroke 33:13–20
Castellanos-Pinedo F, Hernandez-Perez JM, Zurdo M et al (2011) Influence of premorbid psychopathology and lesion location on affective and behavioral disorders after ischemic stroke. J Neuropsychiatr 23:340–347. doi:10.1176/appi.neuropsych.23.3.340
Choi-Kwon S, Choi J, Kwon SU et al (2008) Fluoxetine improves the quality of life in patients with poststroke emotional disturbances. Cerebrovasc Dis 26:266–271. doi:10.1159/000147454
Iosifescu DV, Renshaw PF, Dougherty DD et al (2007) Major depressive disorder with anger attacks and subcortical MRI white matter hyperintensities. J Nerv Ment Dis 195:175–178. doi:10.1097/01.nmd.0000253820.69362.87
Greenop KR, Almeida OP, Hankey GJ et al (2009) Premorbid personality traits are associated with post-stroke behavioral and psychological symptoms: a three-month follow-up study in Perth, Western Australia. Int Psychogeriatr 21:1063–1071. doi:10.1017/S1041610209990457
Rush BK, McNeil RB, Gamble DM, Luke SH, Richie AN, Albers CS, Brown RD, Brott TG, Meschia JF (2010) Behavioral symptoms in long-term survivors of ischemic stroke. J Stroke Cerebrovasc Dis 19(4):326–332
Mok VCT, Wong A, Wong K et al (2010) Executive dysfunction and left frontal white matter hyperintensities are correlated with neuropsychiatric symptoms in stroke patients with confluent white matter hyperintensities. Dement Geriatr Cogn Disord 30:254–260. doi:10.1159/000318744
Buijck B, Zuidema S, Eijk M (2012) Neuropsychiatric symptoms in geriatric patients admitted to skilled nursing facilities in nursing homes for rehabilitation after stroke: a longitudinal multicenter study. Int J Geriatr Psychiatry 27:734–741
van Almenkerk S, Depla M, Smalbrugge M (2012) Institutionalized stroke patients: status of functioning of an under researched population. J Am Med Direct Assoc 13:634–639
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Sources of funding
Funding for Fundação para a Ciência a Tecnologia (FCT) PhD Programmes between July 2009 and July 2013—SFRH/BD/44792/2008.
Conflicts of interest
The authors declare that they have no conflict of interest.
Ethical standards
The study was approved by the Ethical Committee of the University Hospital (Faculdade de Medicina, Hospital de Santa Maria).
Informed consent
Patients gave their informed consent.
Rights and permissions
About this article
Cite this article
Santos, A.C., Ferro, J.M. The impact of anger in adherence to treatment and beliefs about disease 1 year after stroke. J Neurol 264, 1929–1938 (2017). https://doi.org/10.1007/s00415-017-8577-x
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00415-017-8577-x