Research report

The effect of aphasia upon personality traits, depression and anxietyamong stroke patients

Ghaydaa A. Shehata a,n, Taha El Mistikawi b, Al Sayed K. Risha b, Huda S. Hassan b

a Department of Neurology and Psychiatry, Assiut University Hospital, Hospital of Neurology and Psychiatry, Floor # 7, Room # 4, P. O. Box 71516,Assiut, Egyptb Department of Psychology, Faculty of Arts, Assiut University, Assiut, Egypt

a r t i c l e i n f o

Article history:Received 6 September 2014Received in revised form9 October 2014Accepted 14 October 2014Available online 22 October 2014

Keywords:DepressionAnxietyPersonality traitsStrokeAphasiaBehavior

a b s t r a c t

Background: Post-stroke patients with aphasia have higher levels of psychological distress. We aimed tofind the relation between post-stroke aphasia and depression, anxiety and personality traits.Methods: One month after stroke, 61 consecutive patients with stroke were included in this study. Thirtypost-stroke patients with aphasia and 31 patients without aphasia. We used the following scales aclinical-friendly: Aphasic test, Eysenck Personality Questionnaire, Hamilton anxiety and Beck DepressionInventory.Results: Depression and anxiety were more prominent among patients with aphasia than stroke withoutaphasia. Psychosis was more prominent among post-stroke patients with aphasia.Limitations: Our results may not exclusively exclude pre-morbid personality traits.Conclusions: Our study highlights the growing need to develop community rehabilitation services in thedeveloping world, which address both physical and psychological morbidity.

& 2014 Elsevier B.V. All rights reserved.

1. Introduction

Aphasia is an acquired disorder of language that affects anindividual's comprehension and expression across the range ofmodes of communication (listening, reading, speaking, writing,gesture, drawing, and calculation) (Maas et al., 2012). Aphasia causesreal functional disability and figures prominently into treatmentdecisions (Cruice et al., 2010). Wide ranging impact on the lives ofthose impaired and their families, affecting employment, and rolesirrespective of how severe the linguistic impairment.

It is well documented that depression is common after stroke(Bergersen et al., 2010). Findings suggest that post-stroke anxietyproblems are common and both more stable and persistent thanpost-stroke depression (Bergersen et al., 2010). However, adultswith aphasia and their relatives report many negative conse-quences of aphasia (Cruice et al., 2010). These changes are difficultin communication, changes in interpersonal relationships, diffi-culty controlling emotions, physical dependency, loss of autonomy,and restricted activities, fewer social contacts, loneliness, changedsocial life, stigmatization, and negative feelings of irritation, stress,annoyance, and anxiety (Le Dorze et al., 1995). Furthermore, they

experience a range of emotional responses, including fear, anxiety,bewilderment, despair, fury, amusement, frustration, isolation,shock, embarrassment, and depression, and as time goes by,resignation or increasing confidence. The prevalence of post-stroke depression with aphasia is difficult to estimate as studieshave inconsistently and irregularly measured and reported depres-sion, about 60% of patients with aphasia have depression 1 yearpost-stroke (Cruice et al., 2010; Kauhanen et al., 1999).

2. Methods

2.1. Sample

This cross-sectional study, 30 stroke patients with aphasiarecruited from Assiut University Hospital, Neurological DepartmentInpatient Unit. Clinical diagnosis of stroke made according to WorldHealth Organization monitoring. Diagnosis confirmed with com-puted tomography or magnetic resonance imaging evidence of anacute infarct, which was part of the standard clinical stroke protocol.For the purposes of this study, all patients meeting the followingcriteria included: inclusion criteria for the study were: 1) Egyptianethnicity; 2) well documented clinical presentation and CT and/orMRI scan of the brain after first acute stroke occurring withinone month. Ischemic or hemorrhagic acute strokes and history oftransient ischemic attacks included; 3) ability to give consent of

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Journal of Affective Disorders

http://dx.doi.org/10.1016/j.jad.2014.10.0270165-0327/& 2014 Elsevier B.V. All rights reserved.

n Corresponding author. Tel.: þ20 88 2297075, þ20 1225605574;fax: þ20 88 2333327.

E-mail address: ghaydaa83@yahoo.com (G.A. Shehata).

Journal of Affective Disorders 172 (2015) 312–314

relative to give proxy consent to take part in the study; and 4) abilityto have informed knowledge of the patients and age 418 years.Patients with an impaired level of consciousness, other acutemedical or neurological illness, or a pre-morbid Axis I psychiatricdiagnosis was also excluded. Thirty one matched stroke patientswithout aphasia considered as controls. They were matched asregard age, sex, educational level, and socioeconomic status.

Written informed consent obtained from all participants ortheir substitute consent givers after discussing a detailed descrip-tion of the study. The study was approved by the research ethicsboards of Assiut university hospitals.

2.2. Clinical data and psychometric measures

Clinical and medical histories assessed through meticulousneurological assessment and patient interviews. Demographicinformation included age, gender, marital status, living situation,employment, and educational history. Concomitant medicationsand time since stroke recorded.

2.3. Measures

2.3.1. Developing a clinical-friendly aphasic testThis scale is a measure of language functioning for persons

with aphasia. It offers a rapid, convenient means of obtaining ascore to find changes in language functioning during the earlypost-onset period (Marshall and Wright, 2007).

2.3.2. Beck depression inventoryA standardized and validated Arabic version (Gharyb, 2000) of

the Beck Depression Inventory used to assess symptoms ofdepression (Steer et al., 1998). Participants responded to 21 four-choice statements, selecting the statement that most accuratelydescribed him/her over the past 2 weeks with emotional, beha-vioral, and vegetative symptoms. Total scores range from 0 to 63;with 0–13 considered as ‘minimal depression’, 14–19 as ‘mild’,20–28 as ‘moderate’, and 29–63 as ‘severe’. Test–retest reliability is0.93, with internal consistency of 0.93 (Beck et al., 1996).

2.3.3. Eysenck personality inventoryParticipants also completed a standardized and validated

Arabic version (Gharyb, 2000) of the Eysenck Personality Inven-tory (Eysenck and Eysenck, 1978), which covers neurosis, psycho-sis, extroversion–introversion, and lying.

2.3.4. Hamilton anxiety scaleThe Hamilton Anxiety Scale consists of 14 types of symptom.

The total score ranges from 0 to 56. A total score of 18 or moremeans anxiety (Hamilton, 1969).

2.3.5. Assessment of motor and functional disabilitiesThe degrees of patients' motor and functional disabilities

assessed using Scandinavian Stroke Scale (SSS) (Lindenstromet al., 1961) and Barthel Index (BI) (Mahoney and Barthel, 1965).Each takes 10 min to administer.

2.4. Procedure

The method-used in this study is quasi-experimental. It isbased on using natural manipulation of independent variables(personality traits, depression and anxiety in normal and patientswith stroke) with no interference on the part of the researchers,subjects in both the clinical and controlling groups subjected tothe same tests. The procedure conducted individually by having aresearcher and a subject sitting facing each others.

2.5. Statistical analysis

Descriptive statistics (mean, SD, and percentages) calculated usingSPSS software package for Windows, Version 16. Results analyzedusing independent-sample T test that did not assume equal var-iances. Pearson correlation coefficient was used to check the impactof stroke disability, depression and anxiety upon personality traits instroke patients. Significance level set at pr0.05.

3. Results

No significant differences detected between stroke patientswith aphasia and stroke patients without aphasia as regard to age,sex, education and handiness as shown in Table 1. Neurosis,extraversion and crime personality traits were much higheramong patients with stroke without aphasia than patients withaphasia. Psychosis was much higher in patients with aphasia thanother group. Depression and anxiety were significant higheramong patients with aphasia stroke patients without aphasia(Table 2). Study on the relation between stroke and aphasia uponpersonality traits is given in Table 3. Correlation between person-ality traits (extraversion) and depression was 0.430n(P¼0.016).

Table 1Demographic data of studied groups.

Stroke patients withoutaphasia N¼30

Stroke patients withaphasia N¼31

Pvalue

SexMales 14(45.2%) 10(33.3%) 0.248Females 17(54.8%) 20 (66.7%)Education� Illiterates� Primary

schools� Prep schools� Secondary

schools� University

26(83.9%) 25(83.3%) 0.7351(3.2%) 0(0.0%)2(6.5%) 1(3.3%)1(3.2%) 2(6.7%)1(3.2%) 2(6.7%)

Handiness� Right� Left

31(100%) 28(93.3%) 0.2380 2(6.7%)

Age (mean7S.D.)

60.32713.68 56.07715.514 0.260

Data are expressed as number (percentage) or means7Standard deviation.

Table 2Personality traits, depression and anxiety among studied groups.

Stroke patients withoutaphasia N¼30

Stroke patients withaphasia N¼31

Pvalue

Personality traits� Neurosis� Extraversion� Psychosis� Lying� Crime

6.7171.88 10.2372.39 0.00017.9772.49 10.7373.02 0.0001

15.5572.29 13.4373.09 0.00410.8471.98 10.5371.89 0.54113.0673.61 17.7373.04 0.0001

Beck DepressionInventory

32.4274.85 14.6079.52 0.0001

Hamilton anxietyscore

35.64710.92 27.9377.75 0.002

Data are expressed as means7standard deviation; p value significant r0.05.Independent-sample T test that did not assume equal variance.

G.A. Shehata et al. / Journal of Affective Disorders 172 (2015) 312–314 313

4. Discussion

Although there have been many researches from high-incomecountries into psychiatric problems following stroke, there havebeen few studies investigating these problems in low and middle-income countries, despite high levels of documented strokerelated morbidity (Howitt et al., 2011). There were two mainfindings from this study. First, depression and anxiety associatedwith patients with aphasia more than stroke patients withoutaphasia; a second, psychotic personality trait was more prominentamong patients with aphasia. In addition, neurosis, extraversionand crime personality traits were more among stroke patientsthan aphasic patients.

Post stroke depression is well reported in many studies,however the presence of aphasia will be more complicated picture.In addition, Aphasia causes real functional disability and moreliability to depression and anxiety. Unfortunately, the author couldnot found in the literature (up to our knowledge) any study toinvestigate the relation between post stroke aphasia and depres-sion, anxiety or personality traits.

However, the association between depression and stroke oraphasia is not the only cause of post stroke depression; there arenumber of reasons that show that depression is implicated. First,depressed patients may be less compliant with treatment and riskfactor (such as control of hypertension). Second, depression linkedwith chronic noradrenergic stimulation which may aggravate car-diac ischemia or serious arrhythmias (Robinson et al., 1986). Third,depressions are associated with hypothalamic-pituitary-adrenaldysfunction and raised plasma cortisol, possibly altering immunefunction and raising vulnerability to infection and malignancy, sothere is liability to more deterioration (Morris et al., 1993).

However, stroke and of course super added aphasia should alsobe considered a negative life event to which patients may respondwith depression, depending on the interaction between person-ality factors and negative physical, psychological, and social con-sequences of stroke (Aben et al., 2002). To decide which factors areindependent predictors of PSD, further studies are needed inwhich personality traits will be taken into account as importantpotential interacts or cofounders.

5. Limitation

A first limitation of our study is that we assessed personalitytraits, depression and anxiety immediately after stroke within onemonth of onset. Because stroke and aphasia are known to potentially

cause personality changes, our results may not exclusively excludepre-morbid personality traits.

6. Conclusion

The results of this study suggest that depression and anxietywere commonly experienced as post stroke. Post stroke aphasialinked to increased depression and anxiety scores. Psychosis wasmore linked to post-stroke aphasia than in stroke patients withoutaphasia. Further longitudinal study will need to find the relation-ships between mood and personality traits. So, the findings in thepresent study suggested that personality traits and post strokedepression with or without aphasia linked and both addressed aspart of the rehabilitative process.

Conflict of interestThe authors declare no conflict of interest.

Role of funding sourceThe authors declare there is no fund source for this research.

AcknowledgmentsThe authors are grateful to the patients and their families for their time and

support. Also, grateful to the anonymous reviewers and editors who provided veryuseful feedback on an earlier draft of the manuscript.

References

Aben, I., Denollet, J., Lousberg, R., Verhey, F., Wojciechowski, F., Honig, A., 2002.Personality and vulnerability to depression in stroke patients: a 1-yearprospective follow-up study. Stroke 33, 2391–2395.

Beck, A.T., Steer, R.A., Brown, G.K. (Eds.), 1996. Manual for the Beck DepressionInventory, 2nd ed. The Psychological Corporation, San Antonio, TX.

Bergersen, H., Froslie, K.F., Stibrant Sunnerhagen, K., Schanke, A.K., 2010. Anxiety,depression, and psychological well-being 2 to 5 years poststroke. J. StrokeCerebrovasc. Dis. 19, 364–369.

Cruice, M., Worrall, L., Hickson, L., 2010. Health-related quality of life in people withaphasia: implications for fluency disorders quality of life research. J. Fluen.Disord. 35, 173–189.

Eysenck, H., Eysenck, S. (Eds.), 1978. Eysenck Personality Questionnaire (Junior andAdult). Hodder & Stroughton Educational, London.

Gharyb, A. (Ed.), 2000. Beck Depression Inventory II (BDI-II): Arabic Examiner'sHandbook. Cairo: Dar El-Anglo, Cairo, p. 2000.

Hamilton, A., 1969. Diagnosis and rating of anxiety. Br. J. Psychiatry 3, 76–79.Howitt, S.C., Jones, M.P., Jusabani, A., Gray, W.K., Aris, E., Mugusi, F., Swai, M.,

Walker, R.W., 2011. A cross-sectional study of quality of life in incident strokesurvivors in rural northern Tanzania. J. Neurol. 258, 1422–1430.

Kauhanen, M., Korpelainen, J.T., Hiltunen, P., Brusin, E., PhLic, M.A., Mononen, H.,Määttä, R., Nieminen, P., Ka, S., Myllylä, V.V., 1999. Poststroke depressioncorrelates with cognitive impairment and neurological deficits. Stroke 30,1875–1880.

Le Dorze, G., Lever, N., Ryalls, J., Brassard, C., 1995. Values of certain prosodicparameters obtain with French-speaking probands without communicationproblems. Folia Phoniatr. Logop. 47, 39–47.

Lindenstrom, E., Boysen, G., Christiansen, L., Hansen, B., Nielsen, P., 1961. Reliabilityof scandinavian neurological stroke scale. Cerebrovasc. Dis. 23, 646–652.

Maas, M.B., Lev, M.H., Ay, H., Singhal, A.B., Greer, D.M., Smith, W.S., Harris, G.J.,Halpern, E.F., Koroshetz, W.J., Furie, K.L., 2012. The prognosis for aphasia instroke. J. Stroke Cerebrovasc. Dis. 21, 350–357.

Mahoney, F., Barthel, D., 1965. Functional evaluation: the Barthel index. Md. StateMed. J. 14, 61–65.

Marshall, R.C., Wright, H.H., 2007. Developing a clinician-friendly aphasia test.Am. J. Speech-Lang. Pathol./Am. Speech-Lang.-Hear. Assoc. 16, 295–315.

Morris, P.L., Robinson, R.G., Samuels, J., 1993. Depression, introversion and mortalityfollowing stroke. Aust. N. Z. J. Psychiatry 27, 443–449.

Robinson, R.G., Bolla-Wilson, K., Kaplan, E., Lipsey, J.R., Price, T.R., 1986. Depressioninfluences intellectual impairment in stroke patients. Br. J. Psychiatry 148,541–547.

Steer, R., Kumar, G., Ranier, W.A.B., 1998. Use of the Beck Depression Inventory IIwith adolescent psychiatric outpatients. J. Psychopathol. Behav. Assess. 20,127–137.

Table 3Correlation between the severity of aphasic stroke and personality traits, depres-sion and anxiety.

Scandinavian stroke scale Barthel stroke scale

Personality traits� Neurosis� Extraversion� Psychosis� Lying� Crime

� �0.068(0.715)� 0.160(0.391)� 0.143(0.443)� 0.129(0.489)� 0.113(0.544)

� �0.023(0.904)� 0.136(0.467)� 0.567(0.001)nn

� 0.031(0.870)� �0.034(0.856)

Beck Depression Inventory 0.324(0.076) 0.062(0.739)Hamilton anxiety score �/0173(0.352) 0.197(0.289)

Pearson correlation coefficient was used.

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