Emotional changes after stroke

Stroke can have all sorts of different effects. Many are physical - that you can see and recognise easily - but there can also be hidden effects, like emotional changes1. Although we cannot see feelings or thoughts, changing emotions often lead to a change in behaviour which may signify that all is not well 2. his factsheet e!plains some of the emotional changes that can arise after stroke, tips for coping and the help that is available.

Why have my emotions been affected?

"f your emotions or behaviour have changed since your stroke, or you feel different, this may be partly caused by physical damage to your brain. #ifferent parts of the brain control different functions within the body $ including how we feel. "f the part of your brain that normally controls your emotions becomes damaged by a stroke, the result can be a change in how you think, feel or behave%. No two strokes are ever the same because the part of the brain affected and the e!tent of the damage& differs from person to person. So, you may e!perience very different symptoms to someone else who has also had a stroke. As well as the physical damage caused by the stroke, it is normal to e!perience a change in your emotions after any difficult or traumatic life experience. Stroke

happens without any warning. "t takes time to come to terms with the changes that a stroke can bring to your day to day life. #on't be surprised if you feel anxious, depressed, frustrated, angry or bewildered5. All of these feelings are common.

What emotional changes can happen after stroke?

Appro!imately one third of stroke survivors report e!periencing some emotional problems after their stroke(. )sually they will fade away with time and you will begin to feel more like your old self. Some of the emotional changes that arise may be more persistent than others and you may need coping mechanisms to help you deal with them. Some of these are listed in this factsheet. *ne of the most common changes in emotion after a stroke is depression+. ,ou can read about 1

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this separately in our factsheet F10 Depression after stroke. *ther changes that you may be e!periencing are0 anxiety emotionalism23having difficulty controlling your emotions4 personality changes1. anger11.
1

1. having another stroke or "A, particularly whilst out in public or whilst asleep 2. being unable to communicate in an emergency, for e!ample, to call an ambulance %. being unable to drive or return to work &. taking medication $ worrying about any side effects and whether it is helping 7. falling (. feeling embarrassed in social situations +. understanding how to get help from the 8/S and social services 1. waiting for test results and follow-up appointments 2. never feeling any better

Anxiety
Anxiety is both a physical and psychological response to a frightening situation. "f you are an!ious you will probably have feelings of fear or unease. At the same time, there is an increase in blood flow to the heart and muscles, preparing us for action. his can be accompanied by sweating, rapid heart rate, shortness of breath, di55iness and tremor. An!iety can very suddenly arise, or may develop slowly over a long period of time.12 "t is natural to e!perience anxiety during stressful situations, for e!ample, when attending a 6ob interview or speaking in public1%. After a stroke you might e!perience fears or worries connected to your health or other aspects of your life. his is very common. Some of the most commonly reported worries are listed below0

1.. feeling family members have an increased risk of stroke. hese fears may be heightened if you live alone. ome anxiety is to be e!pected and is normal and healthy1&. "t often reduces in time. /owever, if an!iety persists for a long time 2

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and begins to feel overwhelming, then you may have developed an anxiety disorder that you need to get some help with. /ere are some signs to look out for0 ,ou feel irritable, have difficulty concentrating or get tired very easily. ,ou are avoiding things you would normally do $ like going out to see friends, or going shopping. ,ou are having trouble sleeping because you are worrying so much. ,ou are spending a lot of your waking hours thinking about things which worry you. ,ou have a persistent feeling of dread with physical sensations like a racing heart or restlessness17.

local groups or help you e!plore our online services. See page 1. for our contact details. here are also many other useful organisations listed at the back of this factsheet that you can contact, or your doctor, family or carers may be able to help support you 1+. Another way to reduce an!iety is to find ways to relax your mind and body. his can be difficult to do initially, but becomes easier with practise. ry to find time to rela! every day for two weeks and see if you can feel the benefits. here are lots of different ways to relax, like soaking in a hot bath, listening to calming music, meditating, deepbreathing e!ercises or even going for a walk11. Some people find that writing down their worries on a piece of paper helps them to feel better12. ry to find something that works for you and build it into your daily routine. What treatments are available? "f you are in hospital you will have an informal check for anxiety#$. his will involve a brief chat by a member of staff and they will ask whether you have any concerns. "f you have family members visiting, they may also be asked if they have noticed anything that needs to be addressed. Any issues that arise should be discussed with 3

!ow can " help myself? A good start to reducing feelings of an!iety is to seek out information. 9eing informed takes away the fear that arises from uncertainty1( and gives you some control over your situation. We can offer you support and information by telephone or email. :e can tailor an information pack to your needs, check for support services in your area, put you in touch with

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

you and you should be given information21. "f an!iety is affecting your recovery or distressing you, you will need a more thorough assessment with a trained member of staff to find out if you have developed an anxiety disorder. ,ou may then be referred to a specialist, such as a psychologist, who will aim to help you overcome this22. )sually the symptoms of an!iety settle down over time, but, if this does not happen, or if you have not been seen in hospital, you should see your %&. ,our ;< will help you access the right therapy, depending on your needs. *ne type of therapy commonly offered is 'ognitive (ehavioural )herapy 3'()42%. his therapy aims to help you change the way you think, feel and behave, so that you can be more positive in your thoughts and actions2&,27. "f you are e!periencing severe or prolonged anxiety and the psychological treatments have not helped, you might be offered one of the following medicines0 medicines that treat anxiety directly include dia5epam=lora5epam#*, alpra5olam and o!a5epam2+which are all from a

group of medicines called ben5odia5epines buspirone, another type of medicine for an!iety21 antihistamines such as hydro!y5ine.

he medicines listed above are used to treat an!iety on a short term basis. >onger term medicines for an!iety include some antidepressant medicines such as sertraline, paro!etine22 and venlafa!ine. "f these are not suitable for you, pregabalin is an alternative medicine. "t is used to treat epilepsy, but can be helpful for an!iety.

Emotionalism
Emotionalism can arise with many neurological conditions 3those affecting the brain and nervous system4 and often happens after a stroke%.,%1,32. "t is a term you may hear if, since your stroke, you have become more emotional than usual and=or have difficulty controlling your emotions%%. 3*ther terms for this condition include emotional lability, pathological laughing=crying and pseudo-bulbar affect.%&4 ,ou will probably find you suddenly have very intense emotional reactions when talking to people, 4

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

watching television, carrying out tasks, or even thinking. Although these emotions may reflect how you are feeling, you will probably e!press them in a particularly strong way.35 "t might be that your emotions are very close to the surface, with the smallest thing setting you off%(. ?or e!ample, you might get upset more easily, or cry at things you would never have cried at before%+. ,ou might also have outbursts of crying for little or no reason. Similarly, you may laugh at inappropriate times 3although this is less common4. ,ou may even swing from crying to laughing @uite suddenly%1 . hese reactions usually do not mirror your actual emotions%2. hey often seem out of place and can come and go very @uickly, unlike when you feel genuinely upset or happy&.,&1. here are usually triggers that will cause this type of response0 someone being kind to you, asking how you are, or talking about something which always makes you feel emotional normally&2. "t can all be very distressing, especially if you have never been an emotional person before. "t can also be particularly difficult if you are a man because society often e!pects men not to display their emotions&%.

Such a loss of control is upsetting for a great many people, but you are not alone and knowing this can be reassuring. here will be other people who have had similar e!periences who you could talk to. Aontact us to find out how to meet other stroke survivors.

!ow can " help myself? 'oping with emotionalism can have added complications $ it can be distressing for everyone concerned&&. "f you feel embarrassed by your emotions, &7 try talking openly about your e!perience. he more you talk to others, the more people will understand that the e!aggerated 3and often uncontrollable4&( emotional reactions are a part of your stroke and not necessarily a cause for concern&+. )ell people how you would like to be treated if you become emotional. Bveryone is different but some of the following tips may help you0 C 9eing told not to cry will not help to stop your tears and might lead to further frustration. C here's no need for others to feel embarrassed or to avoid talking about topics that might cause you 5

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

to cry. "n fact, this may even delay your recovery&1. C "f you don't want to get emotional, for e!ample, if you are out socially, ask someone to distract you. hey can do this simply by changing the sub6ect of conversation&2. C "f you find it harder to control your emotions when other people are emotional $ tell them. <eople do not have to change their behaviour but at least it will not be a surprise if you cry more than usual, or choose to leave the room. C #on't let people ignore you, or leave the room, unless that is what you want7.. C Bncourage people to treat your emotionalism as a minor inconvenience and continue the conversation as if it will go away. "t usually does.71 C )ouch can be helpful $ on the arm or hand or even a hug if it is appropriate. his can make you feel more emotional but you might prefer this. "t's okay to cry, and it might make you feel better. C ell people if you are genuinely upset so it isn't mistaken for emotionalism. ,ou will still need empathy and understanding from time to time.

What treatments are available? Bmotionalism is usually worse soon after the stroke happens, and often lessens or goes away as you recover72. "f this doesn't happen, your ;< may be able to help. Some medicines that are used to treat depression can also help with the control of emotions even if you are not depressed7%. *ne such anti-depressant that you might be offered is called fluoxetine 3<ro5ac47&. As with all medicines, there may be unwanted side effects77. "f these are troubling you, let your doctor know. here are a number of anti-depressants available. ,ou could also ask your ;< about psychological services7(. Sometimes talking to someone can be very therapeutic and can help you understand what you are going through. hese services are also a good option if you have a mixture of emotionalism and depression7+.

&ersonality changes
&ersonality is a difficult concept to e!plain. ?or simplicity, we could describe it as a combination of behaviours, thought patterns and feelings71. <eople who know you well may sometimes finish your sentence or predict how you will respond to something because you 6

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

will normally be @uite consistent. A stroke can cause changes to your personality72so that to others you may seem like a different person altogether. Sometimes your character traits can be reversed, for e!ample - if you were previously mildmannered, you may now be more aggressive. *r, if you have always been loud and outspoken, you may now be more passive. More often, however, existing personality traits are exaggerated(.. ,ou might be unaware that your personality is different and deny that you have changed. /owever, your family and friends might be more aware of how you are different(1. here are many ways your personality can change. Some of the most commonly reported changes are listed below0 1. becoming impatient and irritable(2 2. becoming withdrawn and introspective 3focussed inwards4(% %. showing a loss of inhibitions, for e!ample making inappropriate comments or swearing

&. becoming aggressive(&, either verbally or physically 7. showing a loss of interest in aspects of your life you once en6oyed(7 (. becoming impulsive - making sudden, sometimes rash decisions(( +. showing more stress and anger.

!ow can " help myself? Bven if you don't feel as though you have changed in any way, try to take on board other people+s comments. "f everyone is telling you that they are surprised by your behaviour and that you've never acted in that way before, perhaps they are right. 8ot all behaviours are problematic, but if you have changed, others around you may need a little time to ad,ust to the new you(+. "f you have become less inhibited, other people may find your comments or behaviour upsetting and difficult to put up with. ry to understand how they are feeling. <ause before you speak or act and @uestion whether or not they will view it as appropriate. 7

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

Seek out information and support. *ur information- advice and support ervices can offer support to the whole family. hese services are currently available in some parts of Bngland, :ales and 8orthern "reland. 'ontact us to see if we have a service near you. here are also organisations listed at the end of this factsheet that can help. What treatments are available? "f you are concerned by changes to your personality, your %& can help by referring you to a psychological service, such as a specialist Neuropsychology service for an assessment.(1

stimulate the heart, lungs, blood vessels and nervous system+1. Anger is a normal, healthy emotion that we all feel and show from time to time, particularly during stressful situations+2, like trying to do lots of things in a short space of time, or getting soaked by a passing car in the rain. After a stroke you might find you e!perience anger much more fre.uently, have less control over your outbursts and=or get angry over things that would not normally cause you to feel that way+%. ,ou are likely to direct this anger at your family and carers+&. ypical triggers for angry outbursts are0 struggling to do something, like get dressed, which has become more difficult since your stroke, for e!ample, because your arm is weak or paralysed other people doing things for you all the time not having enough time to respond during conversations not being able to express yourselfD your wants and needs

Anger
As with an!iety, anger is both a physical and psychological response. "t usually occurs when we feel intense displeasure, offense or exasperation. "t is another part of our survival strategy $ the part that comes into play when we prepare to fight. #esigned to improve our performance $ it may kick in if we are provoked or attacked(2. "t is normal for feelings of anger to be accompanied by a surge of energy going through the body+.. his is because chemicals 3like adrenaline4 are released which

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

other people making choices and decisions for you getting things wrong feeling embarrassed not being able to do something you en,oy because of a disability, for e!ample, watching your favourite programme on .E if your stroke has caused visual problems being tired feeling overwhelmed, either by too many people, or too many distractions going on around you making concentration difficult+7

normal part of the recovery process $ a sign that you are aware of the changes the stroke has caused to your everyday life++. "f you want to regain control over your angry outbursts, try doing something physical to let off steam, like 6ogging or dancing+1. "f you aren't able to do these things, try pounding a pillow. Another techni@ue is to look at yourself in the mirror when you feel angry $ the image looking back at you may surprise you, provoking laughter or tears instead$ this is fine+2. A release of the tension that has built up is good for you1.. "t is easy to be yourself with the people nearest and dearest to you $ after all, they know and love you and will most likely forgive you if you have a bad day. "f you have become more aggressive since your stroke, try to be aware of how your behaviour is affecting others. ?or e!ample, are members of your family crying, shouting or leaving the room because they feel frightenedF What treatments are available? )sually, your anger will become less severe over time as your stroke recovery continues11. he more you can do and the more you regain control, the less frustrated you will feel. "f this is not happening, or you have concerns 9

Although some anger is normal, it can have a negative effect on health. "t can, for e!ample0 cause digestive problems increase blood pressure lower your immune system lead to depression lead to addictive behaviour 3such as smoking4+(.

"f you have concerns about how angry you feel $ speak to your %&. !ow can " help myself? #on't be too hard on yourself. ,ou're bound to feel some anger and frustration after a stroke. "t's a

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

that you are behaving aggressively, speak to your %& about psychological services.

"+m a carer / what about me?

:hen people e!perience personality changes or become angry following an illness, their anger is often directed at family and=or those caring for them12. "f you are a carer, you may from time to time be on the receiving end of angry outbursts that frighten or upset you, especially if they feel like a personal attack. ,ou may feel strongly that the behaviour is unfair if you have been spending a lot of time taking care of someone you love1%. Bmotions can escalate all round when people are tired and fed up. Sometimes, anger and aggression can be avoided. ry to give the person you are caring for as much choice as possible, even down to small things $ like which socks they want to wear $ after all, these are normal choices they would have made for themselves prior to the stroke. 9e patientD allow plenty of time for them to carry out tasks and to respond to you. <ay attentionD don't ask them to do something you know they will not be able to do as failure is likely to cause anger1&.

<eople are more likely to become frustrated and angry if they cannot think as clearly or as @uickly as they did before their stroke. 0educing distractions when doing a particular task can help someone to focus and concentrate on what they are doing. 17 "t is important not to get drawn into an angry or aggressive encounter as it is unlikely to help anyone in the situation1(. "t is also important to look after your own health and safety. -ust because someone has had a stroke does not give them the right to hurt or abuse you in any way. here are coping techni.ues for dealing with aggressive behaviour that may help you. hese include0 explaining that the behaviour is not acceptable asking friends and family to support you by giving the same message being firm but polite using the word 1"+ instead of 1you+, for e!ample, G" feel really upset when we argue', instead of Gyou really upset me'. explaining that you are frightened or upset 10

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

walking away reward or be positive about appropriate behaviour 2 this can reinforce the likelihood of it happening again.1+

control of life by working out and trying to find solutions to problems21. ,our ;< will be able to help you access the appropriate service $ but there may be a waiting list. here are a range of specialists available, depending on the resources in your local area. hey may include0 1. ocial worker $ offers short term counselling whilst in hospital22. Aan specialise in mental health.

,ou may need to repeat yourself many times before someone begins to understand the impact that their behaviour is having on others. "f you're finding this difficult you can seek support by speaking to your ;< or contacting us11.

&sychological services explained

<sychological services aim to encourage you to talk about your thoughts and feelings and help you come to terms with what has happened.12 Accepting how life has changed is an important step in the recovery process. :ith the guidance of a trained professional you will have the opportunity to look at how the stroke has affected your life and discover ways of moving forward2.. hese sorts of services can be especially helpful if you have a range of problems. hey allow you the space and time to talk things through at your own pace so you can gain a clearer picture of what lies ahead. )sually this process helps you feel more in

2. N! counsellor or psychotherapist $ uses a talking therapy to help you identify problems and find solutions. *ften based within the ;< practice2%. Aounsellors cannot prescribe medicine. 3. 3ccupational therapist $ helps you with practical tasks and to adapt to your environment. )sually helps with specific concerns and draws on a range of other services2&. &. 4ental health team $ provides help in the community during difficult periods. May involve home visits and include the support of a community psychiatric nurse 3A<84.27

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

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7. 'linical psychologist $ may work as part of a community mental health team or in hospital. Aan undertake a thorough assessment of mental health needs and provide individual or group therapy. Aannot prescribe medicine2(,2+. (. 'linical neuropsychologist $ has specialist knowledge of the brain and behaviour. Aan provide an assessment of cognitive and emotional functioning.21 +. 'onsultant psychiatrist $ usually works as part of the community mental health team. /as overall responsibility for the patients. Aan provide therapy and prescribe medicine22. herapy is also available privately 3the cost varies between therapists but can be @uite e!pensive4. here may also be local organisations which offer counselling, sometimes at a reduced cost, so it is worth checking in your telephone directory, online or at your library for more local contacts. Many people benefit from talking through their difficulties, but if your stroke has left you with problems communicating or understanding others, this may not be so easy. ,ou will probably re@uire the specialist skills of a speech and

language therapist1..to enable you to communicate as effectively as possible with others1.1. here are many ways to communicate, including writing, drawing, using pictures, gestures and communication aids1.2. "t may be possible for a speech and language therapist to accompany you to your appointment 3although not all counsellors will agree to this4. "f you think this would be helpful $ why not askF Alternatively, there is an organisation called '3NNE') that you can contact 3see Useful organisations section4. hey aim to find you the right tools to make communication possible. hey also offer a counselling service to people with communication problems, although this service is currently limited to people living in >ondon1.%. ?or more detailed information about communication problems, see our factsheet F3 Communication problems after stroke. 5ooking after yourself "t is important that you are helped to find some way to make your future life as meaningful and fulfilled as possible. Heeping up your morale is a crucial aspect of your psychological well-being1.&. hose around you can contribute greatly to this. hey should ensure that they understand the reasons 12

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

for any changes in your behaviour or emotions after a stroke, so they can make sense of what has happened and help as much as possible1.7. here are also many things you can do yourself to improve your psychological well2 being. See factsheet F10 Depression after stroke for more ideas.

6seful organisations
All organisations are )H-wide unless otherwise stated. )he troke Association /elpline0 .%.% %.%% 1.. :ebsite0 www.stroke.org.uk Bmail0 infoIstroke.org.uk Aontact us for information about stroke, emotional support and details of local services and support groups. Anxiety 67 Jion Aommunity Kesource Aentre, %%2 Stretford Koad, /ulme, Manchester M17 &J, el0 .1&&& ++7 ++& :ebsite0 www.an!ietyuk.org.uk A national charity for people suffering from an!iety disorders. <rovides information, support and has a range of services including therapy. (ritish Association for 'ounselling and &sychotherapy 8(A'&9

9AA< /ouse, 17 St -ohn's 9usiness <ark, >utterworth >B1+ &/9 el0 .1&77 11% %.. :ebsite0 www.bacp.co.uk <ublish the Aounselling L <sychotherapy Kesources #irectory. his lists organisations, counsellors and psychotherapists in the )H. Some counsellors operate a sliding scale of charges according to income. (ritish &sychological ociety 8(& 9 St Andrews /ouse, &1 <rincess Koad Bast, >eicester >B1 +#K el0 .11( 27& 27(1 Bmail0 en@uiriesIbps.org.uk :ebsite0 www.bps.org.uk /olds lists of counselling psychologists and clinical neuropsychologists. 'arers 67 2. ;reat #over Street, >ondon, SB1 &>M Aarersline0 .1.1 1.1 ++++ 3open :ed L hur 1.$12pm L 2$ &pm4 Bmail0 advicelineIcarersuk.org :ebsite0 www.carersuk.org <rovides information and support to carers. '3NNE') 1($11 Marshalsea Koad. >ondon SB1 1/> el0 .2. +%(+ .1&. Bmail0 infoIukconnect.org 13

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

:ebsite0 www.ukconnect.org /as counsellors with personal e!perience of aphasia who are trained to help counsel people with communication problems. 'ounselling :irectory www.counselling-directory.org.uk :ebsite listing recognised and @ualified counsellors and psychotherapists with a postcode search facility. :ifferent trokes 2 Aanon /arnett Aourt, :olverton Mill, Milton Heynes MH12 78? el0 .1&7 1%. +1+2 Bmail0 infoIdifferentstrokes.co.uk :ebsite0 www.differentstrokes.co.uk A charity for younger people affected by stroke. %ofal 'ymru 2( #unraven <lace, 9ridgend A?%1 1-# el0 .1(7( (&++22 email0 en@uiriesIgofal.org.uk :ebsite0 www.gofal.org.uk A range of support services for people with mental health problems in :ales. 4ankind "nitiative ?look /ouse, 9elvedere Koad, aunton, Somerset, A1 19 el0 .112% %%&2&& :ebsite0 www.mankind.org.uk Support for males e!periencing domestic abuse or violence.

4"N: Mindinfoline, <* 9o! 2++, Manchester M(. %M8 el0 .1&7 +(( .1(% Bmail0 infoImind.org.uk :ebsite0 www.mind.org.uk Mind is a national mental health charity offering a range of publications and information on local services and support groups. Niamh Wellbeing 8Northern "reland Association for 4ental !ealth9 1. )niversity Street, 9elfast, 9 + 1/B el0 .21 2.%2 1&+& :ebsite0 www.niamhwellbeing.org A network of support services throughout 8orthern "reland supporting mental well being. upport in 4ind 8 cotland9 ( 8ewington 9usiness Aentre, #alkeith Koad Mews, Bdinburgh, B/1( 7;A el0 .1%1 ((2 &%72 Bmail0 infoIsupportinmindscotland.org.uk :ebsite0 www.supportinmindscotland.org.uk Supports people with mental health problems in Scotland, offers information, support and a drop in resource centre. 0E5A)E <remier /ouse, Aarolina Aourt, >akeside, #oncaster, #8& 7KA el0 .%.. 1.. 12%& :ebsite0 www.relate.org.uk 14

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

0elationships cotland 11 ,ork <lace, Bdinburgh, B/1 %B< el0 .1&7 112 2.2. :ebsite0 www.relationshipsscotland.org.uk /ave local branches and provide counselling for couples and individuals with relationship problems. 67 'ouncil for &sychotherapy 867'&9 2nd ?loor, Bdward /ouse, 2 :akley Street, >ondon, BA1E +> el0 .2. +.1&2277 Bmail0 infoIukcp.org.uk :ebsite0 www.ukcp.org.uk /olds national register of psychotherapists and psychotherapeutic counsellorsD

details what these therapies involve and how to find a therapist. Womens Aid /ead *ffice, <* 9o! %21, 9ristol 9S22 +:S el0 .1.1 2... 2&+ - 2& /our Bmail0 helplineIwomensaid.org.uk :ebsite0 www.womensaid.org.uk "nformation and support for women e!periencing domestic abuse or friends=relatives=professionals seeking information on their behalf. :isclaimer0 he Stroke Association provides the details of other organisations for information only. "nclusion in this factsheet does not constitute a recommendation or endorsement.

?or further information, phone the Stroke /elpline on .%.% %.%% 1.., email infoIstroke.org.uk or visit our website www.stroke.org.uk <roduced by he Stroke Association's "nformation Service. ?or sources used, visit www.stroke.org.uk ?actsheet 2( version .1 published -une 2.11 3ne!t revision due #ecember 2.1%4. N he Stroke Association 2.11. he Stroke Association is registered as a Aharity in Bngland and :ales 38o 211.174 and in Scotland 3SA.%++124. Also registered in "sle of Man 38o 2&74 -ersey 38<* %(24 and in 8orthern "reland.

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

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0eferences

he Stroke Association -une 2.11 Stroke /elpline .%.% %. %% 1.. website www.stroke.org.uk

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Stein,- et al. 32..24. Stroke recovery and rehabilitation. #emos Medical <ublishing, )nited States of America. <&7%. 2 ;odefroy, * and 9ogousslavsky, -. 32..+4. The behavioural and cognitive neurology of stroke Aambridge university press, Aambridge. <2(. 3 Kudd, A., "rwin, <. and <enhale, 9. 32..74. Stroke at your fingertips 2nd Bdn. Alass <ublishingD >ondon. <(. 4 8/S Ahoices website. Symptoms and signs of stroke http0==www.nhs.uk=Aonditions=Stroke=<ages=Symptoms.asp! 3updated 17th *ct 2.1., accessed %.th 8ov 2.1.4. 5 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <+2, 1&, 17, 1&2 L 172. 6 McHevitt, A. et al. #ec 2.1.. U" Stroke survivor needs survey. he Stroke Association, >ondon. <2. 7 8/S Ahoices website. Stroke recovery. http0==www.nhs.uk=Aonditions=Stroke=<ages=recovery.asp! 3updated 17th *ct 2.1., accessed %.th 8ov 2.1.4. 8 Stein,- et al. 32..24. Stroke recovery and rehabilitation. #emos Medical <ublishing, )nited States of America. <&(%. 9 "bid 10 ;odefroy, * and 9ogousslavsky, -. 32..+4. The behavioural and cognitive neurology of stroke Aambridge university press, Aambridge. <722. 11 ;odefroy, * and 9ogousslavsky, -. 32..+4. The behavioural and cognitive neurology of stroke Aambridge university press, Aambridge. <721. 12 "bid 13 "bid 14 8/S Ahoices website. !n#iety http0==www.nhs.uk=Aonditions=An!iety=<ages="ntroduction.asp! 3updated 1st Apr 2.1., accessed 1(th #ec 2.1.4. 15 9eers, M. et al. 32..%4 The $erck $anual of $edical %nformation 2nd edn. <ocket 9ooks0 8ew ,ork. <(.(. 16 Sassoon, K. 32..24. Understanding stroke. <ardoe 9lacker <ublishing, Susse!. <2% 17 Kutherford, #. 32..(4. Strokes. 8et #octor. /odder L StoughtonD >ondon. <11%. 18 99A website. &ealth' ! guide to rela#ation techni(ues to help prevent stress and an#iety http0==www.bbc.co.uk=health=emotionalOhealth=mentalOhealth=copingOrela!ation.shtml 3updated #ec 2..1, accessed &th -an 2.114. 19 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <12. 20 Koyal Aollege of <hysicians and the Alinical Bffectiveness L Bvaluation )nit. 32..14 )ational Clinical *uidelines for Stroke. %rd Bdn. >avenham <ress >tdD Suffolk. <1(. 21 Koyal Aollege of <hysicians and the Alinical Bffectiveness L Bvaluation )nit. 32..14 )ational Clinical *uidelines for Stroke. %rd Bdn. >avenham <ress >tdD Suffolk. <1(. 22 Scottish "ntercollegiate ;uidelines 8etwork 3S";84. 32..14. $anagement of patients +ith stroke or T%!' 'assessment, investigation, immediate management and secondary prevention ! national clinical guideline. <&%. 23 8/S Ahoices website. !n#iety - treatment. http0==www.nhs.uk=Aonditions=An!iety=<ages= reatment.asp! 3updated 1st Apr 2.1., accessed 7th -an 2.114. 24 8/S Ahoices website. Stroke. recovery. http0==www.nhs.uk=Aonditions=Stroke=<ages=recovery.asp! 3updated 17th *ct 2.1., accessed &th -an 2.114.

he Koyal Aollege of <sychiatrists website. Cognitive behavioural therapy /C0T1 http0==www.rcpsych.ac.uk=mentalhealthinfoforall=treatments=cbt.asp! 3updated 8ov 2.1., accessed 27th -an 2.114. 26 he 9ritish Medical Association. Si!th Bdn. 3Keprinted 2..&4. )e+ *uide to $edicines 2 Drugs #orling Hindersley >imitedD >ondon. <2(2. 27 he 9ritish Medical Association. Si!th Bdn. 3Keprinted 2..&4. )e+ *uide to $edicines 2 Drugs #orling Hindersley >imitedD >ondon. <1%. 28 8/S Ahoices website. !n#iety - treatment http0==www.nhs.uk=Aonditions=An!iety=<ages= reatment.asp! 3updated 1st Apr 2.1., accessed 7th -an 2.114. 29 he 9ritish Medical Association. Si!th Bdn. 3Keprinted 2..&4. )e+ *uide to $edicines 2 Drugs #orling Hindersley >imitedD >ondon. <%1.. 30 8/S Ahoices website. $otor neurone disease - symptoms . http0==www.nhs.uk=Aonditions=Motor-neurone-disease=<ages=Symptoms.asp! 3updated 1&th May 2..2, accessed %.th 8ov 2.1.4. 31 <atient )H website. 3ascular dementia. http0==www.patient.co.uk=doctor=Eascular#ementia.htm 3updated 11th -an 2.1., accessed %.th 8ov 2.1.4. 32 Multiple Sclerosis Society website. $ood s+ings and emotionalism http0==www.mssociety.org.uk=aboutOms=symptoms=moodOdepressionOandOemotions=moodOs wingsOand.html 3updated 21st May 2.1., accessed %.th 8ov 2.1.4. 33 :arlow, A., ;i6n, -.E., #ennis, M et al. 32..14. Stroke practical management %rd Bdn. 9lackwell <ublishingD *!ford. <(.1. 34 "bid 35 Stein,- et al. 32..24. Stroke recovery and rehabilitation. #emos Medical <ublishing, )nited States of America. <&(&. 36 Kudd, A., "rwin, <. and <enhale, 9. 32..74. Stroke at your fingertips 2nd Bdn. Alass <ublishingD >ondon. <11( 37 Kudd, A., "rwin, <. and <enhale, 9. 32..74. Stroke at your fingertips 2nd Bdn. Alass <ublishingD >ondon. <11( 38 Kudd, A., "rwin, <. and <enhale, 9. 32..74. Stroke at your fingertips 2nd Bdn. Alass <ublishingD >ondon. <11(. 39 :arlow, A., ;i6n, -.E., #ennis, M et al. 32..14. Stroke practical management %rd Bdn. 9lackwell <ublishingD *!ford. <(.1. 40 ;odefroy, * and 9ogousslavsky, -. 32..+4. The behavioural and cognitive neurology of stroke Aambridge university press, Aambridge. <722. 41 :arlow, A., ;i6n, -.E., #ennis, M et al. 32..14. Stroke practical management %rd Bdn. 9lackwell <ublishingD *!ford. <(.1. 42 :arlow, A., ;i6n, -.E., #ennis, M et al. 32..14. Stroke practical management %rd Bdn. 9lackwell <ublishingD *!ford. <(.1. 43 Kudd, A., "rwin, <. and <enhale, 9. 32..74. Stroke at your fingertips 2nd Bdn. Alass <ublishingD >ondon. <11(. 44 :arlow, A., ;i6n, -.E., #ennis, M et al. 32..14. Stroke practical management %rd Bdn. 9lackwell <ublishingD *!ford. <(.2. 45 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <1(1. 46 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <1(1. 47 Kudd, A., "rwin, <. and <enhale, 9. 32..74. Stroke at your fingertips 2nd Bdn. Alass <ublishingD >ondon. <11(. 48 Kudd, A., "rwin, <. and <enhale, 9. 32..74. Stroke at your fingertips 2nd Bdn. Alass <ublishingD >ondon. <11(.
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Bdmans, -. Bd. 32.1.4 4ccupational therapy and stroke 9lackwell <ublishing >td0 *!ford. <1%. 50 :arlow, A., ;i6n, -.E., #ennis, M et al. 32..14. Stroke practical management %rd Bdn. 9lackwell <ublishingD *!ford. <(.2. 51 Bdmans, -. Bd. 32.1.4 4ccupational therapy and stroke 9lackwell <ublishing >td0 *!ford. <1%. 52 ;odefroy, * and 9ogousslavsky, -. 32..+4. The behavioural and cognitive neurology of stroke Aambridge university press, Aambridge. <722. 53 :arlow, A., ;i6n, -.E., #ennis, M et al. 32..14. Stroke practical management %rd Bdn. 9lackwell <ublishingD *!ford. <(.2. 54 Kudd, A., "rwin, <. and <enhale, 9. 32..74. Stroke at your fingertips 2nd Bdn. Alass <ublishingD >ondon. <11(. 55 Scottish "ntercollegiate ;uidelines 8etwork 3S";84. 32..14. $anagement of patients +ith stroke or T%!' 'assessment, investigation, immediate management and secondary prevention ! national clinical guideline. <&&. 56 "bid 57 :arlow, A., ;i6n, -.E., #ennis, M et al. 32..14. Stroke practical management %rd Bdn. 9lackwell <ublishingD *!ford. <(.2. 58 <ervin, >.A., and -ohn, *.<. 32..14. 5ersonality theory and research. -ohn :iley L Sons, 8ew ,ork. <&. 59 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <1(. 60 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <1+. 61 Kush, 9.H et al. 3-uly-Aug 2.1.4. 0ehavioural symptoms in long.term survivors of ischaemic stroke. -ournal of stroke and cerebrovascular diseases. Eol. 12, 8o &. <%%. 62 Stone, -, et al. 32..&4. 5ersonality change after stroke' some preliminary observations . 8eurol 8eurosurg <sychiatry 8o +70 1+.1-1+1%. 63 "bid 64 "bid 65 "bid 66 Marler, -.K. 32..74. Stroke for Dummies :iley <ublishing, "ncD /oboken. <21%. 67 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <1+. 68 #r Melanie ;eorge email to paula.desou5aIstroke.org.uk 21=.2=11 69 Eenes, #. 32..14. Taber6s cyclopedic medical dictionary. ?.A.#avis company, <hiladelphia. <117. 70 99A website. &ealth' anger management http0==www.bbc.co.uk=health=emotionalOhealth=mentalOhealth=copingOangermanagement.shtml 3accessed 11th -an 2.114. 71 9eers, M. et al. 32..%4 The $erck $anual of $edical %nformation 2nd edn. <ocket 9ooks0 8ew ,ork. <2%2.
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Eenes, #. 32..14. aber's cyclopedic medical dictionary. ?.A.#avis company, <hiladelphia. <117. 73 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <+2. 74 Eenes, #. 32..14. aber's cyclopedic medical dictionary. ?.A.#avis company, <hiladelphia. <117. 75 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <+&. 76 Mind website. &o+ to deal +ith anger. http0==www.mind.org.uk=help=diagnosesOandOconditions=dealingOwithOanger 3updated 2..2, accessed 11th -an 2.114.
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/inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <+2. Mind website. &o+ to deal +ith anger. http0==www.mind.org.uk=help=diagnosesOandOconditions=dealingOwithOanger 3updated 2..2, accessed 11th -an 2.114. 79 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <+&. 80 Mind website. &o+ to deal +ith anger. http0==www.mind.org.uk=help=diagnosesOandOconditions=dealingOwithOanger 3updated 2..2, accessed 11th -an 2.114. 81 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <(1. 82 Eenes, #. 32..14. aber's cyclopedic medical dictionary. ?.A.#avis company, <hiladelphia. <117. 83 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <+2. 84 #ementia )H :ebsite. 7ight caregiver ma#ims for dealing +ith perple#ing behaviours http0==www.dementiauk.org=assets=files=infoOandOsupport=docsOandOreports=MAM"MSO?*KO# BA>"8;O:" /O<BK<>BM"8;O9B/AE"*)KS.pdf 3updated *ct 2..1, accessed 11th -an 2.114. 85 #r Melanie ;eorge email to paula.desou5aIstroke.org.uk 21=.2=11 86 Al5heimer's Society website. Dealing +ith aggressive behaviour http0==al5heimers.org.uk=site=scripts=documentsOinfo.phpFdocument"#P2( 3updated Aug 2.1., accessed 1&th -an 2.114. 87 #r Melanie ;eorge email to paula.desou5aIstroke.org.uk 21=.2=11 88 Aounselling #irectory website. &o+ to manage anger effectively. http0==www.cousellingdirectory.org.uk=counselloradvice1.211.html 3updated 1st Aug 2.1., accessed 11th -an 2.114. 89 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <1%(. 90 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <1%(. 91 /inds,#.M. 32...4. !fter stroke. Martins the printers >td. 9erwick )pon weed. <1%(. 92 Kudd, A., "rwin, <. and <enhale, 9. 32..74. Stroke at your fingertips 2nd Bdn. Alass <ublishingD >ondon. <112. 93 Kudd, A., "rwin, <. and <enhale, 9. 32..74. Stroke at your fingertips 2nd Bdn. Alass <ublishingD >ondon. <1&&. 94 8et #octor website. $ental health professionals http0==www.netdoctor.co.uk=diseases=depression=mentalhealthprofessionalsO...%71.htm 3updated 1st -une 2..7, accessed 11th -an 2.114. 95 8et #octor website. $ental health professionals http0==www.netdoctor.co.uk=diseases=depression=mentalhealthprofessionalsO...%71.htm 3updated 1st -une 2..7, accessed 11th -an 2.114. 96 Scottish "ntercollegiate ;uidelines 8etwork 3S";84. 32..14. $anagement of patients +ith stroke or T%!' 'assessment, investigation, immediate management and secondary prevention ! national clinical guideline. <(.. 97 8et #octor website. $ental health professionals http0==www.netdoctor.co.uk=diseases=depression=mentalhealthprofessionalsO...%71.htm 3updated 1st -une 2..7, accessed 11th -an 2.114. 98 #r Melanie ;eorge email to paula.desou5aIstroke.org.uk 21=.2=11 99 8et #octor website. $ental health professionals http0==www.netdoctor.co.uk=diseases=depression=mentalhealthprofessionalsO...%71.htm 3updated 1st -une 2..7, accessed 11th -an 2.114. 100 Sassoon, K. 32..24. Understanding stroke. <ardoe 9lacker <ublishing, Susse!. <2%.
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Koyal Aollege of <hysicians and the Alinical Bffectiveness L Bvaluation )nit. 32..14 )ational Clinical *uidelines for Stroke. %rd Bdn. >avenham <ress >tdD Suffolk. <1&1. 102 Koyal Aollege of <hysicians and the Alinical Bffectiveness L Bvaluation )nit. 32..14 )ational Clinical *uidelines for Stroke. %rd Bdn. >avenham <ress >tdD Suffolk. <1&2. 103 Aonnect $ the communication disability network website. Counselling https0==www.ukconnect.org=Aounselling-for-people-with-aphasia.asp! 3updated, accessed 27th -an 2.114. 104 Bdmans, -. Bd. 32.1.4 4ccupational therapy and stroke 9lackwell <ublishing >td0 *!ford. <11. 105 Kutherford, #. 32..(4. Strokes. 8et #octor. /odder L StoughtonD >ondon. <11%.
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