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Cerebrovascular Disease: Psychosocial Aspects
Stroke is the third leading cause of death and the leading cause of adult disability, affecting an estimated 700,000 new persons a year in the United States. As a disease of sudden onset that damages the brain, stroke has the ability to rapidly and catastrophically throw all the psychosocial features of one's life into chaos and upheaval. To a greater extent than perhaps any other condition, stroke can have profound ill effects on cognition, personality, memory, social functioning, physical functioning, mental health, and work life. We briefly review the progress that has been made in understanding the role that psychosocial and behavioral factors play in the onset and course of stroke and stroke recovery. Attention is also paid to the impact of stroke on psychosocial functioning. Finally, intervention research, while somewhat limited compared to other conditions such as arthritis or heart disease, is briefly reviewed. The theme of this entry is that stroke is an ideal “strategic site” for the study of psychosocial factors and health, and that a greater understanding of the role of psychosocial factors will advance theory, research, and clinical practice in stroke.
Impact of Psychosocial Factors and Stroke Onset
In theory, psychosocial risk factors for stroke should be similar to those that have been demonstrated in coronary heart disease. Both conditions arise from vascular disease that can involve thrombosis, hemorrhage, coagulation disorders, and various disease processes that lead to ischemia. However, many of the psychosocial risk factors that have been found to be robust predictors of heart disease have not been clearly demonstrated in stroke. This constitutes something of a puzzle. An example is the work on stress. Factors such as work stress, stressful life events, and so forth have produced very mixed results. Some studies suggest an increased risk for those living stressful lives, but the evidence is generally weak. There is fairly consistent evidence that depression and depressive symptoms are associated with increased risk of stroke, especially for stroke mortality.
Psychosocial Factors and Stroke Course
While the evidence in favor of an etiologic role for psychosocial factors and stroke is less than clear, a great deal of evidence suggests that a wide range of psychosocial and behavioral factors influence the recovery trajectories of stroke survivors. The main variables that have been studied include social support (especially emotional support), social network ties, and family function broadly defined. The bulk of this evidence suggests that social support from family and friends plays an important role in boosting functional recovery and social participation after stroke. Emotional support appears to be unconditionally positive, whereas instrumental support can be a doubleedged sword. High levels of instrumental support are associated with worse outcome in some studies, due perhaps to failure to control adequately for health status or stroke severity, or because high instrumental support means that caregivers are overfunctioning in their role and that patients who are overly protected or understimulated have worse outcomes. Overprotection can also increase the risk of poststroke depression, perhaps by undermining the autonomy of the stroke survivor. The reasons for the strong association between social support and functional recovery are not entirely clear, but appear to be explained by a number of mechanisms, including greater treatment adherence, higher activity levels, better mood, and higher motivation for recovery. A related and strong finding is that the presence of a support network offers robust protection against nursing home placement after hospitalization for stroke.
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