Date Published: March 15, 2019
Publisher: Public Library of Science
Author(s): Britta Nijsse, Jacoba M. Spikman, Johanna M. A. Visser-Meily, Paul L. M. de Kort, Caroline M. van Heugten, Marina A. Pavlova.
Behavioural changes after stroke might be explained by social cognition impairments. The aim of the present study was to investigate whether performances on social cognition tests (including emotion recognition, Theory of Mind (ToM), empathy and behaviour regulation) were associated with behavioural deficits (as measured by proxy ratings) in a group of patients with relatively mild stroke.
Prospective cohort study in which 119 patients underwent neuropsychological assessment with tests for social cognition (emotion recognition, ToM, empathy, and behaviour regulation) 3–4 years post stroke. Test scores were compared with scores of 50 healthy controls. Behavioural problems were assessed with the Dysexecutive Questionnaire (DEX) self rating and proxy rating scales. Pearson correlations were used to determine the relationship between the social cognition measures and DEX scores.
Patients performed significantly worse on emotion recognition, ToM and behaviour regulation tests than controls. Mean DEX-self score did not differ significantly from the mean DEX-proxy score. DEX-proxy ratings correlated with tests for emotion recognition, empathy, and behavioural regulation (lower scores on these items were associated with more problems on the DEX-proxy scale).
Social cognition impairments are present in the long term after stroke, even in a group of mildly affected stroke patients. Most of these impairments also turned out to be associated with a broad range of behavioural problems as rated by proxies of the patients. This strengthens the proposal that social cognition impairments are part of the underlying mechanism of behavioural change. Since tests for social cognition can be administered in an early stage, this would allow for timely identification of patients at risk for behavioural problems in the long term.
Behavioural changes are a frequent complication after stroke and may have a negative impact on the quality of life of patients, but also on the quality of life of caregivers. Since behavioural changes often relate to inadequate or inappropriate social-emotional behaviour, for example hurtful or insulting communication and emotional indifference, it is plausible to assume that social cognition impairments are part of the underlying mechanism of behavioural change. Social cognition comprises the capacities of individuals to process social information, that is, to understand the behaviour of others and to react adequately in social situations. These capacities involve different, but interrelated, processes.[3,4] First, it requires the ability to recognize other people’s emotions, e.g. by facial expressions. Second, intentions, dispositions and beliefs of others have to be inferred by forming a Theory of Mind (ToM). Furthermore, one should be able to empathize with others by linking other people’s emotions to one’s own emotional experience. A final element is behaviour regulation, which involves monitoring, control and inhibition of one’s own behaviour, emotions, or thoughts, in accordance with the demands of the situation. Collectively, all these skills facilitate appropriate social behaviour. And consequently, impairments in social cognition might be related to disturbances in social-interpersonal behaviour. Social cognition impairments have been found in stroke patients, with evidence for deficits in emotion recognition, ToM[7–9] and empathy. To date, the relation between these impairments and social-behavioural problems has not been investigated yet.
A total of 395 patients were included in the Restore4Stroke cohort study. At T6, 160 of them (40.5%) were eligible for further testing. With respect to the 235 resigned patients, 33 patients died, 120 patients refused further participation, 47 patients could not be reached by T6, and in 35 patients it was not possible to conduct the T6 assessment because of their general physical condition. Two patients had evidence of visual neglect according to the results of the Bells test, ten patients had evidence of language disorder according to the results of the BNT or the clinical judgement of the neuropsychologist. They were all excluded, which resulted in a total of 148 patients. In 119 patients, both DEX self reports and DEX proxy reports were available, so they were included in the present study.
Our study found a significant relationship between deficits in emotion recognition, empathy and behaviour regulation in stroke patients, and behavioural changes reported by significant others. This finding supports the hypothesis that deficits in aspects of social cognition may underlie behavioural deficits after stroke.
Social cognition impairments are present in the long term after stroke, even in a group of mildly affected stroke patients. Most of these impairments also turned out to be associated with a broad range of behavioural problems as rated by proxies of the patients. Although only cross-sectional data were presented, this strengthens the proposal that social cognition impairments are part of the underlying mechanism of behavioural change. When patients at risk of behavioural problems could be identified in the early stages after stroke by performing social cognition tests, targeted social cognitive treatment can be given. Whether such treatment, that has been proven effective in TBI patients, is also effective in stroke patients, is a topic for further investigation.