Topics in Stroke Rehabilitation

ISSN: 1074-9357 (Print) 1945-5119 (Online) Journal homepage: http://www.tandfonline.com/loi/ytsr20

Psychological, Behavioral, and Environmental

Influences on Post-Stroke Recovery

Jan Remer-Osborn

To cite this article: Jan Remer-Osborn (1998) Psychological, Behavioral, and Environmental
Influences on Post-Stroke Recovery, Topics in Stroke Rehabilitation, 5:2, 45-53

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Published online: 02 Feb 2015.

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 Post-Stroke Recovery 45

Psychological, Behavioral,
and Environmental Influences on
Post-Stroke Recovery

Research has demonstrated that recovery from stroke is influenced by several factors including premorbid
personality, degree of physical loss, amount of social support, and severity of cognitive change. Psychologi-
cal disturbances and behaviors, including depression, adjustment disorders, anxiety, personality changes,
Downloaded by [University of California, San Diego] at 04:46 04 April 2016

aggression, and non-compliance may significantly impact outcome. Environmental and extra-therapeutic
circumstances provide an often-overlooked framework for the recovery process. Selected issues drawn from
clinical experience and recent literature addressing these variables are examined to further understanding
and to provide a practical approach in optimizing recovery. Key words: adjustment, aggression, depression,
family-centered rehabilitation, rehabilitation team, stroke

Jan Remer-Osborn, PhD SCOPE OF THE PROBLEM

Psychologist, Brain Injury Program
Rehabilitation Institute of Chicago
Instructor, Department of Physical
Medicine and Rehabilitation
Northwestern University Medical School
Chicago, Illinois
Research has demonstrated that recovery
from stroke is influenced by several factors
including premorbid personality, degree of
physical loss, amount of social support, and
severity of cognitive change. Psychological
disturbances and behaviors, including depres-
sion, adjustment disorders, anxiety, personal-
ity changes, aggression, and noncompliance
may significantly impact outcome. Environ-
mental and extra-therapeutic circumstances
provide an often-overlooked framework for
the recovery process. Selected issues drawn
from clinical experience and recent literature
addressing these variables are examined to
further understanding and to provide a practical
approach in optimizing recovery.

INDIVIDUAL DIFFERENCES

The unique circumstances and response of

each individual experiencing physical and/or
cognitive loss or disability should always be
considered (Galski, Bruno, Zorowitz, &

Top Stroke Rehabil 1998;5(2):45–53

© 1998 Aspen Publishers, Inc.
45
 46 TOPICS IN STROKE REHABILITATION/SUMMER 1998
Walker, 1993). Assumptions are generally
made that all stroke survivors are experienc-
ing pain, distress, or grief. The majority of
patients and family members have never
been treated by a mental health professional.
Education regarding the specific role of psy-
chology in a rehabilitation setting assists
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patients and families in making informed
choices regarding the use of psychological
services. Honoring patients’ and/or families’
wishes to decline psychological intervention
for adjustment issues is necessary though
challenging at times for hospital staff. Sensi-
tivity to the individual’s ethnic, religious,
and cultural background by the psychologist
and all hospital staff is key.
ANATOMICAL CORRELATES OF
NEUROBEHAVIORAL
DISTURBANCES
Recent neuroimaging techniques such as
MRI, SPECT, and PET have enabled correla-
tions to be made between lesion location and
behavioral changes. The research literature
presents conflicting evidence regarding some
of these correlations, however. For example, de
Hann and colleagues (1995) found that lesion
location and stroke categories did not signifi-
cantly influence level of emotional distress nor
was emotional distress necessarily a conse-
quence of stroke. Knowing exactly where the
lesions are located aids in predicting potential
physical, psychological, and/or behavioral
changes and assists the team in devising appro-
priate therapeutic goals and education of the
patient and family.
DEPRESSION
Estimates of the prevalence of depression,
the most frequently cited and studied psy-
chological reaction, vary widely depending
upon the study cited. Researchers have found
that anywhere from 33 to 50 percent of all
stroke patients develop a significant depres-
sion requiring treatment. Depression appears
to be more likely as the lesion approaches the
left frontal pole. Frontal lobe lesions may
also affect the ability to modulate vocal ex-
pression (aprosodia), masking the effects of
depression and contributing to underesti-
mates of emotional distress by professionals
and family in this population. Posterior le-
sions of right hemisphere and left subcortical
lesions may be associated with emotional
distress (Parikh et al, 1988). Lesions in the
right posterior temporal-parietal area may
lead to limited ability to understand vocal
emotional inflections that can cause the indi-
vidual to misinterpret verbal information and
respond inappropriately.
Patients frequently verbalize or indicate
depressed mood or sadness. Suicidal
thoughts and/or a pervasive sense of hope-
lessness are a clear indication that the indi-
vidual is experiencing a severe adjustment
reaction. Other symptoms to recognize in-
clude diurnal mood variation, loss of energy,
anxiety and restlessness, weight loss and
decreased appetite, early morning awaken-
ing, delayed sleep onset, irritability, ineffi-
cient thinking, difficulty concentrating, and
social withdrawal. Indifference, apathy, in-
appropriate cheerfulness, and joking also can
signal emotional distress.
Mr. X is 73-year-old male with a left-frontal
infarct with resultant mild dysarthria and right
hemiplegia. A successful semiretired entre-
preneur, he also received intensive psychiat-
ric treatment for depression and anxiety in
the past. In addition, he also was character-
ized as exhibiting significant dependency
issues. The stroke exacerbated his premorbid

condition. Mr. X’s anxiety escalated to the
point where he was requesting talk to his
physician several times a day, and calling his
psychiatrist twice daily. His participation in
therapies was marginal. Despite his rela-
tively good recovery from the stroke, he made
catastrophic predictions. The goal of psycho-
logical intervention was to help the patient
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control his anxiety so that he could fully
benefit from his treatment program. It was
hypothesized that the patient was obtaining
secondary gain from his negative statements.
The patient was taught to counter each nega-
tive statement with its’ opposite. The patient
was frequently praised for his ability to imple-
ment this strategy which was incorporated
into all his therapies. Within a few days he
was able to temper his catastrophic thinking
and point out positive aspects of his recov-
ery. He complied fully with treatment and his
use of medications to treat anxiety also di-
minished. By the end of his stay he was
visiting other patients to help cheer them up.
LABILITY
Emotional lability may be present as long
as one year in post-stroke survivors (Morris,
Robinson, & Raphael, 1993). Discussion of
sad situations or the individual’s symptoms
may trigger the manifestation of symptoms.
Experienced by individuals with temporal or
left-frontal lesions, the ability to inhibit emo-
tional responses towards relatively innocu-
ous events or topics is reduced. Clinically,
males appear to have more difficulty with
these reactions than females, possibly due to
differences in gender attitude regarding emo-
tional expression.
Patients and families benefit from an expla-
nation of the neuroanatomical substrates that
contribute to this phenomenon. When they
understand this response is physiologically
Post-Stroke Recovery 47
based and does not necessarily represent a
“real” emotional reaction, they are able to cope
with this better. Point out to the families and
patients that the patients are usually easily
redirected. The patients’ themselves can be
taught to redirect themselves by using cogni-
tive strategies. Education informing patients
and families that the lability decreases over
time with perhaps some residual effects usually
will allay their concerns.
Mrs. Y had a right hemisphere frontal inf-
arct. She frequently burst into tears and was
embarrassed by her inability to control her
emotions. She had prided herself as the
strong one in her family, the one whom every-
one would ask for help. Her husband of
almost 50 years was in the medical profes-
sion and felt it was his responsibility to re-
move his wife’s distress. The hospital staff
was concerned about his level of exhaustion
and emotional stability. Interventions for the
patient used a combination of antidepres-
sants, education, support, redirection and
thought substitution. An important patient
issue was assisting her to accept assistance,
and to redefine her role and sense of self-
worth. Education, support, and reassurance
was provided to the spouse. He was encour-
aged to involve his adult children in the care
of his wife to give himself needed respite.
AGGRESSION
Paradiso, Robinson, & Arnt (1996) found
that stroke patients who had violent outbursts
had greater cognitive impairment, higher
scores on a depression scale, higher fre-
quency of left hemisphere lesion and greater
proximity of the lesion to the frontal pole.
When level of depression was controlled for,
the effects of left anterior lesion and cogni-
tive impairment were still significant. This
suggests that this behavior may be consistent
 48 TOPICS IN STROKE REHABILITATION/SUMMER 1998
with other frontal lobe injuries (traumatic
brain injury) and/or that reduced cognition
affects the patient’s abilities to cope with the
environment appropriately.
Violent and aggressive outbursts are the
most difficult post-stroke behavioral conse-
quence for the family and hospital staff. The
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behavior can be unpredictable and frighten-
ing. Clinically, this behavior has been ob-
served in the author’s experience with pa-
tients who have Broca’s aphasia, which is
consistent with the literature. The likely
combined effect of a frontal lesion that may
decrease inhibition and the inability to effec-
tively communicate needs and desires ap-
pears to be precipitants of this behavior.
Language abilities are often interpreted as an
indicator of intellectual capabilities. Indi-
viduals who are unable to utilize language
may be inadvertently treated or made to feel
that they are intellectually deficient.
Families benefit from learning that this
behavior is usually short-lived and may not
be totally in the voluntary control of the
patient. Family members are often the pri-
mary targets of this aggression. Patients may
be less inhibited with family or perceive
them as having control over the patient’s
situation. Family and staff should monitor
possible precipitants to the behavior such as
triggers or patterns of escalation. Behavioral
interventions and/or medical interventions
may be appropriate. Effective strategies in-
clude environmental control such as chang-
ing sleep patterns, reducing number of visi-
tors, increasing rest breaks, allowing the
patient to have choices, coordinating treat-
ment to the patient’s best time.
Mr. Z was a 49-year-old banker who man-
aged a large department with severe Broca’s
aphasia. Used to giving orders, he appeared
to have an especially difficult time not being
able to communicate or to comply with medi-
cation regimen. He frequently refused to eat.
During one family visit, his wife frequently
encouraged him to eat more. Without appar-
ent warning he struck out at his teenage son
and grabbed his wife. The family was devas-
tated by his violent attack. Intervention con-
sisted of several educational components. A
model of a brain was used to show lesion
location. The patient’s disinhibition and in-
ability to easily control and modulate behav-
ior was explained as a function of the injury to
the brain area that controls these behaviors
rather than a personal attack. It was also
pointed out that these behaviors are ob-
served with others who have similar disor-
ders and were not unique to this patient. This
behavior, the family was reassured, is usu-
ally of time-limited duration. Explanations
were also provided delineating which factors
were likely to precipitate this behavior, such
as fatigue or circumstances that highlighted
his loss of autonomy and authority.
PHARMACOLOGICAL
INTERVENTION
The entire rehabilitation team in addition
to the psychologist and the family provide
input to the physician regarding the patient’s
emotional and behavioral state. When to uti-
lize medical management for psychological
and behavioral disturbances is dependent on
the individual physician. Issues that arise
when determining the use of medication in-
clude discriminating between relatively nor-
mal adjustment difficulties, problems that
are amenable to nonmedical interventions,
and finally those that appear intractable with
other interventions.
Antidepressant drugs such as serotonin
reuptake inhibitors, tricyclic agents, tetra-
cyclic agents, stimulants can be helpful in
addressing depression, sleep disturbances,

psychomotor slowing and occasional ag-
gression. Benzodiazepines, buspirone,
lithium, and propanolol, used less fre-
quently, may address anxiety, agitation, ma-
nia, and violence. Antiepileptic drugs are
useful with some patients in treating aggres-
siveness and mood disturbances (Absher &
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Toole, 1996; Bishop & Pet, 1995).
Caution should be used with psychotropic
medications as individuals who have cere-
brovascular disease respond differently and
present unique risks. The family and stroke
survivor, when possible, should be informed
regarding the benefits and side effects of the
medication. Occasionally the stroke survivor
is unable to make appropriate decisions re-
garding medical care. Steps should be taken
to determine that proper advance directives
have been established. This may be a stum-
bling block to families who have reserva-
tions regarding eliminating the patient’s
right to make decisions.
PSYCHOLOGICAL INTERVENTION
Supportive therapy provides a forum for
patients to express their feelings in a safe,
nonjudgmental, and caring environment. Cog-
nitive-behavioral therapy, which is consistent
with other rehabilitation therapies such as
physical, occupational, and speech therapy in
that specific goals are delineated, attempts to
restructure irrational and catastrophic thought
processes by replacing them with realistic and
rational self-statements and to replace mal-
adaptive behaviors with functional behaviors.
In practice, both types of interventions may be
interwoven together to facilitate adjustment
and promote compliance with treatment goals
in order to enhance recovery.
All team members can work with the psy-
chologist to increase the patients’ adaptation
to current challenges and to encourage pa-
Post-Stroke Recovery 49
tients to identify gains and improvements
they have experienced since the onset of the
stroke. A simple, but effective exercise is to
have patients list the activities they can still
engage in or pleasures they can still enjoy at
the present moment despite their disability.
This is a powerful tool in contradicting the
overwhelming though unrealistic belief that
the stroke has robbed them of any chance to
enjoy life. Next, focus on having them target
goals they want to achieve by the time of
discharge from the hospital. Finally, ask
them to delineate goals for the next six
months to a year. It is helpful to review these
goals and ask patients to rate (from 1 to 10)
their belief that they will achieve each goal.
Further intervention by psychology and/or
the hospital chaplain affecting quality of life
and spiritual issues may involve assisting
patients to redefine roles, values, and mea-
sures of self-worth.
Support groups and peer interaction provide
a unique service for both the stroke survivor
and family members that may have a profound
effect on their overall adjustment. The de-
mands on family members or caregivers in-
crease at the point of the patient’s discharge
concurrent with a decrease of professional and
emotional support. Support groups may be the
only forum family members can find or afford
to obtain and understanding with the stressful
role they have undertaken. While a psycholo-
gist or social worker frequently facilitates inpa-
tient support groups, outpatient support groups
are more likely to have non-professionals lead-
ing the group, which may contribute to greater
variability in their effectiveness.
FOCUSING ON THE STRENGTHS OF
THE PATIENT
The training of psychologists focuses on
pathology and the “presenting problem.” In
 50 TOPICS IN STROKE REHABILITATION/SUMMER 1998
our zeal to correctly identify a problem and
provide effective treatment, strengths pa-
tients and their families have brought to us
that can fortify our treatment arsenal are
overlooked. Effective intervention draws
from the patient’s prior coping strategies and
utilizes analogies congruent with their expe-
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rience. Patients frequently cannot recognize
for themselves the qualities and abilities they
still maintain because they are focusing on
their losses. As mentioned above, assisting
patients to identify remaining attributes is an
important therapeutic strategy. Having a
stroke is not a personal failure. Physical
disabilities may affect certain areas of func-
tioning but they do not affect all. Abilities to
be a member in the work force may be ham-
pered, however, the role and example as a
parent or grandparent continues. The ability
to play ball or golf with one’s son may be
gone, but the ability to listen, provide sup-
port, and even model to one’s offspring how
to cope with illness is still present.
Assisting the patient and family to identify
current and potential strengths and abilities can
reduce the sense of being overwhelmed and
hopeless. Pointing out to patients what they
would do if situations were reversed and their
spouse had the stroke helps them to deal with
their newfound dependent role. Reminding
patients who fear being a burden that they cared
for their elderly parents because they loved
them, gives them permission to accept help
from their children. Emphasizing gains and
small victories made since the stroke instead of
“the way they were” promotes a sense of effi-
cacy and mastery versus feeling not good
enough or deficient.
CREATING A THERAPEUTIC
ENVIRONMENT
The hospital can be a depersonalizing expe-
rience for patients who may feel vulnerable and
frightened. Hospital personnel may be desensi-
tized to the effects of the environment on
patients and families. Patients and families
repeatedly express their distress at viewing the
trauma and circumstances of other patients, in
addition to their own situation.
The foundation for a program that wants to
expedite patient recovery is to provide an
atmosphere that does not detract from or
impede this goal. This is an essential step to
prevent and mitigate emotional distress or
potential behavioral difficulties. Special care
must be taken that the families and hospital
staff convey the respect and regard for the
patient regardless of profession or socioeco-
nomic status. Delivery of care is just as
crucial as the care itself.
An especially sensitive issue is the use of
restraints. When measures are instituted for the
patients’ safety, such as seat belts that may
upset both family and patients, communication
that imparts understanding their distress, in
addition to the rationale can lessen the negative
impact. Inflections and tone of voice as well as
content can communicate to the patient that he
or she is being treated like a child. Common
pitfalls range from addressing the patient in a
loud voice as if they are hearing impaired,
talking about the patient in the third person as
if he or she is not there, to discussing medical /
private issues in a public setting.
Every interaction with patients is an inter-
vention. Prior to their stroke, most patients

functioned as autonomous adults and exer-
cised control and decision making ability.
Now, they may find they cannot ask to use the
bathroom or express what is distressing
them. They feel helpless and dependent.
Their sense of humanity may be challenged.
Family members may also be in crisis and
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experiencing a loss of control. Frequent com-
munication regarding the patient’s medical
condition, progress in therapies, or changes
in treatment can mitigate their distress.
DENIAL
Frustration for the rehabilitation team may
occur when the stroke survivor and /or family
are unable or unwilling to acknowledge the
short and long-term consequences of the
stroke. Denial, it is important to recall, is a
protective and adaptive emotional mechanism
that helps individuals cope with depression,
anxiety or other psychopathology. It may
present throughout initial inpatient rehabilita-
tion or even later. Spontaneous recovery in
paralysis or hemiplegia can reinforce the firmly
held belief of a complete return to normal.
It is crucial that the rehabilitation team un-
derstand the function of denial as an appropri-
ate method of coping at this stage of the recov-
ery process. To the treatment team, denial in
view of the patient’s clinical presentation and
information provided to family members is
difficult to comprehend and can be frustrating.
The team may feel that treatment is being
impeded or be concerned that treatment goals
for the patient may not be met.
Education is an important component of
the recovery process for the stroke survivor
Post-Stroke Recovery 51
and family. The family may comment that
the patient always had a poor memory, or
exhibited certain personality characteristics.
The family’s attempt to normalize or mini-
mize the patient’s behavior often conflicts
with the staff ës view of the patient’s present
status as representing new deficits or inap-
propriate behavior. Attempts, however, to
drive home the reality to the stroke survivor
and sometimes the family may result in a
debilitating emotional response and promote
alienation towards the hospital staff. Para-
mount for all staff is not to take away the
patients’ and families’ hope.
FAMILY CONSIDERATIONS
No matter the age of the patient, prior
medical history, stage of life, or economic
circumstances, a stroke is devastating to fam-
ily members. Research has shown the impor-
tance of family support in the recovery of the
patient. Good relationships between the hos-
pital staff and the family will positively im-
pact the patient. Efforts should be made to
review the typical course of rehabilitation to
prevent misunderstanding. Many people be-
lieve that more therapy means faster recov-
ery. The importance of rest periods or
“downtime” for the recovery process must be
explained.
“Discharge” is a word that elicits a gamut of
reactions from the patient and family. The
patient’s targeted discharge date from an acute
rehabilitation setting to day rehabilitation or
outpatient program is typically well before the
family anticipates or thinks they are ready care
for the patient. Conversely, the patient may feel
 52 TOPICS IN STROKE REHABILITATION/SUMMER 1998
the length of stay is too long. Often, the amount
of recovery achieved is not as much as the
patient and family desired. If the patient’s
rate of progress is not appropriate for an acute
rehabilitation program, discharge to a sub-
acute or nursing facility is sometimes recom-
mended. The family may express the feeling
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that the hospital staff has given up hope for
the patient’s progress or even state that the
staff is abandoning the patient. Education of
the family members at admission regarding
the rehabilitation continuum of care, and
options following acute rehabilitation pro-
motes more realistic expectations.
For families who are witnessing loved
ones struggle with physical and communica-
tion changes, depression, anger, noncompli-
ance with treatment, personality changes, a
myriad of responses are observed. Emotional
distress, grief, fear, anger at the treatment
team, anger at the patient, shame, unrealistic
expectations of the staff, and demands for
more or less sessions can emerge. These
types of reactions, if expected and under-
stood by all members of the treatment team,
will aid them in responding in an objective
and compassionate manner. It is important to
normalize and validate the difficulties fami-
lies are experiencing.
QUALITY OF LIFE—THE
ULTIMATE GOAL
The study of “quality of life” (QOL) issues
has recently emerged as a component of
rehabilitation outcome research (Kelly-
Hayes & Page, 1995). Research has sug-
gested that depression, social support, and
functional status predict better QOL (King,
1996). From this psychologist’s viewpoint,
QOL is the overarching goal of psycho-
Strategies To Remember for the
Rehabilitation Team
• Every interaction is an intervention.
• Coordinate treatment and communicate
with all involved in patient care.
• Treat the patient in age-appropriate man-
ner.
• Remind yourself that the patient/family
is new to coping with stroke.
• Educate family/patient without jargon.
• Always give the patient/family hope.
• Respect individual differences.
• Be empathetic; put yourself in patient/
family’s position.
• Become an advocate for individuals with
disabilities.
• Obtain continuing support and education
for yourself.
therapy. Assisting patients to discover mean-
ing and value in their lives and to develop
options despite perceived and real limita-
tions is an extremely important aspect of
treatment. Patients have reported that volun-
teering in hospitals, churches, or schools;
sharing their recovery experiences with oth-
ers, or returning to modified employment has
altered their outlook. Recent studies suggest
that any positive personal change can en-
hance adaptation with serious illness (Tay-
lor, 1983; Rybarczyk, Nicholas, &
Nyenhuis, 1997). Among them are setting
new priorities, focusing on relationships,
enjoying life and valuing life itself.
With the advent of cross-training, interdis-
ciplinary, and transdisciplinary teams, ac-
tivities that were more in the domain of the
psychologist, necessarily have shifted to
other team members. Alternatively, the
psychologist’s understanding of physical as-

pects of the patient’s recovery is also essen-
tial. Quality of life issues are related to
society’s view of disability in general. Many
patients express deep concern of not just
what they will be able to do but also of how
they will be perceived and treated by the
community or the social environment. For
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Post-Stroke Recovery 53
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