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Introduction: the biopsychosocial reintegration of stroke patients requires a multidisciplinary and integrated assessment including the evaluation of psychosocial factors. This is illustrated through a clinical case report concerning a hospitalized patient. Case description: the patient was a middle-aged married woman who had a left haemorrhagic stroke; the lesion is sub-cortical and medial in the basal ganglia lenticular region. She did not have a severe motor impairment but the cognitive profile showed some executive and working memory deficits that negatively affected the rehabilitation process. She presented severe hypertension which was caused by a renal artery stenosis diagnosed during her hospital stay. In order to assess the psychosocial factors, both observer-rated (Structured Clinical Interview for DSM-IV and Diagnostic Criteria for Psychosomatic Research-DCPR) and self-rated (Symptom Questionnaire-SQ, Psychosocial Index-PSI, Affective Neuroscience Personality Scales-ANPS and Family Assessment Device-FAD) instruments were used. DSM-IV Minor Depression and Alexithymia, according to DCPR were found. The patient showed high scores in SQ-Anxiety, Depression and Somatic Symptoms total scales and in ANPS-Fear subscale, while low scores in ANPSSeeking, Play and Spirituality subscales were found. Family functioning was characterized by emotional over-involvement, as evidenced by high scores in FAD-Affective Involvement scale. When PSI scales were considered, work-related stressful life situations and high psychosocial distress emerged. Comment: this case report enlightens the complex interconnection among biological, neurological, neuropsychological, and psychosocial aspects. An integrated and comprehensive assessment is essential to ensure an intervention properly targeted to the characteristics of stroke patient and to provide the best possible treatment outcome.

Recent studies have shed light on the biological foundations of Basic Emotional Systems that can be found both in animals and in human beings. The aim of our study is to reveal the associations that exist between the Basic Emotions making up part of the personality structure, the relationship-based emotional regulatory system, i.e. Attachment Style, and the influence of these on the manifestation and expression of psychological distress. Our sample consisted of 110 subjects (M = 34, F = 76) , of whom 50 suffered from a stroke and 60 suffered from bone fractures; the average age was 72.67 (SD = 11.24). Participants were administered the following questionnaires: Feeney et al.’s Attachment Style Questionnaire (Fossati et al., 2003, Jour. Soc. Pers. Rel. 20(1), 55-79) in order to assess adult attachment styles; Zigmond and Snaith’s Hospital Anxiety and Depression Scale (Costantini et al., 1999, Support Care Cancer. 7:121–127) in order to assess the intensity of anxiety and depression; the Affective Neuroscience Personality Scales (Davis et al., 2003, Neuro-Psychoanalysis, 5(1), 57-69) in order to evaluate the Basic Emotional Systems. Notwithstanding the advanced age of the subjects, the analysis indicated the existence of a statistically significant relationship between the Attachment Style (ASQ) and the Basic Emotional Systems of the personality structure (ANPS). In particular, we found a positive correlation between Secure Attachment Style and positive emotions, while the Avoidant Attachment Style seemed to modulate only partly adaptive emotions and psychological distress (HADS).

Una stretta relazione lega attaccamento, malattia, e disagio psicologico: il pattern di attaccamento influisce su: percezione dei sintomi, ricerca di assistenza sanitaria (Ciechanowsky, 2002), vulnerabilità alla malattia, comportamento di malattia (Maunder e Hunter, 2001) e modo di affrontare crisi e nuovi adattamenti manifestati dal paziente. Soggetti sicuri, con schemi di Sé e degli atri positivi, hanno una migliore capacità di resilience rispetto agli insicuri (Bartholomew e Horowitz, 1991). Nella clinica riabilitativa, il familiare di riferimento svolge un ruolo attivo e partecipa dei processi mentali del paziente. Esistono diverse modalità di caregiving (Feeney, 1996): soggetti con stile sicuro tendono ad essere più empatici, responsivi e attivi nel fornire aiuto degli insicuri. Ci si propone di indagare con appositi strumenti psicometrici lo stile di attaccamento, il disagio psichico, il recupero funzionale e le loro relazioni, in pazienti con esiti di ictus ospedalizzati e relativi familiari di riferimento rispetto ad un gruppo di controllo costituito da pazienti con esiti di frattura e loro familiari di riferimento. Si ipotizza che i soggetti con stile di attaccamento sicuro presentino livelli di disagio psicologico inferiori rispetto a quelli con stile insicuro, e livelli di indipendenza funzionale maggiori; inoltre, si ipotizza che una relazione in cui paziente e familiare manifestano strategie di attaccamento sicuro sia correlata ad un esito migliore del ricovero rispetto a quelli con stile insicuro; infine possono esserci differenze tra pazienti con lesioni all’emisfero destro, sinistro e con i pazienti ortopedici. I risultati preliminari ottenuti sembrano confermare la maggior parte delle ipotesi formulate. Bartholomew, K., Horowitz, L.M. (1991). Journal of Personality and Social Psychology, 61, pp. 226-244. Ciechanowsky, P.S., Walker, E.A., Katon, W.J., Russo, J.E. (2002). Psychosomatic Medicine, 64, pp. 660-667. Feeney, JA. (1996). Personal Relationships, 3, pp. 401-416 Maunder, R.G., Hunter, J.J. (2001) Psychosomatic Medicine, 63, pp. 556-567.

In the practice of clinical rehabilitation, the caregiver plays an active and participating role in the patient’s mental processes. Moreover, the attachment style of the caregiver is associated with a particular type of care (Feeney, 1996). Caregivers with a secure style tend to be empathic and to actively offer assistance, while those with an insecure style exhibit different types of non-responsive caregiving, depending on their particular type of insecurity. We hypothesise that subjects with a secure attachment style will exhibit lower levels of psychological distress and higher levels of functional independence compared to those with an insecure style. We further expect that a relationship between patient and caregiver characterised by secure attachment strategies will be correlated with a more positive outcome of recovery compared to relationships based on an insecure style. Finally, differences may be found between patients with lesions of the right hemisphere, those with lesions of the left hemisphere and orthopaedic patients. Description of the sample: The study excludes patients with severe cognitive deficits. The sample consists of 35 stroke patients (M = 66%, F = 34%; average age = 69 with SD = 9.7; married = 66%) and 30 patients with fractures (M = 27%, F = 73%; average age = 75 with SD = 9.3; married = 50%), as well as the patients’ caregivers. In the neurological patients, the cerebral lesion is located in the right hemisphere in 60% of the cases, while most of the strokes are ischaemic in nature (66%). A share of 70% of the patients with right-hemisphere lesions exhibits modifications in cognitive functioning (neglect: 38%). Among the patients with lesions of the left hemisphere, around 60% show alterations in the cognitive profile (aphasia: 43%). A share of 50% of the orthopaedic patients (74% of the cases with femoral fractures) exhibits modifications of the cognitive profile. The caregivers of the post-stroke patients (spouse: 43%, son or daughter: 46%) are more frequently women (57%) with an average age of 53; 74% are married. Men and women are equally represented among the caregivers of the orthopaedic patients (spouse: 47%, son or daughter 50%); these caregivers have an average age of 61, and 80% are married. Tools and methodology: The HAD (Hospital Anxiety and Depression scale by Zigmond and Snaith, 1983), with separate subscales for anxiety and depression, was used to assess the psychological distress of the patients on admission and on discharge. The patients’ level of functional independence was also tested on admission and discharge by means of the FIM scale (Functional Independence Measurement, by Dodds et al., 1993). The CES-D scale (Center of Epidemiologic Studies Depression scale, by Radloff, 1977 in the Italian form validated by Fava, 1982) was used to measure the presence and degree of depression in the caregivers, likewise on admission and discharge. The attachment style of both patients and caregivers was identified using RQ (Relationship Questionnaire by Bartholomew and Horowitz, 1991) and ASQ (Attachment Style Questionnaire by Feeney, 1996 in the Italian version validated by Fossati et al., 2003). The ASQ evaluates attachment style according to five key factors: “confidence discomfort with closeness”, “need for approval”, preoccupation with relationships” and “relationships as secondary”. The preliminary findings appear to confirm most of the hypotheses formulated above.

Lo studio dell’attaccamento, offre un interessante spunto di approfondimento per l’analisi dei vissuti psicologici dei pazienti in riabilitazione a causa di deficit cognitivi e motori e dei loro familiari, poiché in condizioni emotive come quelle descritte, gli individui tendono a riattivare e ad accentuare l’insieme dei comportamenti tipici del legame di attaccamento (ricerca di vicinanza, bisogno di sicurezza e di protezione, protesta per la separazione). Pertanto l’attaccamento, che si manifesta negli stili rappresentazionali connessi al mantenimento dei sentimenti di sicurezza e protezione, contribuisce a comprendere l’adattamento globale del soggetto a tale condizione di bisogno e di pericolo.

Il lavoro si pone l’obiettivo di: 1) analizzare le caratteristiche e i cambiamenti nelle condizioni cliniche, in particolare ansia e depressione, di pazienti in riabilitazione e relativi familiari di riferimento, e se queste sono correlate con il recupero funzionale dei pazienti stessi; 2) stabilire la presenza o meno di una sofferenza psicologica maggiore nel gruppo di pazienti con esiti di ictus e dei loro familiari rispetto ai pazienti ortopedici e relativi congiunti; 3) approfondire la distribuzione dei diversi stili di attaccamento nei soggetti del campione, e la loro influenza sull’entità del disagio psichico di pazienti e familiari.

The aim of the current study was to investigate basic emotions and attachment in a sample of 86 stroke patients. We included a control group of 115 orthopedic patients (matched for age and cognitive status) without brain lesions to control for unspecific general illness effects of a traumatic recent event on basic emotions and attachment. In order to measure basic emotions and attachment style we applied the Affective Neuroscience Personality Scale (ANPS) and the Attachment Style Questionnaire (ASQ). The stroke patients showed significantly different scores in the SEEKING, SADNESS, and ANGER subscales of the ANPS as well as in the Relationship as Secondary Attachment dimension of the ASQ when compared to the control group. These differences show a pattern influenced by lesion location mainly as concerns basic emotions. Anterior, medial, left, and subcortical patients provide scores significantly lower in ANPS-SEEKING than the control group; ANPS-SADNESS scores in anterior, right, medial, and subcortical patients were significantly higher than those of the control group. ANPS-ANGER scores in posterior, right, and lateral patients were significantly higher than those in the control group; finally, the ANPS-FEAR showed slightly lower scores in posterior patients than in the control group. Minor effects on brain lesions were also individuated in the attachment style. Anterior lesion patients showed a significantly higher average score in the ASQ-Need for Approval subscale than the control group. ASQ-Confidence subscale scores differed significantly in stroke patients with lesions in medial brain regions when compared to control subjects. Scores at ANPS and ASQ subscales appear significantly more correlated in stroke patients than in the control group. Such finding of abnormalities, especially concerning basic emotions in stroke brain-lesioned patients, indicates that the effect of brain lesions may enhance the interrelation between basic emotions and attachment with respect to the control group.

The concept of SEEKING describes a predisposition to search enthusiastically for rewards in the environment. While SEEKING and its underlying functional anatomy have been extensively investigated in animals, such processes in humans, especially brain-damaged individuals, remain understudied. We therefore conducted an exploratory behavioral study in stroke patients to investigate the effects of brain lesions that anatomically could be interpreted to impact the SEEKING system and predicted relationships to depression. Patients with lesions in anterior, medial, and/or subcortical lesions showed significantly lower SEEKING scores and higher depression scores than nonlesioned subjects in the control group. Based on our data and related work on animals, we propose central involvement of the anterior subcortical-cortical midline system as core of the limbic system in SEEKING in humans.