NeuroRehabilitation An IntenltlCiplina.,. Journal
ELSEVIER
NeuroRehabilitation 11 (1998) 255-260
Expression of anxiety and depression in a case of subcortical motor aphasia Marsha R. Cohen Psychology Department, Hospital for Special Care, 2150 Corbin Avenue, New Britain, CT 06053, USA Accepted 21 August 1998
Abstract A decision tree and decimal rating scales were used for psychotherapy with a patient with post-stroke subcortical motor aphasia. These two methods used in combination were highly efficient in obtaining information about the patient's mood and issues of concern. The patient was able to report on changing levels of anxiety and depression. He was able to relate his emotional state to environmental or personal factors. Values as low as 1 and as high as 10 for anxiety and depression were reported by the patient during the course of 25 psychotherapy sessions. A Pearson correlation indicated that anxiety and depression varied independently. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Subcortical motor aphasia; Post-stroke; Decision tree; Anxiety; Depression
1. Introduction The residual effects of a stroke can be quite traumatic for a patient, especially when one of the sequelae is aphasia. This may render the individual unable to adequately express basic needs as well as feelings of anxiety and depression. The clinician who hopes to conduct psychotherapy with a patient with aphasia needs to be aware of variations in symptomatology so that techniques suitable for the individual patient may be chosen. In a review of literature on aphasia by Damasio [1], four primary types of aphasia are
described. They are Broca's, Wernicke's, conduction and global. These four conditions are of cortical origin. The term motor aphasia is often equated with Broca's aphasia a condition where speech may be slow and effortful, agrammatical or telegraphic. Many words tend to be omitted. In Wernicke's aphasia, speech is fluent but contains many paraphasias and word substitutions. The speech may be nearly incomprehensible. In conduction aphasia, the ability to repeat is impaired as is naming. Defective assembly of phonemes is common. With global aphasia, there is severe impairment of both production and comprehen-
1053-8135/98/$ - see front matter © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S1053-8135(98)00027-4
256
M.R Cohen / NeuroRehabilitation 11 (1998) 255-260
sion of language. Kaplan and Goodglass [2] point out that the presentation of aphasic symptoms does not always fall into clear cut categories. It is not unusual to find overlap among the various types of aphasia. Reitan [3] notes that it is not unusual for dysarthria and aphasia to coexist. These concurrent conditions can be present with the more familiar types of aphasia, but they can also appear together in subcortical aphasias. The net effect, in the case presented here, was to increase the severity of the patient's language difficulties due to impaired pronunciation coupled with fading volume. Aphasia is not a single condition, but a variety of conditions which can result from either cortical or subcortical stroke. Events at different levels of the brain can produce highly similar results. Subcortical events such as stroke may lead to subcortical aphasias [4] which are similar in symptomatology to the types of cortical aphasias described by Damasio. Although most clinicians would associate the term motor aphasia with Broca's aphasia, a more rare form, subcortical motor aphasia has been known to exist for some time and has been alternately referred to as Subcortical Motor Aphasia of Wernicke, Aphemia of Bastian, Anarthria of Marie, Verbal Apraxia, or Pure Motor Aphasia of Dejerine [5]. The various names suggest an aphasic as well as a dysarthric component. In describing subcortical motor aphasia, it has been reported [4] that the patient may lose all capacity to speak while retaining pedect comprehension of spoken words. Faciobrachial palsy may be associated. Speech, when produced, tends to rapidly fade away, perhaps after one word, but when it is audible, there is no agrammatism. Patients with aphasia present a substantial challenge to the psychologist attempting to conduct psychotherapy sessions and for the other members of the rehabilitation team as well [6]. Sadness, grief and frustration are frequently seen in patients with severe disabilities [7] and it is helpful if the psychologist can find a means for the expression of these feelings. Following a stroke, a large number of patients present with dysarthria, up to 34%, in two samples that were studied [8]. Many of these patients, up to 65%, also had dysphasia or a combination of dysphasia
and dysarthria. Both cortical and subcortical lesions have the potential to result in aphasias as seen when two such populations of patients were compared. With subcortical lesions, difficulty in initiating speech and hesitation may result in mutism. When speech does occur, voice volume may be significantly reduced [4]. Stroke impairs patients' adaptive functioning. The inability to pedorm common tasks successfully can trigger intense emotional reactions. Through the development of a questionnaire for stroke patients [9] it has been shown that a high incidence of problems is perceived by the patients. An even higher incidence of problems is observed to occur by the relatives of these individuals. Following a stroke, patients may be concerned about medical conditions, rate of progress in therapy and family finances. These concerns may lead to increased anxiety. As time goes on, the extent of their disabilities become clear to them and many feel frustrated and helpless, leading to depression. Here are patients with a potential need for psychotherapy, yet various types of aphasia can render their ability to participate in conventional psychotherapy almost nil. A variety of methods have been tried to allow patients with unintelligible speech to communicate their wants and needs. In one case, a patient with Wernicke's aphasia spontaneously developed a pattern of body communication to transmit information. The patient was able to convey nouns, verbs and adjectives using various parts of his body including his hand, head, face, foot, etc. [10]. Individuals may develop yes/no systems which may involve head nod or eye gaze for example. Such patients may also be trained to use various mechanical devices to convey the yes/no response [11], In addition to yes/no systems, pointing and shrugging are commonly seen. Sign language is yet another method of communication that may be taught to patients with various types of aphasia. Attempts to train aphasic subjects in the use of sign language was found to be related to the severity cif the aphasia, i.e. the most complex sign language was acquired by the least aphasic subjects with signs being produced with the unaffected left hand of the patient [12]. However, should a patient display both apraxia of
M.R. Cohen / NeuroRehabilitationll (1998) 255-260
speech and motor apraxia, training of sign language may not be effective regardless of intact cognitive functioning. 2. Method The objective in the present case study was to devise .Ii method which would increase the patient's ability to participate in psychotherapy using only his facial gestures and limited finger movements of his right hand. An innovative combination of techniques was found which allowed psychotherapy to proceed. Providing individualized services is crucial for patients with unique combinations of motor impairments and communication deficits [13]. In this case, techniques from the fields of information processing and tests and measurements were employed as methods for conducting psychotherapy with a highly intelligent, non-verbal patient. Decision trees are presently used in the field of artificial intelligence [14] and were also known in antiquity having been used by the early taxonomists in the form of dichotomous keys for the classification of organisms. The dichotomous key is a parsimonious device that potentially eliminates 50% of existing possibilities at each decision point. The key was constructed based upon information gathered from the patient's medical record and interview of the patient and family members. This allowed identification of recurring themes to be included in the key. Then, each time a choice point from the key was read aloud for the patient, he was able to nod to indicate his selection. The second technique in the present case study involved a decimal rating scale similar to a Likert scale, with values indicated by an appropriate display of fingers by the patient. The goal of psychotherapy was to improve and maintain the patient's sense of well being in spite of his complex medical condition and events outside of his control. This goal was achieved in part until new issues confronted the patient or old issues resurfaced. Psychotherapy sessions focused on the reduction of depression and anxiety symptoms. The patient was instructed to rate his mood and emotional state using the 1-10 scales and then attempt to identify causal factors using the decision tree
257
technique. The patient considered his baseline for both anxiety and depression to be 5 on a scale of 10. The mode of therapy tended to be cognitive-behavioral. The treatment methods used in the present case study have the potential to be effective with a variety of patients with impairment of fluency due to aphasia/dysarthria but who nevertheless retain good comprehension: The technique can be exemplified by a session in which the patient reported increased anxiety using the rating scales. Using the dichotomous key, it was determined that the object of the patient's concern was his family. Through further use of the dichotomous key, the patient revealed that he had been exposed to graphic violence on television news which he interpreted as possibly presenting danger for his relatives. This generated fear and anxiety on the part of the patient. From a cognitive perspective, the patient was then asked to view feared events of harm befalling his family members in terms of probabilities and percentages. This helped him to realize that much of his thinking on this issue was catastrophic. From a behavioral perspective, the patient was asked to alter his selection of TV programs so that there was less exposure to violence and more exposure to comedy, drama and sports. Improvement, i.e.' a reduction of anxiety symptoms was seen when the patient followed the psychologist's recommendations. 2.1. Subject
The subject was a 69-year-old male of superior intelligence. He was a doctoral level professional who was hospitalized subsequent to suffering a massive pontine hemorrhage which left him permanently quadriplegic and ventilator dependent. The patient's hearing was intact, but his' vision was impaired due to a cataract in one eye and cranial nerve palsy in the other. He displayed aphasia due to motor deficits and the inability to project his voice subsequent to the stroke. He had a tracheostomy tube and a gastrostomy tube in place. The patient did retain some movement of his right arm, hand and fingers with moderate apraxia present in that extremity, but he was not
258
M.R Cohen / NeuroRehabilitation 11 (1998) 255-260
able to use a keyboard or to depress a single key. Trials with several types of augmentative communication devices, computer keyboards, and a telegraph key were unsuccessful due to the patient's particular combination of visual impairment plus fine motor skill impairment. However, the patient had the ability to use nod and shrug gestures and to display from one to five fingers on his right hand. When attempts were made to have the patient use a talking tracheostomy tube, it became apparent that he spoke in complete grammatical sentences, but his voice would fade away as is frequently seen in patients with subcortical aphasias. The patient learned to participate in the techniques used in psychotherapy after a single explanation by the psychologist. The patient was seen for psychotherapy for a period of 15 months in which 25 therapy sessions occurred using both of the techniques mentioned above. When the decision tree was used, the patient was asked to identify issues that were of
concern to him or about which he wished to communicate. The decision points were read to him and he made his selection by nodding. Using the decision tree, the patient was able to distinguish people vs. environment, himself vs. others, hospital vs. outdoors, and physical conditions vs. emotions. After the last decision point or node was reached, the patient was presented with a simple list of items from the relevant area of concern (Fig. 1). The second technique used was a decimal rating scale. The patient was able to report values from 1 to 10 by holding up the appropriate number of fingers of his right hand either once (1-5) or twice in rapid succession (6-10). Levels of anxiety and depression were reported by the patient at 25 therapy sessions. The patient was able to communicate about absolute as well as relative values. He could indicate hours of sleep, number of times outdoors, number of visitors, etc. Anxiety and depression were reported as relative
Person Yourself
Environment Others
Hospital
Other
Physical
Emotional
Spouse
Room
Outdoors
Pain
Happy
Daughter
Light
Career
Above Waist
Calm
Son
Temperature
Sports
Below Waist
Sad
Relative
Privacy
Current Events
Wet
Worried
Friend
TV
Religion
Cold
Angry
Doctor
Wheelchair
Politics
Hot
Afraid
Staff
Bed Position
Home
Position
Anxious
Patient
Window Blinds
Headache
Depressed
Curtains
Breathing
Tired
Music
Spasms
Bored
Fig. 1. A decision tree for use with aphasic patients. Items from the decision tree were read aloud to the patient. The patient indicated his choice with an affirmative nod.
259
M.R. Cohen / NeuroRehabilitation 11 (1998) 255-260
values on a scale from 1 to 10 with 1 representing the lowest possible intensity and 10 representing the highest.
other. Clinical observations confirmed that increased anxiety tended to occur in the presence of medical diagnoses with uncomfortable physical symptoms. Increased depression tended to occur when opportunities for social interaction were fewer, for example when winter weather reduced visits with friends or relatives. Values for anxiety and depression fluctuated during the course of psychotherapy and thus are not necessarily lower at the end of the 25 sessions. When queried, the patient reported that he did find the sessions to be helpful for reducing anxiety and depression and for increasing his sense of well being. The patient's reported values for each session are shown in Fig. 2.
3. Results The patient reported a wide variety of issues which concerned him using the decision tree. These included items as diverse as spasms in his legs, wanting the window curtains closed, and expressing sentiments toward various people. His reported values for anxiety ranged from 1 to 10 and for depression from 2 to 10 across the 25 sessions. Means and standard deviations for the two variables were calculated: for anxiety, mean = 5.92, S.D. = 2.41; for depression, mean = 6.20, S.D. = 2.35. A Pearson product-moment correlation was pedormed for the anxiety and depression values at each of the 25 sessions, with n = 25, dJ. = 23, r = 0.24, P < 0.20. The results were non-significant suggesting that the patient experienced anxiety and depression independent of each
4. Discussion Used in conjunction, the decision tree and the rating scales were an effective means of communicating with, assessing and conducting therapy with a patient with aphasia who otherwise had
___ Anxiety
T\"
10
~,
EoR
EoR
,.:'
E 8
9
10
11
12
13
14
15
16
....... Depression
.':~".
E = Event R = Recommendation
E
EoR 17
18
19
20
21
22
23
24
25
Session
Fig. 2. Anxiety and depression ratings for 25 therapy sessions. Also shown are sessions when recommendations were made and acted upon by the patient as well as when events occurred that affected the patient's mood.
260
M.R. Cohen / NeuroRehabilitation 11 (1998) 255-260
great difficulty in expressing concerns and emotions. The patient's medical condition was complex and his illness was chronic, placing him in a category where anxiety and depression are likely to be recurrent. Use of the two techniques allowed the patient to communicate with less effort and less frustration. Problems were more readily identified and interventions could be more quickly implemented. The patient remained stable in his cognitive abilities during the course of therapy with fluctuations in mood associated with external events and fluctuations in physical symptoms. Therapy continued for 15 months until a second stroke led to the patient's death. The knowledge derived from these sessions suggested that other patients could potentially benefit from the use of the same or similar techniques. For may types of patients, use of the decision tree would potentially increase the speed and efficiency of communication between the patient and staff. Future research may test the use of the decic sion tree and rating scales as outcome measures for patients with the potential to improve physically and psychologically. The use of these techniques should also be trialed with patients who have less education or a lower level of intellectual functioning to see what may be applicable in a more extensive patient population. While recognizing that this was a somewhat rare case, nevertheless, the techniques used in therapy have the potential to be helpful to a variety of patients who are dysphonetic. The analysis of data was done on a post hoc basis with only one subject so additional research needs to be done for the results to be generalizable. The reporting of this case study will hopefully encourage other clini-
cians to utilize the concurrent use of the rating scales and the decision tree with their patients. References [1] Damasio AR. Aphasia. N Engl J Med 1992;326:531-539. [2] Goodglass H, Kaplan E. The assessment of aphasia and related disorders. 2nd ed. Philadelphia: Lea and Febiger, 1983. [3] Reitan RM. Aphasia and sensory perceptual deficits in adults. South Tucson: Neuropsychology Press, 1984. [4] Kirk A,. Kertesz A. Cortical and subcortical aphasias compared. Aphasiology 1994;8:65-82. [5] Adams RD, Victor M. Affectations of speech and language. In: Principles of neurology. 4th ed. New York: McGraw-Hill, 1989:377-395. [6] Holland AL, Halper AS. Talking to individuals with aphasia: a challenge for the rehabilitation team. Top Stroke Rehabil1996;2:27-37. [7] Adkins ER. Nursing care of clients with impaired communication. Rehabil Nurs 1991;16:74-76. [8] Geddes JML, Chamberlain AM. Improving social outcome after stroke: an evaluation of the volunteer stroke scheme. Clin Rehabil 1994;8: 116-126. [9] Towle D, Lincoln NB. Development of a questionnaire for detecting everyday problems in stroke patients with unilateral visual neglect. Clin Rehabil 1991;5:135-140. [10] Ahlsen E. Body communication as compensation for speech in a Wernicke's aphasic - a longitudinal study. J Commun Dis 1991;24:1-12. [11] Keenan lE, Barnhart KS. Development of yes/no systems in individuals with severe traumatic brain injuries. ACC Augment Alternat Commun 1993;9:184-190. [12] Coelho CA. Acquisition and generalization of simple manual sign grammars by aphasic subjects. 1 Commun Dis 1990;23:383-400. [13] Berde S, Johnson P, Rodrigues H, Johnson K. Providing individualized services: a traumatic brain injury case study. NeuroRehabilitation 1996;7:223-230. [14] Quinlan JR. Decision trees and decision making. IEEE Trans Syst Man Cybern 1990;20:339-346.
ELSEVIER
NeuroRehabilitation 11 (1998) 255-260
Expression of anxiety and depression in a case of subcortical motor aphasia Marsha R. Cohen Psychology Department, Hospital for Special Care, 2150 Corbin Avenue, New Britain, CT 06053, USA Accepted 21 August 1998
Abstract A decision tree and decimal rating scales were used for psychotherapy with a patient with post-stroke subcortical motor aphasia. These two methods used in combination were highly efficient in obtaining information about the patient's mood and issues of concern. The patient was able to report on changing levels of anxiety and depression. He was able to relate his emotional state to environmental or personal factors. Values as low as 1 and as high as 10 for anxiety and depression were reported by the patient during the course of 25 psychotherapy sessions. A Pearson correlation indicated that anxiety and depression varied independently. © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Subcortical motor aphasia; Post-stroke; Decision tree; Anxiety; Depression
1. Introduction The residual effects of a stroke can be quite traumatic for a patient, especially when one of the sequelae is aphasia. This may render the individual unable to adequately express basic needs as well as feelings of anxiety and depression. The clinician who hopes to conduct psychotherapy with a patient with aphasia needs to be aware of variations in symptomatology so that techniques suitable for the individual patient may be chosen. In a review of literature on aphasia by Damasio [1], four primary types of aphasia are
described. They are Broca's, Wernicke's, conduction and global. These four conditions are of cortical origin. The term motor aphasia is often equated with Broca's aphasia a condition where speech may be slow and effortful, agrammatical or telegraphic. Many words tend to be omitted. In Wernicke's aphasia, speech is fluent but contains many paraphasias and word substitutions. The speech may be nearly incomprehensible. In conduction aphasia, the ability to repeat is impaired as is naming. Defective assembly of phonemes is common. With global aphasia, there is severe impairment of both production and comprehen-
1053-8135/98/$ - see front matter © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S1053-8135(98)00027-4
256
M.R Cohen / NeuroRehabilitation 11 (1998) 255-260
sion of language. Kaplan and Goodglass [2] point out that the presentation of aphasic symptoms does not always fall into clear cut categories. It is not unusual to find overlap among the various types of aphasia. Reitan [3] notes that it is not unusual for dysarthria and aphasia to coexist. These concurrent conditions can be present with the more familiar types of aphasia, but they can also appear together in subcortical aphasias. The net effect, in the case presented here, was to increase the severity of the patient's language difficulties due to impaired pronunciation coupled with fading volume. Aphasia is not a single condition, but a variety of conditions which can result from either cortical or subcortical stroke. Events at different levels of the brain can produce highly similar results. Subcortical events such as stroke may lead to subcortical aphasias [4] which are similar in symptomatology to the types of cortical aphasias described by Damasio. Although most clinicians would associate the term motor aphasia with Broca's aphasia, a more rare form, subcortical motor aphasia has been known to exist for some time and has been alternately referred to as Subcortical Motor Aphasia of Wernicke, Aphemia of Bastian, Anarthria of Marie, Verbal Apraxia, or Pure Motor Aphasia of Dejerine [5]. The various names suggest an aphasic as well as a dysarthric component. In describing subcortical motor aphasia, it has been reported [4] that the patient may lose all capacity to speak while retaining pedect comprehension of spoken words. Faciobrachial palsy may be associated. Speech, when produced, tends to rapidly fade away, perhaps after one word, but when it is audible, there is no agrammatism. Patients with aphasia present a substantial challenge to the psychologist attempting to conduct psychotherapy sessions and for the other members of the rehabilitation team as well [6]. Sadness, grief and frustration are frequently seen in patients with severe disabilities [7] and it is helpful if the psychologist can find a means for the expression of these feelings. Following a stroke, a large number of patients present with dysarthria, up to 34%, in two samples that were studied [8]. Many of these patients, up to 65%, also had dysphasia or a combination of dysphasia
and dysarthria. Both cortical and subcortical lesions have the potential to result in aphasias as seen when two such populations of patients were compared. With subcortical lesions, difficulty in initiating speech and hesitation may result in mutism. When speech does occur, voice volume may be significantly reduced [4]. Stroke impairs patients' adaptive functioning. The inability to pedorm common tasks successfully can trigger intense emotional reactions. Through the development of a questionnaire for stroke patients [9] it has been shown that a high incidence of problems is perceived by the patients. An even higher incidence of problems is observed to occur by the relatives of these individuals. Following a stroke, patients may be concerned about medical conditions, rate of progress in therapy and family finances. These concerns may lead to increased anxiety. As time goes on, the extent of their disabilities become clear to them and many feel frustrated and helpless, leading to depression. Here are patients with a potential need for psychotherapy, yet various types of aphasia can render their ability to participate in conventional psychotherapy almost nil. A variety of methods have been tried to allow patients with unintelligible speech to communicate their wants and needs. In one case, a patient with Wernicke's aphasia spontaneously developed a pattern of body communication to transmit information. The patient was able to convey nouns, verbs and adjectives using various parts of his body including his hand, head, face, foot, etc. [10]. Individuals may develop yes/no systems which may involve head nod or eye gaze for example. Such patients may also be trained to use various mechanical devices to convey the yes/no response [11], In addition to yes/no systems, pointing and shrugging are commonly seen. Sign language is yet another method of communication that may be taught to patients with various types of aphasia. Attempts to train aphasic subjects in the use of sign language was found to be related to the severity cif the aphasia, i.e. the most complex sign language was acquired by the least aphasic subjects with signs being produced with the unaffected left hand of the patient [12]. However, should a patient display both apraxia of
M.R. Cohen / NeuroRehabilitationll (1998) 255-260
speech and motor apraxia, training of sign language may not be effective regardless of intact cognitive functioning. 2. Method The objective in the present case study was to devise .Ii method which would increase the patient's ability to participate in psychotherapy using only his facial gestures and limited finger movements of his right hand. An innovative combination of techniques was found which allowed psychotherapy to proceed. Providing individualized services is crucial for patients with unique combinations of motor impairments and communication deficits [13]. In this case, techniques from the fields of information processing and tests and measurements were employed as methods for conducting psychotherapy with a highly intelligent, non-verbal patient. Decision trees are presently used in the field of artificial intelligence [14] and were also known in antiquity having been used by the early taxonomists in the form of dichotomous keys for the classification of organisms. The dichotomous key is a parsimonious device that potentially eliminates 50% of existing possibilities at each decision point. The key was constructed based upon information gathered from the patient's medical record and interview of the patient and family members. This allowed identification of recurring themes to be included in the key. Then, each time a choice point from the key was read aloud for the patient, he was able to nod to indicate his selection. The second technique in the present case study involved a decimal rating scale similar to a Likert scale, with values indicated by an appropriate display of fingers by the patient. The goal of psychotherapy was to improve and maintain the patient's sense of well being in spite of his complex medical condition and events outside of his control. This goal was achieved in part until new issues confronted the patient or old issues resurfaced. Psychotherapy sessions focused on the reduction of depression and anxiety symptoms. The patient was instructed to rate his mood and emotional state using the 1-10 scales and then attempt to identify causal factors using the decision tree
257
technique. The patient considered his baseline for both anxiety and depression to be 5 on a scale of 10. The mode of therapy tended to be cognitive-behavioral. The treatment methods used in the present case study have the potential to be effective with a variety of patients with impairment of fluency due to aphasia/dysarthria but who nevertheless retain good comprehension: The technique can be exemplified by a session in which the patient reported increased anxiety using the rating scales. Using the dichotomous key, it was determined that the object of the patient's concern was his family. Through further use of the dichotomous key, the patient revealed that he had been exposed to graphic violence on television news which he interpreted as possibly presenting danger for his relatives. This generated fear and anxiety on the part of the patient. From a cognitive perspective, the patient was then asked to view feared events of harm befalling his family members in terms of probabilities and percentages. This helped him to realize that much of his thinking on this issue was catastrophic. From a behavioral perspective, the patient was asked to alter his selection of TV programs so that there was less exposure to violence and more exposure to comedy, drama and sports. Improvement, i.e.' a reduction of anxiety symptoms was seen when the patient followed the psychologist's recommendations. 2.1. Subject
The subject was a 69-year-old male of superior intelligence. He was a doctoral level professional who was hospitalized subsequent to suffering a massive pontine hemorrhage which left him permanently quadriplegic and ventilator dependent. The patient's hearing was intact, but his' vision was impaired due to a cataract in one eye and cranial nerve palsy in the other. He displayed aphasia due to motor deficits and the inability to project his voice subsequent to the stroke. He had a tracheostomy tube and a gastrostomy tube in place. The patient did retain some movement of his right arm, hand and fingers with moderate apraxia present in that extremity, but he was not
258
M.R Cohen / NeuroRehabilitation 11 (1998) 255-260
able to use a keyboard or to depress a single key. Trials with several types of augmentative communication devices, computer keyboards, and a telegraph key were unsuccessful due to the patient's particular combination of visual impairment plus fine motor skill impairment. However, the patient had the ability to use nod and shrug gestures and to display from one to five fingers on his right hand. When attempts were made to have the patient use a talking tracheostomy tube, it became apparent that he spoke in complete grammatical sentences, but his voice would fade away as is frequently seen in patients with subcortical aphasias. The patient learned to participate in the techniques used in psychotherapy after a single explanation by the psychologist. The patient was seen for psychotherapy for a period of 15 months in which 25 therapy sessions occurred using both of the techniques mentioned above. When the decision tree was used, the patient was asked to identify issues that were of
concern to him or about which he wished to communicate. The decision points were read to him and he made his selection by nodding. Using the decision tree, the patient was able to distinguish people vs. environment, himself vs. others, hospital vs. outdoors, and physical conditions vs. emotions. After the last decision point or node was reached, the patient was presented with a simple list of items from the relevant area of concern (Fig. 1). The second technique used was a decimal rating scale. The patient was able to report values from 1 to 10 by holding up the appropriate number of fingers of his right hand either once (1-5) or twice in rapid succession (6-10). Levels of anxiety and depression were reported by the patient at 25 therapy sessions. The patient was able to communicate about absolute as well as relative values. He could indicate hours of sleep, number of times outdoors, number of visitors, etc. Anxiety and depression were reported as relative
Person Yourself
Environment Others
Hospital
Other
Physical
Emotional
Spouse
Room
Outdoors
Pain
Happy
Daughter
Light
Career
Above Waist
Calm
Son
Temperature
Sports
Below Waist
Sad
Relative
Privacy
Current Events
Wet
Worried
Friend
TV
Religion
Cold
Angry
Doctor
Wheelchair
Politics
Hot
Afraid
Staff
Bed Position
Home
Position
Anxious
Patient
Window Blinds
Headache
Depressed
Curtains
Breathing
Tired
Music
Spasms
Bored
Fig. 1. A decision tree for use with aphasic patients. Items from the decision tree were read aloud to the patient. The patient indicated his choice with an affirmative nod.
259
M.R. Cohen / NeuroRehabilitation 11 (1998) 255-260
values on a scale from 1 to 10 with 1 representing the lowest possible intensity and 10 representing the highest.
other. Clinical observations confirmed that increased anxiety tended to occur in the presence of medical diagnoses with uncomfortable physical symptoms. Increased depression tended to occur when opportunities for social interaction were fewer, for example when winter weather reduced visits with friends or relatives. Values for anxiety and depression fluctuated during the course of psychotherapy and thus are not necessarily lower at the end of the 25 sessions. When queried, the patient reported that he did find the sessions to be helpful for reducing anxiety and depression and for increasing his sense of well being. The patient's reported values for each session are shown in Fig. 2.
3. Results The patient reported a wide variety of issues which concerned him using the decision tree. These included items as diverse as spasms in his legs, wanting the window curtains closed, and expressing sentiments toward various people. His reported values for anxiety ranged from 1 to 10 and for depression from 2 to 10 across the 25 sessions. Means and standard deviations for the two variables were calculated: for anxiety, mean = 5.92, S.D. = 2.41; for depression, mean = 6.20, S.D. = 2.35. A Pearson product-moment correlation was pedormed for the anxiety and depression values at each of the 25 sessions, with n = 25, dJ. = 23, r = 0.24, P < 0.20. The results were non-significant suggesting that the patient experienced anxiety and depression independent of each
4. Discussion Used in conjunction, the decision tree and the rating scales were an effective means of communicating with, assessing and conducting therapy with a patient with aphasia who otherwise had
___ Anxiety
T\"
10
~,
EoR
EoR
,.:'
E 8
9
10
11
12
13
14
15
16
....... Depression
.':~".
E = Event R = Recommendation
E
EoR 17
18
19
20
21
22
23
24
25
Session
Fig. 2. Anxiety and depression ratings for 25 therapy sessions. Also shown are sessions when recommendations were made and acted upon by the patient as well as when events occurred that affected the patient's mood.
260
M.R. Cohen / NeuroRehabilitation 11 (1998) 255-260
great difficulty in expressing concerns and emotions. The patient's medical condition was complex and his illness was chronic, placing him in a category where anxiety and depression are likely to be recurrent. Use of the two techniques allowed the patient to communicate with less effort and less frustration. Problems were more readily identified and interventions could be more quickly implemented. The patient remained stable in his cognitive abilities during the course of therapy with fluctuations in mood associated with external events and fluctuations in physical symptoms. Therapy continued for 15 months until a second stroke led to the patient's death. The knowledge derived from these sessions suggested that other patients could potentially benefit from the use of the same or similar techniques. For may types of patients, use of the decision tree would potentially increase the speed and efficiency of communication between the patient and staff. Future research may test the use of the decic sion tree and rating scales as outcome measures for patients with the potential to improve physically and psychologically. The use of these techniques should also be trialed with patients who have less education or a lower level of intellectual functioning to see what may be applicable in a more extensive patient population. While recognizing that this was a somewhat rare case, nevertheless, the techniques used in therapy have the potential to be helpful to a variety of patients who are dysphonetic. The analysis of data was done on a post hoc basis with only one subject so additional research needs to be done for the results to be generalizable. The reporting of this case study will hopefully encourage other clini-
cians to utilize the concurrent use of the rating scales and the decision tree with their patients. References [1] Damasio AR. Aphasia. N Engl J Med 1992;326:531-539. [2] Goodglass H, Kaplan E. The assessment of aphasia and related disorders. 2nd ed. Philadelphia: Lea and Febiger, 1983. [3] Reitan RM. Aphasia and sensory perceptual deficits in adults. South Tucson: Neuropsychology Press, 1984. [4] Kirk A,. Kertesz A. Cortical and subcortical aphasias compared. Aphasiology 1994;8:65-82. [5] Adams RD, Victor M. Affectations of speech and language. In: Principles of neurology. 4th ed. New York: McGraw-Hill, 1989:377-395. [6] Holland AL, Halper AS. Talking to individuals with aphasia: a challenge for the rehabilitation team. Top Stroke Rehabil1996;2:27-37. [7] Adkins ER. Nursing care of clients with impaired communication. Rehabil Nurs 1991;16:74-76. [8] Geddes JML, Chamberlain AM. Improving social outcome after stroke: an evaluation of the volunteer stroke scheme. Clin Rehabil 1994;8: 116-126. [9] Towle D, Lincoln NB. Development of a questionnaire for detecting everyday problems in stroke patients with unilateral visual neglect. Clin Rehabil 1991;5:135-140. [10] Ahlsen E. Body communication as compensation for speech in a Wernicke's aphasic - a longitudinal study. J Commun Dis 1991;24:1-12. [11] Keenan lE, Barnhart KS. Development of yes/no systems in individuals with severe traumatic brain injuries. ACC Augment Alternat Commun 1993;9:184-190. [12] Coelho CA. Acquisition and generalization of simple manual sign grammars by aphasic subjects. 1 Commun Dis 1990;23:383-400. [13] Berde S, Johnson P, Rodrigues H, Johnson K. Providing individualized services: a traumatic brain injury case study. NeuroRehabilitation 1996;7:223-230. [14] Quinlan JR. Decision trees and decision making. IEEE Trans Syst Man Cybern 1990;20:339-346.
