Category: Advancing Modules

Lisa feels that she has made good progress over the last few months. She has been meeting with her employers about returning to work and would like to start a phased return soon.  

Click on the options that you think would be helpful for Lisa at this point:

Pre therapy Lisa’s HADS was: Anxiety: 16/21; Depression: 18/21 

Lisa’s Goals were to:  

• Spend time playing with the kids – baking, playing at the park, art/making things, film nights 
• Socialise with my friends – go out for a meal, go shopping 
• Start running again 
• Take back some of my responsibilities at home from my partner – e.g. plan a break for us as a family at half term 

Match the items on the bottom with the goal reached by Lisa in her post-therapy.

Based on this formulation (shared understanding of why Lisa has been feeling as she has), Lisa has been working on: 

• Discussing with the Stroke Clinical Psychologist how fatigue, anxiety and depression can all impact on cognitive functioning, as well as a stroke. Using strategies to more effectively manage the cognitive demands of tasks in everyday life.  
• Using fatigue management strategies to reduce the impact of fatigue on daily life. 
• Despite thoughts running through her mind that she’s a failure, Lisa has tried explaining to her family and friends more about the invisible symptoms of stroke that she still experiences, and shared information from CHSS, Stroke Association and Different Strokes with them. They were more understanding and supportive than she thought they would be, and have been open to making changes to support Lisa better. 

• Using a graded approach to exercise to help her restart activities that she used to enjoy, both alone and with friends. 
• Using CBT to manage her insomnia. 
• Recognising that the critical voice in her mind isn’t helping her to make the changes that matter to her, and practising being more compassionate to herself so that she can do the things that will help her to live the life that she wants to. This is a particular challenge for Lisa and one that she and the Stroke Clinical Psychologist work on a lot in their sessions together. 

Lisa has been working with the Stroke Clinical Psychologist for 5 months now, and they repeat the outcome measures that they have been using. Lisa’s scores on the Hospital Anxiety and Depression Scale have reduced and just as importantly, she has been achieving some of the behavioural goals that she and the Stroke Clinical Psychologist agreed at the start of therapy. 

Lisa has been meeting with the Stroke Clinical Psychologist regularly for the last two months. Lisa was keen to understand what was happening to her, if there was a name for it or if she was “losing her mind”. The Stroke Clinical Psychologist explained that her symptoms were closest to a diagnosis of Adjustment Disorder, with mixed anxiety and depressed mood.  

In therapy, Lisa and the Stroke Clinical Psychologist have been working on a formulation (shared understanding) of why Lisa has been feeling as she has. They identify that the sudden onset of a serious illness has shaken Lisa’s belief in herself as healthy, fit and capable. Lisa is still experiencing residual symptoms of stroke, including fatigue and sensitivity to noise. This is making it hard for her to do the things she enjoys or be in social situations, so she avoids them. This is leading her to feel isolated and depressed. Lisa experiences high levels of anxiety when she thinks about doing anything physical (e.g. running), which is one of the ways she used to cope with stress. Lisa wants to feel and seem like her “normal self” so she is reluctant to talk to her friends and family about how she is feeling. They seem to think that she is fine, as she doesn’t have any obvious physical impairment from her stroke. This is reinforcing Lisa’s expectations of herself that she should be “back to normal by now” and that she is failing because she isn’t. She often worries about whether she will ever get better, or be able to go back to work, particularly at night. This is making it harder for her to sleep, and so she is even more tired in the daytime. When she has these worries in the daytime, she tries to push herself even harder to get back to her “normal self”, or distract herself by keeping busy, but these strategies tend to lead to her feeling even more fatigued and irritable. At this point, she criticises herself for not being a good enough mother or partner. She feels hopeless and depressed. 

What can the SLN do to support Lisa? Click to choose which options you think are best:

Lisa was contacted by the Stroke Liaison Nurse (SLN) at home within a month of her stroke as part of routine follow up where discussion and advice was given. Lisa felt she was doing well and had no major ongoing concerns at that time and had a lot of support from her family.  

However at 4 months post-stroke and as part of routine follow up the SLN contacted Lisa again and Lisa was very tearful and expressing feeling: 

• Not myself anymore.
• Overwhelmed by emotions.
• Out of control.
• Crying most days. 
• Irritable with family, struggling to cope with noise from children. 
• Struggling with unpredictable fatigue.
• Getting less support from family – “as fine (physically)”. 
• Withdrawing from friends- not able or wanting to do activities with them: noise, fatigue, lack of motivation.
• Don’t want to be a burden to friends. 
• Not doing the things used to enjoy – e.g. running. Anxious about what is capable of due to Fatigue and worrying about the perceived potential to trigger another stroke. 
• Poor sleep – racing mind when trying to fall asleep. 
• Don’t feel  as “sharp” as before. Struggling to process information at speed, switch attention, manage complex tasks.  
• Concerned about ability to return to work. 
• About to go onto statutory sick pay at 6 months – worried about how the family will manage financially. 

  Lisa explains to the SLN that she’s been feeling this way for the last 6 weeks.

Lisa had an ischaemic stroke five months ago. 

She presented to A&E with word finding difficulties, slurred speech and mild right sided weakness. 

Brain imaging showed multiple small infarcts in the left frontal, parietal and insular regions, which were likely embolic in nature.  

Lisa had a short admission to hospital; after 2 days on the ward, the multi disciplinary team (MDT) felt she had made a good recovery, with no residual physical symptoms or activities of daily Living (ADL) impairment and no outpatient rehabilitation was required.