Catastrophic reaction

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The sudden onset of anxiety, tears, aggressive behavior, swearing, displacement, refusal, denouncement, and compensatory boasting constitute a syndrome referred to by Goldstein (1948) as a catastrophic reaction (CR). Goldstein believed that this syndrome represented a response to the inability of an organism to cope when faced with a serious defect in their physical or cognitive function. These emotional outbursts would generally last only a few seconds and were usually associated with a stressor, such as a demanding, cognitive examination or a request to perform a task. Gainotti (1972) was the first investigator, to my knowledge, who systematically studied CRs in patients with stroke or other causes of brain damage. Gainotti examined 160 patients with brain injury due to stroke, traumatic brain injury or other causes. Eighty patients had left-sided lesions and 80 patients had right-sided lesions. Of those, 53 had vascular lesions of the left hemisphere and 58 vascular lesions of the right hemisphere. When the presence of CRs was compared between patients with left and right hemisphere lesions, patients with left hemisphere lesions had significantly greater frequency of anxiety reactions, tears, swearing, refusal, and renouncement. He noted that patients with Broca's aphasia were particularly prone to developing CRs with 68% of these patients showing outbursts of tears during the examination. Gainotti believed that both psychological and physiological factors played a role in the development of the depressive/CRs. In patients with Broca's aphasia, he believed that inactivation of a physiological mechanism such as cortical control of emotional discharge was the main determinant of a CR. On the other hand, among patients with anomic aphasia, tears appeared long after the patient showed increased anxiety and failure at verbal communication which Gainotti hypothesized led to a psychological cause for the CR and response to disability. It should be remembered that in this Gainotti study, the nature of the brain injury ranged from neoplastic to traumatic and there was great variability in the time since injury to examination. Thus, these mechanistic hypotheses are, at best, highly speculative.

Subsequently, Gainotti (1989) suggested that patients diagnosed with poststroke depression were actually having CRs. According to this hypothesis, the CR had been triggered by the stress of the examination, leading the patient to report more depressive symptomatology than they actually experienced and subsequently an inappropriate diagnosis of poststroke depression when the underlying disorder was a CR.

In an effort to examine the frequency of CR and its relationship with depression, we developed a CR scale (Starkstein et al. 1993) which is shown in Table 36.1. Patients who were assessed using the anosognosia and denial of illness scales were also assessed by the CR scale. A total of 70 patients were investigated in this way, but 8 of them were excluded because of a prior history of cerebrovascular lesion (n = 5) or comprehension deficits on the token test (n = 3). Most of the items on the CR scale were selected from Gainotti's and Goldstein's reports on the CR. The neurologist who administered the CR scale was blind to the findings of the psychiatrist who conducted the present state examination for assessment of depression or anxiety disorders.

The internal consistency of the CR scale was determined by Cronbach's a, which calculates a mean correlation coefficient between each individual item in the scale

Table 36.1. CR scale

1 = Slight (once during the interview)

2 = Moderate (several times during the interview)

3 = Extreme (most of the interview)

1. Patient appeared to be anxious (i.e., patient showed an apprehensive attitude or expressed fears).

2. Patient complained of feeling anxious or afraid (i.e., patient referred to feeling tense or having psychological concomitants of anxiety).

3. Patient became tearful (i.e., patient cried at some point during the evaluation).

4. Patient complained of feeling sad or depression (i.e., patient spontaneously reported sad feelings during the evaluation).

5. Patient behaved in angry manner (i.e., patient shouted, contradicted the examiner, performed tasks in a careless way).

6. Patient complained of feeling angry (i.e., patient reported being upset with the evaluation and/or the examiner).

7. Patient swore (i.e., patient swore at some point during the evaluation).

8. Patient expressed displaced anger (i.e., patient complained about the hospital, doctors, and fellow patients).

9. Patient refused to do something (i.e., patient stopped doing a task or refused to answer some questions).

10. Patient described a feeling of suddenly become depressed or hopeless (i.e., patient reported feeling worthless, sad, and lacking in confidence).

From Starkstein et al. (1993) reprinted with permission.

and all the other items. The CR scale showed a high degree of internal consistency (a = 0.85). Interrater reliability was determined by having a second interviewer present for 10 interviews in order to provide a second rating of the CR scale. The correlation between the raters'total scores on the CR scale was r = 0.91 (p < 0.01).

The background characteristics of the patients included in the study are shown in Table 36.2. CRs occurred in 12 of 62 patients studied (i.e., 19%) based on having a score of 8 or greater on the CR scale. Although there were no significant differences in age, gender, or education, patients with a CR had a significantly higher frequency of familial and personal history of psychiatric disorder than patients without a CR.

A plot of CR scores for all 62 patients showed a bimodal distribution with a cutoff score of 8 separating the two modes. Based on this frequency distribution, patients with CR scores of less than 8 were considered not to have a CR while patients with CR scores ^8 were considered to have CR. Using a step-wise multiple regression analysis to determine which items on the CR scale were most frequently associated with the diagnosis of CR, the CR items which accounted for most of the variance in total CR score were suddenly becoming depressed or hopeless (p < 0.01), expressing displaced anger (p < 0.01), and feeling anxious or afraid (p < 0.01).

There were no significant between-group differences in the neurological findings: motor impairment was found in 92% of the 12 patients with CR and 78% of the 50 patients without CR; sensory deficits were found in 42% of the CR patients and 30% of those without CR; aphasia was found in 25% of the CR patients and 12% of those without CR (p = NS).

Table 36.2. Demographic findings


CR (n = 12)

No CR (n = 50)

Age (years)

57.6 ± 15.4

58.7 ± 13.2

Education (years)

10.7 ± 4.0

10.0 ± 3.1

Gender (% female)



Race (% black)



Alcoholism (% positive)

33 ± 4

18 ± 9

Personal history of psychiatric disorder

33 ± 4

10 ± 5

(% positive)*

Family history of psychiatric disorder

25 ± 3

4 ± 2

(% positive)**

% right-handed

83 ± 10

92 ± 46

Time since stroke (days)

6.3 ± 3.3

6.1 ± 2.9

From Starkstein et al. (1993) reprinted with permission.

From Starkstein et al. (1993) reprinted with permission.

The frequency of depression in the CR and non-CR patients is shown in Fig. 36.1. The frequency of major depression was significantly greater in patients with CR compared to those without CR (p < 0.0001). In addition to the increased frequency of major depression, patients with CR had significantly higher Hamilton anxiety (Ham-A) scale scores and greater impairment in activities of daily living as measured by the Johns Hopkins functioning inventory (JHFI) than patients without CR (Fig. 36.2). Patients with CR, however, were not significantly more cogni-tively impaired than those without CR (Fig. 36.2).


□ Minor depression □ Major depression *p < 0.001

Figure 36.1 The percentage of patients with and without CRs who also have a depressive disorder. There was a significantly greater frequency of major depression but not minor depression, among patients with CRs (data from Starkstein et al. 1993).

Ham-D Ham-A



Figure 36.2 The impairment scores of patients with and without CRs following acute stroke. The patients with CR had more severe depression (Ham-D) and anxiety (Ham-A) symptoms and greater impairment in activities of daily living (JHFI) than patients who did not have CR. Patients with CR, however, were not more cognitively impaired than patients without CR (data from Starkstein et al. 1993). MMSE: mini-mental state examination.

Since there was a significant association between CR and the existence of major depression, we matched patients in the CR and non-CR groups for depression diagnosis to determine whether there were other factors which may be associated with the existence of CR. In each group, there were 10 patients (7 with major, 2 with minor depression, and 1 non-depressed patient). There were no significant between-group differences in age, education, gender, family, or personal history of psychiatric disorder [family history of psychiatric disorder in the CR group 30% versus 0% for the non-CR group (p = NS), prior psychiatric history 20% in the CR group versus 40% in the non-CR group (p = NS)]. There were no differences in neurological findings and there were no significant between-group differences in Hamilton depression (Ham-D) score, Ham-A score, activities of daily living, or mini-mental state examination (MMSE) score.

Of the 51 patients whose brain imaging scans showed a single stroke lesion, patients with CR (n = 9) had a significantly higher frequency of lesions involving the basal ganglia compared to patients without CR (n = 42) (Fig. 36.3). There was no significant association, however, between lesion volume and the existence of CR (CR group 3.1 ± 3.6 SD versus non-CR 8.1 ± 9.4% of brain volume SD, p = NS). The CR group tended to have smaller lesions because they had a significantly higher frequency of subcortical lesions than the non-CR group (i.e., 8 of 9 versus 20 of 42).

Structural brain imaging examination indicated that patients with CR had significantly more anterior lesions (i.e., the distance of the anterior border of the lesion from the frontal pole as a percentage of the total anterior-posterior distance) than their matched pair without CR. The distance from the frontal pole in patients with CR was 28.4 ± 6.0, SD versus 42.0 ± 5.9 (p < 0.01) in those

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