Patients’ strategies of coping with stress after stroke

Introduction

Modern society is grappling with a variety of crises that present challenges for humanity and contribute to the prevalence of stress. Stress is a natural physiological response that arises when there is an imbalance between demands and an individual’s capacity to manage them. This phenomenon is essential for human development as it prompts full mobilisation, facilitates decision-making, and helps overcome potential obstacles. The concept of stress and significant contributions to its research have been attributed to Canadian endocrinologist Hans Selye, who is often referred to as ‘the father of stress’ [1, 2].
A distinction is drawn between positive stress (acute, eustress) and negative stress (chronic, distress). Acute stress is short-term and acts as a driving force, helping to address challenging situations. In contrast, chronic stress is long-term, arises in emergencies, and can lead to mental or somatic disorders and the onset of disease. While an increase in stress levels can be beneficial, surpassing the optimal level renders stress harmful [2, 3].
It is often observed that a particular stressor may trigger stress in one person, while another person may remain unaffected. This difference in reactions arises because the situation itself does not inherently cause stress; rather, it is the individual who assigns it a positive or negative meaning. There is a subjective evaluation of the events experienced, which involves a primary assessment – evaluating the significance of an event for the individual – and a secondary assessment, which involves judging a person’s ability and resources to cope with the stressors. Physiological and psychological reactions occur when an individual evaluates an incident in terms of risk, challenge, damage, or loss [2, 4–9].
The research contributions of Lazarus and Folkman have significantly advanced our understanding of stress and the methods for managing it. Coping with challenging stressful situations involves secondary assessment and encompasses process, strategy, and style. According to Lazarus and Folkman, the process of coping with stress is defined as “the cognitive and behavioural efforts of a subject to cope with specific external and internal demands judged to exhaust or exceed the resources of the individual” [10]. Strategies are characterized as typical actions or ways of managing given stressful situations. The style of coping with stress is described as a permanent and characteristic personality disposition aimed at eliminating or reducing stress by contending with the occurring stressors [4, 7, 10].
Every day, individuals face numerous stressors, but not everyone is equipped to manage them effectively. The variety of coping strategies is influenced by factors such as age, perception of a situation, lifestyle, life experiences, and the sense of control over the circumstances. While sudden stressful events are unavoidable, being aware of how to control the stress response can help mitigate the negative effects of stress. Methods for mastering and controlling stress include gaining experience, gradually acclimating to the stressor, seeking information about stressors, and employing appropriate strategies for managing stress. A negative attitude and inability to handle stressors can lead to uncontrolled stress, which in turn increases the likelihood of disease. It is crucial to recognize that while disease can be a stressor, chronic stress can also lead to disease. For instance, persistently high blood pressure over an extended period in someone experiencing consistently the high level of stress can result in uncontrolled hypertension, potentially leading to a heart attack or stroke [2, 11–14].
Stroke represents a significant neurological and societal challenge, as it ranks among the leading causes of morbidity and mortality and frequently results in permanent disability. The likelihood of experiencing a stroke increases with age [12–15]. A key prognostic indicator for stroke is a transient ischaemic attack (TIA), characterised by a temporary disruption of blood flow to specific brain regions lasting no more than 24 hours. It is estimated that nearly half of the patients who experience a TIA will suffer a full stroke within 5 years [16].
Following a stroke, patients often experience mental tension and face both somatic and psychological challenges, including memory impairment, slowed thinking, and mental disorders such as anxiety or post-stroke depression (PSD). PSD is among the most prevalent neuropsychiatric complications, affecting approximately one-third of stroke survivors [12, 13, 15, 17].

Clinical rationale for the study

The most effective way to restore a patient’s physical and mental efficiency after a stroke is through rehabilitation. Unfortunately, stress is not routinely addressed in clinical practice. In terms of health recovery, rehabilitation efforts primarily focus on motor disabilities and speech and language deficits, while psychological stressors are often neglected and omitted. The best outcomes are achieved when prompt treatment is combined with early and comprehensive rehabilitation, incorporating various methods of maintenance psychotherapy and strategies against depression. To effectively cope with stress, it is essential to understand its mechanism of action and be aware of the possibility of controlling the stress response, as well as strategies to alleviate the negative effects of stress activity [12, 13, 15, 17–19].

Aim of the study

The aim of the present study was to assess the perceived stress and strategies of coping with stress by patients after stroke. The following specific objectives have been set: Measuring the severity of stress induced by illness in the last month and examining the statistical relationship with gender and age.
Determining the frequency of undertaking stressful activities by gender and age.
The assessment of typical ways of reacting in situations of experiencing severe stress by patients after stroke and the determination of statistical dependence on age.
Exploring the relationship between the overall stress intensity and strategies for coping with stress.
Exploring the connection between the hemisphere of the brain affected by a stroke (left or right) and the perceived stress levels, as well as the coping strategies employed.

Material and methods

The study was conducted among patients after stroke treated in the Rehabilitation Department, including the Department of Neurological Rehabilitation of the Podkarpackie Voivodeship Hospital. A response was received that ethical approval was not necessary for the preparation of this article. The inclusion criteria included patients who have suffered a cerebral stroke and, according to the Depth of Dementia Rating Scale, the Mini-Mental State Examination Scale (MMSE), who received a minimum of 24/30 points, and agreed to participate in the study. In turn, the exclusion criterion was speech disorders (aphasia), hearing disability, and dementia, i.e. the respondents were excluded from the study who obtained ≤ 23 points in the MINI-MENTAL Scale. From April 2019 to December 2022, 344 respondents were examined. From this pre-selected group of patients after stroke, after application of the exclusion criteria, a group of 143 persons was excluded. Ultimately, therefore, the work was based on a study of a group of 201 respondents, consisting of 87 (43%) women and 114 (57%) men, including 188 patients after ischaemic stroke and 13 patients after haemorrhagic stroke.
To determine a stroke patient’s eligibility for the study and assess the severity of dementia, the Mini-Mental State Examination Scale was employed. This screening tool evaluates the degree of cognitive impairment in individuals, covering aspects such as orientation to place and time, comprehension, naming, memory, recall, arithmetic, language abilities, reading, and the execution of complex written and oral instructions. Following the evaluation of the patient’s cognitive impairments, the research utilised the following questionnaires (in the Polish version): Perceived Stress Scale-10 – PSS-10, Mini Coping Orientations to Problems Experienced – Mini-COPE.
The PSS-10 (Perceived Stress Scale-10), developed by Cohen, Kamarck, and Mermelstein, is used to assess perceived stress related to personal issues, behaviours, and the burdens of life situations experienced over the past month. It comprises 10 questions, each with a corresponding 5-point response scale ranging from ‘never’ to ‘very often’. The PSS-10 score is the sum of all the scores from the questions, with a maximum of 40 points. To interpret the overall indicator, the adopted tens standards were used. A higher score indicates a greater severity of stress experienced [4].
The Inventory Mini-COPE (Mini Coping Orientations to Problems Experienced), developed by Carver, is a tool designed to assess situational coping mechanisms for stress. It comprises 28 statements that are categorised into 14 coping strategies: Active coping, Positive revaluation, Planning, Acceptance, Sense of humour, Turning to religion, Seeking emotional support, Dealing with something, Unloading, Denial, Using psychoactive substances, Blaming oneself, and Withdrawal from activities. These strategies are grouped into categories such as problem-focused behaviour, active coping methods, emotion-oriented strategies, or what is termed ‘other behaviour’. Each strategy’s scale is evaluated separately, with the score for a strategy being the sum of the scores of its two constituent statements, divided by 2. The possible score range for each strategy is 0–3 [7].
The questionnaire interview was conducted individually with each respondent.

Statistical analysis

The statistical analysis was carried out using Statistica 13.3 and R 4.2.2 software. To verify the assumed hypotheses, the chi-square test, Fisher’s exact test, and the Mann-Whitney U test were used. Statistical significance was set at p < 0.05. To assess the relationship between the scales (PSS-10, Mini-COPE) and age, Spearman’s rank correlation was used. The study results are presented in tables.

Results

A total of 201 patients were included in the analysis, comprising 87 (43%) women and 114 (57%) men. Among the respondents, the largest group consisted of women over the age of 75 (43.7%) and men aged 66–75 (42.1%) years. The smallest proportion of both women and men were those aged 55 years and under, comprising 6.9% women and 9.6% men. Of the respondents, 70.1% of women and 61.4% of men resided in the countryside, while the smallest percentage lived in towns with fewer than 10,000 inhabitants. The study did not include residents of cities with populations exceeding 100,000 inhabitants. Among the participants, ischaemic stroke was predominant, affecting 95.4% of women and 92.1% of men (Table 1).
Stress levels were slightly higher among men, with 64.9% experiencing high stress, compared to 57.5% of women across all age groups. Only 9.2% of women and 5.3% of men exhibited low stress levels (Figure 1). The highest incidence of high stress was found in participants aged 55 years and under, at 70.6%, while the lowest was in the 56–65 age group, at 55.8%. On average, about 6–8% of participants across all age groups reported low stress levels (Figure 2).
The women in the study achieved the highest median values on scales indicating a preference for emotion-focused strategies, such as Turning to religion or Seeking emotional support, as well as the problem-oriented strategy of Acceptance. Among the men, the most commonly chosen strategies were Acceptance and, additionally, Active coping with stress. Notably, no participant indicated Using psychoactive substances as a stress-coping strategy. Similar to the women, the men in the study recorded the lowest median values on scales indicating a preference for ‘other behaviour’ strategies, such as Sense of humour and Withdrawal from activities. Additionally, men rarely chose Denial as a strategy (Table 2).
Regardless of age, stroke patients most frequently opted for strategies of Acceptance and Seeking emotional support, while they were least inclined to adopt avoidance-oriented strategies for coping with stress, such as Sense of humour or Withdrawal of activities. Additionally, individuals under 65 years old were equally likely to engage in Active coping with stress, whereas those over 65 often preferred Turning to religion. Respondents aged 55 years and under seldom indicated Denial as a strategy (Table 2).
The age of the study participants influenced how often they opted for problem-oriented strategies, such as Active coping, Planning, and Positive revaluation. This relationship was negative, indicating that as the participants’ age increased, their use of these strategies decreased. Additionally, age had a statistically significant impact on the frequency of employing emotion-focused strategies, like Turning to religion or Denial. However, these correlations were quite weak, and for the strategy of Turning to religion, no linear relationship was observed. The effect of age on strategy choice was also evident in the so-called ‘other behaviours’ (Sense of humour, Withdrawal from activities). For the Sense of humour strategy, the relationship was negative, whereas for Withdrawal of activities, it was positive (Table 3).
It was shown that as perceived stress levels increased, the frequency of using strategies such as Active coping, Planning, Positive revaluation, Seeking instrumental support, Denial, Unloading, and Blaming oneself decreased. Nonetheless, the strength of the relationship for these strategies was very weak (Supplementary Table S1).
Analysis revealed a statistically significant association between the location of the stroke focus in the left versus the right hemisphere of the brain and the respondents’ coping strategies for stress, such as Sense of humour, Unloading, and Blaming oneself. These strategies were slightly more common among patients who experienced an ischaemic stroke in the right hemisphere. However, the median values (Me = 1, and for Sense of humour, Me = 0.5) suggest that these coping methods are generally infrequently used (Supplementary Table S2).

Discussion

Numerous studies have demonstrated a cause-and-effect relationship between stress and disease conditions, with some diseases showing this link in 80–90% of cases [2, 12–14]. Adjusting to a serious illness involves accepting many changes, and the diagnosis is often associated with life-threatening experiences, which, according to stress theory, can become significant sources of stress [20]. Conversely, stress itself can lead to various diseases. The ever-increasing challenges of modern civilization contribute to chronic stress, which in turn fosters the development of diseases of civilization, such as heart disease, cancer, stroke, depression, and addictions [20–23]. Stroke, a neurological disease, has numerous adverse health effects, with reduced mobility being the most noticeable consequence, often exacerbating stress levels. Individuals with disabilities face numerous challenges, such as the inability to perform basic daily activities or maintain social contacts, which frequently result in emotional instability, diminished self-esteem, and a lower quality of life, ultimately leading to severe stress.
According to this study, most post-stroke patients perceived high stress levels, which is probably mainly due to physical and social limitations and lack of faith in the improvement of health. This is consistent with the findings of previous studies [24, 25]. In the study by Ostwald et al. regarding the stress experienced, the PSS-10 questionnaire was also used. This study describes the stress levels in stroke survivors and spousal caregivers at discharge and at 3, 6, 9, and 12 months and identified predictors of stress in couples. Social support, good health, and coping are associated with less stress [25]. Santosa et al. showed that higher perceived stress was significantly related to more depressive symptoms and less functional independence [26]. Analysing the results of our research, it was found that a high level of stress affects people aged 55 years and under more often than older people. Perhaps it is difficult for them to come to terms with the experience of illness and limitations related to it at a younger age.
The problem of stress and ways of coping with stress are undoubtedly of growing interest to researchers. The most effective and efficient strategies for coping with stress are considered to be problem-focused strategies; whereas, less effective strategies are avoidance strategies and so-called ‘other behaviours’ [27]. A study on a group of women with breast cancer showed that coping with stress through an emotional approach was significantly associated with stress reduction and with improvements in the subjective assessment of health; however, after three months, there was an increase in stress levels. Coping with stress using emotion-focused strategies can only be effective for a short time [7, 28]. In this study, the respondents most often declared the use of an adaptation strategy, meaning accepting the situation, and just as often emotion-focused strategies (Turning to religion, Seeking emotional support). The experience of illness, especially among older people, often urges them to find solace in their religion and seek social support. The least frequently indicated strategies were those involving giving up efforts to achieve a given goal (Sense of humour, Using psychoactive substances, Withdrawal from activities). The experience of illness may have influenced the addiction. In the conducted study, correlation analyses showed that the older the age of the participants, the less often Active strategies or Sense of humour were undertaken. Perhaps the reason for choosing such ways of coping with stress was physical limitations, which prevented active coping with stress, as well as the poor mental condition of some patients, which led to a lack of a sense of humour.
Various causes of stress have been described in the literature. After stroke, patients are often dependent, which was also observed in patients participating in this study. Rai et al. indicated that among the respondents with disabilities, the highest scores were seen for Avoidance coping, while the lowest score was seen in strategic of Planning [29].
We examined the relationship between stroke focus in the left and right brain hemispheres and strategies to cope with stress. A statistically significant relationship was found between the location of the stroke and the strategies undertaken by the respondents. The listed ways of coping with stress were slightly more often taken up by participants after an ischaemic stroke of the right brain hemisphere. However, these strategies have rarely been implemented. This is probably because, in the case of a stroke of the left brain hemisphere, language difficulties and logical thinking problems occur, so a stroke occurring in this location of the brain could deprive the patient of these skills. However, when stroke affects the right brain hemisphere, there are more frequent problems with understanding contexts, speech, receiving allusions, and imagination, so that the jokes and contexts are understood. Perhaps this is why these patients rarely cope with stress through a sense of humour and jokes. Despite the dominance of the left brain hemisphere in the regulation of language functions, Syta’s study confirms the important role of the right brain hemisphere in specific speech disorders, termed as pragnosia, including dysfunctions in perception, difficulties in understanding language jokes, and the realisation of prosodic aspects of speech [30].
After stroke, patients may not engage in coping strategies because of limitations related to the disease. Summarising the existing research on coping with stress after stroke is a difficult task. The reason for this is the small number of studies conducted among this clinical group as well as variations in the choice of research tools. The main reason is perhaps that the chosen research group is specific, and there are some exclusion criteria. This study was conducted through individual contact with each patient. In most cases, it cannot be performed in any other way because of physical limitations and their implications. In some cases, this was a cause of embarrassment and restraint for the patient due to the inability to write down the answers themselves and some awkward questions. Some participants withdrew from the study because the questions were sometimes difficult for them or because they were tired of the long duration of the study. Another important aspect that prevented the study from being conducted for approximately a year was the occurrence of the COVID-19 pandemic, which resulted in the study being completely suspended, and subsequent repeated restrictions during the pandemic.

Conclusions

The following conclusions were drawn from the study: Most patients with cerebral stroke experience high levels of stress. After stroke, women most often preferred problem-focused stress management strategy, such as Acceptance and emotion focused strategies, such as Turning to religion or Seeking emotional support. Men most frequently reported strategies for coping with stress, such as Acceptance and Active coping. Respondents were least likely to indicate undertaking strategies, such as Using psychoactive substances, Sense of humour, and Withdrawal of activities. The older the age of the patient, the less frequent the use of problem-focused strategies (Active coping, Planning, and Positive revaluation) and the more frequent the selection of emotion-focused strategies (Turning to religion or Denial). The higher the level of perceived stress, the less frequently the following strategies were used: Active coping, Positive revaluation, Planning, Seeking instrumental support, Unloading, Denial, and Blaming oneself. A statistically significant relationship was confirmed between the location of stroke (left vs. right brain hemisphere) and some of the strategies used to cope with stress (Sense of humour, Unloading, Blaming oneself).

Funding

No external funding.

Ethical approval

Not applicable.

Conflict of interest

The authors declare no conflict of interest.