Innovations In Clinical Neuroscience

JAN-FEB 2018

A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience

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C A S E R E P O R T 45 ICNS Innovations in Clinical Neuroscience • January–February 2018 • Volume 15 • Number 1–2 A Among stroke survivors, 35 percent develop expressive and/or receptive aphasia, 30 percent develop post-stroke depression (PSD), and seven percent complete suicide. 1,2 Treating PSD is important because of increased risks for all-cause mortality, suicide, recurrent stroke, and worse neurological recovery. 2–7 While studies have indicated that antidepressants and psychotherapy are effective for PSD, 2,3,8 psychotherapy options are very limited for those with comorbid aphasia. Only a few studies/ cases have been reported demonstrating positive results with behavioral therapy, 9 counseling 10 and family therapy. 11 Although the ability to communicate is generally considered a prerequisite for psychotherapy, verbal expression of information is not necessary for eye movement desensitization and reprocessing (EMDR) to be successful. 12 EMDR is a psychotherapy that uses, among other techniques, alternating bilateral stimulation (BLS; e.g., eye movement, auditory, tactile) while patients internally attend to memories, emotions, cognitions, images, and bodily sensations. The blind to therapist (B2T) protocol 13 was developed for those unwilling/ unable to describe memories during EMDR due to control, shame/embarrassment, cultural reasons, or language barriers. Though EMDR is effective for depression, 14–16 PubMed, PsycINFO, EMDRIA, and Ingenta Connect searches did not reveal any articles about EMDR in those with comorbid aphasia. We aimed to determine if our patient with PSD could benefit from EMDR despite severe expressive aphasia. CASE REPORT Participant . Written consent for this case report was obtained from the patient, who has been anonymized. "Philomela," a 50-year- old right-handed woman with depression onset after stroke—and no evidence of prior psychiatric symptoms—suffered a left middle cerebral artery stroke resulting in hemiplegia and Broca's aphasia (both implicating frontal lobe). Based on formal speech pathology assessment, she had severely impaired functional spontaneous language skills and written expression and moderately impaired reading and auditory comprehension. Meeting a certified speech-language pathologist 2 to 3 times weekly for seven months, her comprehension difficulties were nearly resolved. However, severe expressive deficits, being wheel-chair bound, anhedonia, and hopelessness led to social withdrawal and dropping out of speech, physical, and occupational therapies. At her first psychiatric appointment—10 months post-stroke—Philomela was dysphoric and mostly used head nods/shakes to communicate with rare "yes"/"no" answers. We discussed diet, exercise, social activity, antidepressants, stroke support groups, and restarting stroke-related therapies. Escitalopram was prescribed because serotonergic antidepressants have been shown to improve PSD and post-stroke neurological recovery 2 and low anti-cholinergic effects, which can potentially worsen neurological deficits compared to others. 17,18 Within weeks, A B S T R A C T While post-stroke depression (PSD) is a common sequelae of stroke, many stroke survivors also have expressive aphasia (i.e., the inability to produce spoken or written language), which limits or prevents treating depression with talk psychotherapy. Unlike most psychotherapy modalities, eye movement desensitization and reprocessing (EMDR) does not require extensive verbal communication to therapists, which might make EMDR an ideal treatment modality for aphasic patients with mental health concerns. The authors present the first known case reporting EMDR in aphasia, describing the treatment of a 50-year-old woman with a history of depression following a left middle cerebral artery stroke. Left frontal lobe strokes are independently associated with both PSD and expressive aphasia. EMDR began two years following the stroke, at which point the patient continued to have persistent expressive aphasia despite previously completing more than a year of speech therapy. Using the Blind to Therapist Protocol, EMDR successfully led to improvement in depressive symptoms and, surprisingly, improvement in aphasia. This case report suggests that EMDR might be beneficial for those with mental health concerns who have expressive communication impairments that might prevent treatment with other psychotherapy modalities. We discuss potential challenges and technical workarounds with EMDR in aphasia, we speculate about potential biopsychosocial explanations for our results, and we recommend future research on EMDR for PSD and other mental health concerns in the context of aphasia, as well as possibly for aphasia itself. Keywords: Stroke, aphasia, depression, EMDR, psychotherapy Wants Talk Psychotherapy but Cannot Talk: EMDR for Post-stroke Depression with Expressive Aphasia by JEFFREY GUINA, MD, and CATHRYN GUINA, BSN, RN, CNRN Dr. Jeffrey Guina is with the Department of Psychiatry, Wright State University Boonshoft School of Medicine in Dayton, Ohio, and the 88th Medical Group, Wright-Patterson Medical Center, Wright-Patterson Air Force Base in Ohio. Ms. Cathryn Guina is with the Neuroscience Institute Stroke Program, Kettering Memorial Hospital in Kettering, Ohio. Innov Clin Neurosci. 2017;15(1–2):45–48 FUNDING: No funding was provided for this article. DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article. CORRESPONDENCE: Jeffrey Guina, MD; Email: jeffguina@yahoo.com.

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