Emotionalism is a distressing condition in which voluntary control over emotional expression is lost or reduced. It occurs in 10-20% of patients following stroke and is therefore a significant problem in stroke services. The disorder commonly co-occurs with depression and there is a proposed aetiological relationship between the two conditions. There has been relatively little research on the association between these conditions to date and such investigation is complicated by difficulties in the definition and measurement of emotionalism. The primary aim of the present study was to investigate both the differentiation of emotionalism and depression and the relationship between them. Additional aims were to examine a potential relationship between emotionalism and anxiety and provide information on the psychometric properties of the emotionalism measures used. A cross-sectional questionnaire design was used to assess emotionalism, depression and anxiety in an opportunity sample of 60 participants, in stroke-care services. Analyses were conducted to assess the emotionalism measures and examine the associations between the study variables. The results suggest that the measures of emotionalism and depression did not confound the conditions and were measuring separate constructs. Both depression and anxiety were found to be positively correlated with emotionalism. It was also demonstrated that emotionalism occurred alone and in combination with depression in this sample. The findings support the opinion that psychological variables are important to an understanding of emotionalism, both in relation to its aetiology and for the development of psychological interventions. Clinical implications of the findings and directions for further research are therefore discussed.

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Emotional distress is common after stroke and has a negative impact on rehabilitation outcome. The aim of this thesis was to identify factors relating to emotional distress after stroke to inform future interventions. This thesis developed a theoretical framework to guide the study of emotional distress and included stroke and demographic characteristics, background information, disability (personal and extended activities of daily living and aphasia) and psychosocial factors (coping, locus of control and social support). This thesis consisted of three studies. The first study developed and validated the Stroke Cognitions Questionnaire Revised (SCQR), as previous studies used cognitions assessments not appropriate for this population. The SCQR assesses the frequency of positive and negative stroke-related cognitions. The scale was developed from treatment notes of depressed stroke patients. The scale had high internal consistency, inter-rater and test retest reliability, and concurrent validity. Depression (Beck Depression Inventory; BDI) was characterized by a preponderance of negative cognitions and, to a lesser extent, a decrement in positive cognitions. This supports the cognitive model of depression. The second study evaluated factors that predicted the severity of depression in a sample of 112 depressed patients recruited to a randomised controlled trial of cognitive behaviour therapy between one and six months post-stroke. Communication impairment (Sheffield Screening Test for Acquired Language Disorders; SST) at recruitment was predictive of severe depression (BDI) at recruitment. Patients with greater communication impairment (SST) and a more external locus of control (Recovery Locus of Control Scale; RLOC) at recruitment were more likely to remain depressed at six months follow-up. Patients who remained depressed at follow-up were more severely depressed at recruitment. The main study of this thesis evaluated the proposed theoretical framework of emotional distress. In a prospective longitudinal study, 100 patients were recruited from hospital at one month post-stroke and assessed on communication (SST), personal activities of daily living (ADL; Barthel Index), distress (Visual Analogue Mood Scales, Visual Analogue Self-Esteem Scale and Stroke Aphasic Depression Questionnaire). Patients who were not aphasic completed additional assessments of distress (Hospital Anxiety and Depression Scale, Beck Depression Inventory II), recovery locus of control (RLOC), coping (Brief COPE) and cognitions (SCQR). Patients were reassessed on the same measures at six months (n=92), in addition to extended ADL (Extended ADL Index) and social support (Significant Others Scale; SOS). Communication impairment and dependence in personal ADL were predictive of distress at one month. Communication impairment and dependence in extended ADL were predictive of distress at six months. In non aphasic patients, externality of locus of control was also predictive of distress at one months and six months and actual social support was predictive of distress at six months. The relationship between coping and distress was mediated by locus of control. Distress remained persistent at six months post-stroke. The factors found to predict distress (communication impairment, recovery locus of control and activity level) will help identify patients at risk of distress. Also, this demonstrates the need to include aphasic patients. The risk factors are amenable to psychological intervention, such as cognitive behaviour therapy and coping skills training. Future research should evaluate the proposed interventions.