Introduction

Globally, stroke is a prominent cause of adult mortality and morbidity and it results in functional dependence and poor quality of life.1 Stroke is the second commonest cause of death and of disability, as measured by disability-adjusted life-years.2 In India, incidence of stroke is higher than that of western countries.3 According to a recent systematic review, the annual incidence of stroke in India ranges from 152 to 262 cases and the prevalence rate ranges from 44.29 to 559 cases, per 1 lakh population.4

Body cathexis, a concept of body satisfaction, is defined as “the degree of satisfaction or dissatisfaction one feels towards various parts and aspects of his or her own body.”5 It is a measure of one’s perceived body image and an integral component of one’s self-concept. For stroke survivors, a sudden, unexpected, unwanted, and uncontrollable change in the body is often difficult to accept, and they often experience stress, anxiety, social isolation, and depression.6 7 Physical dysfunction caused by stroke could adversely affect the body satisfaction and acts as a major reason for poor psychosocial well-being. Life after a stroke is described as “being plucked and planted somewhere else.”7

Kitzmüller et al found that stroke survivors perceive their body as unfamiliar, unreliable, and fragile.8 Stroke survivors were found to intentionally turn inward and keep themselves away from relationships and external activities. In a cross-sectional study, Keppel and Crowe explored stroke survivors’ self-esteem and perception of their own body image, both of which were significantly negatively affected. The authors found that poor body image contributes to reduced self-esteem and depression among stroke survivors.9 It also hinders the patient’s adaptability to accept permanent changes, leading to frustrations.10 11Addressing these factors is highly essential in clinical practice as poor psychological well-being can impede effective rehabilitation, delay recovery process, and can even adversely affect the caregiver health.12

Perception of poor body image is major issue among stroke survivors; however, this is often overlooked in clinical practice. Evaluating body cathexis and envisaging strategies to improve the self-concept can enhance coping, promote self-identity, foster acceptance, and enhance rehabilitation process. However, there is a paucity of Indian studies on impact of stroke on body cathexis. Hence, we aimed to explore the body cathexis of patients with stroke.

Materials and Methods

We adopted a cross-sectional descriptive survey design to explore the body cathexis of stroke survivors. One-hundred and fifty-one participants from two selected rural areas (Kunnamangalam and Koduvally) of Kozhikode district, Kerala, India, (Fig. 1) were selected using purposive sampling technique. The sample size was decided statistically. The study inclusion criteria were (1) those who had stroke within past 1 year, (2) age 25 to 80 years, (3) those with an ischemic or hemorrhagic unilateral stroke, and (4) modified Rankin Scale (mRS) score of 2, 3, and 4. The patients in the community were identified with the help of physicians, physiotherapists, palliative care nurses, and accredited social health activist (ASHA) workers.

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Fig. 1 Study setting.

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Fig. 1 Study setting.

Data Collection Instruments

For data collection, we used a short demographic and clinical data questionnaire, mRS, and body cathexis scale (BCS).

Results

Discussion

Stroke results in a sudden, unexpected change in the body. These changes in the body are often difficult to accept and may influence one’s perception of body image. The main objective of this study was to identify body cathexis of stroke survivors. Body cathexis, “the degree of feeling of satisfaction or dissatisfaction with the various parts or processes of the body,” was measured using the BCS.17 The patients were asked to rate on a five-point scale, their perception of satisfaction (or dissatisfaction) toward the different parts, or functions of their body. The mean age of the participants in the present study was 64.58 years. The majority of participants were males (53.6%), had an ischemic stroke (76.2%), and with left-sided brain lesion (75.5%). The duration of stroke was less than or equal to 6 months for 51.7% participants. The overall mean (SD) BCS scores was 190.09 (5.04). Major areas of dissatisfaction among stroke survivors identified were energy level (98%), wrist (88.1%), elimination (86.1%), fingers (76.2%), and arms (73.5%). The perception of body image was not affected by factors like the gender, duration of a stroke, and side of the lesion.

Our study found that stroke survivors experience disturbances in the perception of body image. These findings are supported by several qualitative studies and a couple of cross-sectional studies. Kitzmüller et al reported that participants perceived their body to be unfamiliar, unreliable, and fragile, and their sense of self is often threatened by negative judgments from others.8 Another study by Timothy et al found that stroke survivors experience problems with self-identity and this could result in dissatisfaction with life, anxiety, and negative emotions.22 In a cross-sectional study, Keppel and Crowe explored the stroke survivors’ self-esteem and perceptions of body image, which were found to be significantly negatively affected. The poor body image was found to be related to low self-esteem. Stroke patients were found to exhibit social withdrawal due to an increased sense of vulnerability.9

It was noteworthy to observe that there was a high variation among satisfaction with the upper and lower extremities. Participants were found to be more dissatisfied with their upper limb and its function. This might be due to the fact that upper limb hemiparesis causes disturbances in performing the activities of daily living (ADL) like eating, brushing, washing, bathing, grooming, and in performing tasks like reaching, grasping, and manipulating. These findings concur with the findings of Kwakkel et al, who described that upper limb hemiplegia was prevalent in 80% of stroke survivors after stroke.23 On the other hand, in the present study, all participants were satisfied with body parts that are not directly involved in ADL such as hair, face color, distribution of body hair, ears, nose, eyes, chin, neck, shape of the head, back view of head, forehead, lips, teeth, trunk, sex, skin texture, height, and their age.

Patients should be given chances to reflect on their own body, their experiences, and perceptions, so as to promote self-identity and acceptance. Redefining of self-identity is necessary to cope up with the disability caused due to stroke. Early identification and managing problems with self-image could enhance their psychosocial well-being and aid in successful rehabilitation. Hence, the assessment of body image could be considered during stroke rehabilitation.

Study Strengths and Limitations

The study was undertaken as a rural community-based study. Most of the studies addressing body image of stroke patients were qualitative in nature,8 22 24 and hence, to have complementary quantitative evidence, we undertook a cross-sectional survey.

There are certain limitations to our study. Body image could change over time in stroke. A longitudinal assessment of body image from acute to chronic stage of stroke is not addressed here, and exploration of which could have been meaningful. The study sample was recruited from a small community setting, which may limit the external validity of the study. Perception of body image could be related to other factors such as depression, anxiety, and self-esteem. However, we could not assess them during this study.

Conclusions

This study contributes to our understanding of body cathexis among stroke patients. Stroke survivors are found to experience disturbances in body image due to low energy levels, poor functioning of upper extremities, and disturbed elimination patterns. Poor body image can lead to anxiety, depression, poor quality of life, and can impede effective rehabilitation. Hence, assessing the body image and envisaging strategies could enhance the biopsychosocial well-being and rehabilitation outcomes of stroke patients.