Mental Health Disorders Following Stroke

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Introduction

So as we know that stroke, or cerebrovascular accident, is particularly characterised by sensory and motor difficulties and which presents as hemiplegia or hemiparesis, leading to difficulty in balance, gait, activities of ADL. (Activities of Daily Living) So now what happens is that we address all of these difficulties, but the mental health aspect remains overlooked. So, as a result of which, what happens that the patient performs poorly in all of these other interventions. And it is very important to identify that this poor performance is because some psychological issues are present which are not been assessed or treated. So psychiatric disorders are very common complications following stroke and which are associated with low quality of life, worsening of treatment outcomes, also increasing the burden on the caregivers, and deterioration of the functional status of the patient.

So neuropsychiatric disorders following stroke also increase the mortality. In this course, I will be talking about three major neuropsychiatric disorders or mental health issues following stroke: post-stroke depression, post-stroke anxiety, and post-traumatic stress disorder. (PTSD) In addition to this some rare disorders, which are not that prevalent, are psychosis and mania. And it can be present in combination of any of these.

Post-Stroke Depression

Description:

Firstly, talking about post-stroke depression or PSD. It is one of the most important neuropsychiatric complications following stroke because it is associated with worsening of treatment outcomes, which leads to social withdrawal of the patient, leads to increase in disability, affects sleep, and cognitive impairments. Also, it increases the burden on the caregivers.

Prevalence:

So it has been found that 33% of stroke survivors show symptoms of PSD and up to 40% of these patients, they remain symptomatic at least for about one year following stroke.

Pathophysiological changes/NT:

Clinical Features:

So moving on, clinical features. First and foremost is a depressed mood. The second is anhedonia. Anhedonia is the term which is used to refer a depressed mood. Also with lack of interest or lack of interest or lack of pleasure in activities which were previously enjoyable to the patient, recreational activities the patient used to enjoy but now does not. Lack of energy. Reduced concentration. Now these things are very important when we are going on for cognitive rehabilitation for the patient because this reduced concentration is going to affect the cognitive rehabilitation part. Lack of energy is going to affect your motor rehabilitation part. Then the next is psychomotor retardation. So psychomotor retardation is associated with slow speech, slow movement, and impaired cognition. So this is all going to have a lot of effect on physical therapy and occupational therapy interventions. The next is anorexia. That is lack of appetite which eventually leads to weight loss. Then insomnia. Some patients also present with hypersomnia, that is excessive sleep. Guilt. The patient is continuously guilty that they're dependent on caregivers. There is low self esteem and suicidal thoughts.

Post-stroke depression has been divided into three major categories. So the first category is that the patient should have at least five of the previously described clinical features for about two weeks or more. So the patient's fall in category one. Category two is that the patient meets some of the previously mentioned clinical features, but they do not have major depressive episodes. So that is what it is. And they have these features on and off, but no major depressive episodes. The last one is, there is a combination of depression with mania.

Preventative measure:

Talking about the clinical course of PSD, the South of London Stroke Registry has defined that PSD begins about within one year following stroke and the recovery rate with the patients who encounter post-stroke depression is quite affected by post-stroke depression, and the recovery is moderate in about 15 to 57% of these patients. The chances of recurrence are about 38% at two years, and about 100% at about 10 to 15 years following stroke. It is interesting to note that post-stroke depression increases the mortality up to five years and this is very common in young patients, young in sense, individuals with less than 65 years of age because They are more independent and after stroke, they are quite more dependent on their caregivers which hamper the psychological health of these patients. And this is independent of any other factors such as smoking, alcohol, or other comorbidities, or social support. So this data is independent of all those things. So that was about post-stroke depression.

Post-Stroke Anxiety

Description:

These patients have a very poor prognosis because they tend to restrict themselves. Because of the anxiety, they tend to restrict themselves a lot and this hampers their social participation sometimes also their participation in the rehabilitation. Now what happens is that anxiety or post-stroke anxiety is of three types. The first is generalised anxiety. The next is social anxiety. That is when the patient is among a group of people. The next is phobia, particular fears. And the next, the last one, is panic disorders or panic attacks.

Prevalence:

Now talking about post-stroke anxiety, which is a very common psychological complication, and the prevalence is up to 20% in the first month of stroke, and which increases up to 24% six months following stroke.

Pathophysiological changes/NT:

Clinical Features:

Now, clinical features, it is very interesting to note that patients with post-stroke anxiety show a lot of physiological features. So there is a physiological arousal which is manifested as increase in heart rate, dizziness, tense muscles, tingling and numbness in hands and feet, headache, chronic muscle spasm, and joint pain. The next is sleep disturbances, particularly insomnia. Avoidance of stress is basically avoiding particular stressors, right? The stressors can be different for different patients, like sometimes going to a social gathering or sometimes doing a particular motor activity, which the patient is not able to do and the patient is stressed while doing that. That is avoidance of stress, avoidance of that particular stressor. Then disruption in cognition. The patient has quite flight of thoughts. There is a persistent worry, like the patient is continuously worried and these worries are associated with unpredictable outcomes of stroke, which are not actually going to happen, but the patient is quite worried that, what if this happens? What if that happens? Right? So avoiding crowded places and even avoiding sexual intercourse, the patient is anxious about these things. The patient is very anxious about going out alone. Also, being at home alone. So the patient is quite anxious about these things. Travelling in public transport. Now, one of the major feature, or contributing feature, of all of these clinical features is that the patient has a continuous anxiety that the stroke will reoccur. There is a reoccurrence of stroke. The patient continuously worries that the stroke is going to happen again. So that is what is associated with post-stroke anxiety.

Preventative measure:

Post-Traumatic Stress Disorder in Stroke

Description:

The next is post-traumatic stress disorder. So DSM-V, that is Diagnostic and Statistical Manual of Mental Health Disorders, fifth edition defines post-traumatic stress disorder as a stress-related disorder which comprises of a cluster of four symptoms. The first is intrusion, the next is avoidance, negative alteration in cognition and mood, and alteration in arousal and activity. So the patient has a feeling of intruding and intrusion, right. And the patient continuously in this intrusive feeling, the patient has continuous flashbacks and memories associated with stroke, that I was admitted, and I had so much of IV (intravenous) lines. Or when the patient had stroke there was a loss of consciousness, or what the patient actually felt while having a stroke attack, or following the hospitalisation and the course. So that is intrusion. Avoidance and negative alterations are associated with these things. A psychological trauma is a key feature of PTSD. And now what happens is when we talk about psychological trauma, the patients, the inpatients, are more prone to this because they're hospitalised, a lot of tests are going on. They're going for an MRI, there are different type of lines, catheters, the patient is completely dependent. So these create a psychological trauma to the patient.

Prevalence:

Now, it has been found that one out of four patients develop PTSD following one year of cerebrovascular vascular accident or stroke.

Pathophysiological changes/NT:

Clinical Features:

Now, the clinical features of PTSD is, first and foremost, the intrusive symptoms that the patient has dreams, memories or flashbacks of the stroke, followed by hospitalisation, or any bad memory or any difficult memory associated with stroke keeps on coming back to the patient. Persistent avoidance of any particular stimulus that the patient is afraid of. Negative alteration in cognition and mood. All of this is physiologically associated with alteration arousal state of the patient, and the patient is always reactive. There is an increase in reactivity, which is followed by irritability, and anger, and outbursts, and the patient is very much agitated because of this. Now this was all about PTSD.

Preventative measure:

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