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Psychological Impact of
Stroke
Dr Kiran Hans
St Georges Hospital
Agenda
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Stroke definitions
Psychological disorders after Stroke
The psychological impact of Stroke
3 levels of assessment & intervention
Case examples
References
Stroke definition
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Medical definition:
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“A clinical syndrome of rapid onset of focal or
global cerebral deficit lasting more than 24 hours
or leading to death, with no apparent cause other
than a vascular one”.
Psychological definition:
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“A stroke is a sudden and often traumatic major
life event that usually occurs with minimal warning
and, for many, results in life-changing
consequences” (Donnellan et al., 2006)
Psychological disorders after stroke
Psychological disorders after stroke have been well
documented
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Depression: 35 – 50%%
Anxiety Disorder: 25%
Apathy: 20%
Pathologic affect 20%
Catastrophic reaction: 20%
Mania: rare
Bipolar disorder: rare
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Psychosis: rare
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Why do psychological problems develop?
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Location of brain injury
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Adjustment to sudden life changes
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Or both …
Impact of stroke on self & others
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Physical
Sensory
Communication
Cognitive
Behavioural
Emotional
Impact of stroke on self & others
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Physical
Sensory
Communication
Cognitive
Behavioural
Emotional
They affect many levels -:
 Personal
 Sense of self
 Identity
 Family
 Role change
 Work
 Responsibilities
 Finance
 Society
 Stigma
 Social networks
 Health services
Common psychological difficulties after Stroke
Normal reaction to an abnormal event
 Sad feelings / Low mood
 Sleep problems – not sleeping through the night, restless sleep
 Anxiety – fear of falling, looking out for stroke signs
 Agitation & Frustration
 Worrying about the future – “how will I cope”, “what if it happens again”
This reaction can become persistent, which can lead to -:
 Disengaging with therapy sessions
 Feelings of hopelessness
 Preoccupation with lost skills or roles
 Unable to adjust to loss / changed sense of identity
 Striving for an unrealistic degree of recovery
 Repeated failure leading to loss of confidence
 Strained family relationships
Tyerman (2008)
What to look out for?
Depression
 Feeling sad (verbally or body
language)
 Tearful
 Not engaging in rehab &
generally de-motivated
 Not sleeping well / sleeping too
much or too little
 Less interest in eating / always
eating
 Constantly thinking about what
has happened and asking why
Anxiety
 Unable to relax
 Nervous
 Scared
 Fear of the worst happening /
losing control
 Heart racing
 Panicking
 Quick and shallow breathing
Why assess?
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Assessment helps establish what the problem is
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i.e. mood, dementia, behaviour, etc.
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Early assessment
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Delayed psychological intervention can lead to
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early intervention
Higher rates or mortality
Increased disability
Secondary health problems
Secondary psychiatric problems (e.g. Depression, Health &
/ or Social anxiety, Panic Disorder +-agoraphobia)
Increased carer burden
Intervention
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Provision of psychological care is multifaceted & involves
many professions and agencies
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Stepped care approach advocated by NICE & ASI
Level 3
Level 2
Level 1
What to do at Level 1?
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MDT to administer prelim mood screen – “Do you feel sad or depressed?”
Initial assessment using a brief standardised measure
 HADS, SADQ-H, GDS, DISCs, Visual analogue
If sub-threshold – MDT to use low level supportive strategies
 Provide information about stroke & rehabilitation pathway
 Make the environment pleasant
 Acknowledge the patient’s distress
 Active listening
 Validate their feelings – “I can see that you are upset”
 Normalise their feelings – “I understand why you feel upset”
 Engage in pleasurable activity
What to do at Level 2?
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Mood assessment interview by CP
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Standardised assessment
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HADS, SADQ-H, GDS, DISCs or other Visual analogue
Risk Assessment
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Presenting problem, History of mood related difficulties,
perception of what is happening, support network, health related
behaviours and attitudes, goals and perceived progress
Current plans, History
Interventions from Level 1 + 2
In collaboration with CP, the MDT can use
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Supportive counselling, explicit feedback and positive
reinforcement, motivational interviewing & goal planning
Medics to consider pharmacological intervention
What to do at Level 3?
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Mood assessment interview by CP
Standardised assessment
Risk Assessment
Referral to Neuropsychiatry / Mental Health Team / GP IAPT
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Interventions from Level 1, 2 & 3
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CP to use formal psychological interventions
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Behavioural therapy (incl. relaxation, distraction, breathing exercises)
Cognitive-Behavioural Therapy
Solution Focused Therapy
Systemic Therapy
Motivational Interviewing
Goal Setting
Adjustment is an ongoing process!
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No time limit
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Adjustment difficulties can be on-going
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Social support groups can be very helpful at
this stage (e.g. Stroke Association, Stroke
Adjustment Group)
Gary was a 75 year old retired businessman. He lived alone
and was very independent. He had three grown up children
whom he met regularly. Gary sustained a shower of emboli
within the anterior and posterior intracranial circulations which
led to multiple infarcts. During Gary’s admission he become
very low in mood, he lost his appetite and needed sleeping
tablets at night. He would spend most of his day sleeping or
thinking about the stroke and how his life had changed. He
was reluctant to engage in rehab sessions and saw little point
in being alive.
He received psychological support from the MDT with the aim
of helping him understand his behaviour and challenge some
of his negative thoughts. He was also given more information
about his brain injury and strategies to help him cope with the
cognitive changes. He was given tips on sleep hygiene to
help him sleep at night and a collaborative goal planning
approach was used to engage him in his rehabilitation. He
was also encouraged to go to the hospital coffee shop for
lunch with his children to build his appetite.
Jenny was a 47 year old lady who worked long hours in the
city as an investment banker. She had a right temporoparietal intracerebral haemorrhage. She was extremely
anxious during her admission to the Stroke unit. Her anxiety
was frequently reflected by her catastrophic thinking (i.e. that
the worst has happened) and continual need for reassurance
about her well-being. She also frequently queried whether all
had been done to help her. Jenny’s initial anxious state
tended to elevate her blood pressure, which in turn lead to
unpleasant physical symptoms. She was hyper-sensitive to
these symptoms, which then acted to reinforce her fears that
she may have another Stroke.
Jenny was given behavioural strategies to manage her
anxiety (distraction, muscular relaxation and deep breathing),
which she used well. When she was successful in managing
her anxiety she noticed a reduction in her blood pressure.
She was given information about Stroke and how to manage
her risk factors.
References
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British Psychological Society (2008) Concise guide for stroke
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Department of Health (2007) National Stroke Strategy
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National Institute for Health & Clinical Excellence (2008) Depression in
adults with a chronic physical health problem
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National Institute for Health & Clinical Excellence (2008), Stroke
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Royal College of Physicians (2004) National Clinical Guidelines for
Stroke, Second Edition
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NHS Improvement (2011) Psychological care after stroke; improving
stroke services for people with cognitive and mood disorders
Questions
Contact details -:
Dr Kiran Hans
Clinical Psychologist
Stroke Services
Tel: 020 8672 1255 ext: 4467
[email protected]