Download Psychological Impact Adjusting to life after a Stroke

Psychiatric manifestation of
cerebrovascular stroke
Presented by
Dr: Islam shaaban
MD of psychiatry
Introduction
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Both neurology and psychiatry deal with
diseases of the same organ (the brain).
Mental disorders and Stroke have a bidirectional
relationship, as not only are patients with stroke
at greater risk of developing mental disorders ,
but patients with mental disorders have a
greater risk of developing a stroke, even after
controlling for other risk factors. (patients with
depression have a two-fold greater risk of
developing a stroke).
Introduction
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Psychological definition:
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“A stroke is a sudden traumatic major life event
that usually occurs with minimal warning and
results in life-changing consequences” (Donnellan
et al., 2006)
“We’re not just legs and arms and a mouth…we
are human beings with a mixture of emotions. All
these feelings…self esteem, confidence, identity
…they’re under attack after a stroke.
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
The prevalence rates and types of
psychiatric disorders after stroke
Depression: (PSD) common 30 – 50%
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The occurrence of PSD peaks three to six
months after a stroke.
Approximately 20 %of patients who have a
stroke meet criteria for major depressive disorder
another 20 % meet criteria for minor depression
The prevalence rates and types of psychiatric
disorders after stroke
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Cognitive impairment
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Delirium occurs in 30% to 40% of patients during
the first week after a stroke, especially after a
hemorrhagic stroke.
Dementia is common following stroke, occurring
in approximately 25% of patients at 3 months
after stroke (vascular dementia ).
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The prevalence rates of common types of
psychiatric disorders after stroke
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Anxiety is common in ischemic stroke, frequently present with PSD
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Between 30-49% up to 12 years post stroke
Phobias, generalised anxiety, panic
PTSD 20% (Flashbacks, avoidance, hyperarousal)
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Catastrophic reaction: 20%
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Emotional Incontinence
common in patients with frontal lobe lesions due to traumatic brain
injury, multiple sclerosis, pseudobulbar palsy
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Apathy: 20%
Obsessive-Compulsive Disorder
reported after strokes, affecting the basal ganglia or brainstem
Bipolar disorder: rare
Psychosis: rare approximately 1%mostly after lesions of the brain stem .
sexual dysfunction
stroke.
sexual intercourse does not increase risk for
The Impact of mental disorders on the
course of the stroke
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Delayed psychological intervention can lead to
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Higher rates of mortality
Increased disability
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Secondary
health
problems(diabetes
dyscoagulation and hypertension)
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Secondary psychiatric problems (e.g. Depression, Health &
/ or Social anxiety, Panic Disorder +-agoraphobia)
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Suicide
Hospital readmission
Higher utilisation of outpatient services
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,dyslipidemia,
The Mechanisms of the effect of mental
disorders on stroke
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There are potential mechanisms to explain the
relationship between mental disorders and
cerebrovascular mortality and morbidity
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Behavioral mechanisms
Physiological mechanisms
Others as side effects of psychotropic drugs
Behavioral mechanisms
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Poor concentration and adherence to medication
regimens.
Lack of motivation to adhere to lifestyle changes
(e g good diet, exercise).
Increased prevalence of habits with negative
health consequences (e.g., smoking. bingeeating).
Reduced activity and social isolation/anxiety
making it more difficult to participate in
rehabilitation programs
Physiological mechanisms
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Hyperactivity of the HPA axis, results in elevated
catecholamine secretion with adverse effects on
the heart, blood vessels and platelets.
Augmented
platelet
responsiveness
or
activation, increasing the risk of clot formation
and atherosclerosis.
Disrupted circadian rhythms and reduced heart
rate , leading to arrhythmogenesis.
Side effects of psychotropic drugs
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Low-potency conventional antipsychotics (e.g., chlorpormazine)
and
atypical
antipsychotics,
quetiapine,
olanzapine
and
clozapine, are associated with higher risk of hyperlipidemia
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Arrhythmogenic and hypotensive effects of TCAs in cardiac
patients
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Recent controlled studies suggest that antipsychotics can impair
glucose regulation by decreasing insulin action, and inducing
weight gain.
Mental disorders and Smoking
patients with current psychiatric disorders have significantly higher rates of
smoking (51% on average) were:
88% for schizophrenia,
70% for mania,
49% for major depression,
47% for anxiety disorders,
46% for personality disorders,
and 45% for adjustment disorders.
Correlation between lesion location
and neuropsychiatric manifestation
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cissalc a si ,aihpargsyd dna ,noitatneirosid thgir -tfel ,aisonga
ni nees ylerar si ti hguohtla ,snoisel lateirap tfel fo noitatsefinam
mrof lluf sti
frontal lesion can disrupt usual frontal functions. Difficulties with
executive function, disinhibition, and apathy are possible
manifestations.
If the lesion is left temporoparietal, it may affect Wernicke's
area.aisahpa na ni tluser dna
patients with anxiety and mania more often have righthemispheric lesions
the left frontal cortex and left basal ganglia lesions are most often
associated with the poststroke depression.
Clinical presentation
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Mental Disorders may be the first presentation of
cerebrovascular stroke as vascular depression,
behavioral changes and psychotic features
Some patients with conversion disorder present
with acute onset of neurological symptoms, they
may be misdiagnosed as having transient ischemic
attacks or strokes.
So we must differentiate between mental Disorders
and psychiatric manifestation of cerebrovascular
stroke
Features That Point to a psychiatric
manifestation of cerebrovascular stroke
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Atypical features: ( History )
Atypical onset (within hours or minutes,
Atypical age of Onset
Atypical clinical course.
Atypical response to treatment.
Atypical disturbances of perception (non auditory hallucination)
Catatonia
Neurological symptoms:
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loss of consciousness
urine / stool incontinence
seizures
head injury
change in headache pattern
Features That Point to a psychiatric
manifestation of cerebrovascular stroke
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Family history:
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Complete lack of positive family history of the
disorder
Past history:
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Association of Significant Injury
Medical illness
Substance abuse
Vascular depression (silent stroke)
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patients with vascular depression are more
likely to present with the following criteria
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late-onset symptoms of depression.
Clinical and/or neuroradiological evidence of
diffuse bilateral white matter lesion or small vessel
disease.
Chronic cerebrovaseular risk factors (CVRF) such
as hypertension, diabetes, carotid stenosis, atrial
fibrillation and hyper-lipidaemia.
Vascular depression
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The symptoms of vascular depression consist of mood
abnormalities, neuropsychological disturbances as
impairment of executive functions, a greater tendency to
psychomotor retardation, poor insight and impaired
activities of daily living
patients with PSD are more likely to present with
catastrophic reactions, hyper activity, and diurnal mood
variation than patients with idiopathic depression,
Duration of PSD symptoms appears to depend on the
vascular branch of the stroke, longer durations identified
in patients with a stroke in the middle cerebral artery,
than in the posterior circulation.
Potential pathogenic mechanisms for
post-stroke depression
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Many risk factors associated with PSD have included
location and size of the stroke, there is relation between
PSD and stroke of temporal lobe, and the size of the
ventricles.
There is a relationship between PSD and left
hemispheric stroke specially left frontal dorsolateral
cortical regions and basal ganglia.
depression appear more than one year after the stroke ,
right-sided lesions are more frequent.
There is significant correlation between the severity of
disability and depression,
Impact of post-stroke depression on the
course of the stroke
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The presence of PSD has been found to
have a negative impact on:
• recovery of cognitive function
• recovery of ability to perform ADL
• mortality risks.
in recent study of 976 stroke patients
followed for one year, those with PSD had
50% higher mortality than those without.
Management
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There are many similarities in diagnosing and treating
mental Disorders in the stroke and primary mental
disorders ,Selective serotonin reuptake inhibitors
(SSRIs), tricyclic antidepressants (TCAs), stimulants,
and electroconvulsive therapy (ECT) have all been
effective in the treatment of poststroke depression
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Antidepressants have been used as prophylaxis to
prevent PSD, physical impairment and mortality
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Avoid antidepressants that interact with the medical
illness, e.g.. arrhythmogenic and hypotensive effects of
TCAs in cardiac patients
Management
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Avoid antidepressants with side effects that may worsen
symptoms of the medical illness, e.g.. venlafaxine in
hypertension, mirtazapine or TCAs in diabetes
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Avoid psychotropic drugs that may interact with other
drugs that patients may be using for the medical
illness, e.g., fluvoxamine with warfarin, fluoxetine and
paroxetine with codeine; TCAs with quinidine•
Be aware of age-and illness-related changes in
pharmacokinetics, e.g., liver disease and hepatic
dysfunction may reduce metabolism and increase
serum levels of psychotropic drugs
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Management
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'Start low, go slow, keep going, stay longer': start
with lower than usual doses, titrate up slowly to
usual therapeutic doses, and maintain on
medications for a longer duration.
relapse with discontinuation of psychotropic drugs is
very common so maintenance treatment of two year;
or longer is recommended
ECT was found useful in many retrospective
studies. None of the pts developed exacerbations
of stroke or new neurological deficits.
Conclusion
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“No health without mental health”
Depression & anxiety are the most common poststroke syndromes.
Both depression and anxiety increase morbidity and
delay rehabilitation.
There are very few treatment studies available.
we must treat post-stroke psychiatric disorders as
early as possible to improve outcome and quality of
life.
Thank you