Posttraumatic Stress Disorder After Cerebrovascular Events

Does your doctor know enough to recognize PTSD and know how to treat it?
http://stroke.ahajournals.org/content/45/11/3182.full

1. Barbara G. Vickrey, MD, MPH;
2. Linda S. Williams, MD

+ Author Affiliations

1. From the Department of Neurology, University of California, Los Angeles (B.G.V.); Department of Neurology, Greater Los Angeles Veteran's Administration HealthCare System, Los Angeles, CA (B.G.V.); Department of Neurology, Indiana University School of Medicine, Indianapolis (L.S.W.); Department of Neurology, Richard L. Roudebush Veteran's Administration Medical Center, Indianapolis, IN (L.S.W.); and Regenstrief Institute, Inc, Indianapolis, IN (L.S.W.).

1. Correspondence to Barbara G. Vickrey, MD, MPH, UCLA Neurology, C109 RNRC, 710 Westwood Plaza, Los Angeles, CA 90095. E-mail bvickrey@ucla.edu

Key Words:

• Editorials
• anxiety
• outcome
• transient ischemic attack

See related article, p 3360.

Posttraumatic stress disorder (PTSD) is defined based on exposure to actual or threatened death, injury, or violence and the presence for ≥30 days postevent of intrusive symptoms (eg, flashbacks), persistent avoidance of stimuli, negative alteration in mood and cognition, and marked alteration in arousal and reactivity (eg, hypervigilance).¹ Although diagnostically distinct, PTSD symptoms overlap with symptoms of depression and anxiety, making it complex to evaluate the unique associations between these different conditions and their contribution to disease trajectory or outcome. In patients with cerebrovascular disease, depression and anxiety have been much more frequently investigated than PTSD, with prevalence estimates for these conditions typically ranging from 20% to 30% in the poststroke period,^2–4 leading to recommendations to screen all stroke patients for depression in the early poststroke period.⁵ A sprinkling of studies of mixed populations of both stroke and transient ischemic attack (TIA) patients have reported estimates of PTSD ranging from 10% to 25%,^6,7 with higher prevalence estimates when based on self-rated measures than by interview. While evidence-based interventions for PTSD after more traditional traumatic precipitants exist,⁸ these limited data in stroke or TIA have not been sufficient to support routine PTSD awareness, screening, diagnosis, or management activities after cerebrovascular events.

The prospective, cross-sectional study of Kiphuth and colleagues⁹ used the Posttraumatic Stress Diagnostic Scale, a self-rated symptom measure that maps onto DSM criteria, to assess PTSD occurrence at 3 months after TIA. Findings were an ≈10× higher occurrence of PTSD (=29.6%) at 3 months after TIA relative to the general population prevalence in Germany; even if all those lost to follow-up were projected to not have PTSD, the estimated prevalence (15%) was still 5× that of the general population. Co-occurring depression and anxiety symptoms were common in those who were classified as having PTSD. Further, PTSD at 3 months post-TIA was associated with maladaptive coping, higher perceived risk of stroke, and aspects of health-related quality of life, but not with knowledge about stroke.

There is a relatively robust literature on PTSD after a variety of acute medical events, so it is not clear if PTSD after TIA or stroke is a different phenomenon than what might be seen with other acute healthcare-related situational stressors.

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