Posttraumatic Stress Disorder After Cerebrovascular Events

Broadening the Landscape of Psychological Assessment

in Stroke and Transient Ischemic Attack
Barbara G. Vickrey, MD, MPH; Linda S. Williams, MD
See related article, p 3360.
osttraumatic 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,24
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

The opinions expressed in this article are not necessarily those of the
editors or of the American Heart Association.
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.).
Guest Editor for this article was Eric E. Smith, MD, MPH.
Correspondence to Barbara G. Vickrey, MD, MPH, UCLA Neurology,
C109 RNRC, 710 Westwood Plaza, Los Angeles, CA 90095. E-mail
bvickrey@ucla.edu
(Stroke. 2014;45:3182-3183.)
2014 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org
DOI: 10.1161/STROKEAHA.114.006865

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. The occurrence of PTSD
post-TIA in the present study is consistent with PTSD prevalence
after cardiac events, intensive care unit admissions, and other
stressful medical events.10 A recent review of research on PTSD
after acute coronary events emphasized that although a range of
patient factors have been associated with PTSD onset after these
events, external and modifiable systems-level factors also appear
to be at play, for example, greater emergency department crowding.11 Importantly, a pooled meta-analysis reported that a positive
PTSD screen after acute coronary syndrome was associated with
a doubling of the risk of a subsequent event, either recurrent cardiovascular event or death, raising the possibility for significant
adverse outcomes for cerebrovascular patients, as well.12
Although the specificity of the association between TIA and
PTSD is not fully understood, the study in this issue of Stroke
raises awareness that TIA may fairly commonly initiate or exacerbate bothersome psychological symptoms after the event that
are independent from any change in physical function. This
finding is clinically important because psychological symptoms
after stroke and TIA are known to be associated with adverse
outcomes, including increased risk of subsequent vascular events
and mortality.13,14 It will be critical to explore the mechanisms
mediating any associations of PTSD and stroke or TIA outcomes;
for example, one study of PTSD and stroke patients found that
poststroke self-reported medication nonadherence was 67%
among those screening positive for PTSD, compared with 35%
for those without PTSD symptoms, according to the checklist
that was administered.15 Future work should include larger prospective, longitudinal cohort studies that include diagnostic measures of PTSD, depression, and anxiety poststroke to elucidate
the unique influence of these conditions on patient outcomes and
modifiable factors mediating those associations and to provide
guidance on application of existing evidence-based interventions
that are tailored to specific, clinically predominant symptoms.

Disclosures
None.

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Key Words: Editorials anxiety outcome transient ischemic attack

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Posttraumatic Stress Disorder After Cerebrovascular Events: Broadening the Landscape

of Psychological Assessment in Stroke and Transient Ischemic Attack
Barbara G. Vickrey and Linda S. Williams
Stroke. 2014;45:3182-3183; originally published online October 2, 2014;
doi: 10.1161/STROKEAHA.114.006865
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2014 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628

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