Psychiatric manifestation of cerebrovascular stroke

1
Psychiatric manifestation of
cerebrovascular stroke

• Presented by
• Dr Islam shaaban
• MD of psychiatry

2
Introduction

• 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).

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Introduction

• Psychological definition
• 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)
• Were not just legs and arms and a mouthwe are
  human beings with a mixture of emotions. All
  these feelingsself esteem, confidence, identity
  theyre under attack after a stroke.

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Impact of stroke on self others

• Physical
• Sensory
• Communication
• Cognitive
• Behavioural
• Emotional

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Impact of stroke on self others

• They affect many levels -
• Personal
• Sense of self
• Identity
• Family
• Role change
• Work
• Responsibilities
• Finance
• Society
• Stigma
• Social networks
• Health services

• Physical
• Sensory
• Communication
• Cognitive
• Behavioural
• Emotional

6
The prevalence rates and types of psychiatric
disorders after stroke

• Depression  (PSD) common 30 50
• 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

7
The prevalence rates and types of psychiatric
disorders after stroke

• Cognitive impairment
• 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 ).

8
The prevalence rates of common types of
psychiatric disorders after stroke

• Anxiety is common in ischemic stroke, frequently
  present with PSD
• Between 30-49 up to 12 years post stroke
• Phobias, generalised anxiety, panic
• PTSD 20 (Flashbacks, avoidance, hyperarousal)
• Catastrophic reaction 20
• Emotional Incontinence
• common in patients with frontal lobe lesions
  due to traumatic brain injury, multiple
  sclerosis, pseudobulbar palsy
• Apathy 20
• Obsessive-Compulsive Disorder
• reported after strokes, affecting the basal
  ganglia or brainstem
• Bipolar disorder rare
• Psychosis rare approximately 1mostly after
  lesions of the brain stem .
• sexual dysfunction sexual intercourse does not
  increase risk for stroke.

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The Impact of mental disorders on the course of
the stroke

• Delayed psychological intervention can lead to
• Higher rates of mortality
• Increased disability
• Secondary health problems(diabetes ,dyslipidemia,
  dyscoagulation and hypertension)
• Secondary psychiatric problems (e.g. Depression,
  Health / or Social anxiety, Panic Disorder
  -agoraphobia)
• Suicide
• Hospital readmission
• Higher utilisation of outpatient services

10
The Mechanisms of the effect of mental disorders
on stroke

• There are potential mechanisms to explain the
  relationship between mental disorders and
  cerebrovascular mortality and morbidity
• Behavioral mechanisms
• Physiological mechanisms
• Others as side effects of psychotropic drugs

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Behavioral mechanisms

• 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.
  binge-eating).
• Reduced activity and social isolation/anxiety
  making it more difficult to participate in
  rehabilitation programs

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Physiological mechanisms

• 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.

13
Side effects of psychotropic drugs

• Low-potency conventional antipsychotics (e.g.,
  chlorpormazine) and atypical antipsychotics,
  quetiapine, olanzapine and clozapine, are
  associated with higher risk of hyperlipidemia
• Arrhythmogenic and hypotensive effects of TCAs in
  cardiac patients
• Recent controlled studies suggest that
  antipsychotics can impair glucose regulation by
  decreasing insulin action, and inducing weight
  gain.

14
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.

15
Correlation between lesion location and
neuropsychiatric manifestation

• Gerstmann's syndrome, manifested by dyscalculia,
  finger agnosia, left-right disorientation, and
  dysgraphia, is a classic manifestation of left
  parietal lesions, although it is rarely seen in
  its full form
• 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 and result in an aphasia.
• patients with anxiety and mania more often have
  right-hemispheric lesions
• the left frontal cortex and left basal ganglia
  lesions are most often associated with the
  poststroke depression.

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Clinical presentation

• 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

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Features That Point to a psychiatric
manifestation of cerebrovascular stroke

• 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
• loss of consciousness
• urine / stool incontinence
• seizures
• head injury
• change in headache pattern

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Features That Point to a psychiatric
manifestation of cerebrovascular stroke

• Family history
• Complete lack of positive family history of the
  disorder
• Past history
• Association of Significant Injury
• Medical illness
• Substance abuse

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Vascular depression (silent stroke)

• patients with vascular depression are more likely
  to present with the following criteria
• 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.

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Vascular depression

• 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.

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Potential pathogenic mechanisms for post-stroke
depression

• 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,

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Impact of post-stroke depression on the course of
the stroke

• 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.

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Management

• 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
• Antidepressants have been used as prophylaxis to
  prevent PSD, physical impairment and mortality
• Avoid antidepressants that interact with the
  medical illness, e.g.. arrhythmogenic and
  hypotensive effects of TCAs in cardiac patients

25
Management

• Avoid antidepressants with side effects that may
  worsen symptoms of the medical illness, e.g..
  venlafaxine in hypertension, mirtazapine or TCAs
  in diabetes
• 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

26
Management

• '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.

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Conclusion

• No health without mental health
• Depression anxiety are the most common
  post-stroke 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.

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• Thank you