Transient Ischemic Attack May Fuel PTSD

Megan Brooks

November 12, 2014

About 30% of patients with transient ischemic attack (TIA) develop post-traumatic stress disorder (PTSD), a new study suggests.

Patients who don't cope well with the TIA and overestimate their subsequent risk of having a full-blown stroke are at higher risk for PTSD. Having depression, anxiety, or reduced physical health also raises the risk, the researchers say.

"PTSD, which is perhaps better known as a problem found in survivors of war zones and natural disasters, can develop when a person experiences a frightening event that poses a serious threat," study author Kathrin Utz, PhD, postdoctoral researcher, Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany, said in a statement.

The study is published in the November issue of Stroke.

Fear, Poor Coping Skills

The study included 108 patients from Germany with TIA. Three months after the event, they completed validated self-rating questionnaires to assess PTSD, anxiety, depression levels, quality of life, coping strategies, and medical knowledge.

Thirty-two of the patients (29.6%) were classified as having PTSD, a rate 10 times higher than that found in a recent survey of the general German population, the researchers point out.

Among all 108 patients, mental quality of life was significantly reduced in 15 (13.9%) and physical quality of life was significantly reduced in 7 (6.5%), compared with a normative sample.

Patients with TIA and PTSD scored significantly higher on measures of depression and anxiety, and had significantly reduced mental and physical quality of life, compared with their peers without PTSD.

"When experienced together, the symptoms from TIA and depression pose a significant psychological burden on the affected patient; therefore, it comes as no surprise that we also found TIA patients with PTSD have a measurably lower sense of quality of life," Dr Utz said.

Patients with negative coping strategies, such as denying the problem, blaming themselves, or turning to drugs for comfort, and those who overestimate their risk for stroke are also at greater risk of developing PTSD after TIA, the researchers say.

Providing patients better risk counseling and more positive adaptive strategies to cope with TIA may help, they add.

The authors believe this is the first study investigating the prevalence of PTSD in a TIA-only sample, which is important for disentangling the contribution of residual impairment after the event and other factors.

"Given that patients with TIA experience only temporary neurological symptoms, which completely recover without leaving brain lesions, the finding of an increased prevalence of PTSD and poor psychosocial outcome is remarkable and deserves increased attention and prevention efforts," they note in their article.

"It seems likely that the sudden experience of the neurological symptoms itself is a major factor in triggering PTSD in patients with TIA," they add.

PTSD After Medical Events

In an editorial accompanying the publication, Barbara G. Vickrey, MD, MPH, from the Department of Neurology at University of California, Los Angeles, and Linda S. Williams, MD, from the Department of Neurology at the Indiana University School of Medicine, Indianapolis, point out that 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 in this study is consistent with the prevalence seen after cardiac events, intensive care unit admissions, and other such events, they note. A recent review of PTSD after acute coronary events showed that while there are patient factors related to PTSD onset, "external and modifiable systems-level factors also appear to be at play, for example, greater emergency department crowding."

Importantly, they add, a pooled meta-analysis suggested that a positive PTSD screen after acute coronary syndrome was associated with a doubled risk for a recurrent event or death, raising the possibility that this may also be true for cerebrovascular patients as well.

"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," they write. "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."

It will be important to explore the mechanisms mediating this relationship, such as poor medication adherence, they add.

"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," they conclude.

The study had no commercial funding. The authors and editorialists have disclosed no relevant financial relationships.

Stroke. 2014;45:3360-3366, 3182-3183. Abstract Editorial

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