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.
P 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 reactiv-
ity (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 tra-
jectory or outcome. In patients with cerebrovascular disease,
depression and anxiety have been much more frequently investi-
gated 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
Downloaded from http://ahajournals.org by on May 12, 2019
on self-rated measures than by interview. While evidence-based
interventions for PTSD after more traditional traumatic precipi-
tants exist,8 these limited data in stroke or TIA have not been suf-
ficient to support routine PTSD awareness, screening, diagnosis,
or management activities after cerebrovascular events.
The prospective, cross-sectional study of Kiphuth and col-
leagues9 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
3182
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 crowd-
ing.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 car-
diovascular 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 exac-
erbate 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 pro-
spective, longitudinal cohort studies that include diagnostic mea-
sures 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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 Vickrey and Williams   PTSD After Cerebrovascular Events    3183
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Key Words: Editorials ◼ anxiety ◼ outcome ◼ transient ischemic attack