Having a Stroke Is Easy: It's What Comes After, aka Post-Stroke Psychiatric Syndromes

Ok. So you had a stroke, and now the drama is over? Wrong! As I always say, having a stroke is the easy part compared to what comes after. There are 7 conditions named here.

In an article in Psychiatric Times, the drama is simply unfolding. 

The researchers say the most commonly reported of these in the studies are:

1. post-stroke depression (called PSD as opposed to PTSD ((Post Traumatic Stress Disorder)) which ALL stroke survivors have) and 

2. post-stroke dementia (PSDem), which may affect mood and cognitive symptoms. The researchers say that assessment of the survivor's living situation, level of support, and attention to caregivers' and family members' behavioral observations are necessary with patients who have cognitive impairment or other neurologic impediments to communication. 

A higher risk of PSD has been found in patients with "left-sided cortical and basal ganglia lesions and to lesions closer to the frontal lobe than to left posterior or right frontal lesions." (This is why I say--all the time--to get as much information from your doctors as possible in regard to what exactly happened to your brain). 

PSD may involve a spectrum of mood disorders,  "vascular depression," and dementia-related depression. (Vascular depression often predating stroke is associated with higher degrees of cognitive impairment). Because these relationships between depression and dementia are currently vague, the physician should offer treatment of PSD early in the post-stroke period to strengthen mood and cognitive function.

Most reviews have found the risk of PSD to be between 20% and 79% for up to 18 months post-stroke, and the risk of depression is nearly twice that in persons who have not had a stroke. Untreated patients are at risk for chronic illness (even after 2 years) although patients with PSD may recover spontaneously within 12 months with tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and psychostimulants (methylphenidate).

PSDem symptoms include poor social judgment, amnesia, cognitive disorganization, language deficits, apraxia, disinhibited and/or unsafe behavior, paranoia, and visual-spatial dysfunction. Thoughts of suicide have been reported up to 24 months after stroke. Patients with PSDem should be followed up monthly, with reassessment of cognitive examination, repeated depression inventory, and screening for psychotic symptoms.

3. Post-stroke mania is rare, but it may be associated with right-sided stroke. Manic symptoms include decreased need for sleep, expansive and/or irritable mood, increased goal-directed activity, disregard for social constraints, recklessness, talkativeness, racing thoughts, excessive laughter or giggling, and poor judgment. Persons with post-stroke mania should routinely be referred for psychiatric care.

4. Anxiety symptoms include episodes of panic, excessive sweating, worrying, and decreased sleep. Risks of 26% for men and 39% for women have been found in a post-stroke anxiety disorders study. A combination of anxiety and depression may be more usual in left cortical stroke, while depression without anxiety may be more usual in left subcortical stroke.

Here's a tip: Avoidance of benzodiazepines is important. These agents may cause cognitive decline, verging on PSDem. Follow-ups should be done in monthly increments. 


Less frequently seen post-stroke psychiatric symptoms include pathologic crying and pathologic laughter (PBA), apathy, and isolated fatigue. 


5. Pathologic laughter and crying are sometimes grouped as pathologic emotions (PE, another name for PBA) with sudden bursts of either laughter or crying, despite of the mood state. 

6. Apathy in the absence of depression may be difficult to evaluate, but it's a complete lack of initiative without tearfulness, sleep/appetite disturbance, hopelessness, or suicidality.

The use of psychostimulants for PSD or apathy, sometimes both, may be associated with a risk of seizure and/or cardiac side effects. Concern for these risks must be balanced against undertreatment of PSD. In cases of cardiac disease, consultation with a cardiologist is best with careful dosing of psychostimulants.

7. Post-stroke psychotic disorder symptoms include delusions, hallucinations, thought disorganization, and regressed motor behavior. Post-stroke psychotic disorder has been shown with right-sided lesions and cortical/subcortical atrophy. Persons with post-stroke psychosis should be referred for psychiatric care. A patient with pre-stroke psychotic illness, such as schizophrenia, may ultimately decline following a major stroke.

Having a stroke is the easy part. It's what comes after that's usually a bitch. 

Why You Lose Memory from Brain Injury and Possible Ways to Improve It

This post is for everyone because you never know when you’ll suffer a brain injury. I had a stroke. And with that may come memory loss. I want to say I learn something new every day. In reality, I don't, but pretty close to it. Researching and completing this post over a 2-week period taught me many things about memory, and I'll share them with you. 

Memory is defined as: the faculty of the brain by which information is encoded, stored, and retrieved when needed, vital to experiences, and is the retention of information over time for the purpose of influencing future action. 

Let's get academic for the moment if we haven’t already. This from LumenLearning:

• It is theorized that memories are stored in neural networks in various parts of the brain associated with different types of memory, including short-term memory, sensory memory, and long-term memory.
• Memory traces, or engrams, are physical neural changes associated with memories. Scientists have gained knowledge about these neuronal codes from studies on neuroplasticity.
• Encoding of episodic memory involves lasting changes in molecular structures, which alter communication between neurons. Recent functional-imaging studies have detected working-memory signals in the medial temporal lobe and the prefrontal cortex.
• Both the frontal lobe and prefrontal cortex are associated with long- and short-term memory, suggesting a strong link between these two types of memory. Damage there is monumental.
• The hippocampus is integral in consolidating memories but does not seem to store memories itself.

For all those who know what part of the brain-sustained damage, and you should demand to know by asking your doctor, the following descriptions of the different types of memory will be useful to determine where your loss is according to where it's positioned. 

• Sensory Memory: 

Brain part most relevant: Temporal and  Occipital lobes 
The ability to retain impressions of sensory information after the original stimuli have concluded and the shortest-term element of memory through the five senses of sight, hearing, smell, taste and touch, which are retained accurately, but very briefly. 

• Short-Term Memory:

Brain part most relevant: Pre-Frontal Cortex, Frontal, and Parietal lobes 
Short-term memory is followed hand-in-hand with sensory memory and allows the ability to hold on to a piece of information temporarily in order to complete a task or remember directions, for example.

Long-Term Memory:

Brain part: Frontal and Temporal lobes 
Long-term memory allows the ability to decode information, create associations among an object’s various properties, and develop opinions.

(For Sensory and Long-Term Memory: The Temporal lobe is where lies the hippocampus, a small organ which forms an important part of the limbic system, the region that regulates emotions and events that happened in the past. Needless to say, it's complicated).

And this from McGill U in Canada:
In regard to long-term memory, researchers found two types: 

Declarative memory, aka explicit memory, is what happens when you recall your birthday or what you recall eating last night. You can name and describe each of these remembered things explicitly.

Non-declarative memory, aka implicit memory, is like riding a bike or tying your shoelaces, where you do things, most often motor skills, that do not require the use of language.  

Here's the bottom line: sensory memory leads to short-term memory which leads to long-term memory. If anything is going on where the process is interrupted, you will have some sort of memory issue.

Another study by researchers at the University of Queensland in Australia found out that, relative to short term memory, using magnetic resonance imaging (MRI) machines, people perform tasks requiring them to hold information, such as the location of a flash of light, and the PFC (pre-frontal cortex) becomes active. In terms of the sides of the brain, the left is more involved in verbal memory while the right is more involved in spatial memory, such as recalling where the flash of light happened. 

So can you do anything to get your memory restored? It depends. The amount of damage is certainly important.  

One study said practicing meditation, drinking coffee (albeit before 2pm if you have trouble sleeping at night), eating berries (blueberries are high in flavanoids), chewing gum (because it may improve concentration), and doing exercise (the brain is stimulated) can help improve memory. But the most important? Getting enough sleep.

A study reported on memory- challenged participants to memorize illustrated cards, testing their memory. Then they had a 40-minute break--one group napped and the other stayed awake. After the break, both groups were tested on their memory recall of the cards. Surprisingly, the group who had napped performed better, retaining on average 85 percent of the patterns compared to 60 percent for those who had remained awake.

On the other hand, the brain is the least understood part of the human body. But practicing meditation, drinking coffee, eating berries, chewing gum, doing exercise, and getting enough sleep are harmless, and one or some of those activities may do the trick. 

You know what I always say: if it works, use it. 

Everything Happens For a Reason? Utter Nonsense!

Once in awhile, you hear somebody say, when something disastrous occurs, "Everything happens for a reason." (And its corollary: It's a blessing in disguise. Ugh.) I used to say it, too. But now, it brings up thoughts of infants dying of SIDS, of good people having a fatal disease, of innocent folks experience a mudslide without insurance. Why would anything happen to them!

 

I believe in God, albeit an agnostic right at the edge, but I believe it's a random occurrence for how things shake down. It's all bad luck. Don't fool yourself. It's not "God's plan." How could it be!

Canadian philosopher Dr. Paul Thagard says, "For some people, thinking this way makes it easier to deal with relationship problems, financial crises, disease, death, and even natural disasters such as earthquakes. It can be distressing to think that bad things happen merely through chance or accident. But they do."

Adversity strategist Tim Lawrence writes, “Some things in life cannot be fixed. They can only be carried.” 

Freelance journalist Nicholas Clairmont argues, "'Everything happens for a reason' is my very least favorite thing for someone to say."

The list is endless. Can they all be wrong? 

Let me give you some scenarios when "Everything happens for a reason" is said most--when some friend is going through a relationship break-up and you say, "Everything happens for reason." It's ridiculous. Fucked up. Or when somebody lost all their retirement money in a scam. Or when somebody lost a child. Egads, person! Everything happens for a reason? Get real!

The event that changed my mind forever in not saying "everything happens for a reason" was my stroke on April 8, 2009. I had low cholesterol, low blood pressure, no diabetes, and participated in none of the life choices people make to cause a stroke to happen. I couldn't have prevented a stroke anyway because as it turns out, I had "S protein deficiency" that  is a disorder of blood clotting. People with this condition have an increased risk of developing abnormal blood clots. And I had clots in every limb. 

"Everything happens for a reason" was said by a friend, M, when I had the stroke, two months after.

"Look what it did! Everything happens for a reason because if you didn't have a stroke, your book [The Tales of a Stroke Patient] wouldn't have been written."

I thought, What a moronic thing to say. I am an author,  having written a book and articles before my stroke. I hid in the bathroom for about an hour, sobbing, dry heaving, and thinking she's a stupid jerk. I imagine she felt better, thinking that expression was kind, giving me cause to write, but I felt so much worse. I would write some other book. 

So why even try if it's God's plan anyway? How about if you cruise through life on a shoestring budget because if it's God's plan, why bother? Those words are blasphemy to some, but if there really is God, and I think there is, why wouldn't He want the best for everyone? 

These are God questions that I asked in elementary school, sixty and some odd years ago. I still have no answers about God and His plans. But "everything happens for a reason" is bullshit. I answered that 10 years ago.

Depression, Anxiety, and Brain Injury : It's So Much More Than the Blues

Needless to say for the readers of this blog, I had a stroke. I feel fine one day and mopey the next for whole afternoons. Two weeks pass and then I feel good again for the next two days and mopey the next evening. I used to say it was depression. But it's not. Not even close. 

Depression symptoms may include feelings of sadness, loss of interest in activities that were once contenting, helplessness, sleep problems, and suicidal thoughts or actions. [I said I was suicidal, but I did not even attempt to try killing myself--not even once].

I've heard it said, in its most simplistic definitions, that depression is worrying about the present; anxiety is worrying about the future. But they are related. I mean, how can you worry about the present without worrying about what's coming tomorrow? 

The Stroke Foundation in Australia says it is normal to feel sad or worried after a stroke. I agree with that statement, but I detest the timelines like in the following. 

"If you feel sad, down or miserable for more than two weeks, you may have depression. You may lose interest or pleasure in things you normally enjoy. You may lack energy, have difficulty sleeping, or sleep more than usual. You may find it difficult to concentrate, to solve problems and to keep appointments," the Aussies say. 

"Feeling anxious is normal when we feel under pressure. The feelings usually go away when the stressful situation is over. If anxious feelings do not go away, or if you are anxious for no particular reason, you may have anxiety."

What happened to "all strokes are different"? Like snowflakes, it is often said. In my opinion, it's so much more complicated that that.  

So what does this mean? I'll make it clearer. Stroke has the potential to affect your worth as a human being, questioning your existence and the part you play in it [depression], and make you worry about the future, like about the future, like altering responsibilities, work, relationships, and finances [anxiety]. 

Depression and anxiety--intertwined at one point or, maybe, forever. Depression is most common the first year after a stroke, but it can prolong, along with anxiety which may occur during the same time frame or following each other, or later. Loved ones and caregivers, of course, may experience depression and anxiety as well. (I hear the incantations "every stroke is different" playing somewhere in my brain, for the strokee and all who participate in the care of such).

WedMD says, "Many people who have a stroke or so-called mini-stroke (transient ischemic attack, otherwise known as TIA) become depressed afterward, yet up to two-thirds are not getting ample treatment for their depression."

"A lot of people are not aware of this risk,” Nada El Husseini, MD, Duke University stroke researcher says. “Even if they are feeling depressed, they don’t think it’s relevant.”

However, it is relevant. Depression can affect rehabilitation as well as recovery following a stroke. Chad Miller, MD, an Ohio State University associate professor of neurology and neurologic surgery, says, “Depression needs to be added to the checklist of things that stroke patients [and other brain injuries as well] need to be evaluated for.”

A new study in which Dr. Miller participated, included 1,450 U.S. adults who had a stroke and nearly 400 who'd had a TIA.  

Around 18% of the stroke survivors and about 14% of those who'd had a TIA were depressed three months after. A year after the stroke, 16% were depressed and 13% of those who had a TIA. 

"Depression was more likely to last in people who were younger, were more disabled by their stroke, and who were unable to return to work three months after their stroke," the study says.

The study goes on to say, "Around 70% of people with constant depression weren't being treated with antidepressants at either the three and 12-month mark."

“Each stroke doctor is somewhat aware of this risk, but it may not be one of the priorities,” Miller says. Many stroke specialists focus on addressing risk factors to prevent another stroke from occurring and rehabilitation issues. 

Uh huh. What does that sentence even mean? And who are these stroke specialists?

If you think you have depression and/or its sister, anxiety, like trouble sleeping or feelings of hopelessness, after a brain injury like stroke, you would be better off visiting your primary physician and tell all the symptoms that make you think you have depression and/or anxiety. A trusted doctor may treat your depression/anxiety or refer you to someone who can. 

Remember, stroke affects the essential organ--the brain. The brain is the most complex organ in the body, made up of a complex network of billions of nerve cells called neurons. So the takeaway? One, it is not uncommon to have depression and anxiety after a stroke and two, the feelings you have are your feelings. Don't let anybody diminish them.