**1. Introduction**

246 Post Traumatic Stress Disorders in a Global Context

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K., Spanagel, R., Northoff, H., & Gebicke-Haerter, P.J. (2007) Differential gene expression in peripheral blood of patients suffering from post-traumatic stress Stroke is a sudden and devastating illness that occurs when the blood supply to the brain is cut off due to a blood clot or when blood vessels supplying the brain burst, thereby damaging or destroying brain cells. Stroke is the third most common cause of death after heart disease and all cancers in both the UK and the US. In the UK approximately 100,000 people have a stroke each year, with stroke causing over 50,000 deaths. Stroke predominantly affects older people, with almost 80% of first-time strokes occurring in people aged 65 years or older. Stroke is a leading cause of severe, long-term disability. Stroke survivors may experience a range of ongoing problems including weakness or paralysis, problems with balance and coordination, speech and language impairments (e.g., aphasia), cognitive and psychological problems, and emotional lability. As well as the direct care costs, which have been estimated to be £2.8 billion per annum, stroke accounts for £1.8 billion per annum in lost productivity and disability and £2.4 billion per annum in informal care costs in the UK. In the US, the direct and indirect costs of stroke for 2010 have been estimated to be \$73.3 billion (American Stroke Association, 2011; Stroke Association, 2011).

Elevated levels of psychological distress have been documented after stroke, although research to date has focused almost exclusively on depression and general anxiety symptoms (e.g., Fure et al., 2006; Hackett et al., 2005; Leppavuoir et al., 2003). However, stroke has many of the characteristics of events likely to trigger post-traumatic stress disorder (PTSD) symptoms in that it is unexpected, uncontrollable and potentially lifethreatening (Field et al., 2008). Stroke is a "frightening experience" with the symptoms (e.g., weakness or numbness down one side of the body or face, problems with balance and coordination, problems with communication, confusion) appearing suddenly and without warning (Stroke Association, 2011). Thus, in addition to coping with chronic stressors that may arise from ongoing disability, stroke survivors also have to come to terms with the sudden, unexpected and life-threatening nature of the stroke event itself.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association, 1994, p. 424), defines PTSD as "the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's

Posttraumatic Stress Disorder after Stroke: A Review of Quantitative Studies 249

Traumatic Stress Disorder Checklist, PCL, Posttraumatic Diagnostic Scale, PDS, Clinician-Administered PTSD Scale, CAPS, Structured Clinical Interview for DSM-IV, and SCID. Combinations of these two sets of search terms were searched using the Boolean operator "AND". In addition, the reference lists and citation histories of relevant articles were also examined in order to identify further studies to be included in the review. Studies on adult stroke survivors, with a self-report measure of PTSD symptomatology or a clinical interview to diagnose PTSD, that were published in English in peer-reviewed journals were included in the review. Single case studies, qualitative studies, papers without primary data (e.g., editorials), conference abstracts, dissertations, and studies on childhood stroke or

The searches identified 411 articles. After applying the inclusion and exclusion criteria detailed above, 10 articles reporting 9 studies were included in the review; one study was reported in two articles (Sagen et al., 2009, 2010). The following data were extracted from each study (see Table 1): date of publication, country of origin, study design, recruitment site, number of patients screened and excluded, main exclusion criteria, response rate, first or recurrent stroke, sample size, age, gender, stroke location, time since stroke, assessment of PTSD, prevalence of PTSD, and significant correlates of PTSD symptom

Seven studies reported the prevalence of PTSD after stroke. There was considerable variability in the estimated prevalence of PTSD after stroke, which ranged from 3% (Sagen et al., 2010) to 31% (Bruggimann et al., 2006). This variation is likely to be due to differences in assessment methods, time since stroke, and recruitment procedures (e.g., exclusion criteria, response rates). Nonetheless, despite the heterogeneity in study designs and reported prevalence rates, research to date indicates that stroke survivors are at risk of developing PTSD in line with work on other life-threatening illnesses (Tedstone & Tarrier, 2003). For example, Spindler and Pedersen (2005) reported that the estimated prevalence rate for PTSD after heart disease ranged from 0% to 38%. The estimated prevalence of PTSD after stroke is higher than that found in large-scale community studies which have reported PTSD prevalence rates of less than 1% among older adults (Creamer & Parslow, 2008;

Eight studies examined associations between the severity of PTSD symptoms and potential risk factors. In addition, one study also compared stroke survivors with and without PTSD (Sembi et al., 1998), reporting that those with PTSD had higher levels of neuroticism, anxiety and depression and lower levels of psychological well-being. However, the PTSD group was very small (*n* = 6). A range of significant correlates of PTSD symptom severity has been reported, including demographic variables such as age (Sampson et al., 2003; Sharkey, 2007) and gender (Bruggimann et al., 2006), stroke details including the number of previous strokes (Merriman et al., 2007), time since stroke (Merriman et al., 2007) and post-stroke disability (Wang et al., 2011), personality variables such as neuroticism (Sembi et al., 1998), negative affect (Merriman et al., 2007), emotionalism (Eccles et al., 1999) and alexthymia

subarachnoid haemorrhage were excluded.

**3. Results and discussion** 

**3.1 Prevalence of PTSD after stroke** 

Maercker et al., 2008; van Zelst et al., 2003).

**3.2 Correlates of PTSD after stroke** 

severity.

physical integrity" (Criterion A1) and is associated with feelings of intense fear, helplessness or horror (Criterion A2). The symptoms includ "persistent reexperiencing of the traumatic event (Criterion B), persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (Criterion C), and persistent symptoms of increased arousal (Criterion D)". In addition, these symptoms must be present for at least one month (Criterion E) and have a significant negative impact on social, occupational or other areas of functioning (Criterion F). Research on PTSD has traditionally focused on traumas such as war, physical and sexual assaults, and road traffic accidents (Shalev et al., 1993). However, there has been growing recognition that PTSD symptoms may occur after a range of medical events (Tedstone & Tarrier, 2003), including cancer (e.g., Kangas et al., 2005), myocardial infarction (MI) (e.g., Kutz et al., 1994), and subarachnoid haemorrhage (e.g., Berry, 1998). Accordingly, life-threatening illnesses were added as an example of a traumatic event that may lead to the development of PTSD in DSM-IV (APA, 1994).

The experience of PTSD after stroke may have important implications for recovery. For example, PTSD has been related to poorer physical health in the general population (Spitzer et al., 2009) as well as to non-adherence to medication and adverse clinical outcomes in MI patients (Shemesh et al., 2001), worse functional recovery in patients with severe traumatic brain injury (Bryant et al., 2001), and higher levels of disability following hospitalization for physical injuries (e.g., resulting from road traffic accidents) (O'Donnell et al., 2009). PTSD is also likely to have a negative impact on stroke rehabilitation (Williams, 1997). First, the experience of intrusions may place high demands on the already limited cognitive resources of many stroke survivors, which may further restrict their ability to fully process, and come to terms with, the trauma experience. Second, survivors with PTSD are likely to try to avoid reminders of the stroke, which may hinder attempts to integrate them back into the community. Third, survivors with PTSD are likely to engage in catastrophic thinking and to have excessively negative perceptions of possible future harm which may further impede rehabilitation efforts.

Previous reviews have focused on the prevalence and correlates of PTSD following a range of life-threatening physical illnesses (e.g., Pedersen, 2001; Spindler & Pedersen, 2005; Tedstone & Tarrier, 2003). However, these reviews have either been very general in their scope (e.g., Tedstone & Tarrier, 2003) or have focused on specific medical conditions other than stroke (e.g., Spindler & Pedersen, 2005). In relation to the psychological consequences of stroke, reviews to date have only focused on the prevalence (Hackett et al., 2005) and the correlates (Hackett & Anderson, 2005) of depression after stroke. The main aims of the current review were to (i) assess the prevalence of PTSD after stroke, (ii) identify the main correlates of PTSD after stroke, (iii) highlight a range of methodological issues in research on PTSD after stroke, and (iv) make recommendations for future research.
