**4. Conclusions**

262 Post Traumatic Stress Disorders in a Global Context

admissions to stroke units/wards should be recruited. The resultant sample should then be compared with the patient population from which it was drawn in order to assess its representativeness. Given the severity of stroke and the ensuing levels of disability, it is likely that many stroke survivors will be unable to give informed consent and/or complete self-report measures or clinical diagnostic interviews. This is likely to affect the representativeness of the sample and restrict the extent to which the findings can be generalized to all stroke survivors. Studies should therefore provide detailed information on their recruitment procedures and exclusion criteria. In addition, future work should attempt to amend recruitment and assessment procedures in order, as far as possible, to recruit stroke survivors with communication and cognitive impairments into studies on post-stroke PTSD. For example, research on depression and aphasia (Thomas & Lincoln, 2008) has used visual analogue scales (Brumfitt & Sheeran, 1999) to assess emotional distress in stroke survivors with communication difficulties. Future work should therefore also focus on developing measures of PTSD symptom severity that can be completed by stroke survivors with communication difficulties and/or cognitive

Future research should assess a comprehensive range of potential risk factors, including stroke details, when assessing the predictors of post-stroke PTSD. In particular, future research should draw upon current models of PTSD (Brewin & Holmes, 2003) to assess the impact of more proximal psychological variables that have been found to be the strongest correlates of PTSD symptomatology across a range of traumas in meta-analytic reviews (e.g., Brewin et al., 2000; Ozer et al., 2003). Future research should routinely employ prospective designs and conduct multivariate analyses in which proximal psychological variables (e.g., appraisals, memory processes) are assessed shortly after stroke (e.g., within one month) and are related to the subsequent development of PTSD and/or symptom severity at later time points, while controlling for the influence of more distal factors (e.g., stroke details, demographics) and initial PTSD symptoms. In this way, future studies may assess the extent to which the effects of distal variables are mediated by these more proximal variables, thereby increasing our understanding of the mechanisms, or processes, underlying the

When studying psychological reactions to life-threatening illnesses, such as stroke, that are associated with severe levels of disability and instability in the patient's medical condition, researchers need to be cognisant of ethical as well as scientific considerations (Tedstone & Tarrier, 2003). Particular attention needs to be paid to issues of informed consent given the cognitive and communication impairments experienced by many stroke survivors. PTSD has become a popular diagnosis over recent years (Summerfield, 2001), as evidenced by the increasing range of events, including life-threatening illnesses, that have been the focus of PTSD research (Tedstone & Tarrier, 2003). While such research has increased our understanding of psychological reactions to life-threatening illnesses, researchers should be aware of the risk of pathologising normal reactions to a traumatic event that may naturally

impairments.

**3.4.5 Assessment of risk factors** 

development of PTSD after stroke.

remit over time (Middleton & Shaw, 2000).

**3.5 Ethical considerations** 

Post-stroke traumatic stress is an important but relatively neglected psychological consequence of stroke. It would be valuable to have reliable and accurate prevalence data from clinical diagnostic interviews with large, representative samples of stroke survivors collected over several time points. In addition, further work is required on the assessment of potential risk factors for the development of PTSD. This should include assessment of a full range of risk factors, including variables from current models of PTSD, shortly after stroke that can be related to subsequent PTSD caseness and symptom severity at later time points. A better understanding of the risk factors for PTSD after stroke has important clinical implications for the management of stroke survivors. It may assist in better differentiating the organic effects of stroke from the behavioural and psychological symptoms of the psychiatric disorder. More importantly, there is now a large body of evidence to guide the effective treatment of PTSD (Ponniah & Hollon, 2009). Appropriate use of such interventions has the potential to improve the quality of life, and reduce the care costs, of this population.
