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448 – Post Stroke Psychosocial Issues
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director: AllCEUs
Podcast Host: Counselor Toolbox, Case Management Toolbox, NCMHCE Exam Review

• Examine the prevalence of and risk factors for stroke
• Identify Post-Stroke Psychosocial Issues
• Many of our clients are at high risk of stroke
• People with anxiety disorders have a 33% higher risk of stroke partly due to HBP and lifestyle factors such as smoking
• Mood stabilizers were collectively associated with a significantly increased risk for stroke in participants with bipolar disorder
• Benzodiazepine use is associated with a 20% higher risk of stroke
• Almost 40% received 1 or a combination of drugs hypothesized to impair recovery during the first 30 days after stroke.(e.g. clonidine which reduces NE levels, atypical antipsychotics, benzodiazepines)
Risk for Stroke
• Smokers are 2-4x as likely to have a stroke
• Make blood sticky and more likely to clot, which can block blood flow to the heart and brain
• Damage cells that line the blood vessels
• Increase the buildup of plaque (fat, cholesterol, calcium, and other substances) in blood vessels
• Cause thickening and narrowing of blood vessels
• Alcohol increases stroke risk by 38%
• Causing A-Fib
• Development of atherosclerosis, or the hardening and narrowing of arteries
• Liver damage impairing blood clotting
• HBP during detoxification
Risk for Stroke
• Stimulant abuse increasing blood pressure
• High blood pressure
• Sleep apnea
• Non-sleep-apnea sleep disorders
• Age
• Diabetes doubles the risk of stroke
• Use of nonsteroidal anti-inflammatory drugs (NSAIDs), but not aspirin, may increase the risk of heart attack or stroke, particularly in patients who have had a heart attack
• The signs and symptoms of a TIA resemble those found early in a stroke and may include sudden onset of:
• Weakness, numbness or paralysis in your face, arm or leg, typically on one side of your body
• Slurred or garbled speech or difficulty understanding others
• Blindness in one or both eyes or double vision
• Dizziness or loss of balance or coordination
• Sudden, severe headache with no known cause
• 70% reported that their TIA had long-term effects including memory loss, poor mobility, problems with speech and difficulty in understanding. 60% of people stated that their TIA had affected them emotionally

• When
• Just before discharge
• One month after stroke
• Three months after stroke
• Six months after discharge
• What to look for
• Cognitive functioning
• Depression
• Anxiety
• Social withdrawal
• Changes in physical presentation
Impacts of Stroke
• General Physical Issues
• Reduced mobility / independence
• Vision problems
• Difficulty with ADLs
• Difficulty swallowing
• Sleep problems (36%)
• Chronic headaches
• Pneumonia
• Pain

Impacts of Stroke
• Difficulty understanding or expressing emotions
• Post-stroke depression (PSD) (67%)
• Post-stroke depression may remit as the person regains function
• Correlated with hospitalization, functional loss and particular areas of the brain being damaged
• Post-stroke anxiety (25%)
• Post-stroke emotional incontinence (PSEI) uncontrollable outbursts of involuntary laughing or crying for no apparent reason (34%)
• Functional status, serotonin polymorphisms, and low social support were related to PSEI at three months post-stroke
• SSRIs are often effective

• Post-stroke anger proneness (PSAP)
• serotonergic dysfunction seems to play a role in the development of PSAP
• Post-stroke fatigue (PSF) (50%-86%)
• Depression
• Neurological deficits
• Antidepressants
• Sleep disturbances
• Post-stroke pain
• Changes to thinking, memory and perception after stroke can impact how the person sees, hears and feels the world. This can affect how they feel about themselves and others

• Cognitive skills can be affected by emotional state or tiredness, but brain damage caused by stroke can also cause difficulties with
• Ability to learn new skills
• Ability to plan
• Ability to problem solve
• Attention – being able to concentrate and focus
• Orientation – knowing the day and time
• Short-term memory – knowing what happened recently
• Changes in working memory
• Intellectual fulfillment

Attention and Memory Intervention
• Minimum of 1 hour a day of actively listening to music showed recovery in both verbal memory and focused attention, as early as 3 months after a stroke
• Personality changes
• Repetitive behavior
• Disinhibition – tendency to say and do things that are socially inappropriate
• Impulsivity including sudden and socially inappropriate actions.

• Perception is the term that describes how you see, hear and feel the world. After a stroke, your perception can include changes to:
• Feeling contact, pain, heat or cold on the side of your body affected by stroke
• Judging distance
• Performing certain movements even without physical disability (apraxia)
• Recognising shapes and objects, or even your own body
• Seeing or feeling things only on one side – which can cause you to bump into things
• Watching TV or reading – can become difficult
• Vision – some people lose half their vision in each eye (hemianopia).

• Communication after stroke
• Difficulty in finding the right words or understanding what others are saying (aphasia or dysphasia)
• Weakness in the muscles that help speech (dysarthria)
• Dysfunction of the nerve connection between your brain and mouth, making speaking difficult (dyspraxia)
• Reading and writing problems caused by a weak writing hand or problems thinking or seeing.

• Physical changes after stroke
• Difficulty with gripping or holding things
• Fatigue or tiredness
• Incontinence – many types of incontinence can occur, but it can be caused by medication, muscle weakness, changes in sensations, thinking and memory
• Pain – can be caused by actual or potential damage to tissues (nociceptive pain) or by damage to nerves that then send incorrect messages to the brain (neuropathic pain)
• Restricted ability to perform physical activities or exercise
• Swallowing issues
• Vision problems
• Weakness or paralysis of limbs on one side of the body.

• Aphasia
• Affects about one third of the stroke population and 40% continues to have significant language impairment at 18 months post-stroke
• Persons with aphasia (PWA) are especially prone to psychosocial problems, such as
• Anxiety and depression
• Threatened identity
• Changes in interpersonal relationships
• Reduced social networks
• Unemployment
• Abandonment of leisure activities
Post Stroke Grief
• Losses
• Independence
• Function/hobbies/employment
• Home (if moved to an ALC)
• Self-Esteem
• Appearance
Post-Stroke Guilt
• Not being able to do things with kids/family/friends that they used to
• Needing assistance from caregivers/feeling like a burden

Post-Stroke Interpersonal Issues
• Social life
• Personality changes, anger, depression, fatigue may inhibit relationships
• Emotional Incontinence may cause social withdrawal
• Financial challenges
• Loss of employment
• Need for an ALC
• Need for PT/OT
Post-Stroke Caregiver Needs
• Caregivers should be assessed for their ability to provide care
• Regularly assess caregiver wellbeing
• Caregiver Strain Index
• Caregiver Burden Scale
• Support caregivers in balancing personal needs and caregiving responsibilities by providing community programs, respite care, and educational opportunities
• Stroke impacts people physically, affectively, cognitively, and interpersonally.
• It is important to explore the causes of mood or cognitive issues to identify the best interventions
• Brain damage
• Sleep dysfunction
• Cognitive issues
• Life changes