Anxiety associated with stroke-how far is it from us?

*For medical professionals, the incidence of anxiety associated with stroke is far higher than we thought.

Expert Profile: Mu Jun, Associate Chief Physician, Associate Professor, Doctor of Neurology at the First Affiliated Hospital of Chongqing Medical University; Visiting Scholar of the University of Hong Kong, Postdoctoral Fellow in the United States, Master Tutor; Member of the Neuropsychology and Behavioral Neurology Group of the Chinese Medical Association Neurology Branch; Chinese Geriatrics Member of the Psychiatric and Mental Health Branch of the Medical Association; Youth Member of the Psychosomatic Medicine Professional Committee of the Chinese Medical Doctor Association.

One.
Limb numbness? anxiety? The outpatient clinic encountered a female patient in her 60s who was widowed and living alone.

The hands were numb for more than 3 months, the location and duration of the numbness were not fixed, and there were no signs of neurological positioning.

He had a history of acute lacunar infarction six months ago without sequelae; a history of hypertension with reasonable blood pressure control; no history of diabetes.

The outpatient medical records showed that most of the doctors in our department had seen her, diagnosed "peripheral neuritis", "physical symptom disorder", and used serotonin reuptake inhibitors (SSRIs) drugs, methylcobalamin, with very good results.
micro.

According to the patient's original words, he would feel uncomfortable after taking the medicine, so he quickly stopped the medicine by himself, changed to a new doctor, and tried a new medicine, and the cycle went back and forth.

The patient's willingness to talk was very strong, and he asked slowly and found more main complaints, such as difficulty falling asleep, dreaming, worrying, cold feet, and poor appetite.

In particular, she mentioned that a close neighbor who was close to her had cancer.
When it was discovered, it was at an advanced stage.
The first symptom was cold feet.

Later, she talked about her sister, who also had numb hands, and soon died of cerebral hemorrhage.
Then she cried sadly, saying that she didn't want to be like her sister.two.
All kinds of anxiety symptoms-have you encountered it? ▌ Tensions for no reason, feeling scared, and always feeling that something unfortunate happens? ▌Easily get anxious and lose your temper? ▌ Often insomnia, nightmares? ▌Dizziness, headache, backache, numbness of hands and feet, tinnitus? ▌Palpitation, difficulty breathing? ▌Stomach pain, bloating, indigestion? ▌Nocturia increases? Anxiety symptoms are a state that everyone can experience.

Whether anxiety symptoms will develop into anxiety disorders is related to the intensity of the stress event, the patient's personality characteristics and coping strategies.

The diagnosis of anxiety disorder requires long duration of anxiety, severe symptoms, and serious damage to the patient's daily life.

Only a small number of patients will directly show obvious anxiety.
Most stroke patients show more physical symptoms that can affect various systems of the body, just like the patient mentioned at the beginning of this article.

As a result, the anxiety behind the physical symptoms is covered up, delaying diagnosis and treatment! Therefore, it is urgent to increase the attention of patients with anxiety disorders whose physical symptoms are the first or main manifestation! three.
The incidence of anxiety associated with stroke-far higher than you think! More than 25 million people worldwide are diagnosed with stroke, and 6.
5 million people die from stroke each year.

Stroke is the main cause of permanent disability in adults.

In addition to causing physical disabilities, stroke patients often experience various emotional disorders, such as anxiety and depression.

Post-stroke anxiety is related to many factors, such as patients’ worries about recurrence of stroke, worries about not returning to work, worries about insufficient social, economic and family support.

Undoubtedly, emotional disorders can significantly damage the physical and mental health of patients and interfere with long-term stroke recovery.

Anxiety is a common symptom in the acute phase of stroke, several months after stroke, and even years later.

A systematic review published in 2018 updated the incidence of anxiety in the first year after stroke [1].

The study was searched twice in 2015 and 2017 in the EMBASE, MEDLINE, PsycINFO, Cochrane Library, AMED and CINAHL databases.

Including people who were clinically diagnosed with hemorrhagic, ischemic stroke or transient ischemic attack, a total of 37 studies and 13,756 stroke patients were included.

The study population comes from hospitals, rehabilitation centers, communities and general groups.

These patients were diagnosed with anxiety in the first year after the onset of stroke or were assessed with anxiety symptoms through an evaluation scale.

The evaluation scale used is the Hospital Anxiety Depression Scale (HADS).

HADS is a 14-item self-rating scale specially designed for non-psychiatric hospitals, and it has been proven to be a reliable and effective tool for screening stroke anxiety and depression.

HADS can be divided into two parts, HADS-A is used to assess anxiety, and HADS-D is used to assess depression.

Most studies using HADS-A define a score ≥8 as an anxiety symptom.

The results of this meta-analysis show: ▌1.
Regarding the prevalence of post-stroke anxiety: the prevalence of overall anxiety within one year after the onset of stroke patients is 29.
3% (95% CI: 25.
1%-33.
5%; I2=97 %, p<0.
00001), compared with previous studies, the prevalence of anxiety has increased.

A study using the HADS-A scale showed that 27.
4% of patients (95%CI: 22.
5%-32.
3%; I2=97%, p<0.
00001) had anxiety symptoms in the first year after stroke.

▌2.
Regarding the subgroup prevalence at different times after stroke: the probability of anxiety occurring 0–2 weeks after stroke is 32.
3% (95% CI: 22%-42.
5%; I2=90%, p<0.
00001), 2 weeks to 3 months after stroke 24.
1% (95% CI: 16.
7%-31.
4%; I2=98%, p<0.
00001) and 23.
8% (95% CI: 12.
9%) 3-12 months after stroke -34.
7%; I2=96%, p<0.
00001).

It can be seen that the prevalence of anxiety between the acute phase and the 2-week to 3-month period after stroke has been maintained at a high level.
Although there is a downward trend, there is no statistical difference. ▌3.
Regarding the prevalence of different patient sources: Compared with the rehabilitation center and the community subgroup, the hospital subgroup has a particularly high incidence of anxiety in stroke patients.
The overall proportion of anxiety patients is 29.
5%, and the anxiety patients within two weeks after stroke The ratio is as high as 36.
7%.

four.
Severely underestimated stroke with anxiety.
This updated meta-analysis overall estimates that at least one-third of stroke patients have anxiety.

Anxiety and worries lead to a significant decline in the quality of life of patients.

However, according to a study published in 2012, compared with other emotional and psychological problems after stroke, such as post-stroke depression, post-stroke cognitive impairment, and post-stroke anxiety received significantly less attention.

The reasons may be related to the following factors: ▌1.
There is still a lack of high-quality epidemiological studies on post-stroke anxiety: most of the studies (65%) included in this meta-study are only of moderate quality.

The most common reasons for not being classified as high-quality studies are the lack of standardized assessment tools, the lack of long-term continuous follow-up of subjects, and the high rate of follow-up loss to follow-up, leading to bias.

▌2.
Lack of unified and standardized tools for anxiety evaluation: In most studies, post-stroke anxiety is often analyzed together with post-stroke depression.
For example, the HADS scale is a comprehensive evaluation scale that simultaneously evaluates depression and anxiety.
Therefore, these Studies focusing on depression also incidentally reported the incidence of anxiety symptoms.

Although most studies using HADS-A to assess anxiety have used a cutoff value of ≥8 to define anxiety, some scholars have suggested that a score of 4 or 5 is the best choice when screening for anxiety.

The scoring standards used in the same evaluation scale are not uniform, which may also cause the prevalence of anxiety disorders to be underestimated and not received enough attention.

▌3.
The insidiousness of post-stroke anxiety symptoms: Anxiety symptoms are usually divided into emotional symptoms (worry, fear), physical symptoms (sympathetic overexcitement, involving all systems of the body, various) and behavioral symptoms (appearing corresponding to anxiety Behaviors, such as being easy to startle, being unable to sit still). Post-stroke anxiety patients often have physical symptoms as their main manifestations.
If neurologists cannot identify these physical symptoms in time and effectively establish a connection between physical symptoms and potential anxiety, it will lead to missed diagnosis, misdiagnosis, and delay in treatment.

Fives.
The interactive effects of post-stroke anxiety and post-stroke depression.
Previous studies have found that anxiety and depression are highly related in genetics, biochemistry, immunology, endocrinology, electrophysiology, and imaging.

Therefore, in stroke population, post-stroke depression is often comorbid with post-stroke anxiety.

In most studies, anxiety is analyzed as a group of symptoms in the diagnosis of depression.

Studies have suggested that stroke in the left hemisphere will increase the incidence of depression and anxiety at the same time, and it is related to the degree of cognitive impairment [2].

The study also found that the more anxious the patient, the more severe the accompanying depression.

Therefore, anxiety may be one of the predictors of depression.

Effective management of anxiety contributes to the prevention of post-stroke depression.

Conversely, if the patient is accompanied by depression, the duration of anxiety symptoms will be prolonged [3].

Depressive stroke patients often lack the motivation to recover, while anxiety patients reject recovery plans without auxiliary measures because they are afraid of falling.

The biggest harm of the two coexistence is the severely low quality of life of patients.

six.
Comprehensive management of post-stroke anxiety Anxiety symptoms are common in the first year after a stroke, and one-third of patients have experienced anxiety symptoms.

Anxiety after stroke often manifests as physical symptoms.

Post-stroke anxiety often accompanies depression, which may be a predictor of depression, so it can greatly affect the patient’s quality of life.

Timely and effective management of anxiety symptoms can not only promote the recovery of patients, but also prevent the occurrence of post-stroke depression.

Neurologists should pay attention to the early routine screening of post-stroke anxiety in order to provide appropriate intervention measures.

Due to the lack of large-scale randomized controlled trials (RCT) research evidence for post-stroke anxiety, there is no high-level recommendation on screening scales and treatment [4].

Based on the domestic consensus recommendation [5], post-stroke anxiety can be quickly screened using the easy-to-operate "90-second 4-question method" and the widely used Generalized Anxiety Screening Self-Rating Scale (GAD-7).

In addition to more physical symptoms, some of the patient's prompting characteristics should be vigilant, such as repeated visits to the multi-disciplinary clinic, many chief complaints, detailed symptom list, and excessive attention to insignificant auxiliary examination results or drug instructions.

Drug treatment for post-stroke anxiety can choose SSRIs with anxiolytic effects, serotonin and norepinephrine reuptake inhibitors (SNRIs) or 5-HT1A receptor partial agonists (such as tandospirone) [6].

The elderly should follow the small-dose start, slowly increase, and fully consider the principles of combined medication and individualization.

References: [1] Rafsten L, Danielsson A, Sunnerhagen K S.
Anxiety after stroke: a systematic review and meta-analysis.
Journal of rehabilitation medicine, 2018, 50(9): 769-778.
[2] Suzanne LB.
Depression and anxiety 3 months post stroke: prevalence and correlates.
Arch Clin Neuropsychol.
2007;22(4):519-31.
[3]Kim JS.
Post-stroke Mood and Emotional Disturbances: Pharmacological Therapy Based on Mechanisms.
J Stroke.
2016;18(3):244-255.
[4]Knapp P, Burton CA, Holmes J, et al.
Interventions for treating anxiety after stroke.
Cochrane Database Syst Rev.
2017;5(5):CD008860.
[5] Wang Kai,Zhu Chunyan,Chen Haibo.
Expert consensus on the diagnosis and treatment of anxiety, depression and somatization symptoms in general hospitals[J].
Chinese Journal of Neurology,2016,49(12):908-917.
[6] Zhao Jingping,Lu Zheng.
Tan Expert advice on the clinical application of Duspirone in the treatment of patients with anxiety in general hospitals[J].
China Medicine,2019,14(06):935-939.
Review of previous highlights: 1.
The relationship between negative symptoms of schizophrenia and depression 2.
To treat hyperprolactinemia caused by antipsychotics, it is not always feasible to change the dressing! 3.
Medication for anxiety disorders: current and emerging treatment options 4.
How to balance the dose-effect relationship and safety of medications for schizophrenia? This article explains in detail for you! 5.
How to treat schizophrenia with depressive symptoms? These 7 ways are worth knowing 6.