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Psychiatric Symptoms After a Stroke

When people think about strokes, they often think about physical symptoms such as weakness, numbness, difficulty speaking, vision changes, or trouble walking. However, strokes can also affect mood, motivation, thinking and memory, personality, and behavior.

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Many people develop depression, anxiety, irritability, excessive laughing or crying, or trouble getting started with activities after a stroke. These symptoms are extremely common—affecting over 1/3 of stroke survivors—but often get overlooked because so much attention is understandably focused on physical recovery.

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Post-stroke psychiatric symptoms aren’t just a reaction to a scary medical event or the challenges of living with a physical disability. While these factors can certainly contribute, strokes can also directly affect the brain systems involved in mood, motivation, emotional regulation, and behavior.

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Psychiatric symptoms can occur even after strokes that cause relatively little physical disability. Both ischemic strokes (caused by blood clots in the brain) and hemorrhagic strokes (caused by bleeding in the brain) can cause psychiatric symptoms, and there is no type of stroke that is "too mild" to affect mood, motivation, thinking, or emotional functioning.

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Common psychiatric symptoms after a stroke

 

Strokes can cause many different psychiatric symptoms. Common symptoms include:

  • Depression

  • Anxiety

  • Excessive worry

  • Panic attacks

  • Loss of motivation or trouble getting started with activities 

  • Irritability

  • Crying or laughing for no reason

  • Sleep problems

  • Bothersome memories or nightmares related to the stroke

  • Changes in personality or behavior

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Some people experience relatively mild symptoms, while others develop difficulties that significantly affect quality of life, independence, relationships, and recovery.​

 

Why post-stroke psychiatric symptoms matter

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In addition to causing distress and suffering, post-stroke psychiatric symptoms can negatively affect stroke recovery overall, especially when untreated. However, treating psychiatric symptoms—just like treating problems with moving and talking—can help people recover and get back to living their lives. 

 

Compared with stroke survivors who do not develop depression or other psychiatric symptoms, people with post-stroke psychiatric disorders often experience:

  • Worse quality of life

  • Greater physical disability

  • Slower recovery

  • More difficulty returning to previous activities

  • Increased risk of death

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Psychiatric health and physical health are closely connected. Psychiatric illnesses can increase the risk of stroke in general, possibly through biological mechanisms involving inflammation, blood vessel function, and the body's stress-response systems.

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Psychiatric symptoms can make it harder to participate fully in physical, occupational, and speech therapy. They can interfere with taking medications properly, reduce physical activity, worsen sleep, and make it harder to follow through with the lifestyle changes that help prevent future strokes. 

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Fortunately, treating post-stroke psychiatric symptoms can reduce the risk of these harms and improve outcomes.​

 

Depression

 

Depression is one of the most common psychiatric complications of stroke. Symptoms of post-stroke depression  include:

  • Feeling sad

  • Trouble feeling happy

  • Losing interest in activities

  • Feeling irritable or getting angry easily

  • Not wanting to socialize

  • Feeling hopeless

  • Thinking of death or suicide

 

Depression after stroke is more than simply a reaction to having a serious medical condition. Strokes can directly affect the brain systems involved in mood. Depression can occur even in people who recover well physically and cognitively and are otherwise able to return to their usual activities.

 

Depression may begin shortly after a stroke, but it can also develop months later. People with a prior history of depression are at increased risk, but many individuals with post-stroke depression have never experienced depression before.

 

Post-stroke depression affects much more than mood. People with post-stroke depression often experience:

  •  Slower neurologic recovery

  • Greater disability

  • Worse quality of life

  • Less participation in rehabilitation

  • More difficulty returning to work and other activities

  • Increased risk of death

 

Depression is also associated with more challenges in taking medications consistently and making lifestyle changes to help prevent future strokes. Fortunately, treatment can improve not only mood but also independent functioning, level of disability, and overall outcomes.​

 

Loss of motivation and decreased activity level

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Strokes can cause a decrease in activity levels and loss of motivation, which is called apathy.  Apathy can involve:

  • Loss of motivation

  • Difficulty getting started with activities

  • Spending much of the day inactive, even when still physically able to do things

  • Less interest in hobbies or social interaction

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Apathy is not the same thing as depression, although the two conditions can occur together. People with depression are typically distressed by their symptoms and describe feeling sad, hopeless, or down. However, people with apathy often do not feel sad at all. Instead, they may seem inactive, emotionally disengaged, or uninterested while reporting that they feel perfectly fine.

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Apathy often causes more distress to family members than to the person with the stroke. Loved ones may worry that the person is “lazy”, giving up, or no longer cares about other people. In reality, apathy is caused by changes in brain systems involved in motivation and goals. Understanding this distinction can reduce guilt, frustration, and misunderstandings.

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People with apathy often enjoy activities once they are doing them—the biggest challenge is getting started. Family members and caregivers can help by encouraging participation and getting the person started with an activity rather than waiting for the person to do so on their own.​

 

Anxiety and panic attacks

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Anxiety is also very common after a stroke. Some people find themselves worrying excessively about many different issues. Others experience a constant sense of nervousness, tension, or unease.

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People may also develop panic attacks after a stroke. A panic attack is a sudden episode of intense fear, accompanied by physical symptoms such as:

  • Racing heart or pounding heart

  • Sweating

  • Shaking

  • Shortness of breath

  • Chest pain

  • Dizziness

  • Tingling

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During a panic attack, people may feel like they are going to die, or lose control, or that something terrible is going to happen. Because panic attack symptoms can resemble serious medical symptoms, they can be particularly frightening for stroke survivors—and of course, people can have both panic attacks as well as heart issues or other serious medical issues. In these situations, careful psychiatric evaluation and coordination with PCPs, cardiologists, neurologists, and other specialists can help to clarify the cause of these symptoms and to find the best treatment. ​

 

PTSD

 

A stroke is a sudden, scary, life-threatening event. Because of this, some people develop post-traumatic stress disorder (PTSD).

 

Symptoms may include:

  • Memories of the stroke frequently popping up and bothering you

  • Nightmares

  • Feeling like you are back in the situation when the stroke happened

  • Feeling very upset by reminders of the stroke

  • Trying to avoid things that remind you of the stroke

  • Always being on the lookout for the next bad thing to happen

  • Inability to relax

  • Startling easily

  • Feeling angry and irritable

  • Trouble sleeping

 

Sometimes people think that only combat veterans get PTSD.  However, PTSD can occur after any life-threatening event, including a stroke.

 

PTSD not only causes suffering, but it can also interfere with recovery and stroke prevention.

 

People with PTSD may find it hard to take medications every day, attend follow-up appointments, and make lifestyle changes to reduce the risk of another stroke. This may be because these activities, while positive from a health perspective, can be unwelcome reminders that the stroke happened.

 

Appropriate treatment for PTSD can help you return to feeling and living like yourself again, with the stroke representing just one chapter in your life rather than the main story.​

 

Crying or laughing for no reason

 

After a stroke, some people develop spells of crying or laughing, that seem to occur out of the blue. This is called pseudobulbar affect, pathologic laughing and crying, or involuntary emotional expression disorder.

 

The episodes of crying or laughing can occur totally at random, or for a very minor reason that does not seem to explain such a strong reaction. For example, a person may begin crying during a conversation about what to eat for dinner, or when watching a  sentimental TV commercial. Others may laugh intensely at situations they do not find especially funny, such as seeing a tall person walk a small dog. Sometimes people do feel sad during the crying spells or happy during the laughing spells, but sometimes they actually just feel calm and not particularly emotional during the episodes.

 

These random crying and laughing spells do not represent mood problems. Rather, they occur because strokes can affect the brain systems involved in regulating how we show our emotions. However, people with these spells can also have true depression—feeling consistently sad and down and not enjoying life even when not having the spells—since it is possible to have more than one post-stroke problem.

 

Sometimes just understanding the nature of the crying and laughing spells can help the person with the stroke and their family and friends to not worry about these episodes. However, if the spells cause problems, medications can treat them.​

 

Thinking/memory problems and psychiatric symptoms affect each other

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Strokes can affect attention, concentration, memory, language, planning, organization, and many other aspects of thinking.

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These cognitive changes can make it harder to cope with stress, maintain independence, participate in treatment, use coping skills, and return to previous activities—all of which can affect mood and behavior.  depression, anxiety, PTSD, poor sleep, and other psychiatric changes can also worsen thinking and memory.

 

As a result, cognitive and psychiatric symptoms often become closely intertwined after stroke. Sometimes it can be hard to determine where one problem ends and another begins. Figuring out exactly what is going on plays a huge role in choosing the most effective treatment. ​

 

Our approach to psychiatric disorders after a stroke

 

As a neuropsychiatrist, Dr. Byars uses her combined training in psychiatry, neurology, and cognitive disorders to fully assess your symptoms and functioning, develop an effective treatment plan, and work together with you to achieve your goals.

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Depending on the situation and your goals and preferences, treatment may include:

  • Medications

  • Talk therapy

  • Strategies to improve exercise and activity level 

  • Sleep optimization

  • Family education and support

  • Coordination with neurologists, therapists, rehabilitation clinicians, and primary care clinicians

 

Strokes can cause psychiatric, neurologic, and thinking/memory changes that may blend together and affect one another in complex ways. Effective treatment starts with figuring out the cause of the symptoms. For example, a person who has stopped socializing and participating in activities may have depression, apathy, fatigue, daytime sleepiness, PTSD, difficulties with following conversations, or some combination of these problems. 

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Many psychiatric medications can help post-stroke symptoms without causing harmful side effects. People with a history of stroke should not use medications that have negative effects on thinking, memory, and balance; fortunately, there are many safe and effective options that do not cause these problems.

 

Sometimes stroke survivors have difficulty talking and understanding words, and therefore find it hard to participate in traditional talk therapy. In this situation, therapies that don’t depend on talking—such as music therapy, art therapy, and pet therapy—can help a lot.

 

Exercise can help improve both mental health and physical functioning after a stroke. Exercise also helps reduce the risk of future strokes. Even small increases in physical activity can help.

 

We will work with you to understand what is causing your symptoms and identify the most effective ways to improve your mood, thinking, functioning, and quality of life.​

 

Family involvement

 

If family members or caregivers are involved in your healthcare, we are happy to work with them as part of your team.

 

Family members may notice important changes in mood, motivation, personality, behavior, and day-to-day functioning that may be difficult for the person who experienced the stroke to fully recognize or describe; especially if the stroke affected the person’s ability to talk and understand words.

 

Even when stroke survivors have difficulty expressing themselves in words, meaningful psychiatric treatment can still take place and improve symptoms and quality of life.​

 

There is hope after a stroke

 

Psychiatric symptoms after stroke are common, real, important, and treatable. Effective treatment can improve quality of life, functioning, independence, relationships, and overall recovery.

 

If you would like to explore whether specialized care for psychiatric symptoms after stroke could help you or a family member, we’re happy to talk through your situation and help you think about next steps.

 

You can schedule a free 15-minute phone call to help you decide whether BayLight Psychiatry is the right fit for your needs.

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