Anxiety After Stroke: The Importance of Subtyping

Abstract

Background and purpose: Anxiety after stroke is common and disabling. Stroke trialists have treated anxiety as a homogenous condition, and intervention studies have followed suit, neglecting the different treatment approaches for phobic and generalized anxiety. Using diagnostic psychiatric interviews, we aimed to report the frequency of phobic and generalized anxiety, phobic avoidance, predictors of anxiety, and patient outcomes at 3 months poststroke/transient ischemic attack.

Methods: We followed prospectively a cohort of new diagnosis of stroke/transient ischemic attack at 3 months with a telephone semistructured psychiatric interview, Fear Questionnaire, modified Rankin Scale, EuroQol-5D5L, and Work and Social Adjustment Scale.

Results: Anxiety disorder was common (any anxiety disorder, 38 of 175 [22%]). Phobic disorder was the predominant anxiety subtype: phobic disorder only, 18 of 175 (10%); phobic and generalized anxiety disorder, 13 of 175 (7%); and generalized anxiety disorder only, 7 of 175 (4%). Participants with anxiety disorder reported higher level of phobic avoidance across all situations on the Fear Questionnaire. Younger age (per decade increase in odds ratio, 0.64; 95% confidence interval, 0.45-0.91) and having previous anxiety/depression (odds ratio, 4.38; 95% confidence interval, 1.94-9.89) were predictors for anxiety poststroke/transient ischemic attack. Participants with anxiety disorder were more dependent (modified Rankin Scale score 3-5, [anxiety] 55% versus [no anxiety] 29%; P<0.0005), had poorer quality of life on EQ-5D5L, and restricted participation (Work and Social Adjustment Scale: median, interquartile range, [anxiety] 19.5, 10-27 versus [no anxiety] 0, 0-5; P<0.001).

Conclusions: Anxiety after stroke/transient ischemic attack is predominantly phobic and is associated with poorer patient outcomes. Trials of anxiety intervention in stroke should consider the different treatment approaches needed for phobic and generalized anxiety.

Keywords: anxiety; ischemic attack, transient; neuropsychiatry; phobic disorders; stroke.

Figure 1.

A, Number of cases (sample frequency) of phobic disorder and GAD, (B) comorbid depression in sample at 3 months (n=175). GAD indicates generalized anxiety disorder.

Figure 2.

The thick lines represent median; boxes represent interquartile range; and whiskers represent range. Avoidant behavior in agoraphobic, social, and other specific situations (n=147). FQ indicates Fear Questionnaire.

Figure 3.

Baseline NIHSS, mRS and EuroQoL 5D-5L domains, by anxiety disorder at 3 months poststroke/TIA (n=175). mRS indicates modified Rankin Scale; NIHSS, National Institutes of Health Stroke Scale; and EQ5D-5L, EuroQoL-5D5L.