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Patients presenting at the emergency department (ED) with symptoms that mimic a stroke are three times more likely to have posttraumatic stress disorder (PTSD) than those with an actual stroke, early results of new research suggested.

Lead author, Melinda Chang, research nurse at the Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York City, found the results surprising.

"We would assume that a stroke, which is more life-threatening, would have more PTSD, but in this study, we found people who have less life-threatening disorders have more PTSD," she said.

"Regardless of whether patients had a true stroke or not, neurologists should be assessing for any kind of mental health symptoms because the event might have been traumatic for patients even if they didn't have a stroke."

The findings will be presented at the upcoming International Stroke Conference 2024, held in Phoenix, Arizona.

Research showed a stroke can trigger symptoms of PTSD, but it's unclear if the risk is higher among those who present with stroke-like symptoms but are ultimately diagnosed with a stroke mimic. A stroke mimic is a "rule-out" diagnosis with symptoms that look like a stroke but aren't, said Chang.

The analysis included 1000 patients, mean age 62 years and 52% Hispanic/Latino, who presented to the ED with symptoms of a suspected stroke, including dizziness, headache, trouble speaking, numbness, or vision issues.

While at the hospital, patients were screened for preexisting PTSD using the self-report 20-item PTSD Checklist for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, which asks, for example, about the presence of unwanted memories, disturbing thoughts, and hypervigilance. Scores range from 0 to 80, with clinically significant PTSD defined as a PC-5 score of 33 or more.

Using chart reviews, a neurologist blinded to PTSD status determined that 59.6% of events were stroke, 7.9% were transient ischemic attacks (TIAs), and 27.4% were stroke mimics.

Migraine Most Common Mimic

Researchers put stroke mimics into 14 categories, with the most common being migraines and other headaches. "A very severe headache could be like a subarachnoid hemorrhage, so that's why people thought it was a stroke," explained Chang.

The two other most common mimics were peripheral or cranial neuropathy (nerve damage causing pain) and peripheral vertigo (dizziness typically caused by a problem in the inner ear, which controls balance.)

About a month later, patients were screened for PTSD linked to their ED experience with stroke-like symptoms. Rates of PTSD at 1 month were 15.1% for stroke mimic, 6.3% for stroke, and 5.5% for TIA.

Not surprisingly, those with preexisting PTSD (as determined by the first survey) were more likely to have the condition at the 1-month screen (odds ratio [OR], 10.32; 95% CI, 5.30-20.10; P < .01).

After adjustments for age, gender, ethnicity, initial National Institutes of Health Stroke Scale, discharge modified Rankin Score, and prior PTSD, the odds of 1-month PTSD were almost three times higher for stroke mimics than for patients with stroke (OR, 2.99; 95% CI, 1.45-6.18; P < .01).

Missing Distress

This suggested clinicians are missing psychological distress among patients who don't have a stroke diagnosis, but perhaps migraines or peripheral vertigo, said Chan. "As clinicians, we might assume, 'Oh, you're fine because you didn't have a stroke', but these patients might be suffering psychologically more than we think."

There was no increased risk for PTSD for stroke mimics vs TIA (OR, 1.80; P = .38).

Findings from a sensitivity analysis that excluded people with preexisting PTSD were similar. "People with stroke mimics still had more risk of PTSD than those who had stroke," noted Chan.

The study doesn't determine why PTSD is more common with stroke mimics, but Chang suspected it might have something to do with the uncertainly of the diagnosis. Although a stroke is "very scary" and can be life-threatening, the diagnosis is "clear-cut," and patients are offered lots of support and referrals to occupational and physical therapists, she said.

On the other hand, she added, if patients didn't have a stroke and are diagnosed with something like peripheral neuropathy, "you may not understand your diagnosis at all," don't have a lot of support, and may fear the incident will happen again.

Further, the ED experience itself can be traumatizing. Even if the stroke-like symptoms turn out to be something other than a stroke, this "may not be enough to assuage your fears," said Chang.

Very Surprising Finding

How might this new study affect clinical practice? "I can't say that from this one preliminary study, we should be changing policy, but it's something that needs to be further studied," said Chan. "This is a very surprising finding that I think most medical guidelines don't take into account."

The research team aimed to evaluate the presence of PTSD in these patients at 6 and 12 months and determine which stroke mimics are most likely to lead to PTSD.

Already, preliminary evidence suggested a functional neurologic disorder (where patients experience real neurologic symptoms but clinicians can't find a cause) is more significant at predicting 1-month PTSD (OR, 5.56 vs stroke).

It appears that people with peripheral or cranial neuropathy are also more likely to have PTSD at 1 month (OR, 4.93 vs stroke), which might be related to the impact of pain, said Chang.

The study used self-reported symptoms to determine a PTSD diagnosis rather than evaluations by a healthcare professional. Another study limitation was that data were collected at one urban medical center, located in Washington Heights, New York City, and results may not be generalizable to patients in other areas.

'Fascinating' Research

Commenting on the findings, E. Alison Holman, PhD, professor, Department of Psychological Science, and Associate Dean Academic Personnel, Sue & Bill Gross School of Nursing, UC Irvine, Irvine, California, said she found the research "fascinating."

But some things are unclear; for example, whether the study considered ongoing stressors of people living with a chronic condition that mimics a stroke as well as secondary stressors they may experience such as financial issues and functional decline that may exacerbate their distress.

"This is an important issue that needs to be addressed," said Holman. "This is especially the case since the assessment of PTSD took place a month later, and a lot can happen in a month.

Holman also wondered if data were collected during the pandemic. "The stress associated with being hospitalized during the pandemic combined with the fear or worry of having long-COVID could explain both lingering symptoms and the distress."

She agreed the uncertainty of a diagnosis and course of an illness can increase a patient's distress. "Anticipation of an unknown worsening health problem could fuel distress over time."

The research was part of the ReACH Stroke study (Reactions to Acute Care and Hospitalization — impact of PTSD on cardiovascular risk in survivors of stroke and transient ischemic attack), funded by the National Heart, Lung, and Blood Institute. Chang and Holman had no relevant conflicts of interest.