Anxiety & Relaxation
After Stroke
Dr Sally Dodds (Clinical Psychologist) & Lucy Apps
(Psychology Assistant)
North Tees & Hartlepool NHS Foundation Trust
What we’ll cover
Anxiety
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Overview
After Stroke
How you can help
Exercise
Relaxation
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Why ?
How and when
Tips
Demonstration
Quick Overview of Anxiety
Symptoms
Biological
Cognitive
Psychological
Behavioural
• Dry Mouth
• Shaking
• Sweating
• Heart racing
• Breathing
• Self as
vulnerable
•World chaotic
• Difficulties
concentrating
• over interpretation of
threat
• Anxiety
• Irritability
• Feeling on
edge
• Avoidance
• Increased
dependency
• Wish to escape
Anxiety in Stroke
Types & Prevalence
Effects
• 1 in 10 premorbid anxiety
• Panic attacks
• OCD
• Phobias
• After stroke 22% to 28%
• Generalised Anxiety Disorder
(25%)
• PTSD (5-30%)
• Health Anxiety
• Social Anxiety
• Agoraphobia
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Reduced concentration
Interrupted sleep
Impacts on rehabilitation
Relationship difficulties
Reduced social contact
Burden on services
Poorer outcomes esp. with
comorbid depression
Associated Fears
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Falling (88%)
Having another stroke
Dying (in sleep)
Incontinence
Reaction of others
Going home
Disability
Not being able to cope
Not getting better
Over-exertion
Failure to meet pre-stroke
expectations
• Dependence
• Vulnerability
• Not receiving enough
care
• Restriction & overprotection
• Public transport
• Crossing the road
• Travelling
• Speaking on the phone
• Social situations
• Work
What you can do
WHY?
• Everyone in stroke
team should be able
to support those with
psychological issues
(NICE; RCP)
• Stepped Care
Approach
• Model
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HOW?
Be aware of types of
anxiety
Screening
Onward referral
Understand and assist
at levels 1 or 2
How to Screen for Anxiety
• Routine mood assessment
(NICE & RCP)
• Hospital Anxiety &
Depression Scale (HADS-A)
• Behavioural Outcome of
Anxiety (BOA)
When to refer on
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HADS is not perfect!
Use clinical judgement & knowledge of patient
Anxiety is normal after a stroke – notice, explore, monitor
Check out how they’re feeling
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“You just looked really worried. Can you tell me what went through your
mind?”
“ when you just had that thought of…..did you notice anything about your
body?”
• Ask family
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“Are they usually anxious, what makes them tense, what helps?”
• If anxiety persists consult a psychologist
• Be aware of your local pathways for referral
Understanding Anxiety
• Exercise in twos/small groups
• Case Study
• Think about what might be going on for Bob and
what you can do – use tools provided to help
• 10 minutes
• We’ll then introduce a specific intervention you
can try
BP &
Hyper tension
Anxiety
&
Stress
Depression
Relaxation
Neuro
Rehab
Cardiac
Rehab
Sleep &
Attention
Pain &
Mobility
Relaxation in Stroke
• Local Project funded by
NECVN
• The Stroke Workbook
(Lothian Health Board,
2011) includes relaxation
• Could increase staff
confidence in managing
psychological distress
• Simple skill to learn
• Low-cost intervention
• MDT approach
• Improves motivation,
confidence, and perceived
QoL
• Relaxation and mental
imagery = improvement in
affected upper limb
• Better recovery in
discharged stroke patients
than controls
• Taught to brain injury
patients
Relaxation Resources
• Due to physical and cognitive issues relaxation resources
must be adapted
• Stroke specific relaxation CD & Scripts
• Autogenic Relaxation
• Progressive Muscular Relaxation
• Breathing Control
• Visualisation/Imagery
• Music
How and When to Use?
• For inpatients and outpatients
• CDs can be left with patients
• Staff can demonstrate relaxation techniques to those
who need it
• During physiotherapy or any anxiety-provoking medical
or care interventions
• Once practiced it can be used anytime any place
• Good for managing own stress levels too!
Handy Tips
• Check out patient is happy to try it
• Explain how it may help to reduce their anxiety
• Slows breathing
• Distracts from worries
• Restores calm
• How long it will last
• Agree on what you’ll do if they fall asleep or if they get
restless
• Can lead to initial increase in anxiety so
• Ensure patients do not hold their breath or take deep gasps
• Encourage regular practice
Relaxation Demonstration
• Are you sitting comfortably??
Things to think about
• How might you use what you have learnt today
in your own service?
• What barriers might there be?
• How might you overcome them?
Questions/Further
Information
Sally.dodds@nth.nhs.uk
Lucy.apps@nth.nhs.uk
Stepped Care Model
Taken from: Psychological Care After Stroke (NHS Improvement)
What you can do
CASE STUDY - BOB
Background
Bob is a 54 year old man who had a prominent role in the police force. He lived at home with his wife and two
teenage children. They had an active social life and Bob was a keen golfer. He had no previous physical or
mental health issues and kept himself relatively fit and healthy although his social activities often revolved around
drinking. Both his parents had died suddenly, one from stroke and one from heart attack. At the time of the stroke
Bob had been asleep in bed when he woke with a headache and found he could not speak or move his right
arm. He recalls it being very dark and quiet in the bedroom, he did not understand what was happening and he
felt very frightened. He eventually managed to alert his wife who called an ambulance.
a) Inpatient
During his brief stay at hospital he was agitated and became easily distressed particularly on a night. As a result
he was placed in a quiet area of the ward where he would not disturb other patients. He refused medication to
help him sleep and would instead stay awake at night often pacing around the ward or calling the nurses to
complain of headaches or difficulty breathing. There were no medical causes found for his symptoms however
despite reassurances he remained on edge. During the day he was tired and often refused to engage in his
rehabilitation therapy. When he did engage he was distracted, felt dizzy and could not breathe. He thought
something terrible was about to happen.
b) Community
On his return home Bob was left with some right-sided weakness in his arm however he could walk
independently. His speech had improved dramatically and there were no obvious cognitive issues. Despite this
Bob suffered ongoing headaches, found it difficult to concentrate and had trouble sleeping. He would lay awake
at night experiencing difficulties breathing, racing heart and chest pains. He felt afraid and had a sense that
something awful was about to happen. He often presented to his GP but was told it was all in his head. He
thought he was going mad. He couldn’t concentrate on his physiotherapy exercises and became frustrated at his
lack of progress. He stopped seeing his friends and stayed at home where he couldn’t settle to anything and
became irritable with his family.
EXERCISE
Please use the information you have learned so far today along with the tools provided to think about the
following:
What do you think Bob is experiencing?
What specific fears may he be having?
What might the triggers be?
What could you do?
Relaxation