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Barclay KM, Kilkenny MF, Breen SJ, Ryan OF, Bagot KL, Lannin NA, Thijs V, Cadilhac DA. Denial of Cerebrovascular Events in a National Clinical Quality Registry for Stroke: A Retrospective Cohort Study. J Stroke Cerebrovasc Dis 2021; 31:106210. [PMID: 34864608 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 10/19/2021] [Accepted: 10/28/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES To investigate cerebrovascular event (CVE) denials reported by registered patients to the Australian Stroke Clinical Registry, and to examine the factors associated with CVE denial. MATERIAL AND METHODS CVE denials reported from January 1, 2017 to June 30, 2018 were followed up with hospitals to verify their discharge diagnosis. CVE denials were compared with all non-CVE denial registrants and a 5% random sub-sample of non-CVE deniers according to patient and clinical characteristics, quality of care indicators and health outcomes. Multilevel, multivariable logistic regression models were used. Factors explored were age, sex, stroke severity, type of stroke, treatment in a stroke unit, length of stay and discharge destination. Level was defined as hospital. RESULTS Overall, 339/23,830 (<2%) CVE denials were reported during the 18-month period. Hospitals confirmed 117 (61%) of CVE denials as a verified diagnosis of stroke or transient ischaemic attack (TIA). Compared to non-CVE deniers, CVE deniers were younger, had a shorter median length of stay (four days versus one day) and were more likely to be diagnosed with a TIA (64%) compared to the other types of stroke (11% intracerebral haemorrhage; 20% ischaemic; 5% undetermined). CONCLUSION Very few patients denied their CVE, with the majority of denials subsequently confirmed as eligible for registry inclusion. Diagnosis of a TIA and shorter length of stay were associated with CVE denial. These findings provide evidence that very few cases are incorrectly entered into a national registry, and highlight the characteristics of those unlikely to accept their clinical diagnosis where further education of diagnosis may be needed.
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Affiliation(s)
- Karen M Barclay
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Heidelberg, VIC, Australia
| | - Monique F Kilkenny
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Heidelberg, VIC, Australia; Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Sibilah J Breen
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Heidelberg, VIC, Australia
| | - Olivia F Ryan
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Heidelberg, VIC, Australia
| | - Kathleen L Bagot
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Heidelberg, VIC, Australia; Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia; Alfred Health, Melbourne, VIC, Australia
| | - Vincent Thijs
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Heidelberg, VIC, Australia; Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Dominique A Cadilhac
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, Heidelberg, University of Melbourne, Heidelberg, VIC, Australia; Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia.
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Large R, Samuel V, Morris R. A changed reality: Experience of an acceptance and commitment therapy (ACT) group after stroke. Neuropsychol Rehabil 2019; 30:1477-1496. [PMID: 30924741 DOI: 10.1080/09602011.2019.1589531] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Copious research on the utility of Acceptance and Commitment Therapy (ACT) in long-term conditions has demonstrated promising results. However, little research has been conducted on ACT within stroke, particularly studies that are qualitative in nature. The aim of this paper was to gain insight into stroke survivors' experiences of ACT and to explore what processes help facilitate adjustment in living with residual disability. Interviews with thirteen stroke survivors following their attendance at a stroke-adapted ACT group were analysed using a grounded theory approach. Stroke survivors varied in age, severity of stroke, limitations and duration since stroke. Interviews revealed a main difficulty of "accepting a changed reality" following stroke. Survivors' narratives regarding their experiences of ACT revealed insight into which processes helped facilitate movement towards accepting symptoms and a changed reality and into helpful and less helpful aspects of the intervention. Stroke survivors find ACT helpful in adjusting to stroke limitations. ACT appears to have potential as a psychological intervention for stroke survivors experiencing psychological distress. Amendments to the format of the intervention to enhance the impact of ACT impact are identified.
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Affiliation(s)
- Rebecca Large
- Psychology Department, Cardiff University, Cardiff, UK
| | | | - Reg Morris
- Psychology Department, Cardiff University, Cardiff, UK
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Rabinowitz T, Peirson R. “Nothing is Wrong, Doctor”: Understanding and Managing Denial in Patients with Cancer. Cancer Invest 2009; 24:68-76. [PMID: 16466995 DOI: 10.1080/07357900500449678] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
From a psychological perspective, denial is the process by which the mind defends itself against painful or threatening thoughts, feelings, perceptions, or information and may manifest in healthy or sick persons as well as in patients or those who care for them. For someone with a possible cancer diagnosis, there are several individual steps involved in the denial process, as the threatened meaning of one or more symptoms is sculpted into a more acceptable reality. Although most often felt to be a dysfunctional response, denial of illness is widespread and may serve an important adaptive or coping function, especially in a person facing the challenge of cancer. It may help a person cope with the various stages of their illness and treatment by allowing them time to process distressing information at a manageable rate. However, denial may also be dysfunctional, especially if it causes delay in seeking treatment for symptoms that present in the context of a true malignancy. Many clinicians misdiagnose denial when avoidance, disavowal, or another coping mechanism is invoked or when cognitive impairment or sensory deficits adversely affect perception. This article discusses denial in the context of cancer diagnosis, treatment, and prognosis and strategies for managing this common condition.
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Affiliation(s)
- Terry Rabinowitz
- Department of Psychiatry and Family Medicine, University of Vermont College of Medicine and Fletcher Allen Health Care, Burlington, 05401, USA.
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Santos CO, Caeiro L, Ferro JM, Albuquerque R, Figueira ML. Denial in the first days of acute stroke. J Neurol 2006; 253:1016-23. [PMID: 16598613 DOI: 10.1007/s00415-006-0148-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2005] [Revised: 01/18/2006] [Accepted: 01/24/2006] [Indexed: 11/26/2022]
Abstract
Denial is a disorder of self-awareness that is frequent after acute stroke, with potential negative influence in the care of patients. The aim of this study was to describe the presence and correlates of denial in acute stroke. We assessed denial in a sample of 180 consecutive acute stroke patients (< or =4 days) and in a control group of 50 acute coronary patients using the Denial of Illness Scale (DIS).41% (74) acute stroke patients (mean DIS score=4.1, SD=2.2, range 0 to 10) and 24% (12) acute coronary patients (mean DIS score=3.2, SD=1.5, range 0 to 10) presented denial (chi(2)=4.19, p=.04; U=3405.50, p=.01). Denial was more frequent and severe in patients with lower educational level (chi(2) = 5.04, p=.04; U=2110.50; p=.01), neglect (chi(2) = 21.38, p=.00; U=1130.50; p=.00), cognitive impairment (chi(2) = 6.27, p=.02; U=1181.50; p=.01) and after hemispherical lesions (chi(2) =4.68, p=.05; U=1982.50; p=.04). In logistic regression low educational level, neglect and cognitive impairment were independent factors predicting denial in stroke patients (R(2)= 21%). Patients with denial can express depressive symptoms. Patients with denial had a worse outcome at discharge (chi(2) =4.91, p=.04; U=2918.00; p=.03). Denial is a frequent phenomenon after acute stroke. We propose that there is a multifactorial model for the emergence of denial, lower educational as a predisposing condition, and acute stroke due to hemisphere lesion and causing neglect and cognitive impairment as precipitating events. All these factors limit patients' assessment of their condition and body functions.
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Affiliation(s)
- Catarina O Santos
- Stroke Unit Serviço de Neurologia Department of Neurosciences and Mental Health, Hospital de Santa Maria Faculdade de Medicina, Lisboa, Portugal.
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Aybek S, Carota A, Ghika-Schmid F, Berney A, Melle GV, Guex P, Bogousslavsky J. Emotional Behavior in Acute Stroke. Cogn Behav Neurol 2005; 18:37-44. [PMID: 15761275 DOI: 10.1097/01.wnn.0000152226.13001.8a] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To study emotional behaviors in an acute stroke population. BACKGROUND Alterations in emotional behavior after stroke have been recently recognized, but little attention has been paid to these changes in the very acute phase of stroke. METHODS Adult patients presenting with acute stroke were prospectively recruited and studied. We validated the Emotional Behavior Index (EBI), a 38-item scale designed to evaluate behavioral aspects of sadness, aggressiveness, disinhibition, adaptation, passivity, indifference, and denial. Clinical, historical, and imaging (computed tomography/magnetic resonance imaging) data were obtained on each subject through our Stroke Registry. Statistical analysis was performed with both univariate and multivariate tests. RESULTS Of the 254 patients, 40% showed sadness, 49% passivity, 17% aggressiveness, 53% indifference, 76% disinhibition, 18% lack of adaptation, and 44% denial reactions. Several significant correlations were identified. Sadness was correlated with a personal history of alcohol abuse (r = P < 0.037), female gender (r = P < 0.028), and hemorrhagic nature of the stroke (r = P < 0.063). Aggressiveness was correlated with a personal history of depression (r = P < 0.046) and hemorrhage (r = P < 0.06). Denial was correlated with male gender (r = P < 0.035) and hemorrhagic lesions (r = P < 0.05). Emotional behavior did not correlate with either neurologic impairment or lesion localization, but there was an association between hemorrhage and aggressive behavior (P < 0.001), lack of adaptation (r = P < 0.015), indifference (r = P < 0.018), and denial (r = P < 0.045). CONCLUSIONS Systematic observations of acute emotional behaviors after stroke suggest that emotional alterations are independent of mood and physical status and should be considered as a separate consequence of stroke.
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Affiliation(s)
- Selma Aybek
- Department of Neurology, Centre Hospitalier Universitaire Vaudois, 1011 Lausanne, Switzerland
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