The Psychiatry of Stroke

The neuropsychiatric manifestations of cerebrovascular disease are protean. Dr. Birkett brings an admirable order to this complex topic. His volume, The Psychiatry of Stroke, is well organized, well referenced, and comprehensive. Dr. Birkett appears to have scoured the voluminous literature on the psychiatric, neurological, medical, social, and other aspects of stroke, presenting the reader with what appears at times to be an annotated bibliography. In and of itself, this material would be most useful, but he presents it with a clear and consistent focus on the subjective experience of the human beings who suffer (or whose loved ones suffer) these multiple syndromes.

The book opens with an explication of the diagnosis of stroke, its risk factors, and localization of brain functions. These complex and often controversial topics are presented with sufficient detail, but they are readily accessible to those with only a minimum of training in neurology. The book includes an extensive glossary and an appendix on the basic anatomy of stroke, with many clear and simple diagrams that are far more comprehensible than anything this reviewer encountered in medical school. Numerous tables amplify and clarify the text. Especially impressive is a table on the functional effects of localized brain lesions, which lists 24 neuropsychiatric symptoms, their associated lesions, the quality of evidence for the association, and the relevant references. A chapter on the neuropsychopharmacology of stroke presents a discussion of the exitotoxicity of endogenous neurotransmitters and the potentially toxic side effects of various classes of drugs prescribed acutely to stroke patients.

A large section of the book is devoted to the various neuropsychiatric syndromes with which stroke patients present. A chapter entitled “Speaking and Understanding” reviews the aphasias, akinetic mutism, and more, with a detailed presentation of the available speech therapies and tests for aphasia. Dr. Birkett demonstrates his seasoned clinical skills throughout the book, a good example being his section on the psychiatric management of the “noisy,” agitated aphasic patient who needs to be attended to. The chapter on disorders of “seeing and believing” offers a good review of hallucinations, misidentification syndromes, hysterical blindness, and other syndromes the neuropsychiatrist might be called upon to assess and treat. One wishes that neglect syndromes and anosognosia were covered in more detail. Chapters on sensory disorders, including pain, and sexual dysfunction caused by stroke are presented with solid discussions of underlying neuroanatomy. Perhaps of greatest interest are the chapters on apathy, violence, disinhibition, delusions, depression, anxiety, and dementia. The available literature on the phenomenology, etiology, and management of these syndromes is reviewed in detail, with an especially good table on the controversial localization of depression. The differential diagnostic considerations presented are thorough and genuinely helpful. First-person accounts by stroke victims are used to elaborate on the clinical descriptions and maintain a humanistic focus on the therapeutic interventions presented.

The author presents a rather detailed account of available pharmacological interventions for the various neuropsychiatric syndromes and provides a clear presentation of the indications for ECT in depressed stroke patients. He consistently and correctly promotes psychotherapy for stroke victims and their caretakers, emphasizing a supportive, interactive approach that aims to reduce the anxiety and narcissistic injury that are inevitable in this disease. Typical of the eclectic psychotherapeutic approach presented by the author is an appendix giving the names and phone numbers of national (American and British) organizations that provide information and support for stroke victims. This is a unique and valuable resource for practitioners in the field.

The book concludes with chapters on the course of recovery, the impact of stroke on families, the stroke treatment team and spectrum of care, and chapters on legal, economic, and ethical issues. There is a strong, moving, and cogent appeal for sensitivity to the needs of the family members who care for loved ones devastated by stroke, with an elaboration of the family dynamics that can intrude on this care. The chapter on the stroke treatment team explores the institutional countertransference reactions that can affect health professionals working with seriously and acutely disabled people. One wishes the author had elaborated even further on this important topic.

Probably every clinician and researcher working with stroke patients has an area that he or she feels should be elaborated on. Dr. Birkett is to be commended for providing us with a volume that is thorough and comprehensive, especially given that it is the work of a single author. His style is admirably direct and often witty. (Describing the legal issues involved in contested capacity to make a will, Dr. Birkett advises against the psychiatrist investing too much effort in reality testing for the children of the victim, since “usually the pocket calculator is not a powerful enough tool to dig out deep-rooted sibling rivalry”). With its clear style, easy accessibility, and thoroughness, The Psychiatry of Stroke is an impressive and valuable addition to the neuropsychiatric literature.