Hostility and neuroticism among unselected essential hypertensives

Suppressed hostility predicted hypertension incidence among middle-aged men: the normative aging study

This study tested whether suppressed hostility predicted incident hypertension (HTN) in initially nonhypertensive men, using prospective data from the Normative Aging Study. Six hundred twenty-seven men who completed the MMPI and participated in a subsequent laboratory assessment were included in the study. The Cook-Medley Hostility scale (Ho), a suppression factor, and other risk factors were used to predict incident HTN over a 3-year period. Logistic regression showed a significant three-way interaction among Ho, suppression, and age in predicting incident HTN. Among middle-aged men (<or=60 years) with higher suppression, a 1-point decrease in the Ho score was associated with an 18% increase in HTN risk. This relationship remained significant after controlling for relevant risk factors. Among older participants, the HoxSuppression interaction was not predictive of HTN incidence. These results provide support for the Suppressed Hostility hypothesis in middle-aged men.

Cushing’s disease and melancholia

Striking similarities exist in the endocrinology of Cushing's disease and melancholic depression.Laboratory abnormalities, which have been found in both, include raised urinary,plasma and salivary cortisol, non-suppression of cortisol in the dexamethasone suppression test and adrenocorticotrophin (ACTH) hypersecretion. The hypercortisolism can be so severe in melancholic depression that it is difficult to distinguish from Cushing's disease and has been described as a "pseudo-Cushing's" state. Cerebrospinal fluid corticotrophin-releasing hormone (CRH) levels have been found to be lower in patients with Cushing's disease than in depressed subjects. Dynamic endocrine tests may help to distinguish between the two disorders.An exaggerated response to synacthen has been found in both but a reduced ACTH response to CRH occurs in depression, unlike those with Cushing's disease who show ACTH hyper-responsiveness. Other tests, which may help to distinguish between the two disorders,include the dexamethasone-CRH test, the naloxone test, the insulin-induced hypoglycemia test and the desmopressin stimulation test. Similarities in psychiatric symptoms have been recognised for many years. More recently, the physical complications of melancholic depression have been noted. These include osteoporosis, an increased risk of death from cardiovascular disease, hypertension, a redistribution of fat to intra abdominal sites and insulin resistance. Cushing's disease shares these physical complications and we propose that the common underlying factor is excessive plasma glucocorticoids. The increasing recognition of the physical complications and the increased morbidity and mortality in those who suffer from depression underscores the necessity for early detection and treatment of this illness and screening for undetected physical complications.

Psychological variables in hypertension: relationship to casual or ambulatory blood pressure in men

OBJECTIVE

The evidence linking hypertension with personality or psychological characteristics, such as anger, anxiety, or depression, remains equivocal. This may be due in part to limitations of personality theory, confounding by awareness of hypertension, and/or inherent difficulties in measuring blood pressure. This study was designed to investigate the association between mild hypertension as defined by both ambulatory and casual (clinic) blood pressure measurements and various measures of personality and psychological characteristics.

METHODS

We examined this association in a population-based sample of 283 men between the ages of 30 and 60 years from eight work sites in New York City, using an ambulatory blood pressure monitor and controlling for age, race/ethnicity, and body mass index.

RESULTS

We found no consistent difference between participants with mild hypertension and those with normal blood pressure on any of the psychological variables assessed, including Type A behavior pattern, state and trait anger, anger expression, anxiety, symptoms of psychological distress, locus of control, or attributional style. Results were not due to the use of antihypertensive medication by some of the participants with hypertension nor to the dichotomization of blood pressure into those with and without mild hypertension. This contrasts with previous findings from this study showing a sizable association of ambulatory blood pressure and hypertension with job strain (a situational measure), age, and body mass index.

CONCLUSIONS

These null results suggest that situational, biological, and perhaps behavioral factors are the primary determinants of mild hypertension and that the predictive significance of psychological or dispositional factors is low or negligible in those without overt cardiovascular disease.

Defensiveness and essential hypertension

The purpose of this study was to investigate the association between essential hypertension and defensiveness. Fifty normotensive and 74 hypertensive subjects completed the State-Trait Personality Inventory (STPI) and State-Trait Anger Expression Inventory (STAXI) to assess perceived anger and anxiety, and the Marlowe-Crowne Scale of Social Desirability as an indicator of defensiveness. Hypertensive and normotensive groups did not differ in their scores on the anger, anger expression, and anxiety scales. In contrast, Marlowe-Crowne scores were higher in the hypertensive group (18.1+/-5.5 vs. 15.4+/-5.1) (p=0.006). Stepwise logistic regression that included age, gender, BMI, and Marlowe-Crowne scores (dichotomized at 18) showed that a high Marlowe-Crowne score was associated with a relative risk of 3.63 (CI 1.49-8.83) of being hypertensive, independent of age, gender, and BMI. Anger and anxiety scores did not predict hypertensive status and did not affect the relationship between Marlowe-Crowne score and hypertensive status. We conclude that defensiveness is more closely related to essential hypertension than is self-reported anger or anxiety. Better understanding of conscious and unconscious mechanisms of defensiveness are likely to be important in clarifying the link between emotions and hypertension.

Blood pressure and personality

Measures of blood pressure were not associated with scores on Psychoticism, Extraversion, or Neuroticism for 61 college students.

The psychological and social condition of hypertensives resistant to pharmacological treatment

To characterize patients with therapy-resistant essential hypertension (TR) from a psychosocial point of view, 29 hypertensives, filling specified criteria for TR in a hypertension clinic were selected out of 800 patients screened. A control group of patients with established, but well controlled hypertension, pair-wise matching study patients for age and gender was also selected. TR patients were predominantly of working-class origin (68 vs 19% P less than 0.001). They tended to be more obese (BMI 28.7 +/- 5.5 vs 26.9 +/- 3.9 ns). TR tended to report fewer important life events, and reported significantly fewer positive events from the last 10 year period P less than 0.05. According to the EAI, their ability to channel emotions, especially anger, was impaired (P less than 0.01). So was their instrumental handling of emotions such as anger and sorrow (P less than 0.05). They experienced less of joy, and even had a more negative attitude towards that emotion (P less than 0.05). When adjusted for social class this latter difference was not statistically significant. Their degree of global emotional differentiation was lower (P less than 0.05). In the ISSI interview they had low scores for availability of emotional attachment (P less than 0.01), and friendship (P less than 0.05), but not for social integration. To conclude, when compared to well controlled hypertensives, TR exhibited the pattern, which has been shown to characterize young, asymptomatic, hypertensives in comparison to healthy subjects. These results must not be overinterpreted due to the limited sample.(ABSTRACT TRUNCATED AT 250 WORDS)

Low blood pressure, low mood?

OBJECTIVE

To determine whether a set of physical symptoms is associated with low blood pressure and to investigate the possible role of psychological factors in their occurrence.

DESIGN

Analysis of data collected by questionnaire and physical screening from the first phase of the Whitehall II study, a cohort study of an employed population.

SETTING

23 civil service departments in London.

SUBJECTS

10,314 male and female London based civil servants aged between 35 and 55.

MAIN OUTCOME MEASURES

Symptoms of dizziness-giddiness and unexplained tiredness; psychological functioning as measured by the 30 item general health questionnaire in which the response "no more than usual" to an item about disease was scored as indicating chronic illness.

RESULTS

Dizziness-giddiness in men and unexplained tiredness in both men and women were significantly related to low systolic blood pressure. There was a highly significant inverse relation between general health questionnaire score and systolic blood pressure for both men and women, which persisted after controlling for potentially confounding variables, including age, body mass index, drug treatment, physical illness, and exercise. This association of low blood pressure with physical symptoms was no longer significant when general health questionnaire score was controlled for.

CONCLUSIONS

There seems a strong relation between low systolic blood pressure and minor psychological dysfunction. Associated physical symptoms seem to be secondary to the primary disturbance in mental state.

Psychosomatic factors in borderline hypertensive subjects and offspring of hypertensive parents

Psychosomatic factors, sympathoneural and sympathoadrenal as well as cardiovascular mechanisms, were studied in 24 patients 18-24 years of age with borderline hypertension, 50 age-matched normotensive offspring of hypertensive parents, and 49 controls with no family history of hypertension. They were compared by projective and questionnaire-based psychological tests and their circulatory and neurohormonal reactivity to mental (Stroop color-word conflict test and arithmetic test) and physical stressors (orthostasis and bicycle ergometry test) were measured. Borderline hypertensive subjects externalized aggression less (p less than 0.05) but internalized it more (p less than 0.05) and were more submissive (p less than 0.05) when compared with controls. Offspring of hypertensive parents showed a similar but weaker pattern. Both risk groups reported more positive interactions with their parents (genetic risk subjects versus controls, p less than 0.05; borderline hypertensive patients versus controls, p = 0.08) and had higher state-anxiety levels (p less than 0.05). There were more subjective symptoms of beta-adrenergic receptor-mediated functions (e.g., tachycardia, tremor) in borderline hypertensive subjects and offspring of hypertensive parents, elevated heart rates (analysis of repeated measures, p less than 0.001), and enhanced plasma norepinephrine concentrations (p less than 0.05) when compared with controls. These findings in subjects at risk for the development of hypertension suggest that psychosomatic factors and sympathetic overactivity are involved in the early phase of hypertension.

Psychosocial factors are associated with health care seeking rather than diagnosis in irritable bowel syndrome

The objective of this prospective study was to test the hypothesis that 6 reportedly important psychosocial factors were useful criteria for diagnosing the irritable bowel syndrome. Ninety-seven new patients with entry complaints of abdominal pain, altered bowel habits, or both underwent full evaluation by board-certified or -eligible gastroenterologists in an outpatient setting. The independent measures were 6 questionnaires concerning anxiety, depression, stress, lack of social support, somatization, and abnormal illness behavior. The dependent measure, irritable bowel syndrome, was defined as the absence of an organic disease explanation for patients' entry complaints. Two other board-certified gastroenterologists, independent of the study, made this determination. Their rating was based on full review of transcripts of patients' clinic visits, laboratory data, and the results of a 9-mo telephone follow-up to patients and their physicians. Sixty-five percent of the sample had no organic disease explanation for the entry symptoms, thereby representing irritable bowel syndrome. The psychosocial predictors did not show a significant association with irritable bowel syndrome; the power of the study was 0.86. Post hoc analysis revealed that patients with organic disease, as well as patients with irritable bowel syndrome, had significantly more (p less than 0.01) psychosocial abnormality than normal subjects, which likely contributed to the inability of the psychosocial predictors to distinguish irritable bowel syndrome from organic disease. It was concluded that psychosocial criteria were of limited value in differentiating irritable bowel syndrome from organic disease but that they were determinants of health care seeking for the entire study group.

Essential hypertension: the relationship of psychological factors to the severity of hypertension

165 hypertensive patients attending one general practice in Portugal were found to report significantly higher scores on measures of neuroticism, anxiety, depression and general psychological distress than 152 normotensive patients at the same practice. Hypertensive patients with evidence of organ damage exhibited significantly higher depression scores than those without such damage. These differences between normotensives and hypertensives, and between hypertensive with and without organ damage are discussed and previous research in this area is reviewed.

Symptoms of psychologic distress associated with irritable bowel syndrome. Comparison of community and medical clinic samples

Women with symptoms indicative of irritable bowel syndrome who had not consulted a physician were compared with female patients at a gastroenterology clinic to investigate whether self-selection for treatment accounts for psychologic abnormalities in clinic patients' with irritable bowel syndrome. Two sets of diagnostic criteria were compared: restrictive criteria based on the work of Manning and conventional criteria (abdominal pain plus altered bowel habits). Lactose malabsorbers were included as a control group because they have medically explained bowel symptoms similar to those that define irritable bowel syndrome. Thus they control for the causative effects of chronic bowel symptoms on psychologic distress. Women who met restrictive criteria for irritable bowel syndrome but had not consulted a physician had no more symptoms of psychologic distress on the Hopkins Symptom Checklist than asymptomatic controls. However, medical clinic patients with both irritable bowel syndrome and lactose malabsorption had significantly more psychologic symptoms than asymptomatic controls or nonconsulters with the same diagnoses. Individuals who met only the conventional criteria for irritable bowel syndrome reported more psychologic distress than controls, whether or not they consulted a physician. These results suggest that (a) symptoms of psychologic distress are unrelated to irritable bowel syndrome but influence which patients consult a doctor and (b) conventional diagnostic criteria identify more psychologically distressed individuals than do restrictive criteria.

The relation of essential hypertension to feelings of anxiety, depression and anger

Franz Alexander (1939) offered the hypothesis a number of years ago that hypertension can result from the inhibition of feelings of anger. Although a great deal of research has been done to test this hypothesis, the results remain equivocal. Part of the difficulty is that usually only anger was examined, making it impossible to determine the extent to which the results were specific to anger and not general for other negative emotions. A second prevalent problem has been the failure to match hypertensive and control groups on demographic variables that may be relevant to the relationship of hypertension to anger and its expression, such as education, economic level, and age. A third problem is that most studies have investigated only male hypertensives, thereby limiting the generality of the findings. The present study compares male and female hypertensives with carefully matched controls on measures of anxiety, depression, and anger and its suppression.

Emotional and familial determinants of elevated blood pressure in black and white adolescent males

The relationships between blood pressure and several personality and traditional risk factors were examined in a sample of black and white adolescent males who were enrolled in a health science course in Tampa, Florida. Although a number of personality and traditional risk factors significantly predicted elevated blood pressure for both groups of adolescent males, suppressed anger and weight were the major independent predictors. Among black and white males, those who generally harbored grudges and suppressed their anger had higher systolic blood pressure; diastolic blood pressure was higher only for the white males who frequently held in their angry feelings. Weight and excessive salt usage significantly predicted both elevated systolic and diastolic pressures for white males, while these variables significantly predicted systolic pressures for black males. Familial factors were found to be independent predictors of systolic and diastolic blood pressure only for the white adolescent males. A further examination of the relationship between the frequency that anger is suppressed shows that the shape of the curves relating anger-in scores to blood pressure appears to have a 'threshold'. These findings indicate that adolescent males who are at increased risk for elevated systolic and diastolic blood pressure can be identified by how often angry feelings are held-in and suppressed.

Biobehavioral treatment of essential hypertension: a group outcome study

In a group outcome and follow-up study of 77 patients with essential hypertension, significant reductions were seen in systolic and diastolic blood pressure (BP) and in hypotensive medication requirement. A multimodality biobehavioral treatment was used which included biofeedback-assisted training techniques aimed at teaching self-regulation of vasodilation in the hands and feet. Of the 54 medicated patients, 58% were able to eliminate hypotensive medication while at the same time reducing BP an average of 15/10 mm Hg. An additional 19 (35%) of the medicated patients were able to cut their medications approximately in half while reducing BP by 18/10 mm Hg. The remaining 4 (7%) medicated patients showed no improvement in either BP or medication requirement. Similar reductions in BP were seen in initially unmedicated patients. Seventy percent of the 23 unmedicated patients achieved average pressures below 140/90 mm Hg, with an additional 22% of these patients making clinically significant reductions in pressure without becoming normotensive, and with 8% unsuccessful at lowering pressures to a clinically significant extent. Follow-up data available on 61 patients over an average of 33 months indicated little regression in these results with 51% of the total patient sample remaining well-controlled off medication, an additional 41% partially controlled, and 8% unsuccessful in lowering either medications and/or blood pressures to a clinically significant extent.

The relationship between blood pressure and personality in a large unselected adult sample

As part of a general health survey of a small New Zealand town, the Crow-Crisp Experiential Index, the State-Trait Anxiety Inventory, a shortened version of the Hostility and Direction of Hostility Questionnaire, and the Zung Self-rating Depression Scale were administered to 1173 subjects over the age of 15. Blood pressure was moderately correlated with age and Quetelet's Index, a measure of obesity. Low but significant correlations were found between Somatic Anxiety, Hysteria, and the Urge to Act-out Hostility scale. However, when effects of age were controlled for, in a series of multiple regression analyses, the correlations with psychometric test scores were no longer significant. This study confirms several previous reports that neuroticism, anxiety, depression, and hostility are of little significant in predicting levels of blood pressure in the general population.

Hypertension: psychological aspects and diagnostic impact in a clinical trial

The widespread acceptance of evidence that even mildly raised blood pressure is associated with an increased risk of cardiovascular morbidity has led to the setting up of screening programmes and treatment trials for hypertension in several countries. In order to allay anxieties about adverse psychological consequences of their own treatment trial of mild to moderate hypertension in a population of 35-64 year old adults of both sexes, the Medical Research Council supported a special psychiatric study in the pilot phase of the trial. This case-controlled study demonstrated that there was no increase in psychiatric morbidity after diagnosis (labelling) of hypertension nor during one year on the trial. There was, in fact, a fall in such morbidity for trial entrants, related to a greater rate of improvement for those subjects who displayed morbidity and not to any alteration in the incidence of new morbidity. The improvement in psychological state was not associated with any of the antihypertensive drug regimes, nor was it an artefact of selection; rather it appeared to be a beneficial effect of regular clinic attendance. The results of this study are presented and discussed in the context of current research into the psychological aspects of hypertension.

Psychosocial factors and blood pressure

Blood pressure levels as recorded in a community-wide screening programme were compared with findings in an earlier mental health study for persons who participated in both programmes. Blood pressure was not related to previously ascertained psychosocial characteristics among persons who were not under treatment for hypertension, suggesting that depression, hostility, psychosomatic reactions to stress, or the felt need for help with emotional problems were not important in the pathogenesis of hypertension. Treatment for hypertension, however, was associated with an excess of psychosomatic symptoms, a factor which needs to be taken into account in assessing the benefits of treatment.

Psychological dynamics and self-perceptions of persons with essential hypertension

Recent literature suggests specific dynamic commonalities among hypertensives are unlikely; study of development, building and evaluation of programs tailored to the individual is in order.