CAN HYPERTENSION BE INDUCED BY STRESS? A Case Discussion
Recctit(v. ,fbllowirrg (I r,icrtirig ol'thc?Editon'ul Bourd of'thc. Journal of Human Stress iti Boston. Dr. Hrrbert Bcrisori prcsrtitcd u CUSP histot?, io sonic' (?/'hiscollrugues o t i the Bourd. Whut jbllows is thvir discussion 01' thc. cusi'. txlitrd ./Or p u h lictit ion.
Herbert Benson, M.D.: The patient is a 32year-old physician who sought help on the basis of his concern regarding his longstanding hypertension. He and his parents and siblings present with a negative family history. He was quite well until the age of 19 when, upon facing the prospect of being inducted into the army, he learned from some of his friends that he could induce high blood pressure by thinking inappropriate thoughts, anxious thoughts. He did this before the induction center's examining physician, who noted a blood pressure of 180/90. He was told to come back in several days, during which period he kept himself quite anxious; when he returned for reexamination, he had a similar blood pressure. He was told to consult his personal physician, and he did not pass the examination. Stanislav V. Kasl, Ph.D.: Had his blood pressure been taken before? Benson: No. I n subsequent years, he went on to complete college and medical school. When he learned the significance of high blood pressure, he became very upset and started taking hisown blood pressure. At this point henoticed that upon repeated measurements, unless he was very calm, his blood pressure would re4
Journal of Human Stress
main in the range of 160190. He took no medication and tried to avoid stress. But he became progressively more anxious about this until. at the present time, he panics whenever a blood-pressure cuff starts to constrict around his arm. He felt he could tell when his blood pressure was high by his degree of anxiety. He was in the process of beginning to curtail some of his exposures to stressful events, because he felt that this would reduce high blood pressure. He now recognized that it was very important that his blood pressure be reduced. Upon examination, the patient appeared to be a robust, healthy young man with a blood pressure in the range of 170/100 and a pulse of 96. He was anxious. The remainder of his examination was within normal limits. A complete hypertensive workup was also within normal limits. The diagnosis of essential hypertension, perhaps labile hypertension, was made. Anxiety was a second diagnosis. The patient was instructed how to elicit the relaxation response and was also given a diuretic, hydroclorothiazide. His blood pressure is now in the range of 150/90, but it takes three or four measurements each session before his reactivity to the blood-pressure cuff and his pressure go down. He is still quite concerned March,
1977
CASE DISCUSSION that he might not get over his reaction to stressful events, and fearful of what this means in terms of his blood pressure and ultimate health.
Kasl: Why, specifically, did he seek help?
Benson: Because he had taken his own blood pressure throughout the year, and it had continued to be high. Kasl: But there was no acute reason for consultation? Benson: No.
Kasl: Why hadn't he been taking medication long before this? Benson: Perhaps it is denial of his disease. Robert Rose, M.D.: I wonder if, as you have presented the case, Dr. Benson, you have overemphasized the relationship between particular events and the onset of hypertension, similar to what the patient has done. I t is possible that there are individuals who have been programmed biologically to respond to changes in day-to-day living with increased blood pressure. Because of this biological predisposition, the threshold for increased blood pressure is low, and it does not take a great deal of stress to reach that threshold. I am concerned that this individual, who is a physician, has come to view his own hypertension as his responsibility, and to believe that if only he were different or did different things, it would go away. This comes out in the history, in that he "caused" his high blood pressure prior to the physical examination for the Service. He now feels that he should have control over his own blood pressure. If he thought better thoughts now, for example, he believes high blood pressure would go away. If he could be convinced that his condition is not his personal responsibility, that what he is experiencing is perhaps beyond his control, and that he is a hyper-responder, some of the guilt about his own responsibility in causing his high blood pressure would be diminished. In turn, if he were to be less distressed about this, he might be less apt to take his own blood pressure repeatedly throughout the day - he might be March, 1977
relieved of "sphigmomanometric mania," as it's been called.
Benson: There is something I would like to discuss that is of particular concern. We are undergoing an extensive educational process in the United States with respect to the perils of high blood pressure. It is being called the "silent killer." This and similar phrases are being used to engender fear, so that people will have their blood pressures measured. On top of that, increasingly initial blood pressure measurements are obtained under circumstances that are less than optimal. There are now blood-pressure measurement facilities located at various drug stores and supermarkets, where people are stopped during their busy daily routines to have their blood pressures measured. Taking blood pressures under circumstances that are rather stressful - because subjects don't want to be bothered and therefore are upset - results in less than an accurate baseline measurement. Given that and the fact that almost always errors occur on the high side, a vicious cycle may be started. The blood pressure has not been measured under optimal circumstances. The patient knows the significance of high blood pressure and worries about it. By the time the patient gets back to his/her own physician, a pernicious chain of events has begun. I wonder whether these detection programs aren't more
r ; Herbert Benson
Journal of Human Stress
5
STRESS A N D HYPERTENSION dangerous than they are beneficial, with the particular tactics being used. With this clinical potential for induction of high blood pressure under stressful circumstances, we have an additional variable not present in, for example, cancer detection programs or glaucoma detection programs. where presence or absence of the disease is an indisputable fact.
C. David Jenkins, Ph.D.: There are two streams of thought developing here. The first one deals with the clinical case and the dynamics of the patient's development of high blood pressure. The second deals w i t h the population question of whether an epidemic of high blood pressure is developing as a function of our alarm tactics. Let us try to keep them separate. Let us turn back to the first topic and reflect on this apparent linking of anxiety and high blood pressure. The first we know about this patient's high blood pressure is that it was discovered during his Selective Service physical examination at age 19. We see a continued linking of anxiety and blood pressure at age 32. I'd like to ask several questions. Is there any information about the blood pressure of this man before age 19. about the history of his anxiety. or about his anxiety attacks? Were there school problems, or any parental observations of the sort which might say that either the anxiety or the blood pressure elevation preceded this pairing of them which he reports in himself at the age of 19? In terms of his current life situation. what are the psychological concoinitants of his sweaty palms, high pulse, and elevated blood pressure? Do frightening ideas go through his mind? Does he perhaps ruminate over the means by which he originally raised his blood pressure? He may have lingering guilt over this.
I am also concerned about the fact that despite diuretics and relaxation therapy combined. this man is achieving only a modest reduction in blood pressure, at best. Does he get anxiety attacks over factols in his life other than the taking of blood pressure? We would have thought that either of these treatment techniques would have achieved better bloodpressure lowering if we were dealing with a 6 Joui-nal of Human Stress
siinple and uncomplicated case of hypertension.
Benson: There are several questions to be answered. First of all, no previous blood pressures were taken. Secondly, no extensive psychiatric examination was done. Therefore. no evaluation was procured that deals with his anxiety. Your last question asks, "Should we not have expected more?" Not necessarily. All we need, really. is a 24-hour ineasurenieiit of this man to assess what is happening away from the doctor's office. But this is very difficult to obtain. Rose: One wonders if his blood-pressure response to tlie anticipation of having his blood pressure taken could be extinguished. This might be done by merely placing the cuff'on his arm repeatedly. such as 50 times or so in the course of several houts. This might lead to some sort ofdeconditioning or desensitization.
John W. Mason, M.D.: Does the patieiit tend to show an exaggerated response to other illnesses in any way?
Benson: He is apparently healthy. otherwise. Mason: Psychiatric assessment of this patient in some depth would certainly be of interest. One of tlie issues to consider is whether one is dealing with a phenomenon rather specifically related to blood pressure or with a more general. neurotic characteristic of some individuals to tend to overreact greatly with anxious concern over any physical signs or symptoms they may have.
David Mechanic, Ph.D.: Why haven't you treated more aggressively with drugs?
Benson: Because at 150/90, I feel that he is fairly well controlled, and he does not wish to take more drugs. In fact, one of the reasons he came to me was that he was hoping that a nonpharinacologic approach would handle it.
Rose: To follow up on the second part of Dr. Jenkins' statement, isn't there data available, David, to which you have referred in the past, indicating that regardless of whatever the provocation, those individuals who show increased blood pressure variability are more likely to March. 1977
CASE DISCUSSION creased history of responsivity. It's not so much a question of being anxious, but a question of being anxious and being a blood-pressure responder, which presumably is related to some sort of biological programming.
Benson: Rather than equating this with anxiety, what I'm trying to equate it with is the actual event of having a blood pressure taken, which is linked with anxiety. Yes, the person who is anxious may manifest other physiological changes as well as high blood pressure.
Robert M.Rose develop fixed hypertension later in time? In other words, are there not data to suggest that regardless of what level of stress may be operating, if you are an individual who has shown increased blood-pressure variability. you are more likely to develop hypertension? Another way of stating this question is to ask whether or not individuals who tend to show increased blood pressure at any time are the ones who are going to develop hypertension later on.
Benson: Yes, in direct answer to your questions. But, unfortunately, most ofthe data supporting that contention come from an era when people did not know the significance of blood pressure. Now. with the knowledge of what blood pressure means, I'm afraid the issue is confounded. I should like to ask why we aren't really dealing with the second issue that I brought up, namely iatrogenic disease?
Rose: Not everyone who is anxious has high blood pressure. Benson: That is true.
Rose: One can argue just the opposite. Perhaps one should give people a stress lability test. If you respond with an elevation in blood pressure, you might be a person who should be watched carefully and treated earlier than you might be treated without knowledge of this inMarch. 1977
Rose: It seems to me important to separate people into two different categories. There are those whose blood-pressure response to having their blood pressure taken is part of the picture of having labile hypertension, in that they are already showing significant elevations of blood pressure in a variety of situations - not just that of having their blood pressure taken. These 'people presumably should be differentiated from those who are possibly early in the developmental history of labile hypertension and just have a response to this particular situation, which is not typical for them. Benson: We don't know that yet. Mechanic: If it is true that you have a person who is labile in response to stress, the fact that you pick this u p on the cuff doesn't make it any less significant. Therefore, why define it as iatrogenic when, indeed, it may be something programmed into the person? Benson: Because it may be a result of the cuff itself, and not something that is programmed in the person. Mechanic: Isn't that a testable proposition? Benson: It would be very difficult to test.
Rose: The only problem is that you really can't take blood pressure without putting on the blood-pressure cuff and measuring the blood pressure. It seems that what you are saying, Herb, is that in a population of individuals who are observed to have elevated systolic ar.d diastolic pressure associated with having their blood pressure taken once a month, there is a subgroup whose members are responding to Journal of Human Stress
7
STRESS AND HYPERTENSION who have a much more global tendency for increased blood-pressure response. regardless ofthe particular stimulus.
Mechanic: I guess the issue is how these two alternative conceptions can be tested against one another. Why couldn't you take someone with a cuff response and then elicit other anxiety-provoking material from past information you have on that person, and see what changes take place in blood pressure, above and beyond the baseline, which you get with the cuff alone? If the anxiety hypothesis is correct. wouldn't you then anticipate further elevations?
Kasl: If, every time the blood pressure is taken, it is high. you could create false feedback. David Mechanic
the cuff and another group of people who have true labile hypertension. Froni an epidemiological point of view. we are making an error. because we are adding the so-called "cuff responder" to the individual who has true labile hypertension, and therefore we are falsely increasing the number of people who are deserving of the diagnosis of hypertension.
Benson: Worse than that. What I am saying is that people who may only be cuff responders. after a while go on to become truly hypertensive because of their concern and their manifestat ions.
Rose: I'm arguing from a different point of view. I'm questioning the hypothesis that individuals can make themselves hypertensive because of the intensity of their concern about high blood pressure. I'm questioning whether or not, no matter what the intensity of concern an individual has. or the anxiety helshe manifests regarding the possibility of having hypertension. that this in itself is sufficient unusual mechanism. I wonder if there are. among the individuals who show an increased blood-pressure response to having their blood pressure measured, individuals who. if they were slightly less distressed about this. would very quickly show no response to bloodpressure measurement. These individuals could be distinguished potentially from those
8 Journal of Human Stress
Rose: Can you differentiate cuff hypertension and other hypertension?
Benson: Yes. You can do this with other intraarterial measurements.
Rose: We have some interesting data now that we have gathered from air trat'fic controllers while they are actually controlling traffic. We have been studying men for five hours, repeating our blood-pressure measurements every 20 minutes. We found. if we average all the systolic and diastolic readings on the 360 men we have studied in the field throughout the day. that the mean for both is equal to the mean we have observed when the same men come to Boston University for their physical exams. However. we also find that a significant number of men have very large changes in their blood pressure while they are working. almost I2 percent of them with systolic blood pressures which range more than 50 mm of Hg during the day. But another group does not show any changes in blood pressure at all, working in the same facilities and doing the same work.
Kasl: What is interesting in this discussion is that we are again talking on two levels. We are addressing the problems of the patient. And from a scholarly, scientific viewpoint, we are looking at how complicated these things really are. To get from the case study deeper into this kind of discussion would be terribly useful. March. 1977
CASE DISCUSSION Benson: I chose this case advisedly for both those reasons. Rose: John Mason asked good questions. Does this patient have some increased concern with illness, per se? Does illness have special meaning to him? Does he have special concerns that may explain the intensity of his response to having a blood-pressure cuff placed on his arm? There are questions that David Mechanic asked about his background and his upbringing which may also be a factor. This perhaps is another way of elucidating how we can gain inore relevant information. Kasl: This patient's self-concept is noteworthy: the idea that his hypertension has its origin in srifitidirccd anxiety. Of course, this need not be correct. That event may have had nothing to do with it.
Mason: There is another general question raised by this case which appeals. potentially, to be a very important issue in psychosomatic research. I am referring to the need to move towards making finer clinical distinctions between subgroups of patients within the larger diagnostic categories. A possible implication of this case is that this patient represents one relatively clear-cut subgroup within a larger, heterogeneous population of patients defined as hypertensive. If there are several clearly distinguishable subgroups of hypertensives as defined by clinical, psychiatric, physiological or other parameters, this is a matter which could prove of key importance i n psychosomatic research strategy. Pathogenesis might well be quite different in different subgroups. and this conceptual approach would raise serious questions, for example. about the logic of traditional attempts in psychosomatic research to link a single personality type to a single, broad diagnostic category. I'd like to ask Dr. Benson to what extent he feels it is possible to distinguish clinical subgroups within the larger classification of hypertension. Benson: Right now, it is very difficult to differentiate. Is there a peisonality type that can be identified with this sort of reaction? Will certain patients do better under certain types Murch. I9 77
of therapy, as opposed to pharmacology? Is elevated blood pressure in a population a reaction to the repeated need for behavioral adjustment in the environment - and will virtually anyone respond in the same way? If people are required to behaviorally adjust repeatedly. will this lead first to transient hypertension and then to permanent hypertension?
Rose: Do you subscribe to the concept that if you took a random sampling of the population and exposed those individuals to an increasing amount of life stress, everyone would get hypertensive after a certain period of time? Benson: Virtually anyone has the potential to develop hypertension, given appropriate envirotiniental stimuli. What is meaningful to one person, however, may not be to another. Rose: You mean that you just have to be careful about recognizing each man's personal poison. What I'm wondering about is that not everyone will get hypertensive. Some men may get cancer, some men may get more frequent colds than otheis, and some may even develop ulcers. This relates to my belief in the relevance of biological programming which determines the type of response to stress. I believe that all of us are not capable of developing any one particular response. such as hypertension. Benson: With the feedback - that is. being able to see which response leads to a hypei-tensive response -with time. given control of the environment, I would predict that Rose: You seem to be hypothesizing that there's a kind of Pavlovian response, and that with the right button. so to speak. you could turn on hypertension for anybody. Benson: Just limited physiological responses, for given individuals. Rose: In the real world, what happens is that people may have increased physiological response, i.e., higher blood pressure. But not everyone will experience increased physiological responsiveness turning into hypertension. That's an interesting hypothesis. Benson: It has been tested in animals in several research projects. I've done this, and I've Journal of Human Stress
9
STRESS AND HYPERTENSION found it to be the case. It has been replicated in many research reports. Consider the Russian experiment in which they took baboon families. separated the male from his harem of females. and put him in an adjacent cave while they put i n a new male. The original male. watching his family being exposed to a new male, developed hypertension invariably, according to their repoi-ts.
psychometric assessments, based upon leads such as reported by Dr. Singer, into studies of hypertensives where assessment of physiological parameters is also relatively sophisticated. Clinical subgroups distinguished by such an approach might be found to have implications from a number of theoretical and practical standpoints. including therapeutic management.
Rose: What appears strange to me is that
people studying cancer find increased cancer. People studying ulcers find more ulcers. Those who look for hypertension don't look for gastric or duodenal lesions. and vice versa. Mason: From the standpoint of a psychosomatic approach. we are still essentially dealing with a qualitative search for the most relevant psychological and social parameteis. At this stage, I think we don't need to be very concerned about how "soft" the data may be which can provide us with new leads in this area. I'm deeply impressed, for example. with the psychological data that Margaret Singer has reported on hypertensives.* She found certain traits. such as a characteristic style of perceiving the environment, which are pretty much universal for hypertensives generally. She also was able to distinguish psychologically two subtypes, which she refers to as the "pressurized" and the "defended" types. In turn, she found that these two subtypes differed strikingly in a long-term follow-up of morbidity and mortality. the "defended" group having the best prognosis. I wonder if these leads have been pursued further in recent years, particularly with the addition of a physiological orientation? Benson: Not to the best of my knowledge. Mason: The main reason 1 raised this point is
that it seems to me that we are clearly confronted with the question of further evaluation of cases such as the one Dr. Benson has presented here. There might be much to gain or by incorporating psychological
+Singer, M. T. Trurisuciioris q/' rhe Assuciuriorr q/' L@ Itisurnrice Medical Dirvciurs 01' America. Vol. 51. 1967. pp. 150-173.
10 Journal of Human Stress
Stanislav V. Kasl
I(as1: Another interesting area where theJour rtul oJHuiiruir Stress could make a contribution would be a review of evidence in support of the proposition that certain kinds of social and psychological assessments lead to a useful classification of subtypes of patients with a particular disease. This would be helpful because these subtypes require differential treatment and differential management. For example, are there such subtypes among hypertensives? 1 suppose the evidence is thin, but such a review would certainly be a useful follow-upto a case history presentation.
Jenkins: Before we finish. can you tell us how you plan to carry on the treatment of this man? Benson: 1 plan to take repeated measurements
of his blood pressure. hoping to desensitize or extinguish his response to the blood-pressure cuff. In contrast with our usual treatment of patients for whom home blood pressures are not indicated, we are going to try. by repeated March, 1977
CASE DISCUSSION home blood-pressure measurements, to decondition this patient from his blood-pressure cuff neurosis.
Jenkins: Is he really practicing a relaxation response?
Benson: He claims to be, but I really do not know.
Jenkins: Have you thought about more actively "erasing" his anxiety response by having him take his blood pressure when he is engaged in pleasurable and relaxing things such as when he is sitting in an easy chair drinking sherry?
Benson: Yes. he has been encouraged to do this. Rose: It does seem as if he's a bit neurotic. That intensity of fixing on an event in the past with the magical belief that it causes hypertension is a potentially neurotic manifestation.
Kad: This choice of teaching him relaxation bothers me a bit. In some sense. it may feed into his self-concept as a person with dangerous powers - bringing about thoughts which can then alter his physiology adversely. Relaxation
March, 1977
therapy could be a kind of reminder that he must vigilantly guard against such thoughts. Rose: Let's state that in another way. The fact is. it's his belief that he's done a terrible thing to himself by raising his blood pressue in order to avoid the draft. I'm suggesting that, inside, he perceives himself as having a great deal of power. And his omnipotence has backfired on him, so to speak. I am stating that this appears to me to be neurotic. You might have him see one of your psychiatric colleagues.
Mason: Is it true, in general, that the earlier the therapeutic intervention, the better the prognosis?
Rose: Yes. Jenkins: His is an extreme response. Better interpretation of his psychophysiological dynamics and a better understanding of himself might lead to a reduced chance of this becoming a chronic or recurrent problem. Rose: His fixation on that issue would be somewhat diminished with an understanding of its origins.
Benaon: Thank you very much.
Journal of Human Stress 11
Recctit(v. ,fbllowirrg (I r,icrtirig ol'thc?Editon'ul Bourd of'thc. Journal of Human Stress iti Boston. Dr. Hrrbert Bcrisori prcsrtitcd u CUSP histot?, io sonic' (?/'hiscollrugues o t i the Bourd. Whut jbllows is thvir discussion 01' thc. cusi'. txlitrd ./Or p u h lictit ion.
Herbert Benson, M.D.: The patient is a 32year-old physician who sought help on the basis of his concern regarding his longstanding hypertension. He and his parents and siblings present with a negative family history. He was quite well until the age of 19 when, upon facing the prospect of being inducted into the army, he learned from some of his friends that he could induce high blood pressure by thinking inappropriate thoughts, anxious thoughts. He did this before the induction center's examining physician, who noted a blood pressure of 180/90. He was told to come back in several days, during which period he kept himself quite anxious; when he returned for reexamination, he had a similar blood pressure. He was told to consult his personal physician, and he did not pass the examination. Stanislav V. Kasl, Ph.D.: Had his blood pressure been taken before? Benson: No. I n subsequent years, he went on to complete college and medical school. When he learned the significance of high blood pressure, he became very upset and started taking hisown blood pressure. At this point henoticed that upon repeated measurements, unless he was very calm, his blood pressure would re4
Journal of Human Stress
main in the range of 160190. He took no medication and tried to avoid stress. But he became progressively more anxious about this until. at the present time, he panics whenever a blood-pressure cuff starts to constrict around his arm. He felt he could tell when his blood pressure was high by his degree of anxiety. He was in the process of beginning to curtail some of his exposures to stressful events, because he felt that this would reduce high blood pressure. He now recognized that it was very important that his blood pressure be reduced. Upon examination, the patient appeared to be a robust, healthy young man with a blood pressure in the range of 170/100 and a pulse of 96. He was anxious. The remainder of his examination was within normal limits. A complete hypertensive workup was also within normal limits. The diagnosis of essential hypertension, perhaps labile hypertension, was made. Anxiety was a second diagnosis. The patient was instructed how to elicit the relaxation response and was also given a diuretic, hydroclorothiazide. His blood pressure is now in the range of 150/90, but it takes three or four measurements each session before his reactivity to the blood-pressure cuff and his pressure go down. He is still quite concerned March,
1977
CASE DISCUSSION that he might not get over his reaction to stressful events, and fearful of what this means in terms of his blood pressure and ultimate health.
Kasl: Why, specifically, did he seek help?
Benson: Because he had taken his own blood pressure throughout the year, and it had continued to be high. Kasl: But there was no acute reason for consultation? Benson: No.
Kasl: Why hadn't he been taking medication long before this? Benson: Perhaps it is denial of his disease. Robert Rose, M.D.: I wonder if, as you have presented the case, Dr. Benson, you have overemphasized the relationship between particular events and the onset of hypertension, similar to what the patient has done. I t is possible that there are individuals who have been programmed biologically to respond to changes in day-to-day living with increased blood pressure. Because of this biological predisposition, the threshold for increased blood pressure is low, and it does not take a great deal of stress to reach that threshold. I am concerned that this individual, who is a physician, has come to view his own hypertension as his responsibility, and to believe that if only he were different or did different things, it would go away. This comes out in the history, in that he "caused" his high blood pressure prior to the physical examination for the Service. He now feels that he should have control over his own blood pressure. If he thought better thoughts now, for example, he believes high blood pressure would go away. If he could be convinced that his condition is not his personal responsibility, that what he is experiencing is perhaps beyond his control, and that he is a hyper-responder, some of the guilt about his own responsibility in causing his high blood pressure would be diminished. In turn, if he were to be less distressed about this, he might be less apt to take his own blood pressure repeatedly throughout the day - he might be March, 1977
relieved of "sphigmomanometric mania," as it's been called.
Benson: There is something I would like to discuss that is of particular concern. We are undergoing an extensive educational process in the United States with respect to the perils of high blood pressure. It is being called the "silent killer." This and similar phrases are being used to engender fear, so that people will have their blood pressures measured. On top of that, increasingly initial blood pressure measurements are obtained under circumstances that are less than optimal. There are now blood-pressure measurement facilities located at various drug stores and supermarkets, where people are stopped during their busy daily routines to have their blood pressures measured. Taking blood pressures under circumstances that are rather stressful - because subjects don't want to be bothered and therefore are upset - results in less than an accurate baseline measurement. Given that and the fact that almost always errors occur on the high side, a vicious cycle may be started. The blood pressure has not been measured under optimal circumstances. The patient knows the significance of high blood pressure and worries about it. By the time the patient gets back to his/her own physician, a pernicious chain of events has begun. I wonder whether these detection programs aren't more
r ; Herbert Benson
Journal of Human Stress
5
STRESS A N D HYPERTENSION dangerous than they are beneficial, with the particular tactics being used. With this clinical potential for induction of high blood pressure under stressful circumstances, we have an additional variable not present in, for example, cancer detection programs or glaucoma detection programs. where presence or absence of the disease is an indisputable fact.
C. David Jenkins, Ph.D.: There are two streams of thought developing here. The first one deals with the clinical case and the dynamics of the patient's development of high blood pressure. The second deals w i t h the population question of whether an epidemic of high blood pressure is developing as a function of our alarm tactics. Let us try to keep them separate. Let us turn back to the first topic and reflect on this apparent linking of anxiety and high blood pressure. The first we know about this patient's high blood pressure is that it was discovered during his Selective Service physical examination at age 19. We see a continued linking of anxiety and blood pressure at age 32. I'd like to ask several questions. Is there any information about the blood pressure of this man before age 19. about the history of his anxiety. or about his anxiety attacks? Were there school problems, or any parental observations of the sort which might say that either the anxiety or the blood pressure elevation preceded this pairing of them which he reports in himself at the age of 19? In terms of his current life situation. what are the psychological concoinitants of his sweaty palms, high pulse, and elevated blood pressure? Do frightening ideas go through his mind? Does he perhaps ruminate over the means by which he originally raised his blood pressure? He may have lingering guilt over this.
I am also concerned about the fact that despite diuretics and relaxation therapy combined. this man is achieving only a modest reduction in blood pressure, at best. Does he get anxiety attacks over factols in his life other than the taking of blood pressure? We would have thought that either of these treatment techniques would have achieved better bloodpressure lowering if we were dealing with a 6 Joui-nal of Human Stress
siinple and uncomplicated case of hypertension.
Benson: There are several questions to be answered. First of all, no previous blood pressures were taken. Secondly, no extensive psychiatric examination was done. Therefore. no evaluation was procured that deals with his anxiety. Your last question asks, "Should we not have expected more?" Not necessarily. All we need, really. is a 24-hour ineasurenieiit of this man to assess what is happening away from the doctor's office. But this is very difficult to obtain. Rose: One wonders if his blood-pressure response to tlie anticipation of having his blood pressure taken could be extinguished. This might be done by merely placing the cuff'on his arm repeatedly. such as 50 times or so in the course of several houts. This might lead to some sort ofdeconditioning or desensitization.
John W. Mason, M.D.: Does the patieiit tend to show an exaggerated response to other illnesses in any way?
Benson: He is apparently healthy. otherwise. Mason: Psychiatric assessment of this patient in some depth would certainly be of interest. One of tlie issues to consider is whether one is dealing with a phenomenon rather specifically related to blood pressure or with a more general. neurotic characteristic of some individuals to tend to overreact greatly with anxious concern over any physical signs or symptoms they may have.
David Mechanic, Ph.D.: Why haven't you treated more aggressively with drugs?
Benson: Because at 150/90, I feel that he is fairly well controlled, and he does not wish to take more drugs. In fact, one of the reasons he came to me was that he was hoping that a nonpharinacologic approach would handle it.
Rose: To follow up on the second part of Dr. Jenkins' statement, isn't there data available, David, to which you have referred in the past, indicating that regardless of whatever the provocation, those individuals who show increased blood pressure variability are more likely to March. 1977
CASE DISCUSSION creased history of responsivity. It's not so much a question of being anxious, but a question of being anxious and being a blood-pressure responder, which presumably is related to some sort of biological programming.
Benson: Rather than equating this with anxiety, what I'm trying to equate it with is the actual event of having a blood pressure taken, which is linked with anxiety. Yes, the person who is anxious may manifest other physiological changes as well as high blood pressure.
Robert M.Rose develop fixed hypertension later in time? In other words, are there not data to suggest that regardless of what level of stress may be operating, if you are an individual who has shown increased blood-pressure variability. you are more likely to develop hypertension? Another way of stating this question is to ask whether or not individuals who tend to show increased blood pressure at any time are the ones who are going to develop hypertension later on.
Benson: Yes, in direct answer to your questions. But, unfortunately, most ofthe data supporting that contention come from an era when people did not know the significance of blood pressure. Now. with the knowledge of what blood pressure means, I'm afraid the issue is confounded. I should like to ask why we aren't really dealing with the second issue that I brought up, namely iatrogenic disease?
Rose: Not everyone who is anxious has high blood pressure. Benson: That is true.
Rose: One can argue just the opposite. Perhaps one should give people a stress lability test. If you respond with an elevation in blood pressure, you might be a person who should be watched carefully and treated earlier than you might be treated without knowledge of this inMarch. 1977
Rose: It seems to me important to separate people into two different categories. There are those whose blood-pressure response to having their blood pressure taken is part of the picture of having labile hypertension, in that they are already showing significant elevations of blood pressure in a variety of situations - not just that of having their blood pressure taken. These 'people presumably should be differentiated from those who are possibly early in the developmental history of labile hypertension and just have a response to this particular situation, which is not typical for them. Benson: We don't know that yet. Mechanic: If it is true that you have a person who is labile in response to stress, the fact that you pick this u p on the cuff doesn't make it any less significant. Therefore, why define it as iatrogenic when, indeed, it may be something programmed into the person? Benson: Because it may be a result of the cuff itself, and not something that is programmed in the person. Mechanic: Isn't that a testable proposition? Benson: It would be very difficult to test.
Rose: The only problem is that you really can't take blood pressure without putting on the blood-pressure cuff and measuring the blood pressure. It seems that what you are saying, Herb, is that in a population of individuals who are observed to have elevated systolic ar.d diastolic pressure associated with having their blood pressure taken once a month, there is a subgroup whose members are responding to Journal of Human Stress
7
STRESS AND HYPERTENSION who have a much more global tendency for increased blood-pressure response. regardless ofthe particular stimulus.
Mechanic: I guess the issue is how these two alternative conceptions can be tested against one another. Why couldn't you take someone with a cuff response and then elicit other anxiety-provoking material from past information you have on that person, and see what changes take place in blood pressure, above and beyond the baseline, which you get with the cuff alone? If the anxiety hypothesis is correct. wouldn't you then anticipate further elevations?
Kasl: If, every time the blood pressure is taken, it is high. you could create false feedback. David Mechanic
the cuff and another group of people who have true labile hypertension. Froni an epidemiological point of view. we are making an error. because we are adding the so-called "cuff responder" to the individual who has true labile hypertension, and therefore we are falsely increasing the number of people who are deserving of the diagnosis of hypertension.
Benson: Worse than that. What I am saying is that people who may only be cuff responders. after a while go on to become truly hypertensive because of their concern and their manifestat ions.
Rose: I'm arguing from a different point of view. I'm questioning the hypothesis that individuals can make themselves hypertensive because of the intensity of their concern about high blood pressure. I'm questioning whether or not, no matter what the intensity of concern an individual has. or the anxiety helshe manifests regarding the possibility of having hypertension. that this in itself is sufficient unusual mechanism. I wonder if there are. among the individuals who show an increased blood-pressure response to having their blood pressure measured, individuals who. if they were slightly less distressed about this. would very quickly show no response to bloodpressure measurement. These individuals could be distinguished potentially from those
8 Journal of Human Stress
Rose: Can you differentiate cuff hypertension and other hypertension?
Benson: Yes. You can do this with other intraarterial measurements.
Rose: We have some interesting data now that we have gathered from air trat'fic controllers while they are actually controlling traffic. We have been studying men for five hours, repeating our blood-pressure measurements every 20 minutes. We found. if we average all the systolic and diastolic readings on the 360 men we have studied in the field throughout the day. that the mean for both is equal to the mean we have observed when the same men come to Boston University for their physical exams. However. we also find that a significant number of men have very large changes in their blood pressure while they are working. almost I2 percent of them with systolic blood pressures which range more than 50 mm of Hg during the day. But another group does not show any changes in blood pressure at all, working in the same facilities and doing the same work.
Kasl: What is interesting in this discussion is that we are again talking on two levels. We are addressing the problems of the patient. And from a scholarly, scientific viewpoint, we are looking at how complicated these things really are. To get from the case study deeper into this kind of discussion would be terribly useful. March. 1977
CASE DISCUSSION Benson: I chose this case advisedly for both those reasons. Rose: John Mason asked good questions. Does this patient have some increased concern with illness, per se? Does illness have special meaning to him? Does he have special concerns that may explain the intensity of his response to having a blood-pressure cuff placed on his arm? There are questions that David Mechanic asked about his background and his upbringing which may also be a factor. This perhaps is another way of elucidating how we can gain inore relevant information. Kasl: This patient's self-concept is noteworthy: the idea that his hypertension has its origin in srifitidirccd anxiety. Of course, this need not be correct. That event may have had nothing to do with it.
Mason: There is another general question raised by this case which appeals. potentially, to be a very important issue in psychosomatic research. I am referring to the need to move towards making finer clinical distinctions between subgroups of patients within the larger diagnostic categories. A possible implication of this case is that this patient represents one relatively clear-cut subgroup within a larger, heterogeneous population of patients defined as hypertensive. If there are several clearly distinguishable subgroups of hypertensives as defined by clinical, psychiatric, physiological or other parameters, this is a matter which could prove of key importance i n psychosomatic research strategy. Pathogenesis might well be quite different in different subgroups. and this conceptual approach would raise serious questions, for example. about the logic of traditional attempts in psychosomatic research to link a single personality type to a single, broad diagnostic category. I'd like to ask Dr. Benson to what extent he feels it is possible to distinguish clinical subgroups within the larger classification of hypertension. Benson: Right now, it is very difficult to differentiate. Is there a peisonality type that can be identified with this sort of reaction? Will certain patients do better under certain types Murch. I9 77
of therapy, as opposed to pharmacology? Is elevated blood pressure in a population a reaction to the repeated need for behavioral adjustment in the environment - and will virtually anyone respond in the same way? If people are required to behaviorally adjust repeatedly. will this lead first to transient hypertension and then to permanent hypertension?
Rose: Do you subscribe to the concept that if you took a random sampling of the population and exposed those individuals to an increasing amount of life stress, everyone would get hypertensive after a certain period of time? Benson: Virtually anyone has the potential to develop hypertension, given appropriate envirotiniental stimuli. What is meaningful to one person, however, may not be to another. Rose: You mean that you just have to be careful about recognizing each man's personal poison. What I'm wondering about is that not everyone will get hypertensive. Some men may get cancer, some men may get more frequent colds than otheis, and some may even develop ulcers. This relates to my belief in the relevance of biological programming which determines the type of response to stress. I believe that all of us are not capable of developing any one particular response. such as hypertension. Benson: With the feedback - that is. being able to see which response leads to a hypei-tensive response -with time. given control of the environment, I would predict that Rose: You seem to be hypothesizing that there's a kind of Pavlovian response, and that with the right button. so to speak. you could turn on hypertension for anybody. Benson: Just limited physiological responses, for given individuals. Rose: In the real world, what happens is that people may have increased physiological response, i.e., higher blood pressure. But not everyone will experience increased physiological responsiveness turning into hypertension. That's an interesting hypothesis. Benson: It has been tested in animals in several research projects. I've done this, and I've Journal of Human Stress
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STRESS AND HYPERTENSION found it to be the case. It has been replicated in many research reports. Consider the Russian experiment in which they took baboon families. separated the male from his harem of females. and put him in an adjacent cave while they put i n a new male. The original male. watching his family being exposed to a new male, developed hypertension invariably, according to their repoi-ts.
psychometric assessments, based upon leads such as reported by Dr. Singer, into studies of hypertensives where assessment of physiological parameters is also relatively sophisticated. Clinical subgroups distinguished by such an approach might be found to have implications from a number of theoretical and practical standpoints. including therapeutic management.
Rose: What appears strange to me is that
people studying cancer find increased cancer. People studying ulcers find more ulcers. Those who look for hypertension don't look for gastric or duodenal lesions. and vice versa. Mason: From the standpoint of a psychosomatic approach. we are still essentially dealing with a qualitative search for the most relevant psychological and social parameteis. At this stage, I think we don't need to be very concerned about how "soft" the data may be which can provide us with new leads in this area. I'm deeply impressed, for example. with the psychological data that Margaret Singer has reported on hypertensives.* She found certain traits. such as a characteristic style of perceiving the environment, which are pretty much universal for hypertensives generally. She also was able to distinguish psychologically two subtypes, which she refers to as the "pressurized" and the "defended" types. In turn, she found that these two subtypes differed strikingly in a long-term follow-up of morbidity and mortality. the "defended" group having the best prognosis. I wonder if these leads have been pursued further in recent years, particularly with the addition of a physiological orientation? Benson: Not to the best of my knowledge. Mason: The main reason 1 raised this point is
that it seems to me that we are clearly confronted with the question of further evaluation of cases such as the one Dr. Benson has presented here. There might be much to gain or by incorporating psychological
+Singer, M. T. Trurisuciioris q/' rhe Assuciuriorr q/' L@ Itisurnrice Medical Dirvciurs 01' America. Vol. 51. 1967. pp. 150-173.
10 Journal of Human Stress
Stanislav V. Kasl
I(as1: Another interesting area where theJour rtul oJHuiiruir Stress could make a contribution would be a review of evidence in support of the proposition that certain kinds of social and psychological assessments lead to a useful classification of subtypes of patients with a particular disease. This would be helpful because these subtypes require differential treatment and differential management. For example, are there such subtypes among hypertensives? 1 suppose the evidence is thin, but such a review would certainly be a useful follow-upto a case history presentation.
Jenkins: Before we finish. can you tell us how you plan to carry on the treatment of this man? Benson: 1 plan to take repeated measurements
of his blood pressure. hoping to desensitize or extinguish his response to the blood-pressure cuff. In contrast with our usual treatment of patients for whom home blood pressures are not indicated, we are going to try. by repeated March, 1977
CASE DISCUSSION home blood-pressure measurements, to decondition this patient from his blood-pressure cuff neurosis.
Jenkins: Is he really practicing a relaxation response?
Benson: He claims to be, but I really do not know.
Jenkins: Have you thought about more actively "erasing" his anxiety response by having him take his blood pressure when he is engaged in pleasurable and relaxing things such as when he is sitting in an easy chair drinking sherry?
Benson: Yes. he has been encouraged to do this. Rose: It does seem as if he's a bit neurotic. That intensity of fixing on an event in the past with the magical belief that it causes hypertension is a potentially neurotic manifestation.
Kad: This choice of teaching him relaxation bothers me a bit. In some sense. it may feed into his self-concept as a person with dangerous powers - bringing about thoughts which can then alter his physiology adversely. Relaxation
March, 1977
therapy could be a kind of reminder that he must vigilantly guard against such thoughts. Rose: Let's state that in another way. The fact is. it's his belief that he's done a terrible thing to himself by raising his blood pressue in order to avoid the draft. I'm suggesting that, inside, he perceives himself as having a great deal of power. And his omnipotence has backfired on him, so to speak. I am stating that this appears to me to be neurotic. You might have him see one of your psychiatric colleagues.
Mason: Is it true, in general, that the earlier the therapeutic intervention, the better the prognosis?
Rose: Yes. Jenkins: His is an extreme response. Better interpretation of his psychophysiological dynamics and a better understanding of himself might lead to a reduced chance of this becoming a chronic or recurrent problem. Rose: His fixation on that issue would be somewhat diminished with an understanding of its origins.
Benaon: Thank you very much.
Journal of Human Stress 11
