Brit. 3. Psychiat. (i@7@), 127, 327—36
Psychiatric
The
Aspects of Hypertension
By DAVID
WHEATLEY,
RONALD
LIPMAN,
physiological
response
JEROME
LEVINE,
MARY LOU BAUER and ROLAND
MITCHELL
BONATO
to stress
falls
reliefof anxiety.Wolf and Wolff (i@@o) administeredstressful interviews to @6normo tensive persons and 21 hypertensives and found that both systolic and diastolic pressures were elevated in both groups of subjects as a result of the interviews. More recently, Heine, Sainsbury and Chyno weth (ig6g) investigated blood pressure in
mainly on the cardiovascular system, adrenergic stimulation resulting in peripheral vasoconstric
lion and an increase in systemic blood pressure. The analogous effects that occur provoking situations immediately
in anxiety suggest an
association, whether causal or effectual, between raised blood pressure and anxiety. It has also been suggested that hypertensive individuals exhibit more aggressive traits than others and that thesemay be hidden or suppressed, be coming manifest by abnormal blood pressure (Smirk, 1957).
elevation
patients
of the
There is a wealth of evidence, both experi mental and clinical, to support an association between anxiety and raised blood pressure. Thus, hypertension can be induced in rats by submitting them repeatedly, for several months, to multiple or to single stressful situations, such as loud noises, flashing lights, cage rocks and blastsof air (Farris, Yeakel and Medoff, 1945;
Hudak and Buckley, i g6i; Rosecrans, Watzman
persist for several months after all exposure to the noises has ceased (Smirk, ‘¿949).More recently, Marwood and Lockett (i@7@) have
wood,
adrenalectomy
Ilett and Lockett,
prevents
had
undergone
prolonged
when
referred than those who
pressure,
and
concluded
did not. Robinson
that:
certain pattern of symptoms
this (Mar
1973).
As long ago as 1945, Graham reported an incidence of symptomless hypertension in 27 per cent of 695 men after they had been involved forone yearindesertwarfare.For dayson end, even when there was no immediate danger, these men showed evidence of hyperadrenalaemia, as evidenced by a rapid pulse, pale face and
‘¿Eitherpeople
is typical of them'.
Cobb and Rose (1973) investigated the inci dence of hypertension, peptic ulcer and diabetes in air-traffic controllers and found that the incidence
of hypertension
was four times greater
than in second class airmen (subjected to considerably less stress). Furthermore, air traffic
controllers
working
with
those working
tension was diagnosed
than
at an earlier age among
particularly
low-stress air-traffic controllers. 327
traffic
with low trafficdensities.Hyper
high-stress
after rest and
high
densities showed more cases of hypertension
enlarged pupils. He speculated that this was the probable cause of the blood pressure elevation,
since this dropped
periods
with high blood pressure have relatively severely a high number of the symptoms measured, or a
shown that hypertension can also be induced in rats by withdrawal of all adventitious sounds,
that
who
of emotional disturbance (a long history of depressive illness with agitation). Their results supported the hypothesis that prolonged emo tional disturbance leads to an irreversible increase in blood pressure, although, contrary to their expectations, they found that ratings of anxiety and agitation, but not those of de pression, were correlated with blood pressure levels when ill. Furthermore, patients who showed a fall in diastolic pressure on recovery were significantly more anxious and agitated (1969) investigated the relation between symptoms (fatigue,palpitations, insomnia, breathlessness, anxiety, headache, dizziness and depression) and the discovery of high blood
and Buckley, 1966). Furthermore, hypertension induced in rats by auditory excitation can
and
BALTER,
air-traffic
controllers
compared
to
Finally, investi
328
PSYCHIATRIC ASPECTS OF HYPERTENSION
gating the relationship between arterial pressure and motor car driving, Littler, Honour and Sleight (1973) found that ‘¿there were short periods of raised arteriaF pressure during driving, related to such episodes as overtaking'. Most recently, Bridges (1973) obtained data in 42
students
on
various
physiological
responses
to the stress of an academic oral examination; at the same time anxiety was measured, using various psychological tests. He showed highly significant rises in both systolic and diastolic blood pressure after the stressful situation,
compared
to the control
period,
and this was
associated with ‘¿high prevailing anxiety'. In view of this considerable evidence for an
association between psychiatric symptoms and hypertension, we undertook a survey the overall object of which was to determine whether there is more psychiatric morbidity associated with hypertension, and if so what may be its nature. Furthermore, if there is such an association, whether or not concomitant treatment with a psychotropic drug of appropriate nature might be indicated.
(d) Physician's report. This included the relevant data concerning hypertension, together with details of other medical conditions and complaints, with records of blood pressure readings in the recumbent position after three minutes at rest, pulse rate, weight and height. In addition, records were made of all medica tions the patient was taking, both for hypertension and for other conditions, including psychotropic drugs. Finally, the doctor assessed the following psychiatric
symptoms
on
a five-point
severity
scale
(not present, mild, moderate, severe, and extremely severe): 1. Anxiety
(fearful,
nervous,
tense,
etc.).
2.Depression (sad,blue,hopelessabout the future, etc.).
3. Anger-Hostility(sullen, short-tempered, irritable, etc.). Analysis of variance was used to test for significant differences. OBJECTS
OF THE SURVEY
In new cases, hypertension
is discovered
from
routine examination or because certain symptoms (i.e. headache) lead the doctor to take the blood pressure. In most cases, the patient will be unaware that he has raised blood pressure, and so any associa
ted psychiatric symptomatology, if greater than the METHOD
The survey was undertaken by 90 members of the General Practitioner
Research Group in England,
controls, suggests cause rather than effect. Elt can be argued that the establishment of the diagnosis of hypertension by taking the blood pressure will
each investigatorrecording data on four cases,as
almost
follows: Group i. The first new (undiagnosed) case of hypertension. Group 2. The next patient seen, for whatever cause,
cases, but the self-rating
certainly
anxiety
symptoms
in most
scale was recorded
as it
applied to the past one year, i.e. symptoms that were present before the current consultation.)
In the old cases there may be more or less psychia
matched for age and sex (i.e. new hypertensive control).
tric morbidity,
Group 3. The first old case of hypertension (i.e. already diagnosed and probably under treat ment).
alternatively,
Group 4. The next patient seen, for whatever cause,
induce
since
the patient
now
knows
he has
high blood pressure and may worry over this, or as a result of treatment he may feel
more reassured. If therefore psychiatric morbidity is higher than in the controls and higher than in new cases, this would suggest an effect. In the new
matched to the old hypertensive case for age and sex. For each of these cases, four forms were completed as follows: (a) Demographic data (personal and social history over the past 18 months). (b) Symptom self-rating scale (58 psychiatric symp
cases, there
toms experienced over the past 12 months) (Derogatis,
emotional factors, while the diastolic is not. Com
Lipman, Rickels, Uhienhuth and Covi, 1974). (c) Life situation form (good and bad events over the past i8 months)—completed by patient (Paykel, Myers, Dienelt, Kierman, Lindenthal and Peooer, 1969).
parison
will not as yet have been any medication;
these can therefore be compared
to old cases under
treatment, and this should determine whether lower ing the blood pressure relieves psychiatric
symptoms
and whether there is an indication for the con comitant use of psychotropic
drugs.
The systolic blood pressureismarkedly affectedby of
psychiatric
symptoms
to
these
separate
measures may give further indications as to the role of psychiatric
abnormality
in the
condition.
Thus,
an
association between high psychiatric symptomatology and
high
systolic
blood
pressure
would
suggest
a
BY D. WHEATLEY, M. BALTER, J. LEVINE, R. LIPMAN, M. L. BAUER AND R. BONATO
functional relationship, whereas a similar association to high diastolic blood pressure would suggest an organic relationship.
medical groups
conditions, contained
clearly
much
the
higher
two
329
control
proportions
of
such patients, since the controls were chosen at random from patients presenting with conditions other than hypertension. Therefore, from these data, it can be concluded that the two experi mental groups (i and 3) were well matched to their respective controls (Groups 2 and 4).
RESULTS
Demographw data A total of 348 case reports were suitable for analysis, 87 in each of the four groups. Detailed analysis of the demographic and life-situation data will be the subject of another communica tion, and Table I shows a summary of some of the features of the patient population studied. With the exception of mean age and the percentage of patients with other medical conditions, the four groups matched one another very well in respect of the various items of demographic data recorded. In the case of mean age, this was higher in Group 3 (old hypertensive) and Group 4 (old hypertensive control), as would be expected, since of course Group 3 represented patients who were already under treatment for hypertension and who would therefore be in older age groups. In respect of the percentage of patients with other
Medication Table II shows the proportions taking
various
of patients
types of drugs.
As would be expected, both of the hyper tensive groups contained high proportions of patients
on hypotensive
drugs,
and the fact that
the new hypertensives also contained a high proportion of such cases is explained by the fact that most physicians started anti-hyper tensive medication at the time of diagnosis. The two control groups contained very small proportions indeed of patients taking such drugs. The proportion of patients taking psycho tropic drugs was relatively low in all four
[email protected] Groupi Item
Group 2
New
control%Male
controlGroup hypertensiveGroup
..
..
..
..
54
age
..
..
..
..
53@8
53.7
%Married
..
..
..
..
83
83
..
..
..
2@6
2@3
..
2@2
I @5
Mean
Mean no. ofchildren Mean
no. children
living
at home
% Living with spouse.. .. .. % Up to ii + education (less than 7 yrs. school) .. .. .. % with other medical conditions ..
Old
Old
New
hypertensive
4
3
54
83 73 36 73TAInxII
57@8 83
82
2@3 I@5 82
68 6559
67 3359
58@2
79 2@7 i
77 69
Proportions ofdrugs.Group patients taking various 4Item
i
New control%
@
taking hypotensive drugs .. % taking psychotropic drugs % taking non-psychotropic drugs
hypertensive
.. .. ..
76.5 22@2' 3' .9
Group
2Group
3Group
New controlOld
I 20@2 71.496@5
hypertensiveOld
I9@5 31 @22@3
29@I 70@9
PSYCHIATRIC ASPECTS OF HYPERTENSION
33°
groups, and the figures were very similar for the four groups. Thus, only just over one-fifth of the patients were taking these drugs in the two hypertensive groups and in the new hypertensive control group; the proportion was slightly higher (nearly one-third) in the old hypertensive control group. It is thus apparent that the use of psychotropic
drugs in hypertension,
as revealed
by this survey, is no higher than in other patients not suffering from the condition. Finally, in relation to non-psychotropic medication, the proportions of patients in the two hypertensive groups taking such medica tions was similar, and considerably lower than in the two control groups. Once again, this would be expected, since the control groups contained patients suffering from many other conditions, for which non-psychotropic drugs would be prescribed. In this respect, the new hypertensive and the relevant control groups were comparable to the old hypertensive and relevant (:ontrol groups. It is therefore concluded that the majority of patients suffering from hypertension are in fact treated with hypotensive drugs and that such treatment is initiated at the time of diag nosis in the majority of cases. Furthermore, the proportion of patients treated with psychotropic drugs is no higher in hypertensive cases than in others and only representsapproximately one fifth of the total number of cases.
tions
of patients
the
four
groups,
with
the
considerably higher than that of symptoms of depression or anger-hostility. Thus, no less than
58 (67 per cent) of the new hypertensive patients exhibited symptoms of anxiety, although in the majority
these were only mild (@ cases, 38 per
cent) or moderate
(20 cases, 23 per cent). The
incidence in the new hypertensive controls was lower, since anxiety symptoms occurred in 48 cases
(55
per
cent),
though
the
difference
is not
statisticallysignificant.The proportion of old hypertensive patients with anxiety symptoms was very similar, namely 56 cases (64 per cent),
but this was also very similar to the old hyper tensive control group (53 cases, 6 i per cent). There were no significant differences between the hypertensive groups and their respective controls, either for symptoms of depression or of anger-hostility. It is concluded from this analysis of the results that the majority
exhibit mainly
anxiety
of hypertensive
symptoms,
though
of mild or moderate
severity.
this incidence
of arpciety symptoms
patients
these
are
However,
was no
higher than in the control groups, but equally it was no less in the old hypertensives, i.e. the patients already under treatment with hypo
tensive drugs. analysis
P@yckiatricmorbidity This was measured both on the physician's assessment and the symptom check-list com pleted by the patient.
in
otherdegreesofpsychiatric symptoms. It is immediately apparent that the incidence of anxiety symptoms in all four groups was
It would not appear
of the results that depressive
from this symptoms
or symptoms of anger-hostility occur very frequently in cases of hypertension, and cer tainly no more frequently than in the respective control groups. Therefore, although these results
do not demonstrate
any higher
level of
anxiety in hypertensive cases, either treated or untreated, as compared to their controls, they assessed the degree of three major psychiatric do demonstrate the high level of anxiety that symptom groups as follows: occurs in such patients in relation to other Anxiety (fearful, nervous, psychiatric symptomatology. Not present, tense, etc.) Mild, Depression (sad, blue, hope (b) Self-rating assessments. Table III shows the Moderate, less about the future, etc.) factor and cluster scores in the four groups of Severe, or Anger-Hostility (sullen patients. Extremely short-tempered, irritable, There were no significant differences in any severe etc.) •¿of the four groups in respect of these factor and In fact, there were no cases with extremely cluster scores, or in respect of the total scores on severe symptoms, and Fig. i shows the propor the patient symptom check-list. However, age (a)
Physicia,@s assessments. The
physicians
BY D. WHEATLEY,
M. BALTER,
J. LEVINE,
R. LIPMAN,
M. L. BAUER
AND
R. BONATO
80
80
@, 60
60
I
331
z
w I 0. Li.
40
40
20
20
0
0 0
Gr Gr
Gr Cr
2
Cr Gr
34
Cr Cr
12
Cr Gr
34
12
Cr Gr
34
—¿ SEVERE @
MODERATE
Ff1111 MILD Fio.i. TABI.E III
Mean scoreson itemsfrom self-ratingscale i
ItemGroup controlSomatization
2
New New Old hypertensiveGroup controlGroup hypertensiveGroup
[email protected]()I@
[email protected],.57Obsessive-compulsive .. ......I•
[email protected]@53Interpersonal sensitivity Depiession .. .. .. .. i.@8
Anxiety.. .. Anxietycluster..
.. ..
..
..
I@58
..
..
i@6@
Depressioncluster Anger-hostilitycluster.. Obsessive-compulsive
..
....
..
I@53
cluster..
j.75 ..I@58
1.441.49
and sex analysis for all patients showed that females recorded a greater severity of symptoms on all individual factors and clusters except the obsessive-compulsive cluster (P < 0.05). For
4
3
1.40
1.43
1.43 I'46 1.44
I@48 I@53
1.47
,.@
1.63
,.49I@48
[email protected] Old
I 45 1.48
‘¿.49 I•51 1.56 I'48
and under) recorded more severe symptoms than the others (P