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

Psychiatric aspects of hypertension.

Brit. 3. Psychiat. (i@7@), 127, 327—36 Psychiatric The Aspects of Hypertension By DAVID WHEATLEY, RONALD LIPMAN, physiological response JE...
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