PSYCHOSOMATIC DISORDERS: HIGH BLOOD PRESSURE & EMOTIONAL INTELLIGENCE
HIGH BLOOD PRESSURE
Hypertension, the technical name for high blood pressure, is the most serious
of the physical disorders that are clearly influenced by psychological
factors. When hypertension becomes chronic, it can lead to heart disease,
stroke, or kidney failure. High blood pressure is widely used by insurance
companies as a major predictor of life expectancy, for untreated, it leads to a
mean life expectancy of roughly twenty years following its onset and the
average age of death of untreated individuals is about fifty-five years old
(Lyght, 1966). In the U.S., half of all the deaths of individuals over forty-five
are caused by some form of cardiovascular disease, and hypertension is a
major contributor (Lachman, 1972; Weiner, 1977). In its early stages, hypertension
seems to be symptomless. Roughly 10 percent of American college
students have high blood pressure-most without knowing they have it.
As a person grows older, the risk increases markedly.
The development, the course, and the consequence of high blood pressure
can he influenced by psychological factors. But as we saw with ulcer victims,
these factors act on physically vulnerable individuals. We will first look at
the diathesis underlying hypertension, and then at the role of psychological
stress.
DEFINING HIGH BLOOD PRESSURE
When the blood pressure of an individual at rest is more than 140/90, he is
said to have borderline hypertension, and when more than 160/95 definite hypertension.
* Such individuals are at risk for developing much higher
blood pressure later in life. Roughly 10 percent of high blood pressure is
caused by known kidney and endocrine diseases. The other 90 percent is
called "essential" hypertension, meaning that its causes, physical and psychological,
are unknown.
In hypertension, the small arteries resist the flow of blood, and this resistance
causes the heart to pump the blood through the blood vessels under
higher pressure. In its early stages, no other symptoms may occur, but later,
top-of-the-head headaches, dizziness, ringing in the ears, and irritability are
sometimes experienced. As the disease progresses, the individual becomes
more prone to heart attack and stroke.
SUSCEPTIBILITY TO HIGH BLOOD PRESSURE
*Hypertension hits some populations harder than others. Individuals from
the lower classes are more likely to develop it than are those from the middle
or upper classes. Men have marc hypertension than women, blacks more
than whites, city dwellers more than those who live in the country. In general,
cross-cultural studies indicate that between 5 and 25 percent of adults
have high blood pressure. But some cultures have more of it than others. For
example, among the Zulu of South Africa, 20 percent of men under age
forty-five and an astonishing 58 percent of older men have high blood pressure
(Scotch).
The older one is, the more likely it is that he or she will contract essential
hypertension. About IO percent of twenty-year-olds are hypertensive, but
by age sixty a full 40 percent arc. Among some groups, such as southern
black Americans, the rise is steep and begins early in life, but among other
groups, such as Navajo Indians on reservations and among some rural Africans
and Asians, no increase with age occurs. Young women seem to show
less high blood pressure than young men, but by middle age women may
show more high blood pressure than do middle-aged men (Henry and Cassel, Aleksandrou).
High blood pressure runs in families. If one parent has high blood pressure,
the chances are roughly one in four that the child will have high blood
pressure. If both parents have high blood pressure, the chances are roughly
one in three. If a sibling has high blood pressure, the chances are close to one
in two that the other sibling will also have high blood pressure.
But does high blood pressure run in families for genetic reasons or because
families share similar environments? There is strong evidence that
predisposition to high blood pressure can be inherited. The blood pressure
of identical twins is much more alike than the blood pressure of fraternal
twins (Hines, McIlhaney, and Gage; Mathers, Osborne, and DeGeorge).
This suggests an inherited diathesis for hypertension.
There is also evidence in the family studies, that personality and environment
influence high blood pressure as well. A fascinating result has emerged
from the study of identical twins in which only one of the twins has high blood pressure.
The twin who has the high blood pressure tends to be more
obedient, quiet, reserved, submissive, insecure, and withdrawn than the
twin without high blood pressure (Torgersen and Kringlen). Further,
spouses (who of course are not related except by marriage), tend to have
similar blood pressure for as long as they stay married. This indicates that
part of the reason that blood pressure runs in families is because they share
the same hypertension-inducing environments (Winkelstein, Kantor, Ibrahim,
and Sackett).
PSYCHOLOGICAL INFLUENCES ON HIGH BLOOD PRESSURE
If an individual has the diathesis for hypertension, psychological factors
may come into play. As with peptic ulcers, there is evidence for two sorts of
emotional influence: (1) emotional states of hostility and threat produced by
stressful environments may raise blood pressure, and (2) having a time-urgent,
competitive, and hostile personality contributes to chronic high blood
pressure. Nigel's history illustrates both types of psychological influence, as
shown below:
Nigel was a thirty-nine-year-old businessman. He felt constant pressure from
his business affairs and experienced friction with his business partners. For years
Nigel had always set deadlines for himself and had competed with his business
rivals. He now sensed that he could no longer live up to his standards, and he felt
failure closing in. He could not stop brooding about these problems and took his
troubles home with him. He lay awake at nights alternately angry and anxious,
fretting and expecting financial disaster. The worst did not occur in his business
affairs, but he developed high blood pressure. Psychotherapy, rather than drug
treatment, was recommended. As a consequence of therapeutic advice, he
changed his way of life. He sold his part of his company and used the proceeds to
buy into a business with little pressure. He learned to lower his reaction toward
daily frustrations. He found new outlets for his energy in social and recreational
pursuits. His blood pressure dropped into the normal range within six months.
(Adaptedfrom Lachman).
Both Nigel's personality traits-hard driving, competitive, and time urgent-
and his emotional reaction to daily stresses-anxiety and hostility contributed
to his high blood pressure. We will first look at the evidence that
emotional states raise blood pressure and then at the evidence that certain
personality traits are associated with high blood pressure and cardiovascular
disease.
NOTE: * These two numbers refer to how high the blood pressure can raise a column of mercury. The first number is systolic and the second number diastolic blood pressure. Systolic blood pressure is the arterial pressure when the heart is pumping, and diastolic pressure is the arterial pressure when the heart is at rest.
Emotional States and Blood Pressure
Blood pressure normally increases when individuals experience threat.
Workers who are threatened with job loss and unemployment show high
blood pressure which drops when they find a new job (Kasl and Cobb,
1970). Similarly, those who feel threatened by death or injury also often
have high blood pressure. For example, following an explosion in 1947 in
Texas City, residents had elevated blood pressure for one to two weeks
(Ruskin, Beard, and Schaffer, 1948). How do we react emotionally to such
threats to well-being and security? Two common emotional reactions are anxiety
and hostility, and there is evidence that each of these emotional states can raise blood pressure.
When individuals with high blood pressure keep a record every thirty
minutes of what is happening, what mood they are in, and what their blood
pressure is, a fascinating correlation emerges: high blood pressure occurs
most frequently when the individual is anxious, alert, and under time pressure
(Sokolow, Werdegar, Perloff, Cowan, and Bienenstuhl). This finding is
supported by studies of animals and hypertension.
Rhesus monkeys who learn to avoid shock in a test cage by pressing a
lever on a complex and difficult schedule not only show high blood pressure
while they are being tested, but if the schedule is difficult enough, blood
pressure remains high back in the home cage (Forsyth, 1968). In addition,
there are several ways of producing chronic high blood pressure in mice: (1)
by mixing together male mice who are strangers, (2) by forced crowding,
and (3) by exposing mice to a cat for six to twelve months (Henry, Mehan,
and Stephens, 1967). Situations such as avoiding shock, defending against
strangers, intruders, and predators, all call for a continual emergency reaction.
That is, the animal or human is in a constant state of anxiety and readiness
for danger, with high blood pressure being part of this emergency
reaction to danger. So we have evidence that an anxiety response
to danger raises blood pressure.
Threats of the sort mentioned above not only produce anxiety, but other
emotions as well. Among these emotional reactions is hostility, and there is
evidence that hostility also raises blood pressure. In one experiment, subjects
were brought to anger by being insulted by a stooge. These subjects,
who were already hypertensive, responded to this added stress by an increase
in blood pressure (Schachter).
The elevated blood pressure response of hypertensives may be related to
threat in general and anger toward the threat in particular. When individuals
with high blood pressure were interviewed, blood pressure changes were
related to the emotional tone of the interview. Although the hypertensive individuals
were usually friendly to the interviewer, during the interview their
blood pressure rose more than did the blood pressure of individuals without
hypertension. When the dominant mood was either hostility or anxiety, the
hypertensive's blood pressure rose. When it was despair, their blood pressure
fell (Wolf, Cardon, Shepard, and Wolff). The more hostile the
content of the speech of individuals with high blood pressure, the more their
blood pressure went up (Kaplan, Gottschalk, Magliocco, Rohobit, and
Ross). These findings suggest that hypertensives are particularly sensitive
to hostility and respond with blood pressure elevation.
Our day-to-day lives often require a certain level of diplomatic competence.
This can result in our not expressing the hostility we may feel, let's say
about a particular situation at work. The studies reported above suggest that
hostility can raise blood pressure. But is there a difference in the blood pressure
of those who feel hostility and do not express it, and those who feel and
express it? To investigate this, researchers first demonstrated that when
normal individuals who have to count hack from ninety-nine by two's are
harassed by a stooge, their blood pressure goes up. Later, half of the subjects
are given an opportunity to retaliate and aggress against the stooge, but half
are not. The opportunity to aggress consists in allowing the subject to
choose whether or not he wishes to punish or reward the stooge. As it turned out,
the opportunity to aggress caused the elevated blood pressure to subside.
But for those who had no opportunity to retaliate, blood pressure subsided
more slowly (Hokanson; Hokanson and Burgess; Hokanson,
Willers, and Koropsak). It seems likely that the opportunity to vent
hostility lowers blood pressure, and the failure to release hostility may keep
blood pressure high. Our alternate, less specific view of this data, however,
holds that the emergency reaction-be it elicited by hostility, fear, or pain
-raises blood pressure, and the opportunity to take any action that copes
with the threat reduces blood pressure.
As we have shown, clinical and experimental data indicate that blood
pressure normally goes up when individuals are in the emotional state of
anxiety or of hostility. This makes reasonable biological sense, since the
sorts of threats that elicit anxiety and hostility also elicit the emergency reaction.
An increase in blood pressure is part of the emergency reaction, which
serves an adaptive function when it occurs in response to an occasional
threat. If an individual feels constantly threatened, however, his blood pressure
may become chronically high. This could happen if an individual were
in a chronically stressful job, such as being an air controller in towers with
high density traffic (Cobb and Rose, 1973; Karasek, Baker, Marxer, Ahlborn,
and Theorell, 1981), or it might happen if an individual habitually
viewed the world as a threatening place and was constantly engaged in vigilance
and defense against threat. Such a habitual pattern is an example of a
personality trait that would produce hypertension, and we now tum to the
evidence that such a personality type exists.
Personality and Hypertension
The major theme that runs through psychodynamic theories about the hypertensive
personality is dammed-up hostility. Franz Alexander theorized
that individuals with high blood pressure were struggling against their own
aggressive impulses. As young children, hypertensives have tantrums of rage,
but as they mature they learn to control them because they are afraid of
losing the affections of others. As a consequence, they become unusually
compliant and unassertive. When promoted to executive responsibility,
they are poor at asserting themselves appropriately and making others follow
their orders (Alexander, French, and Pollack). Clinical observation
bears out the role of hostility in patients with high blood pressure
(Dunbar; Wolf, Cardon, Shepard, and Wolff). Some patients
with high blood pressure tend to perceive others as dangerous and untrustworthy
and because of this perception, maintain distant relationships. Paradoxically,
this provokes and angers others-the very reactions the
hypertensive fears most and is trying to avoid (Weiner).
Based only on psychological history and excerpts from interviews, nine
judges attempted to sort out patients with high blood pressure from patients
with the six other psychosomatic disorders. For male patients, the judges
were correctly able to pick out 42 percent of the hypertensives, well above
the chance level of 14 percent (one out of seven). Women with high blood
pressure were not reliably sorted out.
A more recent study offers further evidence that personality affects high
blood pressure. Seventy-eight Harvard juniors were tested in the late 1930s
and early 1940s for high blood pressure and various personality characteristics.
Ten years later, these individuals were given a projective test in which
they told stories about five pictures from the TAT. The
themes of the stories they told were used as indications of what their personality
was like. Twenty years later, in the early 1970s, these men were tested
for high blood pressure. The findings are remarkable.
The expression of need for "power" and need for "affiliation" was judged
from their TAT stories. A person was scored as having a high need for power
if his story contained a reference to having an impact on others by aggression,
persuasion, and prestige. A person was scored as having a high need for
affiliation if his story included being friendly with other people. Finally, a
person was judged for the amount of "inhibition of the need for power" by
the number of times the word "not" appeared in his stories. Those of particular
theoretical interest were the men who had a high need for power (which
was greater than their need for affiliation), but who showed high inhibition
in their stories. Twenty-three of the men fell into this group at approximately
age thirty. By the time these men were in their fifties, 61 percent had
shown definite signs of hypertensive pathology, whereas only 23 percent of
the remaining forty-seven men showed hypertensive pathology. These findings
become even more remarkable when we realize that they are unrelated
to the blood pressure of these men when they were in their thirties. In other
words, the need for power combined with its inhibition at age thirty predicted
that individuals would be at risk for severe high blood pressure at age
fifty, irrespective of what their blood pressure was when they were thirty
years old (McClelland).
The likelihood of the existence of such a high-blood-pressure-prone personality
is greatly strengthened by the research on the Type A personality
carried out over the last decade.
THE TYPE A BEHAVIOR PATTERN.
Type A personality was said to have been discovered by an upholsterer.
When he came to reupholster the chairs in the office of a physician
who specialized in seeing patients who had had heart attacks,
he noticed that the chairs were worn in the front of the seat, not the back.
Coronary-prone individuals,
Type A's, sit on the edge of their chair. They are defined by (1) an exaggerated sense of time
urgency-deadlines are always with them, (2) competitiveness and ambition,
and (3) aggressiveness and hostility, particularly when things get in
their way. They contrast to Type B persons, who are relaxed, serene, and
have no sense of time urgency. When Type A's miss a bus, they become
upset. When Type B's miss a bus, they say to themselves, "Why worry?
There will always be another bus coming along." Both the Type A and the
hypertensive personality discussed above probably see the environment as
threatening, and both seem to be engaged in prolonged emergency reactions.
Classifying individuals into Type A's and Type B's is done either by a
standard stress interview or by a self-administered questionnaire. Typical
questions are:
1, "Has your spouse or friend ever told you that you eat too fast?" Type
A's say, "yes, often." Type B's say, "yes, once or twice" or "no."
2. "How would your spouse (or best friend) rate your general level of activity?"
Type A's say, "too active, need to slow down." Type B's say, "too
slow, should be more active."
3. "Do you ever set deadlines or quotas for yourself at work or at home?"
Type A's say, "yes, once a week or more often." Type B's say, "no" or "only
occasionally." (Jenkins, Rosenman, and Friedman; Glass).
Type A's are more at risk for heart attack than Type B's. In the most
comprehensive prospective study of coronary disease, 3,000 normal men
living in California were followed for eight-and-a-half years. Half of the men
were Type A's, half of them Type B's. Type A's had more than twice as
many heart attacks as Type B's. After the first heart attack, Type A's were
five times as likely to have a second heart attack. Even when the traditional
risk factors for heart attacks, such as cigarette smoking, high blood pressure,
and cholesterol level were held constant, Type A's still had twice the risk of
heart attacks as Type B's. Being a Type A may be the strongest single predictor
of recurrent heart disease, a better predictor than cholesterol and cigarette
smoking (Rosenman, Brand, Jenkins, Friedman, Straus, and Wurm; Jenkins, Zyzanski, and Rosenman).
Type A women, like Type A men, are also more vulnerable to coronary
disease. Nine hundred fifty women, aged forty-five to sixty-four, were given
extensive psychological tests in 1965-1967 in Framingham, Massachusetts.
They were then observed for the next eight years. Type A's had two to three
times as many heart attacks as Type B's. Both working women and housewives
showed this effect and were at similar risk for heart attacks (Haynes,
Feinleib, and Kannel).
Type A individuals seem to be engaged in a lifelong struggle to control a
world they see as threatening. David Glass suggests that it is this struggle for
control that crucially distinguishes a Type A from a Type B personality.
Glass postulates that a cycle of desperate efforts to control the environment,
alternating with giving up when the environment proves uncontrollable, is
repeated over and over again during the lifetime of the Type A individual.
This struggle may result in high blood pressure and other physiological
changes that in turn cause heart attacks.
Glass has demonstrated that Type A's and Type B's show a different reaction
to helplessness and that it is this reaction that may predispose them to
coronary disease (see Chapter 13). Both Type A and Type B subjects are
presented with cognitive problems that are unsolvable, and failure is made
highly salient. Type A's response to this uncontrollable and highly stressful
situation is twofold: (1) they respond to salient and stressful threats to their
sense of control with desperate efforts to keep control, and (2) when they are
forced into the recognition that they are helpless, their giving up is profound
and they fail to solve cognitive problems given later in the experiment. Type
B individuals do not give up in such a profound way, and they end up solving
more easily the solvable problems given later. This confirms Glass's
suggestion that a life of attempting to control, then giving up, then trying all
over again, may characterize Type A individuals and predispose them to
coronary heart disease.
In the last century, Sir William Osler (1849-1919), a famous Canadian
physician, prefigured what was to be learned in our century about personality
and heart attacks:
A man who has early risen and late taken rest who has eaten the bread of
carefulness, striving for success in commercial, professional, or political life, after
twenty-five or thirty years of incessant toil, reaches the point where he can say,
perhaps with just satisfaction, "Soul thou has much goods laid up for many years;
take thine ease," all unconscious that the fell sergeant has already issued the warrant. (Osler, l897).
Thus, psychological factors as well as biological factors influence hypertension
and coronary heart disease. Threatening life events-like loss of
work-particularly when responded to with anxiety and anger, may bring
on high blood pressure or worsen it in individuals who already have high
blood pressure. Individuals who see the world as threatening and are engaged
in a struggle for control may find themselves in a chronic state of readiness
for emergency. Hostility, aggressiveness, and time urgency may be the
psychological components of this emergency reaction, and high blood pressure
the relevant biological component.
TREATMENT OF HIGH BLOOD PRESSURE
(SEE MY PSYCHOTHERAPY RECOMMENDATION BELOW)
High blood pressure can be treated either by drugs or by a variety of' forms of
psychological therapy. For severe high blood pressure, anti-hypertensive
medication is the treatment of choice. In a well-controlled study of
anti-hypertensive drugs, only two of seventy-three medicated patients had heart attacks,
strokes, and other severe complications over one-and-a-half years of
observation, as opposed to twenty-seven of seventy patients who were
treated with only a placebo. The estimated risk of developing a severe complication
over a five-year period was reduced from 55 percent to 18 percent
by drugs (Veterans Administration Cooperative Study Group). Over
the last decade. The incidence of strokes in the United States declined 42
percent, possibly due to the widespread use of medication to control hypertension
(Kalata)---cheering news indeed!
With such good drug results, we might wonder why psychotherapy should
be used at all. There are three basic reasons: First. drug therapy does not
seem to be too effective in patients with mild hypertension; they have heart
attacks and strokes just as frequently as un-medicated controls. Second, the
side effects of anti-hypertensive drugs are highly noxious for some people,
producing depression, sedation, or sexual dysfunction, and a substantial
number of patients stop taking the drugs because of their side effects. Third,
drugs treat the symptoms, but not the cause of hypertension. So there exists
a clear need for alternate treatments, particularly for patients with borderline
high blood pressure (Smith; Agras and Jacob.).
In the last ten years, three specific psychotherapeutic procedures have become
popular in treating high blood pressure: relaxation, biofeedback, and
transcendental meditation (TM). All of them seem to have a significant effect
in lowering high blood pressure. In relaxation, the patient learns to relax
his entire skeletal musculature (Benson; Fine and Turner;
Suedfeld, Roy, and Landon).
In biofeedback, the patient learns to voluntarily lower blood pressure using the visual or auditory feedback from a blood pressure meter. In transcendental meditation the patient sits in a comfortable position twice a day for twenty minutes with his eyes closed and repeats silently a one-syllable "mantra". (Sanskrit).
LEARNING TO CONTROL YOUR BLOOD PRESSURE
In July 1972, AI Fogle, a thirty-six-year-old man, went to visit his sister on Long
Island. As he approached her house, a huge man came racing toward him. Chasing
him was a smaller man waving a revolver. The shorter man shouted, "Kill the
bastard!" and a shot rang out. The bullet hit Fogle in the chest and severed his spinal
cord.
After eight months of rehabilitation, Fogle learned to use his arms, sit up, and
walk on crutches. But a serious problem occurred whenever he elevated himself.
He would faint. The reason for his fainting was purely physical.
When a normal individual is lying down and starts
to stand up, his brain transmits the message
"constrict the blood vessels in the arms and legs" to the
sympathetic nervous system, resulting in extra blood
being pumped to the head. If it did not do this, gravity would
prevent enough blood from flowing to the head. But when the spine is cut,
although the brain still sends its message, the message
cannot be delivered to the blood vessels in the arms and
legs to cause them to constrict, since the message
must go through an intact spinal cord.
Through biofeedback treatment, Fogle learned to raise his blood pressure before
elevating himself At New York's Goldwater Memorial Hospital, he was
treated by a young psychologist, Bernard Brucker, using the theory and findings
of Neal Miller about biofeedback in rats. Fogle was first taught to raise or lower his
blood pressure upon command. Feedback was given to him by telling him the
number of millimeters his blood had been raised or lowered. He succeeded and
eventually was able to increase his blood pressure by as many as twenty millimeters.
In addition, he learned to distinguish changes of a few millimeters. He says
he uses mental imagery to accomplish this: he imagines the terrifying moment in
which he was shot.
Regardless of how he does it, Fogle no longer faints. Before he raises his body,
he voluntarily raises his blood pressure to a point sufficient for the heart to pump
the needed blood to his brain. (Adapted from Kobler.)
CHANGING TYPE A Personality BEHAVIORS
If present health trends continue, the chances are one in two that you will die of
heart attack or a stroke. Many people who are now college students will die from
such diseases long before their time. What is known about susceptibility of college
students to subsequent cardiovascular disease? Students who have high blood
pressure, who smoke cigarettes, who are overweight, who are short, whose parents
die prematurely, who do not exercise, and who are anxious and irritable are
more prone to later cardiovascular disease (Paffenbarger, Wolf, Notkin and
Thorne).
There have been substantial developments in the understanding and treatment
of cardiovascular diseases in the last twenty years: open heart surgery, heart
transplants, anti-hypertensive drugs, and the like. But it is possible that scientific
technology has reached an upper limit on what it can do to save our lives once we
have developed coronary disease. Even if no further technological breakthroughs
occur, vastly better health is still possible. We may be able to reduce our chances
of dying from heart attack and stroke by making certain choices about how we live
our lives.
Our present life style may be leading us into serious risk of cardiovascular disease.
The elements of a life style that does this are known, even though the mechanism
of their deadly action is not fully understood. If we smoke cigarettes and if
we fail to exercise regularly, we substantially increase our risk of premature death.
We have discussed another risk factor for cardiovascular disease: the Type A
personality. If a person has a Type A personality-if he or she is usually time urgent,
hard driving, ambitious, competitive, and striving for control-he or she may
be engaged in a way of life even more deadly than smoking and lack of exercise.
Can the Type A personality be changed? And if it is changed, will this lower the
person's risk of heart disease? The answer to the first question is Yes-a person
can exert voluntary control over Type A behavior. The answer to the
second question is at present unknown.
All we have at the moment is a correlation, not a causal link, between being
a Type A and having heart attacks.
It is possible that some third factor causes both Type A
behavior and susceptibility to heart disease.
If this is so, unless the person also changes this unknown causal factor, changing his
Type A behavior will have no effect on his risk of heart disease.
Should a person try to change his Type A behavior? It is likely that Type A behavior
has benefits, as well as costs. Being time urgent, competitive and ambitious may
well produce professional success in our society, and changing may produce better
health but less success. But if being Type A causes coronary disease, then
changing a person's Type A life style may lower his risk of heart attack.
How can we liberate ourselves from a Type A life style? Meyer Friedman and
word whose sonic properties are known"). Positive results have been reported
for all three procedures in controlled studies, but TM and relaxation
may have a slight edge over biofeedback, although all of them are usually
found to be superior to placebo controls. These results have not been uniform,
however, and all three treatments have, under some circumstances,
also failed to produce large enough decreases in blood pressure to be clinically
helpful (e.g., Frankel, Patel, Horwitz, Friedewalt, and Gaarder, 1978;
Agras and Jacob, 1979).
Counseling that often accompanies drug therapy for high blood pressure
emphasizes three general goals: (1) the therapist tries to get the patient to
recognize that the environment is not necessarily hostile, (2) he also will encourage
the patient to respond to the environment by trying to change it more effectively, and
(3) the therapist will encourage the patient to release
hostility in a constructive way (Schwartz, 1977). In contrast to biofeedback,
relaxation, and TM, there has not been a controlled study of the effectiveness
of this general counseling approach.
Overall, then, anti-hypertensive drugs are the treatment of choice for severe
hypertension. For mild hypertension, systematic training in either relaxation,
transcendental meditation, or biofeedback will produce some
smaller lowering of blood pressure. These methods can also be used as an
adjunct to drug treatment for severe hypertension. No one of the three techniques
has proven itself clearly superior to the others (Agras and Jacob,
1979).
Ray Rosenman, two of the cardiologists who discovered the Type A proneness to
heart attacks, offer a set of drills against "hurry sickness"-drills that allow us to
re-engineer our life:
1. Each morning, noon, and evening remind yourself that life is always an “unfinished experience."
Begin to accept your life as an mélange of activities in which only
some manage to get finished. You are only finished when you are dead.
2. Practice listening quietly to the conversation of others without interrupting or
hurrying them.
3. If you see someone doing a job slower than you know you can do it, don't
interfere.
4. When you are in doubt as to whether you should say something, don't say it
unless it is really important.
5. Whenever possible, shy away from making appointments at definite times.
6. Purposely frequent restaurants and theaters where you know you will have
to wait. Drive at the minimum speed limit. Learn that even if you have to wait and
you go slowly, things will come out all right-you get fed, you see the play, you
catch the plane, anyway.
7. Whenever you catch yourself speeding up your car to get through a yellow
light, penalize yourself by immediately turning right at the next corner and circling
the block to approach the same intersection. Then go through the signal light
again when it is green.
8. Read books that demand your entire attention and a good deal of patience.
9. Find periods each day in which you purposely seek total body relaxation
and empty your mind. Seek out lonely periods. (Friedman and Rosenman).
We do not yet have delineative evidence that changing from
a Type A to a Type B lowers heart attack risk, but
several studies are suggestive. For example, forty-four patients who survived their
first heart attack were given group psychotherapy.
Group therapy emphasized education about heart attacks, and some attempt
was mode to modify coronary-prone behavior. These patients experienced less
coronary illness and death over the following three years, and they succeeded in
reducing their time urgency and overwork more than control heart attack patients
without psychotherapy. One patient who owned several wristwatches in order to
be sure he would always have one working, threw them all away after the group
discussed time urgency. (Roskies, Spevack, Surkis, Cohen, and Gilman, 1978;
Suinn and Bloom, 1978; Jenni and Wallersheim, 1979; Levenkron, Cohen,
Mueller, and Fisher, 1983)
To summarize, hypertension, like ulcers, can be viewed within a diathesis-
stress model. The diathesis, or constitutional factors, that produce hypertension
can be genetically inherited, since identical twins show more
similar blood pressures than do fraternal twins. When an individual has
such a diathesis, psychological factors may act to produce a condition of
chronic high blood pressure. The emotional states of anxiety and hostility
both produce increases in blood pressure. Anxiety and hostility are caused
by threatening situations, and these situations produce increases in blood
pressure. This sequence makes sense biologically, since the emergency reaction
consists, in part, of the perception of threat, followed by the experience
of anxiety and hostility, and is accompanied by an increase in blood pressure.
This is an adaptive response to an occasional threat, but if an individual
engages in an emergency reaction for a large portion of his life,
dangerous chronic hypertension may result. Jobs that produce anxiety or
hostility may also produce hypertension. And personality types who chronically
view the world as a dangerous place may also suffer from high blood
pressure. The Type A personality may be such a type: these individuals are
time urgent, competitive, ambitious, and they become hostile when they are
thwarted. Such individuals not only have higher blood pressure but they are
at substantially greater risk for heart attacks than are Type B individuals.
Severe high blood pressure is best treated by medication, but mild hypertension
can be helped by relaxation, biofeedback, and transcendental meditation.
Hypertension, the technical name for high blood pressure, is the most serious
of the physical disorders that are clearly influenced by psychological
factors. When hypertension becomes chronic, it can lead to heart disease,
stroke, or kidney failure. High blood pressure is widely used by insurance
companies as a major predictor of life expectancy, for untreated, it leads to a
mean life expectancy of roughly twenty years following its onset and the
average age of death of untreated individuals is about fifty-five years old
(Lyght, 1966). In the U.S., half of all the deaths of individuals over forty-five
are caused by some form of cardiovascular disease, and hypertension is a
major contributor (Lachman, 1972; Weiner, 1977). In its early stages, hypertension
seems to be symptomless. Roughly 10 percent of American college
students have high blood pressure-most without knowing they have it.
As a person grows older, the risk increases markedly.
The development, the course, and the consequence of high blood pressure
can he influenced by psychological factors. But as we saw with ulcer victims,
these factors act on physically vulnerable individuals. We will first look at
the diathesis underlying hypertension, and then at the role of psychological
stress.
DEFINING HIGH BLOOD PRESSURE
When the blood pressure of an individual at rest is more than 140/90, he is
said to have borderline hypertension, and when more than 160/95 definite hypertension.
* Such individuals are at risk for developing much higher
blood pressure later in life. Roughly 10 percent of high blood pressure is
caused by known kidney and endocrine diseases. The other 90 percent is
called "essential" hypertension, meaning that its causes, physical and psychological,
are unknown.
In hypertension, the small arteries resist the flow of blood, and this resistance
causes the heart to pump the blood through the blood vessels under
higher pressure. In its early stages, no other symptoms may occur, but later,
top-of-the-head headaches, dizziness, ringing in the ears, and irritability are
sometimes experienced. As the disease progresses, the individual becomes
more prone to heart attack and stroke.
SUSCEPTIBILITY TO HIGH BLOOD PRESSURE
*Hypertension hits some populations harder than others. Individuals from
the lower classes are more likely to develop it than are those from the middle
or upper classes. Men have marc hypertension than women, blacks more
than whites, city dwellers more than those who live in the country. In general,
cross-cultural studies indicate that between 5 and 25 percent of adults
have high blood pressure. But some cultures have more of it than others. For
example, among the Zulu of South Africa, 20 percent of men under age
forty-five and an astonishing 58 percent of older men have high blood pressure
(Scotch).
The older one is, the more likely it is that he or she will contract essential
hypertension. About IO percent of twenty-year-olds are hypertensive, but
by age sixty a full 40 percent arc. Among some groups, such as southern
black Americans, the rise is steep and begins early in life, but among other
groups, such as Navajo Indians on reservations and among some rural Africans
and Asians, no increase with age occurs. Young women seem to show
less high blood pressure than young men, but by middle age women may
show more high blood pressure than do middle-aged men (Henry and Cassel, Aleksandrou).
High blood pressure runs in families. If one parent has high blood pressure,
the chances are roughly one in four that the child will have high blood
pressure. If both parents have high blood pressure, the chances are roughly
one in three. If a sibling has high blood pressure, the chances are close to one
in two that the other sibling will also have high blood pressure.
But does high blood pressure run in families for genetic reasons or because
families share similar environments? There is strong evidence that
predisposition to high blood pressure can be inherited. The blood pressure
of identical twins is much more alike than the blood pressure of fraternal
twins (Hines, McIlhaney, and Gage; Mathers, Osborne, and DeGeorge).
This suggests an inherited diathesis for hypertension.
There is also evidence in the family studies, that personality and environment
influence high blood pressure as well. A fascinating result has emerged
from the study of identical twins in which only one of the twins has high blood pressure.
The twin who has the high blood pressure tends to be more
obedient, quiet, reserved, submissive, insecure, and withdrawn than the
twin without high blood pressure (Torgersen and Kringlen). Further,
spouses (who of course are not related except by marriage), tend to have
similar blood pressure for as long as they stay married. This indicates that
part of the reason that blood pressure runs in families is because they share
the same hypertension-inducing environments (Winkelstein, Kantor, Ibrahim,
and Sackett).
PSYCHOLOGICAL INFLUENCES ON HIGH BLOOD PRESSURE
If an individual has the diathesis for hypertension, psychological factors
may come into play. As with peptic ulcers, there is evidence for two sorts of
emotional influence: (1) emotional states of hostility and threat produced by
stressful environments may raise blood pressure, and (2) having a time-urgent,
competitive, and hostile personality contributes to chronic high blood
pressure. Nigel's history illustrates both types of psychological influence, as
shown below:
Nigel was a thirty-nine-year-old businessman. He felt constant pressure from
his business affairs and experienced friction with his business partners. For years
Nigel had always set deadlines for himself and had competed with his business
rivals. He now sensed that he could no longer live up to his standards, and he felt
failure closing in. He could not stop brooding about these problems and took his
troubles home with him. He lay awake at nights alternately angry and anxious,
fretting and expecting financial disaster. The worst did not occur in his business
affairs, but he developed high blood pressure. Psychotherapy, rather than drug
treatment, was recommended. As a consequence of therapeutic advice, he
changed his way of life. He sold his part of his company and used the proceeds to
buy into a business with little pressure. He learned to lower his reaction toward
daily frustrations. He found new outlets for his energy in social and recreational
pursuits. His blood pressure dropped into the normal range within six months.
(Adaptedfrom Lachman).
Both Nigel's personality traits-hard driving, competitive, and time urgent-
and his emotional reaction to daily stresses-anxiety and hostility contributed
to his high blood pressure. We will first look at the evidence that
emotional states raise blood pressure and then at the evidence that certain
personality traits are associated with high blood pressure and cardiovascular
disease.
NOTE: * These two numbers refer to how high the blood pressure can raise a column of mercury. The first number is systolic and the second number diastolic blood pressure. Systolic blood pressure is the arterial pressure when the heart is pumping, and diastolic pressure is the arterial pressure when the heart is at rest.
Emotional States and Blood Pressure
Blood pressure normally increases when individuals experience threat.
Workers who are threatened with job loss and unemployment show high
blood pressure which drops when they find a new job (Kasl and Cobb,
1970). Similarly, those who feel threatened by death or injury also often
have high blood pressure. For example, following an explosion in 1947 in
Texas City, residents had elevated blood pressure for one to two weeks
(Ruskin, Beard, and Schaffer, 1948). How do we react emotionally to such
threats to well-being and security? Two common emotional reactions are anxiety
and hostility, and there is evidence that each of these emotional states can raise blood pressure.
When individuals with high blood pressure keep a record every thirty
minutes of what is happening, what mood they are in, and what their blood
pressure is, a fascinating correlation emerges: high blood pressure occurs
most frequently when the individual is anxious, alert, and under time pressure
(Sokolow, Werdegar, Perloff, Cowan, and Bienenstuhl). This finding is
supported by studies of animals and hypertension.
Rhesus monkeys who learn to avoid shock in a test cage by pressing a
lever on a complex and difficult schedule not only show high blood pressure
while they are being tested, but if the schedule is difficult enough, blood
pressure remains high back in the home cage (Forsyth, 1968). In addition,
there are several ways of producing chronic high blood pressure in mice: (1)
by mixing together male mice who are strangers, (2) by forced crowding,
and (3) by exposing mice to a cat for six to twelve months (Henry, Mehan,
and Stephens, 1967). Situations such as avoiding shock, defending against
strangers, intruders, and predators, all call for a continual emergency reaction.
That is, the animal or human is in a constant state of anxiety and readiness
for danger, with high blood pressure being part of this emergency
reaction to danger. So we have evidence that an anxiety response
to danger raises blood pressure.
Threats of the sort mentioned above not only produce anxiety, but other
emotions as well. Among these emotional reactions is hostility, and there is
evidence that hostility also raises blood pressure. In one experiment, subjects
were brought to anger by being insulted by a stooge. These subjects,
who were already hypertensive, responded to this added stress by an increase
in blood pressure (Schachter).
The elevated blood pressure response of hypertensives may be related to
threat in general and anger toward the threat in particular. When individuals
with high blood pressure were interviewed, blood pressure changes were
related to the emotional tone of the interview. Although the hypertensive individuals
were usually friendly to the interviewer, during the interview their
blood pressure rose more than did the blood pressure of individuals without
hypertension. When the dominant mood was either hostility or anxiety, the
hypertensive's blood pressure rose. When it was despair, their blood pressure
fell (Wolf, Cardon, Shepard, and Wolff). The more hostile the
content of the speech of individuals with high blood pressure, the more their
blood pressure went up (Kaplan, Gottschalk, Magliocco, Rohobit, and
Ross). These findings suggest that hypertensives are particularly sensitive
to hostility and respond with blood pressure elevation.
Our day-to-day lives often require a certain level of diplomatic competence.
This can result in our not expressing the hostility we may feel, let's say
about a particular situation at work. The studies reported above suggest that
hostility can raise blood pressure. But is there a difference in the blood pressure
of those who feel hostility and do not express it, and those who feel and
express it? To investigate this, researchers first demonstrated that when
normal individuals who have to count hack from ninety-nine by two's are
harassed by a stooge, their blood pressure goes up. Later, half of the subjects
are given an opportunity to retaliate and aggress against the stooge, but half
are not. The opportunity to aggress consists in allowing the subject to
choose whether or not he wishes to punish or reward the stooge. As it turned out,
the opportunity to aggress caused the elevated blood pressure to subside.
But for those who had no opportunity to retaliate, blood pressure subsided
more slowly (Hokanson; Hokanson and Burgess; Hokanson,
Willers, and Koropsak). It seems likely that the opportunity to vent
hostility lowers blood pressure, and the failure to release hostility may keep
blood pressure high. Our alternate, less specific view of this data, however,
holds that the emergency reaction-be it elicited by hostility, fear, or pain
-raises blood pressure, and the opportunity to take any action that copes
with the threat reduces blood pressure.
As we have shown, clinical and experimental data indicate that blood
pressure normally goes up when individuals are in the emotional state of
anxiety or of hostility. This makes reasonable biological sense, since the
sorts of threats that elicit anxiety and hostility also elicit the emergency reaction.
An increase in blood pressure is part of the emergency reaction, which
serves an adaptive function when it occurs in response to an occasional
threat. If an individual feels constantly threatened, however, his blood pressure
may become chronically high. This could happen if an individual were
in a chronically stressful job, such as being an air controller in towers with
high density traffic (Cobb and Rose, 1973; Karasek, Baker, Marxer, Ahlborn,
and Theorell, 1981), or it might happen if an individual habitually
viewed the world as a threatening place and was constantly engaged in vigilance
and defense against threat. Such a habitual pattern is an example of a
personality trait that would produce hypertension, and we now tum to the
evidence that such a personality type exists.
Personality and Hypertension
The major theme that runs through psychodynamic theories about the hypertensive
personality is dammed-up hostility. Franz Alexander theorized
that individuals with high blood pressure were struggling against their own
aggressive impulses. As young children, hypertensives have tantrums of rage,
but as they mature they learn to control them because they are afraid of
losing the affections of others. As a consequence, they become unusually
compliant and unassertive. When promoted to executive responsibility,
they are poor at asserting themselves appropriately and making others follow
their orders (Alexander, French, and Pollack). Clinical observation
bears out the role of hostility in patients with high blood pressure
(Dunbar; Wolf, Cardon, Shepard, and Wolff). Some patients
with high blood pressure tend to perceive others as dangerous and untrustworthy
and because of this perception, maintain distant relationships. Paradoxically,
this provokes and angers others-the very reactions the
hypertensive fears most and is trying to avoid (Weiner).
Based only on psychological history and excerpts from interviews, nine
judges attempted to sort out patients with high blood pressure from patients
with the six other psychosomatic disorders. For male patients, the judges
were correctly able to pick out 42 percent of the hypertensives, well above
the chance level of 14 percent (one out of seven). Women with high blood
pressure were not reliably sorted out.
A more recent study offers further evidence that personality affects high
blood pressure. Seventy-eight Harvard juniors were tested in the late 1930s
and early 1940s for high blood pressure and various personality characteristics.
Ten years later, these individuals were given a projective test in which
they told stories about five pictures from the TAT. The
themes of the stories they told were used as indications of what their personality
was like. Twenty years later, in the early 1970s, these men were tested
for high blood pressure. The findings are remarkable.
The expression of need for "power" and need for "affiliation" was judged
from their TAT stories. A person was scored as having a high need for power
if his story contained a reference to having an impact on others by aggression,
persuasion, and prestige. A person was scored as having a high need for
affiliation if his story included being friendly with other people. Finally, a
person was judged for the amount of "inhibition of the need for power" by
the number of times the word "not" appeared in his stories. Those of particular
theoretical interest were the men who had a high need for power (which
was greater than their need for affiliation), but who showed high inhibition
in their stories. Twenty-three of the men fell into this group at approximately
age thirty. By the time these men were in their fifties, 61 percent had
shown definite signs of hypertensive pathology, whereas only 23 percent of
the remaining forty-seven men showed hypertensive pathology. These findings
become even more remarkable when we realize that they are unrelated
to the blood pressure of these men when they were in their thirties. In other
words, the need for power combined with its inhibition at age thirty predicted
that individuals would be at risk for severe high blood pressure at age
fifty, irrespective of what their blood pressure was when they were thirty
years old (McClelland).
The likelihood of the existence of such a high-blood-pressure-prone personality
is greatly strengthened by the research on the Type A personality
carried out over the last decade.
THE TYPE A BEHAVIOR PATTERN.
Type A personality was said to have been discovered by an upholsterer.
When he came to reupholster the chairs in the office of a physician
who specialized in seeing patients who had had heart attacks,
he noticed that the chairs were worn in the front of the seat, not the back.
Coronary-prone individuals,
Type A's, sit on the edge of their chair. They are defined by (1) an exaggerated sense of time
urgency-deadlines are always with them, (2) competitiveness and ambition,
and (3) aggressiveness and hostility, particularly when things get in
their way. They contrast to Type B persons, who are relaxed, serene, and
have no sense of time urgency. When Type A's miss a bus, they become
upset. When Type B's miss a bus, they say to themselves, "Why worry?
There will always be another bus coming along." Both the Type A and the
hypertensive personality discussed above probably see the environment as
threatening, and both seem to be engaged in prolonged emergency reactions.
Classifying individuals into Type A's and Type B's is done either by a
standard stress interview or by a self-administered questionnaire. Typical
questions are:
1, "Has your spouse or friend ever told you that you eat too fast?" Type
A's say, "yes, often." Type B's say, "yes, once or twice" or "no."
2. "How would your spouse (or best friend) rate your general level of activity?"
Type A's say, "too active, need to slow down." Type B's say, "too
slow, should be more active."
3. "Do you ever set deadlines or quotas for yourself at work or at home?"
Type A's say, "yes, once a week or more often." Type B's say, "no" or "only
occasionally." (Jenkins, Rosenman, and Friedman; Glass).
Type A's are more at risk for heart attack than Type B's. In the most
comprehensive prospective study of coronary disease, 3,000 normal men
living in California were followed for eight-and-a-half years. Half of the men
were Type A's, half of them Type B's. Type A's had more than twice as
many heart attacks as Type B's. After the first heart attack, Type A's were
five times as likely to have a second heart attack. Even when the traditional
risk factors for heart attacks, such as cigarette smoking, high blood pressure,
and cholesterol level were held constant, Type A's still had twice the risk of
heart attacks as Type B's. Being a Type A may be the strongest single predictor
of recurrent heart disease, a better predictor than cholesterol and cigarette
smoking (Rosenman, Brand, Jenkins, Friedman, Straus, and Wurm; Jenkins, Zyzanski, and Rosenman).
Type A women, like Type A men, are also more vulnerable to coronary
disease. Nine hundred fifty women, aged forty-five to sixty-four, were given
extensive psychological tests in 1965-1967 in Framingham, Massachusetts.
They were then observed for the next eight years. Type A's had two to three
times as many heart attacks as Type B's. Both working women and housewives
showed this effect and were at similar risk for heart attacks (Haynes,
Feinleib, and Kannel).
Type A individuals seem to be engaged in a lifelong struggle to control a
world they see as threatening. David Glass suggests that it is this struggle for
control that crucially distinguishes a Type A from a Type B personality.
Glass postulates that a cycle of desperate efforts to control the environment,
alternating with giving up when the environment proves uncontrollable, is
repeated over and over again during the lifetime of the Type A individual.
This struggle may result in high blood pressure and other physiological
changes that in turn cause heart attacks.
Glass has demonstrated that Type A's and Type B's show a different reaction
to helplessness and that it is this reaction that may predispose them to
coronary disease (see Chapter 13). Both Type A and Type B subjects are
presented with cognitive problems that are unsolvable, and failure is made
highly salient. Type A's response to this uncontrollable and highly stressful
situation is twofold: (1) they respond to salient and stressful threats to their
sense of control with desperate efforts to keep control, and (2) when they are
forced into the recognition that they are helpless, their giving up is profound
and they fail to solve cognitive problems given later in the experiment. Type
B individuals do not give up in such a profound way, and they end up solving
more easily the solvable problems given later. This confirms Glass's
suggestion that a life of attempting to control, then giving up, then trying all
over again, may characterize Type A individuals and predispose them to
coronary heart disease.
In the last century, Sir William Osler (1849-1919), a famous Canadian
physician, prefigured what was to be learned in our century about personality
and heart attacks:
A man who has early risen and late taken rest who has eaten the bread of
carefulness, striving for success in commercial, professional, or political life, after
twenty-five or thirty years of incessant toil, reaches the point where he can say,
perhaps with just satisfaction, "Soul thou has much goods laid up for many years;
take thine ease," all unconscious that the fell sergeant has already issued the warrant. (Osler, l897).
Thus, psychological factors as well as biological factors influence hypertension
and coronary heart disease. Threatening life events-like loss of
work-particularly when responded to with anxiety and anger, may bring
on high blood pressure or worsen it in individuals who already have high
blood pressure. Individuals who see the world as threatening and are engaged
in a struggle for control may find themselves in a chronic state of readiness
for emergency. Hostility, aggressiveness, and time urgency may be the
psychological components of this emergency reaction, and high blood pressure
the relevant biological component.
TREATMENT OF HIGH BLOOD PRESSURE
(SEE MY PSYCHOTHERAPY RECOMMENDATION BELOW)
High blood pressure can be treated either by drugs or by a variety of' forms of
psychological therapy. For severe high blood pressure, anti-hypertensive
medication is the treatment of choice. In a well-controlled study of
anti-hypertensive drugs, only two of seventy-three medicated patients had heart attacks,
strokes, and other severe complications over one-and-a-half years of
observation, as opposed to twenty-seven of seventy patients who were
treated with only a placebo. The estimated risk of developing a severe complication
over a five-year period was reduced from 55 percent to 18 percent
by drugs (Veterans Administration Cooperative Study Group). Over
the last decade. The incidence of strokes in the United States declined 42
percent, possibly due to the widespread use of medication to control hypertension
(Kalata)---cheering news indeed!
With such good drug results, we might wonder why psychotherapy should
be used at all. There are three basic reasons: First. drug therapy does not
seem to be too effective in patients with mild hypertension; they have heart
attacks and strokes just as frequently as un-medicated controls. Second, the
side effects of anti-hypertensive drugs are highly noxious for some people,
producing depression, sedation, or sexual dysfunction, and a substantial
number of patients stop taking the drugs because of their side effects. Third,
drugs treat the symptoms, but not the cause of hypertension. So there exists
a clear need for alternate treatments, particularly for patients with borderline
high blood pressure (Smith; Agras and Jacob.).
In the last ten years, three specific psychotherapeutic procedures have become
popular in treating high blood pressure: relaxation, biofeedback, and
transcendental meditation (TM). All of them seem to have a significant effect
in lowering high blood pressure. In relaxation, the patient learns to relax
his entire skeletal musculature (Benson; Fine and Turner;
Suedfeld, Roy, and Landon).
In biofeedback, the patient learns to voluntarily lower blood pressure using the visual or auditory feedback from a blood pressure meter. In transcendental meditation the patient sits in a comfortable position twice a day for twenty minutes with his eyes closed and repeats silently a one-syllable "mantra". (Sanskrit).
LEARNING TO CONTROL YOUR BLOOD PRESSURE
In July 1972, AI Fogle, a thirty-six-year-old man, went to visit his sister on Long
Island. As he approached her house, a huge man came racing toward him. Chasing
him was a smaller man waving a revolver. The shorter man shouted, "Kill the
bastard!" and a shot rang out. The bullet hit Fogle in the chest and severed his spinal
cord.
After eight months of rehabilitation, Fogle learned to use his arms, sit up, and
walk on crutches. But a serious problem occurred whenever he elevated himself.
He would faint. The reason for his fainting was purely physical.
When a normal individual is lying down and starts
to stand up, his brain transmits the message
"constrict the blood vessels in the arms and legs" to the
sympathetic nervous system, resulting in extra blood
being pumped to the head. If it did not do this, gravity would
prevent enough blood from flowing to the head. But when the spine is cut,
although the brain still sends its message, the message
cannot be delivered to the blood vessels in the arms and
legs to cause them to constrict, since the message
must go through an intact spinal cord.
Through biofeedback treatment, Fogle learned to raise his blood pressure before
elevating himself At New York's Goldwater Memorial Hospital, he was
treated by a young psychologist, Bernard Brucker, using the theory and findings
of Neal Miller about biofeedback in rats. Fogle was first taught to raise or lower his
blood pressure upon command. Feedback was given to him by telling him the
number of millimeters his blood had been raised or lowered. He succeeded and
eventually was able to increase his blood pressure by as many as twenty millimeters.
In addition, he learned to distinguish changes of a few millimeters. He says
he uses mental imagery to accomplish this: he imagines the terrifying moment in
which he was shot.
Regardless of how he does it, Fogle no longer faints. Before he raises his body,
he voluntarily raises his blood pressure to a point sufficient for the heart to pump
the needed blood to his brain. (Adapted from Kobler.)
CHANGING TYPE A Personality BEHAVIORS
If present health trends continue, the chances are one in two that you will die of
heart attack or a stroke. Many people who are now college students will die from
such diseases long before their time. What is known about susceptibility of college
students to subsequent cardiovascular disease? Students who have high blood
pressure, who smoke cigarettes, who are overweight, who are short, whose parents
die prematurely, who do not exercise, and who are anxious and irritable are
more prone to later cardiovascular disease (Paffenbarger, Wolf, Notkin and
Thorne).
There have been substantial developments in the understanding and treatment
of cardiovascular diseases in the last twenty years: open heart surgery, heart
transplants, anti-hypertensive drugs, and the like. But it is possible that scientific
technology has reached an upper limit on what it can do to save our lives once we
have developed coronary disease. Even if no further technological breakthroughs
occur, vastly better health is still possible. We may be able to reduce our chances
of dying from heart attack and stroke by making certain choices about how we live
our lives.
Our present life style may be leading us into serious risk of cardiovascular disease.
The elements of a life style that does this are known, even though the mechanism
of their deadly action is not fully understood. If we smoke cigarettes and if
we fail to exercise regularly, we substantially increase our risk of premature death.
We have discussed another risk factor for cardiovascular disease: the Type A
personality. If a person has a Type A personality-if he or she is usually time urgent,
hard driving, ambitious, competitive, and striving for control-he or she may
be engaged in a way of life even more deadly than smoking and lack of exercise.
Can the Type A personality be changed? And if it is changed, will this lower the
person's risk of heart disease? The answer to the first question is Yes-a person
can exert voluntary control over Type A behavior. The answer to the
second question is at present unknown.
All we have at the moment is a correlation, not a causal link, between being
a Type A and having heart attacks.
It is possible that some third factor causes both Type A
behavior and susceptibility to heart disease.
If this is so, unless the person also changes this unknown causal factor, changing his
Type A behavior will have no effect on his risk of heart disease.
Should a person try to change his Type A behavior? It is likely that Type A behavior
has benefits, as well as costs. Being time urgent, competitive and ambitious may
well produce professional success in our society, and changing may produce better
health but less success. But if being Type A causes coronary disease, then
changing a person's Type A life style may lower his risk of heart attack.
How can we liberate ourselves from a Type A life style? Meyer Friedman and
word whose sonic properties are known"). Positive results have been reported
for all three procedures in controlled studies, but TM and relaxation
may have a slight edge over biofeedback, although all of them are usually
found to be superior to placebo controls. These results have not been uniform,
however, and all three treatments have, under some circumstances,
also failed to produce large enough decreases in blood pressure to be clinically
helpful (e.g., Frankel, Patel, Horwitz, Friedewalt, and Gaarder, 1978;
Agras and Jacob, 1979).
Counseling that often accompanies drug therapy for high blood pressure
emphasizes three general goals: (1) the therapist tries to get the patient to
recognize that the environment is not necessarily hostile, (2) he also will encourage
the patient to respond to the environment by trying to change it more effectively, and
(3) the therapist will encourage the patient to release
hostility in a constructive way (Schwartz, 1977). In contrast to biofeedback,
relaxation, and TM, there has not been a controlled study of the effectiveness
of this general counseling approach.
Overall, then, anti-hypertensive drugs are the treatment of choice for severe
hypertension. For mild hypertension, systematic training in either relaxation,
transcendental meditation, or biofeedback will produce some
smaller lowering of blood pressure. These methods can also be used as an
adjunct to drug treatment for severe hypertension. No one of the three techniques
has proven itself clearly superior to the others (Agras and Jacob,
1979).
Ray Rosenman, two of the cardiologists who discovered the Type A proneness to
heart attacks, offer a set of drills against "hurry sickness"-drills that allow us to
re-engineer our life:
1. Each morning, noon, and evening remind yourself that life is always an “unfinished experience."
Begin to accept your life as an mélange of activities in which only
some manage to get finished. You are only finished when you are dead.
2. Practice listening quietly to the conversation of others without interrupting or
hurrying them.
3. If you see someone doing a job slower than you know you can do it, don't
interfere.
4. When you are in doubt as to whether you should say something, don't say it
unless it is really important.
5. Whenever possible, shy away from making appointments at definite times.
6. Purposely frequent restaurants and theaters where you know you will have
to wait. Drive at the minimum speed limit. Learn that even if you have to wait and
you go slowly, things will come out all right-you get fed, you see the play, you
catch the plane, anyway.
7. Whenever you catch yourself speeding up your car to get through a yellow
light, penalize yourself by immediately turning right at the next corner and circling
the block to approach the same intersection. Then go through the signal light
again when it is green.
8. Read books that demand your entire attention and a good deal of patience.
9. Find periods each day in which you purposely seek total body relaxation
and empty your mind. Seek out lonely periods. (Friedman and Rosenman).
We do not yet have delineative evidence that changing from
a Type A to a Type B lowers heart attack risk, but
several studies are suggestive. For example, forty-four patients who survived their
first heart attack were given group psychotherapy.
Group therapy emphasized education about heart attacks, and some attempt
was mode to modify coronary-prone behavior. These patients experienced less
coronary illness and death over the following three years, and they succeeded in
reducing their time urgency and overwork more than control heart attack patients
without psychotherapy. One patient who owned several wristwatches in order to
be sure he would always have one working, threw them all away after the group
discussed time urgency. (Roskies, Spevack, Surkis, Cohen, and Gilman, 1978;
Suinn and Bloom, 1978; Jenni and Wallersheim, 1979; Levenkron, Cohen,
Mueller, and Fisher, 1983)
To summarize, hypertension, like ulcers, can be viewed within a diathesis-
stress model. The diathesis, or constitutional factors, that produce hypertension
can be genetically inherited, since identical twins show more
similar blood pressures than do fraternal twins. When an individual has
such a diathesis, psychological factors may act to produce a condition of
chronic high blood pressure. The emotional states of anxiety and hostility
both produce increases in blood pressure. Anxiety and hostility are caused
by threatening situations, and these situations produce increases in blood
pressure. This sequence makes sense biologically, since the emergency reaction
consists, in part, of the perception of threat, followed by the experience
of anxiety and hostility, and is accompanied by an increase in blood pressure.
This is an adaptive response to an occasional threat, but if an individual
engages in an emergency reaction for a large portion of his life,
dangerous chronic hypertension may result. Jobs that produce anxiety or
hostility may also produce hypertension. And personality types who chronically
view the world as a dangerous place may also suffer from high blood
pressure. The Type A personality may be such a type: these individuals are
time urgent, competitive, ambitious, and they become hostile when they are
thwarted. Such individuals not only have higher blood pressure but they are
at substantially greater risk for heart attacks than are Type B individuals.
Severe high blood pressure is best treated by medication, but mild hypertension
can be helped by relaxation, biofeedback, and transcendental meditation.
EMOTIONAL INTELLIGENCE THERAPY HAS BEEN PROVEN HIGHLY SUCCESSFUL IN TREATING MILD HYPERTENSION.
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For the Treatment method I recommend click here:
http://theliberatormethod.com/Welcome.html