Interview Psychosomatic

7/28/2019 Interview Psychosomatic

1/10

Cardiovascular Reactivity of Patients WithEssential and Renal Hypertension inan Emotion-Triggering InterviewHans-Christian Deter, M D; Angela Blecher, M D; Cora S. Weber, MD

Blood pressure reactivity to mental stress in hyperten.sives is much higher thanin nornwtensives. The authors'aim in this study was to examine whether dif-ferent cardiovascular responses can he induced hy various stimuli in hyper-tensive subgroups. The authors matched 10 essential hypertensives (EHs), 10renal hypertensives (RH s). and 10 normotensives (Ns) according to age andgender, examined them during an emotion-stimulating interx'iew. and mea-sured blood pressure (B P) and heart rate (HR) during the pha.ses ofthe inter-view. They observed differences in BP reactivity between EHs/RHs and Nsunder some stimuli hut not between EHs and RHs. as well as a marked dif-ference in the product of systolic BP (SBP) and H R between both hypertensivegroups in the anger/rage phase fp = .028) and the baseline 2 (p = .02). Thisshows a higher cardiovascular activation under mental stress and a iowerrecovery in EHs and more sensitivity to perturbation or higher central tensioncompared with RHs.Index Terms: cardiovascular reactivity, emotion, essential hypertension,interview, renal hypertension

Essential hypertension (EH) has received much attentionfor many years. Genetic and environmental aspects play amajor role in this context.''^ Menial and psychophysiologi-cal reactivity may both contribute to the development ofEH.'''^ Results from psychosomatic studies have empha-sized tbe role of cardiovascular reactivity to mental stressand the social environment as a possible stressor as well ascertain personality traits'' that may have a particularlystrong influence on the stress experience.^ Substantiatedrisk factors for EH seem to be an increased reactivity tomental stress and a positive family history of EH comparedwith tbose without tbis genetic component.** Psychosomaticfindings bave repeatedly indicated open or latent personali-

Drs D eter. Blecher. an d Weber are with fhe Department ofPsycho-samalic Medicine ami Psychnlherapy. Chariite U niversiidtsmedi-zin. Bfrlin. Germ any.Copyright 2007 H eldref Publications

ty traits, such as increased aggression, anger, and bostili-ty' iR and have sug gested that these traits are associated withincreased cardiovascular reactivity during mental stress.Researchers in various studies""'^ have demonstratedthat certain emotions trigger blood pressure (BP) reactions.Addressing this issue in tbe present study, we aimed to ana-lyze (I) wbetber emotions, such as aggression and anger,represent a specific stress stimulus for essential hyperten-sives (EHs), as assumed earlier'*''*''' and (2) whether theseemotions are generally observed c irculation-activating trig-

gers that occur with the same intensity in normotensives(Ns) and subjects with otber types of hypertension and aretherefore not specific in tbe etiopathogenesis of EH.'*Psychological tests to identify anger traits or bostilitygroups can be done using standardized questionnaires."''Tbese examinations can also be performed under laborato-ry conditions by inducing anger and frustration or by stim-ulating emotions via specific interviewing tecbniques. such

117


2/10

PATIENTS' CARDIOVASCULAR REACTIVITY

as tbe anger-recall technique.'^ Tbe interviewing techniquebas a long tradition'''-" but bad fallen into some disputebecause of unethical arrangements; bowever, this emotion-triggering technique has been revived in recent yearsbecause it is far superior to other tecbniques witb regard tothe level of beart rate and BP reactions.-'

This technique has become establisbed in the testing of 1or 2 emotions-^ but bas thus far not been able to cover thewhole range of several emotional responses, because it isdifficult to provoke tbem validly in a sbort time. Zander etal'*^ had attempted tbis in a structured interview and foundinteresting specific reaction patterns tbat seemed to confirman emotional reaction specificity in EHs. Stemmler's^^ lab-oratory findings concerning reaction specificity also indi-cate an emotional reaction specificity. An earlier studyreported that, in contrast to psychosomatic inpatients andcontrols. EHs had stronger BP reactions in a structuredinterview w itb emotional exposure to rage and anger as w ellas to questions concerning their occupational situation.^

The question was whether this applies to all hypertensivesor only to the specific group of patients witb EH. We want-ed to make a more precise analysis of the disease-reactivefactors of hypertension by comparing EHs. in whicb envi-ronmental factors are repeatedly held responsible for tbedevelopment of tbe disease, with renal hypertensives (RHs),in whom BP increases bave a clearly somatic (ie. nepbro-genic) cause. We speculated that tbis would enable us to dif-ferentiate between factors of reactivity to varying stimulideveloping from tbe high-pressure disease itself and otberetiopatbological factors caused by tbe social environment orpersonality. Our aim in tbis study was to examine whetherdifferent affects would induce different cardiovascular reac-tions in EHs and RHs during an emotion-stimulating inter-view. In accordance with earlier psycbosomatic literature.^'''we expected that EHs would bave (I) stronger BP reactionsthan RHs and normotensive (N) controls to the rage andanger affect (HI), (2) stronger reactions in a psycbosocialsituation triggering negative emotions (H2). and (3) strongerreactions to thoughts about tbeir occupational situation (H3).In a descriptive analysis, we wanted to exam ine if emotionssucb as anxiety, envy, and grief were effective in triggeringa bigber cardiovascular reaction in EHs.METHODS

SubjectsWe conducted tbis study in the Departments of Psycboso-matic Medicine and Nephrology at tbe Charite CampusBenjamin Franklin. Universitatsmedizin Berlin.

Tbe study included hypertensive and N patients aged 20to 60 years; wbo bad a good command of the German lan-

guage; and had no neurological or psychiatric diseases, car-diovascular diseases, otber independent severe organic dis-eases, or alcohol or drug abu.se.We recruited the RHs from the nephrology consultationservice with the following diagnoses; fibromuscular renalarterial steno sis {n = 2) and polycystic kidney disease (n = 8)We selected 10 age- and sex-matcbed EHs from 18 EHs oftbe bypertension clinic at our hospital. We matched 10 of 22Ns for age and sex recruited through intemal blackboardnotices to be included in this study.We obtained tbe internal examination data from tbepatients' medical records, from consultation with the fami-ly pbysician, and from anamnestic questionnaires filled outby all patients.The 3 groups consisted of 3 x 7 men and 3 x 3 womenwitb no significant differences between groups regardingage. body mass index (BMI), and occupational status (Table

1) or smoking and sports activities. Compared witb the RHgroup, tbe EH group reported stronger subjective stressreactions, more frequent occupational activities, and longerdurations of hypertension. RHs smoked more frequently,participated in more sports, and possessed more family his-tories of cardiovascular diseases than did tbe EHs. Meanserum creatinine and target organ damage were comparablebetween EHs and RHs.None of tbe patients had taken any medication 24 hoursbefore the test. Seven in eacb hy pertensive group took anti-bypertensive drugs before tbe test, wbich were: EH group calcium antagonists (4), diuretics (2). and ACE (angioten-

sion converting enzyme) inhibitors (5) and RHgroupcalcium antagonists (6), diuretics (2), and ACEinhibitors (2). A Ionger interruption of drug administrationwould have been ethically unjustifiable. Thus, we per-formed tbe study despite antihypertensive tberapy becausethe 2 groups received comparable medication, witb tbeexception of ACE inhibitors. It was not expected tbat reac-tions to the provoked affects would be systematically dis-torted by possible side effects of the drugs.Study DesignAfter filling out psycbological questionnaires, we per-formed a first baseline and a standardized mental stressexamination (results not reported here). After a 15-minuteresting period and measurement of initial baseline values,we subjected patients to a structured .'iO-minute interviewtbat addressed the following areas in a random order: com-plaints, occupational situation, life situation in which angerand rage were experienced, partnership, life situation inwhicb anxiety was experienced , life situation in wbicb envywas experienced, life situation in which grief was experi-

118 Behavioral Medicine


3/10

DETER. BLECHER. & WEBER

enced, life situation with a strong feeling of well-being, andthe most important negative affect triggered by a stressfulpsycbosocial situation. Tbe second resting period, duration3 minutes, started after tbe end of the interview.

HCD. an experienced scientist and physician trained indepth psychology, conducted tbe interview, recorded it onsound carrier, and transcribed it. We tben blinded the tran-scripts (without knowledge of the physiological data). Tworaters, members of tbe research group, independently defmedtbe 9 sections in the transcripts and we discussed and coordi-nated the differences. We subsequently assessed the individ-ual sections of the transcripts witb respect to BP and HR.Measuring InstrumentsDuring the interview, we recorded HRs using a bipolarextremity lead in a .standard electrocardiogram (ECG). Wemeasured BP at 1-minute intervals using an automaticallyinflatable cuff placed over tbe bracbial artery of tbe left arm.We recorded BP witb Bosomat 11 (Boscb and Son. Jungingen.Germany, wbicb were validated and used in former studies');we recorded the ECG with an amplifier (Scbwarz: Munich.Germany) on registration paper and with an electronic evalu-ation program (Par Electronics: Berlin, Germany).Statistical MethodsBecause of the low sample size in this first pilot study inwhich we examined cardiovascular reactivity in EH andRH, we did not apply multivariate testing but insteadfocused on tbe bypotbesis derived from tbe literature.

We calculated tbe BP differences between tbe 3 groupswith tbe H test (Kruskal-Wallis test) for tbe tbree samples.We caicuiated the differences in mm Hg between baseline

systolic BP (SBP) and diastolic BP (DBP) and SBP andDBP in tbe individual phases of tbe interview. We recordedBP as well as HR and tbe product of HR and SBP We cal-culated tbe differences between 2 unrelated samples withMann-Whitney's V test. Tbe significance level was p < .05for the 3 hypotheses and, as adjustment for multiple com-parisons (Bonferroni), p< .02 for tbe 3 fields of tbe descrip-tive analysis and p < .01 for the other variables.

RESULTSEH compared witb RH had higher initial SBP, but compa-rable DBP before the experiment (difference not signifi-cant). We obtained these initial baseline values. Baseline 1SBP: EH = 156.5; RH = 143.9; N = 125.6; DBP: EH =103.3; RH = 98.3; N = 84.9 mm Hg, (Table 1), prior to com-pleting tbe standardized mental stress examination (data notreported bere). The BP values did not return to this level intbe subsequent interview. Wben starting tbe interview, BPlevels for EHs and RHs were not statistically different,SBP: EHs = 165.5: RHs = 164.3; Ns = 129.9; DBP: EHs =108.4; RHs = 110.2; Ns = 87.8 mm Hg. SBP and DBPincreased strongly during the interview. The mean maximalSBP increase per phase was 30.2 mm Hg for EHs, as bigbas 44.7 mm Hg for RHs, and 28.6 mm Hg in Ns (Table 2).DBP increased by 23.9 mm Hg in EHs. by 26.1 mm Hg inRHs. and by 19.0 mm Hg in Ns. Tbe intragroup comparisonof values in the interview situation and the initial baselineyielded significant to highly significant values for all groupsin each interview pbase.

As we had assumed, there were no statistically signifi-cant differences in SBP and DBP behavior between RHsand EHs witb respect to anger/rage (HI), psychosocial sit-

TABLE 1. General Patient Characteristics

CharacteristicAg eBody Mass IndexSexMale

FemaleOccupationWorkerEmployee/civil servantUnemployed/student/reiiree

Essentialhypertensives

{n = 10)n M SD

44.8 9.725.9 2.6

73172

Renalhypertensionn

7305

(n = 10)M SD

41.6 9.824.6 3.5

Normotensivesn

73064

(n = 10)M SD

43.0 10.224.5 2.4

Vol 32. Winter 2 007 119


4/10

P A T I E N T S ' C A R D I O V A S C U L A R R E A C T I V I T Y

TABLE 2. Blood Pressure in Essential(RHs), and Normotensives

Interview phase

Initial baselineStart of interviewComplaintsOccupationAnger/ragePartnershipAnxietyEnvyGriefWell-beingStrong negative emotionEnd baseline

initial baselineStart of interviewComplaintsOccupationAnger/ragePartnershipAnxietyEnvyGriefWell-beingStrong negative emotionEnd baseline

Initial baselineStart of interviewComplaintsOccupationAnger/ragePartnershipAnxietyEnvyGriefWell-beingStrong negative emotionEnd baselineNote. EUs: n = iO;RHs:n=]O;

Hypertensives (EHs), Renal H ypertensives(Ns) During the Individual Phases of the Interview

EHsM

156.5165.6180.4180.6188.8180.2181.1184.5188.3183.4182.8174.6

103.3108.4119.4120.1127.0120.6120.8126.3128.1123.8125.6113.4

84.788.692.993.693.692.391.090.490.188.091.983.5

N s : n = 1 0 .

SDRH s

M SDNs

M

Systolic blood pressure (mm Hg)20.527.224.117.822.718.817.827.923.325.619.616.2

143.9164.3173.5179.5182.7183.5183.9186.2184.2188.6184.0168.8

11.610.615.713.618.421.319.725.318.315.717.516.2

125.6129.9141.3150.8154.2154.4150.3149.0149.8151.9184.0140.9Dialostic blood pre.ssure (mm Hg)11.914.113.510.812.110.113.514.1n.o13.112.110.7

17.316.5U . I11.611.211.210.112.39.911.710.810.7

98.3110.2119.2121.3119.8123.5119.8119.8120.5125.4122.7110.2

11.614.510.511.813.313.810.814.516.419.015.510.9Heart rate (bpm)

76.072.480.680.180.879,477.478.178.079.779.971.2

15.912.415.016.314.613.514.714.712.912.115.912.2

84.987.897.7101.4101.2104.8102.199.7103.3103.9102.992.9

72.872.774.175.975.275.274.876.476.973.374.869.8

SD

15.420.919.416.220.023.420.721.918.920.517.517.0

12.3II.311.512.312.612,211.710.78.815.39.18.9

12.210.713.313.612.712.712.210.814.711.912.811.5

uation tr igger ing negative emotions (H2) , and occupationals i tuation (H3) . In these areas , mean reactions comparedwith baseline I were higher in RHs than in EHs.

In contras t to our expectat ions , RHs had s tronger SBPreactions than did EHs at the start of the interview {p =.046) and in the situations that stimulate anxiety (p = .052)



5/10

D E T E R , B L E C H E R , & W E B E R

and well-being (p = .08), DBP reactivity did not differ sig-nificuntly between the 3 groups; EHs reacted (as a statistictendency) stronger than did Ns in the phase focusing onfeelings of anger /rage. EHs versus Ns, p = .09] (Table 3).

EHs had the highest and RHs the second highest initialHR va lues {Table 2). We found this suc cession in all inter-view phases except the starting one. in which Ns had slight-ly higher values than did RHs. As anticipated, EHs had thehighest values for anger/rage and occupation but not for thepsychosocial s i tuation tr igger ing negative emotions . Like-wis e , RHs had also the strongest reaction (on a lower level)to anger/rage, whereas Ns had the highest values for envyand grief. In all 3 groups, the HR dropped below the initiallevel at the end of the interview, with the least markeddecrease for EHs.

We also examined whether the product on SBP and HRinduced by the items discussed in the interview (anger/rage,psychosocial s i tuation tr igger ing negative emotions , andoccupation) w as s tronger in EHs than i t was in RHs (Figure1) . Th e 3 sam ples could be clearly differentiated by theabsolute values of this variable. EHs had the highest initialand final values, which clearly exceeded those of the other2 groups during the entire interview. RH had higher initialand final values than did Ns in all interview phases. In con-trast to Ns, EHs and RHs had clearly increa.sed values in thecourse of the in terv iew and a s teep decline thereaf ter . How-ever, the values in all 3 groups remained above the initiallevel . We found s ignif icant d if ferences betwe en the 3groups in all interview areas including initial and the base-line after the interview. The differences between the 2

TABI.K 3, Systolic and D iastulic Blood Pressure DifferencesHyperten.sives (RHs), and Normotensives (Ns; Controls)

Interview phase

Start ai interviewComplaintsH3: OccupationH I: Anger/ragePartnershipAnxietyEnvyGriefWell-beingH2 : Strong negative emotionEnd baseline

Start (tf interviewComplaintsOccupationAnger/ragePartnershipAnxietyEnvyGriefWell-beingStrong negative emotionEnd baselineNole. NS = not significant.*Witcoxon's rank sum test.

("M

4.615.725.228.627.124.724.324.226.326.2\5.:i

3.312.816.516.316.917.215.118.419.018.48.0

Ns= iO)SD

10.813,310.613.114.616.215.714.813.613.110.8

4. 77.67.28.99.79.25.78.69.010.46.9

(nM

to Initial Baseline in

EHs= 10)SD

Essential

RH s(n

M= 10)

SD

Hypertensivei

Ns/EHsp *

Systolic blood pressure differences (nun Hg)9.123.925.328.524.824.628.430.229.226.318.1

12.512.615.418.015.114.717.815.517.013.914.7

14.429.635.638.839.640.042.340.344.739.924.9

8.98.06.89.812.612.120.018.513.313.78.8

NSNSNSNSNSNSNSNSNSNSNSDiastolic blood pressure differences (mm Hg)5.717.520.521.920.418.4

21.923.020.522.29.8

4.56.910.25.66.38.73.22.86.14.35.9

6.919.621.420.622.920.221.322.326.121.610.4

6.88.08.39.49.27.99.012.611.812.312.2

NSNSNS.091NSNS.028NSNSNSNS

(KHs),

Ns/RHsp *

NS.028.019NSNS.041.066.046.019.085.083

NS.085NSNSNSNS.042NSNSNSNS

Renal

EHs/RHsp *

.046NSNSNS.080.052NSNS.080NSNS

NSNSNSNSNSNSNSNSNSNSNS

Vol 32, Winter 20 07 121


6/10


Essential hypertensivesRenal hypertensivesNomiotensives

16 -

6 14-12 -

10 -

^ Ititerview Phases -v"FIGURE 1. Medians of the product from sy.stolic bloodpressure (SBP) and heart rate (HK) in the individualinterview phases with essential hypertensives, nor-motensives, and renal hypertensives.

hypertensive groups were highly significant in the categoryanger/rage in terms of our expectations (p = .028) but notfor the other prognosed categories (occupation and psy-chosocial situation with negative emotions). The grief phase(p = .011) and the second resting phase after the interview(p < .02) were also different between the 2 hypertensivegroups (Table 4).C O M M E N T

As anticipated, both hypertensive groups had stronger meanSBP and DBP reactions to the stress interview than did theN controls. The hypertensive groups differed in their initialSBP (EH > RH) on the day of the experiment, but not in theprevious ciinical examination. The BP differences becameles.s pronounced during the interview. The varying initialconditions led to a maximal SBP increase of 29.2 mm Hg inEHs and 44.7 mm Hg in RHs in the highest phase (well-being). Thus, our resting values may have already beenchanged by the behavior of EHs who had a higher level ofstress anticipation accompanied by an increased HR thandid other groups. This must be kept in mind when inter-

preting the calculations of differences between baselinevalue and various values ofthe interview p hases. Interestingdifferences between the hypertensive groups are the higherreaction values of RHs at the start of the interview and dur-ing the phase in which the test subjects had to recall an anx-iety situation; however, these differences were not withinthe anticipated range with respect to anger/rage, occupa-tion, and the negative emotion phase. C omparing BP valueswithin groups, both Ns and tbe 2 hypertensive groups hadsignificantly higher levels during the individual interviewphases than at baseline.Analysis of HR showed that already in the resting phase,EHs had 12 more beats/min than Ns had and 8 more

beats/min than RHs had. In the psychodiagnostic study ofthese patients, we did not detect any differences betweenEHs and RHs in anxiety and depression (Deter et a!). EHshad a total maximum increase of 9 beats/min (occupation,anger phases) and RHs had a maximum increase of 4beats/min (anger phases). Ns only had a m aximum increaseof 4 beats/min (grief phase). Even though these differencesare not significant, they demonstrate that EH s could be acti-



7/10

DETER, BLECHER, & WEBER

TABLE 4. Differences Between Normotensivesand Renal Hypertensives (RHs) inHeart Kate (HRl in the Individual the Product(Ns), Essential Hypertensives (EHs),of Systolic Blood Pressure (SBP) andPhases of the Interview (Absolute Values)

Ns/EHs/RHs*Interview phasesInitial baselineStart of interviewComplaintsH3: OccupationH1 : Anger/ragePartnershipAnxietyEnvyGriefH2 ; Strong negative emotionEnd baseline

P

.018.040.004.007.011.018.003.002.(X)l.007

.001

Ns/EHstP

.006.018.007.007.011.018.005.011.011.007

.005

Ns/RHstP

.028.046.010.066.020.028.015.011.028.017

.015

EHs/RHstP

.085.079.068NS.028NS.066NS.011NS

.020Note. NS = nol significant. Tlie p values represent the differences between groups product of SBP x HR.Friedman test.tWilcoxon's test.

vated to a higher degree than could the other 2 groups. ThisfiniJing can be statistically confirmed by the product of SBPand HR. There were significant differences between EHsand RHs with respect to the interview phases in which westimulated anger/rage and grief. As anticipated, emotionalstimulation of anger/rage produced cardiovascular activa-tion that was stronger in EHs than il was in RHs and extend-ed beyond the interview period in EHs but not in RHs.The findings obtained in the present study have to be con-sidered in the light ofthe disproving of our initial hypothe-ses (SBP and DBP reactivity to anger/rage provocation isenhanced in EHs compiu-ed with RHs). Both RHs and nor-mal controls have similar BP reactions as do E Hs to specif-ic interpersonal conditions (feelings of anger/rage, experi-ence of the occupational situation, and psychosocialsituations triggering strong negative emotions). On the onehand, we were unable to confirm our hypothesis formulatedin agreement with the specificity hypothesis of Alexander^

and a number of other authors"''^^* that EHs react in a spe-cific manner to defined emotional conditions or con-flicts.-^-'' On the other hand, our study clearly confirmedthe previously reported finding of increased cardiovasculartension being more evident in EHs-^** than in RHs (measuredby the product of SBP and HR).The findings in this pilot study that included RHs in astress experiment also have to be carefully considered in the

light of the relatively small number of test subjects. EHsand RH s were representative for a clinical study populationwith hypertensive grade I and II with comparable BP levelsin a clinical examination. W e recruited the Ns from hospitalpersonnel without any disease. We matched groups accord-ing to sex and age, but other possibly influencing factorscouid not be evaluated.'" The main hypotheses (reaginicresponse to recalled emotional topics) seemed to be compa-rable between the 3 groups.The results may have been influenced by antihyperten-sive drug intake some days before the experiment. A lon gerinterruption of drug administration would have been ethi-cally unjustifiable and was therefore not possible in the 2hypertensive groups; however, this possible effect may nothave been very strong because the test subjects withoutmedication had essentially the same subevaluation findingsas did those with medication.The structured interview, in which we addressed different

topics within 50 minutes, has to be critically examinedbecause individual situations or emotional states may havebeen too strongly related or not experienced intensivelyenough in the interview situation.^' A provocation with 2 or3 emotional areas in the experiment might have provided abetter control for these conditions; however, this pilot studyaimed particularly at determining whether the various possi-ble emotions and life situations would yield different find-

Vol 32, Winter 2007 123


8/10


ings. Thus, it was very interesting that grief and anxietyelicited, in part, the same strong BP reactions as anger/rage.tt seemed to be a limiting factor to focus hypertensionresearch only on the aggression-anger-hostility complex,and the results confirm earlier studies relating EH to theeffects of grief or anxiety. - After all, SBP reactions of upto 40 mm Hg per phase in RHs and maximal reactions of upto 60 mm Hg in individual patients have demonstrated thatemotion-triggering interviews have a considerably strongereffect than do standardized stress situations, with clearlylower mean SBP reactions of 15-20 mm Hg.-' A possiblesource of bias in the study could be the interviewer, whoknew the diagnosis at the time of the interview. The differ-ences observed between EHs and RHs indicate that high BPalone is not responsible for all the reactions under stress inthese patient populations. But the results presented here donot confirm the specificity hypothesis'-" that certain emotionstrigger higher BP reactions in EHs. The EHs evidenced non-specific characteristics indicative of higher cardiovascularactivity"" and perhaps higher neurogenic tension; however,we showed that social environment and mental stress areimportant factors in both EHs and RHs. There is evidencethat these are conditions for worsening of the disease and fordeveloping EH-'*- " in the long run, in addition to biologicalrisk factors,^' certain personality traits (eg, anger or copingbehavior), and social mechanisms (eg, life events or socialsupport' ). Further analyses in high-risk Ns and other hyper-tensive groups are needed to gain a better understanding ofthe etiopathogenesis and long-term outcome of EH.

NOTEFor comment or further information, please address correspon-dence to H. C. Deter. MD. Department of Psychosomatic Medi-cine and Psychotherapy. Charite Universitatsmedizin. CampusBenjamin Franklin. Hindenburgdamm 30, 12200 Berlin, Germany(e-mail: [email protected]).

REFERENCES1. Baxendale-Cox LM. Anoverview of essential hypertension inAmericans as a multifactodal phenometion: interaction ofbio-logic and environmental factors. Prog Cardiova.sc Nurs.2(X)O;15(2):43-39.2. Pickering. TG. Th e effects of environmental and lifestyle fac-tors on biood pressure and the intermediary role of the sympa-thetic nervous system. J Hum Hypertens. 1997;1 l(l):9-18.3. Deter HC , Klepper A. Schulte KH. Preliminary resultsof a dif-ferentiated emotion-stimulating interview in patients withessential hypertension as compared with inpatients of a psy-chosomatic unit and normal controls. Fsychother Psvchosom.1996;65(5):262-27I.4. Folkow B. Physiological aspects of primary hypertension.PhysiolRev. 1982;62:347-503.

5. Julius S. Changing role of the autonomic nervous system inhuman hypertension. J Hypertens. 1990;8:59-65.6. Jorgensen RS, Johnson BT, Kolodzlej ME. Schreer GE. Ele-vated blood pressure and personality: a meta-analytic review.Psydwl Bull. l996:l20f2):293-320.7. Dimsdale JE. Pierce B, Schoenfeld D, Brown A, Zusman R,Graham R. Suppressed anger and blood pressu re: the effects ofrace, sex, social class, obesity, and age. Psvchosom Med.1986:48:430-436.8. Frederikson M, Matthews K. Cardiovascular responses tobehavioral stress and hypertension: a meta-analytic review.Ann Behav Med. 1990; 12:30-39.9. Alexander F. Psvchosom Med. New York: Grune and Stratton;

10. Linden W, Chambers W, Maurice J. Lenz J. Sex differences insocial support, self deception , hostility and ambulatory cardio-vascular activity. Heallh P.sychol. I993;13:376-380.11 . Lai JY. Linden W. Gender, anger expression style, and oppor-

tunity for anger release determine cardiovascular reaction toand recovery from anger provocation. Psxchosom Med.!992;54:297-310.12. Christensen AJ, Smith TW. Cynical hostility and cardiovascu-lar reactivity during self disclosure. Psychosom Med.1993:55:193-202.13. Everson SA. Goldberg DE. Kaplan GA, Julkunen J. SalonenJT. Anger expression and incident hypertension. PsvchosomMed. 1998;60(6):730-735.14. Weiner H. Psychobiology and Human Disease. New York;Elsevier: 1977.15. Zander W. Engel RR, Kitscher M. Wiedemann G. Psy-chophysiologische Korrelationsuntersuchungen wahrend eineshalbstandardisierten Interviews hei Patienten mil Ulcus duo-

deni und Hyperwnie. In: Zander W. ed. ExperimentelleForschungsergebnisse in der psychosomatischen Medizin.Gbttingen, Germany: Vandenhoeck & Ruprecht; 1981;120-128.16. Noll G. Wenzel RR, Schneider M. et al. Increased activation ofsympathetic nervous system and endothelin by mental stress innormotensive offspring of hypertensive parents. Circulation.1996:93(5):866-869.17. Haeri SL, Mills PJ, Nelesen RA. el al. Acute psychologicstress reactivity in blacks versus whites: relationship to psy-chologic characteristics. Blood P ress Monit. 1996; 1:27-32.18. Ironson G,Taylor CB, Boltwood M, et al. Effects of anger onleft ventricular ejection fraction in coronary artery disease. AmJCardiol. l992;7O:281-285.19. Wolf S. Wolff H. A summary of experimental evidence rela-tion life stress to the pathogenesis of emotional hypertensionin man. In: Bell E T. ed. Hypertension. Minneapolis: Universi-ty of Minnesota Press, 1951.20 . Tlieorell T. SchaiMng. D, Akerstedt T. Circulatory reactions incoronary patients during interviewa noninvasive study. BiolPsychol. 1977;5:233-243.21 . Dimsdale JE, Stem MJ, Dillon E. The stress interview as a toolfor examining physiological reactivity. Psychosom Med.



9/10

DETER, BLECHER, & WEBER

1988;50:64-71,22 . Svensson JC. Theorell T. Cardiovascular effects of anxietyinduced by interviewing young hypertensive male subjects. JP.syclwsom Res. 1982;26(3):359-370.23 . Stemmler G. P.sychophysiologische Emotionsmuster: Ein

empirischer und methodologischer Beilrag zur intra- undinteriindividuellen Begrimdbarkeii spezifischer Profile beiAngst, Arger und Freude. Frankfurt. Germany: Lang; 1984.24 . Jammer UD. Shapiro D. Hui KK. Oakley ME. Lovett M . Hos-tility and differences between clinic, self-determined, andambulatory blood pressure. Psychosom Med. 1993;55:203-211.25 . Miller SB. Cardiovascular reactivity in anger-defensive indi-viduals: the influence of task demands. Psycho.som Med.1993;55:78-85.26. Mann S J, James G D. Defensiveness and essential hyp erten-sio n. 7 P.iyc/jtJ^owi Res. 1998;45(2):139-I48.27.Rutledge T, Linden W, Davies R. Psychological response

styles and cardiovascular health: confound or independ riski'actor? Health Psychol. 20 0 0 ;1 9 :4 4 1 ^5 L

28 . Amann FW. Bolli P. Buhler FR. Personality and adrenergicfactors in essential hypertension. Contrib Nephrol.1982:30:64-69.29 . Frederikson M. Psychophysiological theories on sympatheticnervous system reactivity in the development of essentialhypertension. Scand J Psychol. 1991;32:254-274.30 . Dimsdale JE. Mills O. Dillon E. Does reactivity testing in thelaboratory reflect blood pressure changes elsewhere? ./ Psy-chosom Res. 1992:36:701-705.31 . Deter HC. Buchholz K. Schorr U. Schachinger H. Turan S,Shamia AM. Psychophysiologica! reactivity of salt-sensitivenormolensive subjects. J Hyperten.w 1997; 15: 839-844.32 . Light K. Gindler S. Sherwood A, et al. High stress responsiv-ity predicts later blood pressure only in combination with pos-itive family history and high life stress. Hypertension.I999;33:1458-1464.

Vol 32 , Winter 2007 125


10/10

Documents

Interview Psychosomatic