Psychological Factors in Essential Hypertension

Abstract

Essential hypertension is one of the most emphasized psychosomatic disorders. Age, sexuality, excessive salt and alcohol consumption, lower activity level, fatigue, personality traits, emotional factors and stress are some of the risk factors for essential hypertension. The presence of emotional factors in the etiology of the essential hypertension and the emergence of psychiatric symptoms in the course of the illness has driven considerable attention from mental health workers on the disease for a long time. Some of the personality traits that make a person vulnerable to hypertension are being over controlled, being submissive, and hardworking. Hypertension is accepted to be a reaction against suppressed emotions and an adaptive and defense mechanism of the body. Among persons who are prone to hypertension, sympathetic nerve system is affected as a response to emotional stress and hypertension appears as a result of vasoconstriction and other autonomous responses. All at once, it was also shown that vasoconstrictor response continues much longer in hypertensive individuals than in normotensive patients. Autonomic response to stress almost always displays itself as hypertension in individuals who are prone to hypertension. Moreover, normotensive children of hypertensive parents also have elevation in blood pressures as a response to emotional stress almost without exception. The increase in sympathetic stimulus, re-modulation of bar receptors by structural and functional changes are the main features of the most commonly valid hypothesis in essential hypertension, currently. According to this hypothesis: as a result of emotional stress, inhibition over vasomotor center decreases and output of stimulus increases; epigenetic changes in endothelial structure of carotid sinus and/or aortic arch and/or vasomotor centers occurs; and finally stress increases sympathetic stimulus output. This situation leads to neurohormonal excitation; increases in systemic vessel resistance; and in turn increase in the secretion of vasoconstrictor compounds from endothelial cells of over-resistant vessels. Hypertension develops as a result of vasoconstriction. In the previous studies, emotional factors and particular personality traits are consistently confirmed for being predisposing factors in hypertensive individuals. In this article, we focused on the association between essential hypertension and psychological factors, and discussed the common pathophysiological mechanisms.

Keywords

• Hypertension, Hypertensive Personality, Stress, Anger, Psychosomatic Disorders

Esansiyel Hipertansiyonda Psikolojik Etmenler

Öz

Esansiyel hipertansiyon üzerinde en çok durulan psikosomatik hastalıklardan biridir. Yaş, cinsiyet, yüksek miktarda tuz ve alkol tüketimi, obezite, yüksek kalorili beslenme, düşük aktivite düzeyi, yorgunluk, kişilik özellikleri, stres gibi duygusal etmenler esansiyel hipertansiyon etiyolojisinde rol oynayan bazı risk faktörleridir. Hipertansiyon, hem etiyolojisinde duygusal nedenlerin rol oynaması hem de seyri sırasında psikiyatrik belirtilerin ve bozuklukların ortaya çıkması nedeni ile ruh sağlığı çalışanları tarafından yıllardır araştırılmaktadır. Yapılan çalışmalarda; aşırı kontrollü ve uyumlu olma, işte sürekli çaba gösterme, agresif dürtüleri bastırma gibi özelliklerin hipertansiyona yatkınlığa neden olduğu gösterilmiştir. Hipertansiyonun baskılanmış duygulara karşı bir tepki, bir uyum ve savunma mekanizması olduğu kabul edilmektedir. Hipertansiyona yatkın kişilerde, duygusal streslere cevap olarak sempatik sinir sisteminin etkilendiği, vasküler vasokonstriksiyon ve diğer otonomik cevapların sonucu olarak hipertansiyon ortaya çıkmaktadır. Strese vasokonstriktör cevabın hipertansif olanlarda, tansiyonu normal olanlara göre çok daha uzun olduğu da gösterilmiştir. Hipertansiyona yatkın olan kişilerde, strese karşı otonomik yanıt özelliği kan basıncının yükselmesi şeklindedir. Esansiyel hipertansiyonluların normal tansiyonu olan çocuklarında da duygusal streslere yanıt olarak kan basıncının yükseldiği gösterilmiştir. Esansiyel hipertansiyonda sempatik uyarı artışının kilit bir etmen olabileceği, baroreseptörlerin yapısal ve işlevsel değişiklikler göstererek yeniden düzenlendiği günümüzde en geçerli olan varsayımdır. Bu varsayıma göre; duygusal stres sonucu vazomotor merkez üzerindeki baskılanma azalır ve uyarı çıkışı artar. Ardından yeniden düzenlenme ile karotis sinüsü, aort kavsi ve vazomotor merkezlerdeki endotel örtüsünde epigenetik değişiklikleri oluşur ve bu değişiklikler sonrası stres sempatik sistemdeki uyarı çıkışını daha da çoğaltır. Sempatik sistemde uyarı çıkışının artması nörohormonal eksitasyona neden olarak sistemik damar direncini artırır. Dolayısıyla direnci artmış damarlardaki endotel hücreleri daha çok vazokonstriktör madde salgılamakta ve ortaya çıkan vazokonstriksiyon sonucu da hipertansiyon gelişmektedir. Bu zamana kadar yapılan çalışmalar, tutarlı biçimde hipertansif kişilerde duygusal faktörlerin ve belirli kişilik özelliklerinin hastalığı hazırlayıcı olduğunu göstermiştir. Bu yazıda esansiyel hipertansiyon ile psikolojik etmenler arasındaki ilişki gözden geçirilmiş, ortak patofizyolojik düzenekler tartışılmıştır.

Anahtar Kelimeler

• Hipertansiyon, Hipertansif Kişilik, Stress, Öfke, Psikosomatik Bozukluklar

Kaynakça

1. Öztürk MO. Ruhsal Etkenlerle Bağlantılı Fizyolojik İşlev veya Yapı Bozuklukları. Ruh Sağlığı ve Bozuklukları. Hekimler Yayın Birliği, Ankara.1997.
2. Çevik A. Psikosomatik Hastalıklar. Ruh Sağlığı ve Hastalıkları. (Ed. I. Sayıl) Antıp A.Ş. Yayınları, Ankara. 2000.
3. Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. The sixth report of The Joint National Committee on Prevention, Dedection and Treatment Of High Blood Pressure. Arch Intern Med 1997; 157:2413-2446.
4. Guidelines Subcommittee of The World Health Organization. World Health Organization-International Society of Hypertension guidelines for the management of hypertension. J Hypertens 1999; 17:151-183.
5. Akıllı, A. Tanı, Sınıflama, Klinik Yaklaşım, Tetkikler. Hipertansiyon.İlsan-İltaş İlaç Firma- sı, İzmir.1998; s.1-23.
6. Ulusal Hipertansiyon Tedavi ve Takip Klavuzu. Türk Kardiyoloji Derneği Novartis İlaç Ürünleri, İstanbul. 2000; s.22-23.
7. Özmen M. Hipertansiyon, kişilik yapısı ve stres. Hipokrat Dergisi 2002; 11:339-342.
8. Davies SJ, Ghahramani P, Jackson PR, Hippisley-Cox J, Yeo WW, Ramsay LE. Panic disorder, anxiety and depression in resistant hypertension--a case-control study. J Hypertens 1997; 15:1077-1082.

9. Grassi G, Quarti-Trevano F, Dell’Oro R, Mancia G. Essential hypertension and the sympathetic nervous system. Neurol Sci 2008; 29:33–36.
10. Charmandari E, Kino T, Souvatzoglou E, Chrousos GP. Pediatric stress: hormonal mediators and human development. Horm Res 2003; 59:161-79.
11. Ahrens T, Deuschle M, Krumm B, van der Pompe G, den Boer JA, Lederbogen F. Pituitary-adrenal and sympathetic nervous system responses to stress in women remitted from recurrent major depression. Psychosom Med 2008; 70:461-467.
12. Cameron OG. Anxious-depressive comorbidity: Effects on HPA axis and CNS noradrenergic functions. Essent Psychopharmacol. 2006; 7:24-34.
13. Ruthledge T, Hogan BE. A quantitative review of prospective evidence linking psychological factors with hypertension development. Psychosom Med 2002; 64:758-766.
14. Alexander F. Emotional factors in essential hypertension. Psychosom Med 1939; 1:175-179.
15. Wolf S, Wolff HG. A summary of experimental evidence relating life stress to the pathogenesis of essential hypertension in man. in Hypertension (Ed. TE Bell) University of Minnesota Press, Minneapolis. 1951, pp.288.
16. Pickering TG. Does psychological stress contribute to the development of hypertension and coronary disease? Eur J Clin Pharmacol 1990; 30:1-7.
17. Perini C, Muller FB, Rauchfleisch U, Battegay R, Hobi V, Buhler FR. Psychosomatic factors in borderline hypertensive subjects and offspring of hypertensive parents. Hypertension 1990; 16:627-634.
18. Sparrow D, Garvey AJ, Rosner B, Thomas HE. Factors in predicting blood pressure change. Circulation 1982; 65:789-794.
19. Markovitz JH, Matthews KA, Kannel WB, Cobb JL, D'Agostino RB. Psychological predictors of hypertension in the Framingham Study. Is there tension in hypertension? JAMA 1993; 270:2439-2443.
20. Baer PE, Collins FH, Bourianoff GG, Ketchel MF. Assessing personality factors in essential hypertension with a brief self-report instrument. Psychosom Med 1979; 41:321-330.
21. Jonas BS, Franks P, Ingram DD. Are symptoms of anxiety and depression risk factors for hypertension? Longitudinal evidence from the National Health and Nutrition Examination Survey I Epidemiologic Follow-up Study. Arch Fam Med 1997; 6:43-49.
22. Markovitz JH, Matthews KA, Wing RR, Kuller LH, Meilahn EN. Psychological, biological and health behavior predictors of blood pressure changes in middle-aged women. J Hypertens 1991; 9:399-406.
23. Light KC. Psychosocial precursors of hypertension experimental evidence. Circulation 1987; 76:67-76.
24. Falkner B, Onesti G, Hamstra B. Stress response characteristic of adolescent with high genetic risk for essential hypertension. Clin Exp Hypertens 1981; 3:583-591.
25. Campbell RJ, Henry JP. Animal Models of Hypertension. In Handbook of Psychology and Health Vol. 3. Cardiovascular Disorders and Behavior.(Eds. Krantz DS, Baum A, Singer JE). Lawrence Erlbaum,New Jersey. 1983, pp.155-198.
26. ÖzkanT. Kalp Dolaşım Sistemi Hastalıklarının Psikodinamiği. Psikosomatik Hastalıklar, İstanbul. 1991.
27. Florans JS. Epinephrine and the genesis of hypertension. J Hypertens 1992; 19:1-18.
28. Özaydın S. Psikosomatik Hastalıkların Fizyopatolojisi. Psikosomatik Hastalıklar. (Ed. E. Adam), İstanbul. 1991.
29. Pickering TG, Schnall PL, Schwartz JE, Pieper CF. Can behavioural factors produce a sustained elevation of blood pressure? Some observations and a hypothesis. J Hypertens 1991; 9(Suppl 8):S66-S68.
30. Shepher JT. Increased systemic vascular resistance and primary hypertension: The expanding complexity. J Hypertens 1990; 8:15-27.
31. Berkowitz L, Jones EH. Toward an understanding of the determinants of anger. Emotion 2004; 4:107-130.
32. Eckhardt C, Norlander B, Deffenbacher J. The assesment of anger and hostility: a critical review. Aggress Violent Behav 2002; 9:17-43.
33. Yu BH, Kang EH, Ziegler MG. Mood states, sympathetic activity and in vivo beta adrenerjik receptor function in a normal population. Depress Anxiety 2008; 25:559- 564.
34. Everson SA, Goldberg DE, Kaplan GA, Julkunen J, Salonen JT. Anger expression and incident hypertension. Psychosom Med 1998; 60:730-735.
35. Barcroff H, Konzet H. On the actions of noradrenaline, adrenaline and isopropyl noradrenaline on the arterial blood pressure, heart rate and muscle blood flow in man. J Physiol 1949; 110:194-204.
36. James GD, Yee LS, Harshfield GA, Blank SG, Pickering TG. The influence of happiness, anger, and anxiety on the blood pressure of borderline hypertensives. Psychosom Med 1986; 48:502-508.
37. Çelik C, Özdemir B, Çaycı T, Aparcı M, Özmenler KN, Özgen F ve ark. Esansiyel hiper- tansiyonda öfke düzeyi ve öfke ifade tarzı. Gülhane Tıp Dergisi 2009; 51: 158-161.
38. Sinha R, Lovallo WR, Parsons OA. Cardiovascular differentiation of emotions. Psychosom Med 1992; 54:422-435.
39. Harburg E, Gleiberman L, Russell M, Cooper ML. Anger-coping styles and blood pressure in black and white males: Buffalo, New York. Psychosom Med 1991; 53:153- 164.
40. Ohira T, Tanigawa T, Iso H, Sankai T, Shimamoto T. Impact of anger expression on blood pressure levels in white-color workers with low-coping behavior. Environ Health Prev Med 2000; 5:37-42.
41. Steele MS, McGarvey ST. Anger expression, age, and blood pressure in modernizing Samoan adults. Psychosom Med 1997; 59:632-637.
42. Harburg E, Blakelock EH, Roeper PR. Resentful and reflective coping with arbitrary authority and blood pressure: Detroit. Psychosom Med 1979; 41:189-202.
43. Perini C, Muller FB, Buhler FR. Suppressed aggression accelerates early development of essential hypertension. J Hypertens 1991; 9:499-503.
44. Somova LI, Connolly C, Diara K. Psychosocial predictors of hypertension in black and white Africans. J Hypertens 1995; 13:193-199.
45. Shapiro AP. Psychological factors in hypertension: An overview. Am Heart J 1988; 116: 632-637.
46. Zhang J, Niaura R, Todaro JF, McCaffery JM, Shen BJ, Spiro A 3rd, et al. Suppressed hostility predicted hypertension incidence among middle-aged men: the normative aging study. J Behav Med 2005; 28:443-454.
47. Diamond EL. The role of anger and hostility in essential hypertension and coronary heart disease. Psychol Bull 1982; 92: 410-433.
48. Baer PE, Collins FH, Bourianoff GG, Ketchel MF. Assessing personality factors in essential hypertension with a brief self-report instrument. Psychosom Med 1979; 41:321-330.
49. Kidson MA. Personality and hypertension. J Psychosom Res 1973; 17:35-45.
50. Harburg E, Julius S, McGinn NF. Personality traits and behavioral patterns associated with systolic blood pressure levels in college males. J Chronic Dis 1964; 17:405-414.
51. Ostfelt AM, Lebovitz BZ. Personality factors and pressor mechanisms in renal and essential hypertension. Arch Intern Med 1959; 104:43-52.
52. Steptoe A, Melville D, Ross A. Essential hypertension and psychological functioning: a study of factory workers. Br J Clin Psychol 1982; 21:303-311.
53. Weder AB, Julius S. Behavior, blood presssure variability and hypertension. Psychosom Med 1985; 47:406-413.
54. Çevik A. Özgül Psikosomatik Bozukluklar. Psikiyatri Temel Kitabı, (Eds. C Güleç, E Köroğlu) Ankara, Hekimler Yayın Birliği, 1998.
55. Wolf ES. On the Development Line of Self Object Relations. In Advances in Self Psychology. (Ed. A. Goldberg A) International Universities Press, New York. 1980.
56. Schnall PL, Landsbergis PA, Baker D. Job strain and cardiovascular disease. Annu Rev Public Health 1994; 15:381-411.
57. Schnall PL, Schwartz JE, Landsbergis PA, Warren K, Pickering TG. A longitudinal study of job strain and ambulatory blood pressure: results from a three-year follow-up. Psychosom Med 1998; 60:697-706.
58. Cottington EM, Matthews KA, Talbott E, Kuller LH. Occupational stress, suppressed anger, and hypertension. Psychosom Med 1986; 48:249-260.
59. Knox S, Svensson J, Waller D, Theorell T. Emotional coping and the psychophysiological substrates of elevated blood pressure. Behav Med 1988; 14:52- 58.
60. Theorell T. Family history of hypertension an individual trait interacting with spontaneously occurring job stressors. Scand J Work Environ Health 1990; 16 (Suppl 1):74-79.
61. Kahn HA, Medalie JH, Neufeld HN, Riss E, Goldbourt U. The incidence of hypertension and associated factors: The Israel ischemic heart disease study. Am Heart J 1972; 84:171-182.
62. McClelland DC. Inhibited power motivation and high blood pressure in men. J Abnorm Psychol 1979; 88:182-190.
63. Friedman HS, Booth-Kewley S. The "disease-prone personality". A meta-analytic view of the construct. Am Psychol 1987; 42:539-555.
64. Irvine MJ, Garner DM, Olmsted MP, Logan AG. Personality differences between hypertensive and normotensive individuals: influence of knowledge of hypertension status. Psychosom Med 1989; 51:537-549.
65. Rostrup M, Mundal HH, Westheim A, Eide I. Awareness of high blood pressure increases arterial plasma catecholamines, platelet noradrenaline and adrenergic responses to mental stress. J Hypertens 1991; 9:159-166.