Essential hypertension: The relationship of psychological factors to the severity of hypertension

Jownal ofl?,vrhowntur,r PrInted in Great Britain

K~w~,r~ I,. Vol. 33. No. 2. p,, 1X7-IYh. ,YXY.

ESSENTIAL

0

HYPERTENSION:

PSYCHOLOGICAL

lWl22-3Y9YiXY $3.IHI + .lXI IYXY Pergamon Prcw plc

THE RELATIONSHIP

FACTORS

OF

TO THE SEVERITY

OF HYPERTENSION Rur COELHO,*~

(Received

ALAN

M. HUGHES,* A.FERNANDES MICHAELR.BOND$

DA FONSECA* and

25 May 1988, accepted in revised form 6 September 1988)

Abstract-165

hypertensive patients attending one general practice in Portugal were found to report significantly higher scores on measures of neuroticism, anxiety, depression and general psychological distress than 1.52 normotensive patients at the same practice. Hypertensive patients with evidence of organ damage exhibited significantly higher depression scores than those without such damage. These differences between normotensives and hypertensives, and between hypertensive with and without organ damage are discussed and previous research in this area is reviewed.

INTRODUCTION THE SEMINAL work of Alexander in 1939 [l, 21 suggesting that psychological factors may play a role in the aetiology of hypertension stimulated much subsequent research. Until the 1960s this work was broadly psychoanalytic in approach and focused, in the main, on the role of anger and repressed hostility in the genesis of hypertension [l-5]. These were important and interesting studies but had a number of methodological shortcomings including the small numbers of patients studied, lack of adequate control groups, inadequate measurement of blood pressure, arbitrary definitions of hypertension, use of non-standardised subjective measures and problems with patient selection. Many of the studies over the last two decades have attempted to overcome these methodological problems. In addition they have broadened the scope of research from solely the importance of psychological factors in the aetiology of hypertension to include the effects of hypertension, its diagnosis and treatment, on the patient’s psychological state. Following Sainsbury’s report in 1964 [6] that patients with hypertension differed from a control group of patients by exhibiting higher levels of neuroticism this has been a recurring theme in the recent literature [7-91. Unfortunately the patients in these studies were either recruited from hospital clinics [7, 81 or by postal correspondence [9] and thus these studies may have been contaminated by the effects of selection or hospital attendance. Further, it must be noted that there are a number of discordant results [lO-141 which have failed to show any significant increase in levels of neuroticism and one [12] report of lower levels of neuroticism with increasing blood pressure. *Department0 de Psiquiatria e Saude Mental, Faculdade de Medicina do Porto, Hospital de S. Joao. 4200 Porto. Portugal. *Author to whom reprint requests should be addressed. *Department of Psychological Medicine, Glasgow University, Glasgow. Scotland Cl2 8QQ. U.K. 187

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Neuroticism may be considered as a measure of a personality trait indicating how prone the individual is to experiencing anxiety in any given setting. When anxiety occurs a component of the normal physiological response is an elevation of blood pressure and this has led a number of workers to consider the relationship between state anxiety and morbid hypertension [7-10, 1.5-211. In general, with the exception of Wheatley et al. [14], it is reported that hypertensives have higher levels of anxiety than controls. As before, these studies are often limited to hospital attenders [7, 8, 15, 16, 19, 201 or other selected groups (e.g. responders to newspaper advertisements [21]). It is surprising that depression has received relatively little attention in the psychosomatic study of hypertension as this is a common focus of attention in other putative psychosomatic disorders (e.g. rheumatoid arthritis [22, 231, chronic pain [24, 251) and the medically ill [26]. The studies which have considered the relationship between depression and hypertension [7-10, 14-16, 201 have given conflicting findings. Some studies report higher rates of depressive symptoms [7, 8, 1.51 while others fail to do so [9, 10, 14, 16, 201. Following Alexander [l-3] other workers have shown an association between hypertension and a specific personality structure notable for suppressed hostility and aggression [17,19,27-291. However, not all studies confirmed this [13, 14,301, and some have shown a relationship between aggression (rather than suppressed hostility) and hypertension [7-9, 211. Mann in 1977 [31] in an M.R.C. trial of treatment reported no difference in hostility scores in his total population. However, there was a trend for hypertensives to have higher scores on ‘acting-out hostility’ and ‘criticism of others’ scales while having lower scores on the ‘self criticism’ scale. This runs counter to the theory that hypertensives have difficulty in expressing hostile feelings. Thus the relationship between hypertension and hostility and anger still remains unclear. Few studies have addressed the relationship of anti-hypertensive therapy or hypertensive target organ damage and the above psychological variables. With regard to treatment Santonastaso et al. [19] found no differences at all between treated and untreated patients while Bulpitt et al. [16] only found a relationship between phobic anxiety in women and the treatment with propranolol. Even less attention has been paid to the question of target organ involvement and any possible relationship this may have to psychological distress or abnormality in hypertension. Berglund et al. [27] reported the surprising finding that in a group of untreated hypertensives those with evidence of organ damage reported fewer symptoms than those without. However, the authors themselves were aware that their study concerned a sample too small to draw any reliable conclusions. As there are still areas of controversy concerning the relationship of hypertension and psychological factors and as many of the earlier studies have shortcomings it was felt reasonable to undertake further research. The present study attempts to address some of the problems that have been noted above. It concerns patients with hypertension who do not attend hospital for their disorder and in addition to assessment of personality traits also considers mood state and general psychological distress. Further, attention is paid to the effect of target organ involvement as a measure of severity of hypertension. In particular it attempts to answer the following questions

Psychological

factors

and severity

Do hypertensive patients differ from normotensive patients with personality or psychological state? - Do any differences noted relate to the severity of the hypertension?

-

MATERIAL

AND

189

of hypertension

regard

to

METHOD

Patients and controls were both recruited from one general practice in Porto, Portugal. The hypertensives were drawn from consecutive practice attenders whose blood pressure was checked during routine clinical evaluation. All those with a diagnosis of essential hypertension and who were, by W.H.O. criteria, currently hypertensive with a severity less than Class III [32], were entered into the study. The prevalence of hypertension in this practice was found to be 14.8%. Patients attending the same general practice with disorders other than hypertension (and confirmed as normotensive) were recruited as controls. These control patients suffered from a variety of cardio-respiratory, gastrointestinal, urinary and rheumatological disorders and were very unlikely to be selectively free from psychological disturbance. Initial matching, by age and sex, of patients and controls was undertaken on a group basis; however, nearing completion of recruitment matching was performed in pairs to improve accuracy. At the onset of the study 200 Caucasian hypertensive patients and 200 Caucasian controls were recruited. From these 35 hypertensives (9 males, 26 females) were withdrawn as they were currently attending hospital for treatment of their hypertension. Health care staff were also excluded from the study and for this reason 48 normotensives (12 males, 36 females) were withdrawn from the control sample. Those withdrawn at this point did not differ significantly, in terms of age or sex, from the remainder of the study sample. However, health care workers differed significantly on social class being predominantly members of socio-economic class II [33]. All blood pressure recordings in both hypertensives and controls were taken by the same clinician. Three recordings were made on three separate occasions with a mercury sphygmomanometer on the right arm after the patient had been seated for a period of 5 min. The systolic blood pressure (SBP) was reported as the 1st sound and the diastolic blood pressure (DBP) as the 5th. There was no evidence of observer bias in preference of recording any particular digit (e.g. 0 or 5). Hypertension was defined in accordance with the W.H.O. criteria of SBP greater than or equal to 160 mmHg and/or DBP greater than or equal to 9.5 mmHg. Controls were considered suitable and normotensive if their SBP was less than or equal to 140 mmHg and their DBP was less than or equal to 90 mmHg. Ail three recordings were required to be positive to meet these criteria. Hypertensives were graded as either Class I or Class II by the W.H.O. criteria of target organ involvement. Class II hypertensives were those who exhibited such involvement by any of the following - left ventricular hypertrophy (clinical, radiological, ECG, or echocardiograph evidence), focal or generalised retinal artery narrowing, proteinuria and raised plasma creatinine not due to causes other than hypertension. Within one week of entry into the study both patients and controls were seen for psychological assessment. All assessments were undertaken by a separate investigator (R.C.) who was blind to the patient’s status as either hypertensive or normotensive. Assessment took the form of a structured medical interview which incorporated Warner’s scale for determining socio-economic status [33] followed by a number of self-report questionnaires. The Eysenck Personality Inventory (EPI) [34] was employed as a measure of the personality traits of neuroticism-stability and extraversion-introversion. Anxiety and depression were measured respectively by the Zung Anxiety Scale (SAS) [35] and the Beck Depression Inventory (BDI) [36]. A global index of symptomatic psychological distress was obtained by the Symptom Checklist 90 (revised) (SCL-90-R) [37]. Of these instruments the BDI, EPI and SAS have been evaluated for use in a Portuguese population [38-42] and the SCL-90-R has been used in Portuguese samples [43-44]. Data was analysed on microcomputer by t-Test, Chi Square Test, Jonckheere Trend test as appropriate. The level of statistical significance was held to be p < 0.05 and all tests were two-tailed.

RESULTS

The matching of the hypertensive patients (HTP) (n = 165) and normotensive control patients (NTC) (n = 152) was satisfactory. They did not differ significantly with respect to age (HTP 46.61 + 11.10 yr, NTC 47.45 + 12.31 yr, t-Test NS) or sex (HTP 44.1% female, NTC 42.1% female, X2 Test NS). Nor did they differ in respect to marital status or social class which is summarised in Table I.

RUI COELHO~~ al.

190

TABLE I.-SOCIO-ECONOMICCLASS Class I

Class II

Class III

Class IV

Class V

Normotensives Hypertensives

I 1

19 23

39 47

57 52

30 42

Hypertensives WHO Class 1 WHO Class II

1 0

18 5

36 11

36 16

30 12

,$ test NS.

The WHO Hypertension Severity Class I (HTPl) (n = 121) and Class II (HTP2) (n = 44) patients did not differ significantly on age (HTPI 45.62 + 10.67 yr, HTP2 49.40 + 11.78 yr, r-Test NS), sex (HTPI 42.9% female, HTP2 50.0% female, r-Test NS), or social class (see Table I). Hypertensive patients and normotensive control patients differed on a number of the self-report questionnaire measures. The results of these measures are summarised in Table II. On the EPI the hypertensives had significantly higher neuroticism scores (t3i5 = 3.920 p < 0.001); however, there were no significant differences on either the extraversion score (t315 = 0.786 p = NS) or the Lie Score (tXls = 0.500 p = NS). On the SAS the Total Anxiety Score (f3i5 = 2.560 p < 0.02), Cognitive (r3,5 = 1.993 p < 0.05) and Vegetative (r 315 = 3.124~ < 0.005) subscales were higher in the hypertensives while the Motor (r 315 = 1.818 p = NS) and Central Nervous System (r3,5 = 0.712 p = NS) subscales did not differ significantly. The BDI Total Score was significantly higher in hypertensives than in the controls (r3,s = 2.403~ < 0.02) as were the subscales concerningMotivation (r3,5 = 2.068 p < 0.05), Delusion (r3,s = 2.712 p < O.Ol), Physical Symptoms (r3,s = 3.420~ < 0.001). The Affective (r3,s = 1.560~ = NS), and Cognitive (r3,s = 1.740 p = NS) subscales did not differ significantly. The three global indices of the SCL-90-R were higher in the hypertensive patients: the General Symptomatic Index [GSI] (r3,s = 3.260 p < O.OOS), the Positive Symptom Total [PST] (r_1,s = 2.669 p < 0.01) and the Positive Symptom Distress Level [PSDL] (r3,s = 6.023 p < 0.001). The subscales of the SCL-90-R which were significantly higher in the hypertensives were the following TABLE II.--RESULTSOFOUES~-IONNAIREASSESSMENTS Psychological measures EPI

Normotensives

Neuroticism Extraversion Lie Scale

SAS Total

11.83 + 5.59 11.70 f 3.76 5.36 + 1.63

Hypertensives 14.33 f 5.73$ 11.36 + 3.77 NS 5.26 + 1.73 NS

Hypertensives Class I 14.48 + 5.73 11.31 t 3.82 5.22 + 1.74

Score

38.69 + 9.43

41.57 +_ 10.44*

40.88 + 9.78

BDI Total Score

10.64 + 9.14

13.11 + 9.05*

12.18 f 8.66

SCL-90-R:

GSI PST PSDL

NS = non-significant;

1.05 f 0.52 52.42 + 18.77 1.45 +_ 0.68

1.27 + 0.65t 58.21 + 19.67+ 1.87 k 0.56$

1.27 f 0.66 58.40 k 19.44 1.86 * 0.55

* = p < 0.05; $ = p < 0.01; $ = p < 0.001.

Class II

14.28 + 5.74 NS 11.50 f 3.63 NS 5.36 f 1.69 NS 43.48 i

11.87 NS

15.66 + 9.61* 1.28 f 0.60 NS 57.6X + 20.27 NS 1.89 f 0.57 NS

Psychological

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of hypertension

Somatisation (t 315 = 2.797 p < O.Ol), Obsessive-Compulsive (t3i5 = 2.821 p < O.Ol), Interpersonal Sensitivity (&is = 2.590~ < 0.02), Anxiety (tsrs = 3.451 p < O.OOl), Anger (t3r5 = 1.969~ = 0.05), Phobic Anxiety (t3r5 = 2.993 p < 0.005) and Psychoticism (f3r5 = 3.663 p < 0.001). All the remaining subscales showed no significant differences between hypertensives and normotensives. Though the scores were higher in the hypertensives none of the mean scores for the subscales was above the cut-off point indicating clinically important psychopathology. Comparing Class I and Class II hypertensives fewer significant differences were noted and these were limited to the BDI Total Score and Cognitive subscale (Table II). The BDI total score was significantly higher in Class II hypertensives than in Class I (tlh3 = 2.201 p < 0.05) as was the Cognitive subscalk (flh3 = 2.360 p < 0.02).All other measures (EPI, SAS and SCL-90-R), total scores and subscales scores, did not differ significantly between Class I and Class II hypertensives. It was noted that there was a significant trend (p = 0.0002 Jonckheere Trend test) for increasing BDI score with increasing age. However, this was not seen amongst the hypertensives (p = 0.063) possibly reflecting their already raised scores. No other significant trends were noted. These results are summarised in Table III. The 35 patients who were excluded from the present study as they attended a hospital clinic did not differ in severity from the others in terms of Class I (n = 29) and Class II (n = 6) (i(’ NS). However, they exhibited significantly higher scores than the general practice hypertensives on a number of measures: Neuroticism (p< O.OOl), Zung Total Anxiety (p < O.OOl), Beck Total Score (p < O.OOS), SCL-90-R indices of GSI (p < 0.005) and PST (p < 0.02). The majority of treated patients in the study were receiving a two-drug regimen for their hypertension and the small number who were not on medication (n = 12) makes it difficult to evaluate the influence of treatment on the results. None the less those not on treatment had scores which were not significantly different from those on treatment.

TABLEHI.-THEINFLUENCEOFAGEONTESTRESULTS

Normotensive <40 yr n=48

Test

patients

>=55 yr n=47

<40 yr n=50

4&55 yr n=76

>=55 yr n=39

12.5 + 6.3 11.8 f 3.6 5.2 + 1.7

12.3 + 4.9 11.2 + 3.8 5.6 + 1.8

14.2 f 6.7 12.2 f 3.7 5.1 f 1.7

13.8 + 5.5 10.9 f 4.1 5.3 * 1.7

15.4 + 4.8 11.1 * 3.0 5.3 f 1.9

10.2

39.4 f 8.5

42.5 + 11.8

40.3 + 9.9

42.9 + 9.5

12.6 f

10.5

12.7 f 8.4

14.6 + 8.2

1.3 f 0.8 58.5 f 22.4 1.9 f 0.7

1.3 f 0.6 58.1 f 18.7 1.8 + 0.6

1.3 f 0.5 57.4 f 17.5 1.9 + 0.4

EPI Neuroticism Extraversion Lie Scale

10.6 + 5.2 12.1 f 3.9 5.3 + 1.8

SAS Total

Score

37.1 + 9.1

BDI Total

Score

6.7 f 6.6

12.3 + 10.2

12.7 f 8.7

SCL-90-R:

GSI PST PSDL

1.0 + 0.5 51.3 + 21.0 1.6 + 0.4

1.1 f 0.5 54.8 + 18.8 1.4 * 0.7

1.1 f 0.5 50.7 f 15.8 1.3 f 0.8

HypertensivesJnormotensives

Hypertensive

patients

40-55 yr n=57

39.5 f

and age group

x2 = NS.

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RUI COELHO etal.

DISCUSSION

In this study hypertensive patients differed significantly from normotensive patients in that they exhibited higher levels of neuroticism, anxiety, depression, and the global indices of the XL-90-R. This replicates and consolidates previous research work which has generated similar results [6-9, 15-21, 27-291. Though the design of our study is not ideal [12, 451 for examining the psychological characteristics of hypertensives, as it does not avoid any influences due to the patient’s awareness of the diagnosis and the effects of treatment of hypertension, it does circumvent some of the problems of earlier studies. A major difficulty in assessing the importance of previous findings concerns problems of selection of both the patients studied and the comparison control groups. Many studies are limited by their exclusive assessment of hypertensives attending hospital [6-8, 15, 16, 19, 20, 291 who are probably atypical of hypertensives as a whole, and others by their recruitment via newspapers [21] or the postal service [9]. In this study hypertensives were excluded if they were attending a hospital clinic as it was felt that patients who were only attending general practice were less likely to be atypical on account of selection bias. Indeed, hospital attenders who were excluded from this study were shown to exhibit significantly higher scores on all scales from those who were not. Often earlier studies lacked a control group [l, 2, 4, 8, 15, 21,291 or had control groups which were inadequately defined or selected [7, 9, 11, 161. In addition to adequate matching on demographic variables the use of non-hypertensive patients in this study as a control comparison group allowed the control of factors relating to tenure of the sick role or attending for medical treatment which would not be possible with a healthy control group [46, 471. The sample sizes in this study tries to avoid the earlier problems of extrapolating from findings based on small numbers of observations. However, the majority of patients in the study were receiving treatment and the small number of untreated patients make it unwise to place great stress on the finding that there was no significant influence of treatment on the test results. Berglund et al. [30] reported similar results albeit with similar limitations. The findings of increased neuroticism and anxiety in hypertensive patients in this study simply add to the established body of evidence of this association [6-9, 15-18, 20, 21, 471 and is similar to results obtained in another Portuguese study undertaken of hypertensive out-patients attending a hospital clinic [48]. It has been suggested that psychosomatic disorders are associated with increased introversion as well as neuroticism and this was reported in hypertensive patients in 1960 by Sainsbury [47]. This combination was taken to reflect dysthymia and proneness to anxiety or depression with their consequent physiological disruption. However, this was not observed in this study as no significant differences were noted on extraversion scores which were within the normal range. Similarly the Lie Scale did not differ between the groups and results were comparable with those seen in a normal population in Portugal [40]. These results for Extraversion and Lie Scales suggest that the properties of the EPI have been maintained in these populations. Our study was not designed to assess the importance of suppressed hostility in hypertension and thus findings in this area from this study must be treated with

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caution. To assess this area adequately measures specific for hostility, along with assessment of behavioural and situational variables influencing this emotion, would have been necessary and should have been directed towards both inwardly and externally directed hostility [30,49]. The only measure of hostility used was AngerHostility Subscale of the SCL-90-R. However, the results from this study do not help settle the persistent controversy by showing significantly higher expressed hostility (as opposed to suppressed) in hypertensives. The finding of higher levels of depression, though reported elsewhere [7, 8, 151, is less well established. Unfortunately none of the earlier studies employed specific depression rating scales but rather assessed depression by subscales of larger inventories (Cornell Medical Index, SCL-90, Middlesex Hospital Questionnaire respectively). In our study, however, the BDI was employed as a measure of depression since it was specifically designed for this purpose and places stress upon cognitive components of depression and thus is less likely to be influenced by somatic symptoms. It is also unlikely that the elevation in depression scores was simply a reflection of somatic symptoms of hypertension as the increased scores were not limited to the total score but also subscales relating to drive and ideation and conversely no increase was observed in the subscale concerned with depressive vegetative shift. If one proposed that the psychological differences seen in hypertensives were a consequence of the patient’s raised blood pressure and associated biological changes one would expect to see increasing psychological disturbance paralleling Some studies have reported such positive increasing severity of hypertension. correlations between severity of blood pressure levels and measures of neuroticism and anxiety [ 15, 20, 21,50,51], others have found no correlation [ 10, 11, 131, while still others show a negative correlation [12]. In our study the only measure which differed significantly (albeit modestly) between the Class I and Class II hypertensives was the BDI which returned higher scores in Class II patients. It is possible that the relationship between severity of hypertension and psychological measures is not unitary with all psychological variables influenced in a like manner. It is likely that these variables will be under the influence of a variety of differing,factors (e.g. disease, treatment, duration, age, sex, social class, etc.) and it is naive to presume that they will all respond in a similar way. The question in this study is why only depression scores are higher in Class II hypertensives. It is possible that the increased depression scores in Class II hypertensives are a direct consequence of the organ damage and a symptom of this. Class II hypertensives may differ in their treatment to Class I and this may influence depression ratings. It is conceivable that Class I and Class II hypertension do not differ simply in terms of severity but represent different biological forms of the disorder with different associated psychopathological characteristics and further one should consider whether the possible psychological factors in the aetiology and course of hypertension differ between the two classes. These questions require to be addressed directly and cannot be answered by the data from this study. However, those patients in this study with Class I hypertension continue under assessment and it is the intention of the authors to determine whether those who progress to Class II differ psychologically from those who do not. this study demonstrates psychological differences between In conclusion,

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hypertensives and normotensives and has overcome some of the confounding variables of previous work. While it adds to our knowledge of this area there still remains controversy which should promote continuing investigation. In addition it looks at the influence of end organ damage and finds this related to depression scores - this is an area which has been neglected and which requires further work and clarification, particularly as it is end organ damage which accounts for hypertension’s morbidity and mortality and depression, more than other psychological variables, which is likely to give rise to patient distress. Acknowledgements-This work was undertaken as part of a doctoral thesis by Dr R. Coelho for the University of Porto under the supervision of Professor Fonseca. This work would not have been possible without the support of Professor E. Fernandes and Dr J. Teixeira. We are grateful for the financial assistance of the Calouste Gulbenkian Foundation which facilitated this research. We also acknowledge Dr Lever for his advice and helpful criticism.

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