Behaviour analysis and treatment of essential hypertensives

BEHAVIOUR

ANALYSIS

AND TREATMENT

OF ESSENTIAL

HYPERTENSIVES* D KALLINKE,

B KULICK

and P HErhlt

(Reterbed 2 0~ tober 198 I. accepred rn retrsedfom

I5 March

1982)

Abstract-Parlous relaxation techmques hare the potenttal to hrmg about promwng blood pressure (BP) redusrlons In essential hbpertenslon. but the treatment gams often fall to he sustamed o\er a prolonged period of time Unul no\+, behabloural treatment approaches hake not Included effort> to Increase patlent auarene,s o1 situation> that proloke BP ele\atlon, In our stud), numerous BP measurements were therefore taben In \arIous sltuatlons b) approxImateI> I20 essential hqpertensl\es These measures were used to acquamt the patients ntth their own BP \arlablltv, to help them understand ps\chologlcall) Induced BP-LarIatIons, and to encourage them to cope with their hlper reacu\lt> In general and In response to speclflc stresstul sltuatlons Fort\-eight patients were gnen the opportumtb to learn to relay and to cope with stresstul lrfe sltuatlons The) showed promwng BP reductions after treatment and at follow-up one vear later But our dragnostlc flndlngs wng these method, lndlcate that essential hvpertenslke, are anqthlng but a homogeneou, group A \arlety ol treatment approache, ma\ therefore be required

INTRODUCTION ALTHOUGH relaxation procedures seem to habe the potenttal for producmg promwng BP reductions m essenttal hypertenston [l-7], the evidence at present IS mtxed In part these dtscrepancles seem to be due to the fact that very different, tf not mcom-

patlble, types of Inter\enttons are subsumed under the headmg of ‘relaxation’ Some authors vie!{ relaxation trarnmg as a theraplst-Induced or semi-automated form of deep muscle relavatlon conducted m the theraptst’s office Others ask their patients to relarc at home as well More sophwcated clIntclans aim at some transfer of the relaxatton response mto everyday life sttuatlons tn order to hold down the average level of BP or to akotd exceswe BP rises due to the ctrcadlan \arlattons Still other theraplsts regard relaxation as an elementary copmg response, glbmg the tndlvldual some time to take a deep breath before engagtng m attempts at actl\e problem-sol\ Ing The authors of this article endorse the latter wew, and Introduce relaxatton as a basic coping skill to be applied m a Larlety of stressful life sltuatlons The authors feel that thts ‘psychotherapeuttc’ rather than dtdacttc approach IS necessary to make a reasonable impact on the pattern-frequent11 found m suscepttble mdtvtduals-of BP increases in response to situational demands Furthermore, m trying to otercome the problem that treatment gatns cannot be sustained o\er a reasonable period of tune unless the patlent continues to practlse relaxation [I, 5, 71, the authors use a new stress management approach based on the beha\lour

anallsls

of factors associated

wrth BP \arlablllty

[&IO]

hlETHODS SubJect, Here recrulred b\ articles in local neaspapers or mere reterred b) thelr general practitioner SelectIon \\a, made after a brief anamnestlc mter\lea and three casual measurements, m order to ek.clude *Paper presented at the NATO-Symposium on Behakloural hledwne Porto Carras, July 3, 1981 +Stittung Rehablhtauon Heidelberg Posttach IO 14 09. D-6900 Hetdelberg German 541

Greece, June 30Federal Repuhhc

5-l:

D h4LLlfuhE

B hllLlch

and P HEIM

people \\ho had b~sn d~qno>cJ h\psr~sn\t\s\ h\ thrtr Joc~r~r. hut \rho \\zre dettnttcl\ normoten~t\r 111the laborator\ 4 total ot n = IX male ,ubJecr> \rtth Lon>~>tanr BP\ abws 111) 90 mm Hp acre >tuJtr’J Th? d~agno\tk tn\c>ttgatton\ de,crtb?d helo\r r\Lludcd SU~JSLI~ irho turned OUI to 3utter trcm wLa,ndar\ h\psrren\ton as hetng narmotenrl\e on all tneawreb The rsduLsd ~mplc ot I I6 htper and : \\ho \\r‘re tndentttwd tenbtkes Lon~l\trd ot 49 borderltne hbperren\lies* (mean ~~att~al BP = 143 92 mm Hg) dnci 6’ e\wntlrll h\pertenst\s\’ (mean cnu4 BP = I57 lo-1 mm Hg) The patrent\ In the \dmple acre ot normal bad\ 58% reported a tarnIl\ ht\tor\ ot clc\nred Hsrght and their ages ranged from I6 to 5’ L\pproxlmatel\ BP, JnJ #“;I \scrc currentI\ treated utth antth\pertcn,t\c medtcatton th?ld Ltln\tant during rhs p\\Lholc>gtcal treatment pr,yrnmme) ber~rzen II = I I6 [repeared ~dtt\dl Due IO mt,>tn.g or non nnal\>ible dat.1 rhz ~~mplc .ILT \,lrwd mea,uremenl) >tre>> IC>I) II = Ilx) (inter\ te’u) and II = 9-l (Al msawemznt4 In order IO s~aluats the ettcal\cnc\> ot the treatment programme dcxrlbcd brlwr the author\ pro\tJed >tre\\ managemcn~ rratntng IO the foll~xrlng group, a \erle> ot 26 C~~W~UII~C tndl\lduJl maw tp~lor ,tud)) irho reLetted I 2 ~c~~ton~ ot 90 mtn Indl\ldual therJp\ rllmo\t tdenttL.sl ~tth the group programme conducted urrh tour group, The tour group, totalleJ 2’ patwnr\ Thrs? dt\LcIn[tnucJ treatment either beLawe rh?\ had tv be ho>plraltrsd trr=Z) or lclr ttnhnwn rea\on\ (n = II OutLoms ciat.~ had not \et been annl\wxl ttlr 2 out ot 24 patients Hho had completed the tralnrng programme. b\ the Ilrne tht\ report ~a\ \\rtttcn Therefore the total number ot patlent> trcatcd and dcxumrnred h=zrr I, -M (26 tndt\!dudl dnd 22 group partent,) The maln LhardLwrt\llc\ ot the \amplc are xho\tn on Table I

-9-11 casual meawremenrb tn the laborator\ (comparable to measures [ahen in rhs doLtar \ otttce) --4r least three darl\ ,ell measurement\ (rtme sampling) tor at lea\t one \\ceh Thrwz acre comhtned ulth \elt report3 ot \uhtectl\s state and rltuatlonal Llrcumsrance, (tar an example \ce Fig I) --4tttomattc reglstrnrton ot BP c\zr\ minute durtng d semt btructured tnler\ieu ot at Ica\t one hour > durarlon focublng on problem area, tn the partenth Itkcs e g Fig 2 - 4utomattc BP measurements clerk 30-60~ and >lmultaneou, recordtngs ot heart ralc muAsten~ton and cleclrodermal acwtt\ during a ,rre\s Ic\I ot I!-mtn duration Thth requtred rhe patwnt to cops atth the folloHInp strw sltualton> SI artrhmcttc under llrne prel,ure S2 being reproached b\ one’\ superior (role plab Htth the e\pertntenter) S1 maktng a speech The rc>uIt* ot these measurements uere dlscu,,ed \rtth the portents uho \tt‘rct cnLouragcd IO thmh about and IO montlor the powble role ot their oun heha\tourc tn hrrnglng ahour >lruartonal BP rtce, Thu\ the ex~en~t~e wrws of dtagno>llL mearurement, wrlcd rhs purpo>c ot prwtdtne bakelmc data whtls ,tmultaneowl\ prrpartne the parwnt tar trca[ment Trearmenr phare Treatmsnr uas Larrted out a\er 12 ,e\swn, ot W-mtn durdttirn The pattent\ \berc rhar gt\e rl,e IO BP tratned IO rrla\ and IO mnh? tunctt~nG~l ~nalbv~ ot the &II\ >trc \\ sttuatlirn, &\atton>, or other bodll\ response, astereotkped reaLttcln \ or ,trss+augmentlng Trrarmen! oum IN derarl (u, rmplemenwd rn u srty-ht
Treatment

124662466_1468

of essential hvpertenwes

;Ir8;4ta24681-16824t,a

533

D h9LLINKE

u-4

B hL#LICK

and

P HEIM

prop?)\ ot ,en>lrlzlng parlent> 10 the \arlablllr\ ol blood prel,ure lnltlared an the dlagno,rlc pha,s \ra. >\+emaucnll\ Inren,llled in the courre 01 rherapb The rherapl>l> rrwd to -encourage pailem, to regwer bircssful sltuatlonl occurrIng beI\reen trearmen[ w~\Io~I,. -encourage pallem, to dtxu>> rhslr ob>er\atlons \\llh other group member>. -ash parwnis roYocu> on and 10 monllor IheIr bsha\lour in rhsw cltuallon>, --Incrcabe rhe paricnr~ und ot rhe bodllb \en,arion\ occurrIng in demanding ~IIU~~IOII~, and ot galnlng llme tar the arw,,menr ot \IIUJ~IO~, belore tahlng acrlon --reach rela\arion a\ a mean, ol Impro\lng belt monllorlng ( doe> ihe leehng 01 hclng under >Ire\\ re\uI[ tram demand> ol the oursldc \rorld or am I mablng m\sell nerloub’ ). --reach relaxallon a, a prerequl>lle IO >ell-desenslrlrailon agalnsr phobic anrilcIle> abour ,peclllc prohlemr, ->cn>lilze parleni, 10 s[re\> augmenting thought, and >ell \erballrarlonl ( I II nrber ,ucLeed I an, a lallure’ I sannor al lord 10 mahe a mlsrake’ eii ) -demon>rrate the ren>lcln-rcduclng eflccl 01 Lomlorrlng and encouraging commenlarwz (Al-ialh) on dl>appointlng ourcomes t tou HOII [ allow others 10 drl\e \ou mad ‘don I ger upset’ I hate managed mush more dlffcull sltuallons belore ), -encourage problem-4\ ~ng beha\ iours in the lace ol ,Iiuallonal demands amenable IO change Co~rrseo/rreornwnr st=~s~o~~ In the IIr,r wss~on ihc parwnrb received lnformarlon on hkperrenwn and on rela\almn as an clemen~ar\ coping responle, h\ mean> of which [he\ could help rhemwlies modrlk blre\>tul e\cnt, and a>wclaled BP rise> In rhe tollo\rlng rhrsc or four ,ecwn> rhe parlent> acre Introduced IO rhe Jacohwn merhod uhlLh enraIl\ deep mu>Lular relaxaimn \rhlle Iilng on the floor Patients were ashed IO reld\ a[ home too u>~ng a [ape o1 the In>rrucllon> plien during rhe rherapv sebwn) \I hen e\er\ group member reporred achle\lng deep relaxa~lon rhc parwnrl learned an abbrs~larsd lorm o1 the programme a\ an aId to,r rhe managzmenr ol renrmn arlsmg in rhe court ol rhe da\ In addlIlon LO thl\ learning programme the group member, \\ere a\hed 10 repor and (0 andl\se rhs ,lrelblul (prohabl\ BP \rlmulatlng) ,IIuallon, uhlch oLcurred during rhe Iall Ieu da\< The therapl\t\ rclralncd lrom g111ng [he ,ewon, a rIgId \trucrure rarher rhea [rled IO create an open armo\phrre encouraglnp each group member LO reparr on hi> problem\ and IO rake parr in [he group dl\cusslon 01 Ihedlttlculrlss mentioned b\ other partlclpanr\ CentI\ dlrecred b\ the rhcrapw>, the locus ol aticnllon proceeded tram an enumerdtlon ot >tre,\tuI e\rnrl IO the more particular a,pecrb 01 the problem> and respclmes 10 ihe problem> a> dcsxhcd under rhe headIn@ ol Ircalmcnt alrnl (\ec ahwcl

RESllLTS

Dlagnostrc

results

Both casual (n= 116) and self-measurements (II= 84 with complete data bets) wealed a btrlking BP \artablllt) In partvxlar, self-measurements dtsplabed an aLerage range of 35 25 mm Hg (btandard dellatlon I2 3 ‘8 5 mm Hg), iawing hetbreen I3 and 75 mm Hg bvstohc and 9 to 53 mm Hg dlastohc m different mdl\lduals As \\as antwpated, the selt-measurements i\ere 13,8 mm Hg loirer than the aLerage casual recordings of 152/99 mm Hg Casual measurements exceeded the averaged sbstolls and or diastolic self-measurements b\ more than 20 mm Hg In about 25@‘0 ot the cases Correlation anal>srs relealed that only 25vo ot the Larlance of selt-measured s\stollc and 3Oro ot selt-measured diastolic BP \%as predictable from the average office readings (r systolic = 50, dtastohc = 63) The low correspondence bet\\een office and home \iorh BP values underlines the need for multiple measurement approaches During the stress Inter\ le\%s (n = 100). considerable svstollc and or IO mm Hg dlastollc were observed

BP rise\ ot at least 20 mm Hg in 51 ro ot cases, e\en atter

Treatment

ot es,enrlal

htperren,~\es

545;

mentlonmg comparatl\ely trIvIaI and common everydav stress sttuatlons, eg sttuatlons tmplyng time pressure, competmon, social comparison and self-assertlon In a further 2Oob of cases, BP rises \\eere related to rather specific problem areas of clinical relevance OnI!. 29Wo of the patients showed Irrelvant or no BP Increases during the Inter1 IW Prellmlnary analyses of the antecedent condtttons Inducing BP mcreases In the Inter\le\i (n= 100) re\ealed that the followlnp problem area were salient In a htgh percentage of patients --Hark (time pressure, Interruptions, responslblllty) -social Interactions at work (competition, self-assertlon or superiors)

130-O

tonards

colleagues

54vo -social situations in private life, e g social comparison processes, problems with partners, disputes wlthln the family or \\tth nelghbours, fears of heterosexual contacts, etc 36vo During the stress test (n = I l6), we observed marked aLerage Increase5 In hoth heart rate and BP (Table 11) TABLE

II

-ALERAGE

INcRE4hEs

Ilu

TARDIOI

45cl1tm

SITlIATlOk5

Item,

4rlrhmetlc S\> d1a

n

Tolal ,ample tn = 116) Borderhne hvpertensl\es H\pericnllkes (n =67) ‘Calculated

IN

(n =49)

on the haslsol

Intralndlvtdual

26 II 22 I2 29 I6

differences

HI PERTENSIi

HR

s\s

1-t I? 14

a reduced ,ampleot

PARU~ETERS

116

RESPONSE

Speech dia

32 20 28 19 34 20

75 (31 borderllnc

In BP reactIon

IN

TO

STANDARD

STRESS

ES

HR II IO II

hbpertensl\e,,U

to the different

s\s

Role pIa\ * dla HR

25 I’ 22 I’ 27 IX

6 4 7

h\pcrrcnsl\e,)

Items of the stress teht

\cere considerable (r among items not more than 0 60-O 70), suggesting that there IS some specltlcltb m the cardlo\ascular hqper-reactions of hypertenslbes Stmllarly, slmultaneouslg recorded measures of other autonomous parameters (such as EDA and EI\lG, not reported tn this paper) showed a highly Larlahle reaction The onI1 stgntflcant difference bet\\een essential and borderltne hgpertenslieb was m the systolic and dlastohc reactions to mental arithmetic under time pressure (f-test p = 1Fo) Nevertheless, mtercorrelatlons values calculated from casual

bet\\een BP during mental arithmetic and aLerage measurements were weak (r=O 27/O 23, p < 1~0)

No differences \%ere ohser\ed between patients ntth and without medtcatlon m response to the standard stressors, although the overall IeLels ot BP Here distinct The degree of BP reactlon to stress did not correlate Hlth bodb weight. genetic rlsh factors, subJecti\e stress reports or eien wrth duration of illness There was however,

a modest

correlation

with

the age of patients

(r-systolic

= 0 29, pI> l”‘o)

Trearment resulrs Indrvrdual treatments (n = 26) U’hen a comparison was made of casual measurements three \\eehs before and after treatment, we observed mean BP reductions of -19 mm Hg systolic and -10 mm Hg diastolic O\er the course of treatment, the 26 Indl\ldual patients stgnlflcantly reduced aLerage BP from 154) 102 mm Hg to 135 mm Hg (SD before treatment 18 7’10 7, after 13 3’10 I)

546

D

KaLLINhE

B krlllchand

P HEM

(one At foIloH-up t\\el\e months later, 13 ot these pattents \\ere re-euammed patlent from the ortglnal sample had died from an accident, nine had moved to another place and three refused further euamtnattons) These I3 patients had similar characterlstlcs to the original sample Ho\\e\er, the aLerage BP reductions achleled during treatment were slIghti) lo\\er In this subsample, declining slgntftcantl! (,u < 0 01) from 150, 100 mm Hg dotin to 132 91 mm Hg Nevertheless the gains \sere malntalned on 12 month5 FoIloH-up (131 88 mm Hg)

Group rreafmenfs (n = 22) T\\el\e

of the 22 patients

treated

rn groups

had been

observed during a no-treatment control phase before the begmnmg of the programme, In \\hlch a constant average BP level of approumately 150; 100 mm Hg \%as recorded Across the \\hole sample undergoing group treatment, average BP values decreased slgmftcantly during mter\entton from 157’ 102 to 113:92 mm Hg (standard de\latlons being I5 5/9 8 mm Hg betore and I3 5 I I 0 after treatment) The treatment gains (- 14, - IO mm Hg) In terms ot casual measurements were slIghtI> below those found m the patients treated mdwtdually (-198- 10 mm Hg) However, thedifferences between sgstohc and dlastoltc dtd not reach the conventional

reductions In group level of significance

and Indl\tduall> treated patients (/, ) 0 OS), tndtwdual and group

procedures seemed therefore to be eyulialent m terms of effectlkeness For the whole group of treated patients (mdn Idual plus group treatment, n = 38) \tlth average mitral values of IS6 102 mm Hg, BP reductions during Interientlon amounted to - I7 - IOmm Hp Surprtsmgly, there were no slgntflcant differences in response to therapy between patients recelbmg antlhypertenslle drugs during treatment (n=27) and those ~lthout medlcatton (w = 21) This seems to suggeht that patients under drug treatment can The potential of comblnlng both also benefit trom psychological Interventions forms of treatment should be further explored Attempts to shot\ the effects of treatment under condtttons the ‘stress test’) proled decreased slgntftcantl>

to be less encouragmg by the end of treatment,

of stress (repetition

of

Although BP rises under stress had the reductions In terms of absolute

values \\ere much less ImpresslLe than those found m casual measurements (Table 111) In self-measurements modest BP reductions of -51-2 mm Hg Here registered in the 33 protocols suitable for analyls (out of the total sample of 38) These results seem to be of little relevance to the effect of the programme on e\erJdav measures tahen at home sho\\ed extreme11 low average values eien before 4 floor effect may therefore ha\e prekented a more tmpresslve reductton hloreover.

It should

be noted

that most patients

preferred

to take their

BP, since treatment of Lalues o\\n

BP in

Treatment

541

of essential hypertensnes

sltuattons where demands were absent, so that these measurements were perhaps representattve of BP under everyday condmons Strlkmg Inter-mdtvldual differences m treatment gain were evident m both mdl\ldual and group treatments This IS Illustrated m Fig 3, where mdlvtdual BP changes are plotted m terms of casual measurements for the 26 single cases

, t

FIG

3 -lndl\ldual

changes in ,\>IOIIC and dlaswllc 9 causal measurements recorded

BP as a re,ulr of Indl\ldual at 3 sessions n = 26 parlents)

[rearmem

(mean

01

The high vanabIlIty of differences betueen BP values before and after mter\entlon demonstrable not onlh between but also within mdl\ldual patients For the correlations betkveen aberage BP reductions based on dtfferent outcome criteria (causal measurements, stress test, self-measurements) are weak (r < 0 40) This pattern The again emphaslses the problem of deftrung adequate outcome criteria heterogeneous reactions to treatment suggest that Indl\lduals differ m the degree to which they are ltkel~ to beneftt from the treatment programme This suggests a need both for mdnlduahzed trammg programmes and for tdtosgncrattc outcome measures IS

DlSCllSSlON

Essential hypertenslles are a \erv heterogeneous group, In which a \arlety of antecedent condmons give rtse to BP elebatlons, and a variety of reaction patterns m BP and other autonomic parameters are recorded Taking into conslderatlon both type and trequencl of antecedent condltlons on the one hand, and strength and duration of physlologlcal stress reactions on the other, the authors retrospectively feel that among their n = 100 SubJects, three types of hhpertenslves can be discerned First, persons lacking any sign of BP \artablllty, second, persons experlenctng speclflc stressful life events, and third, persons \\ho

.(-is

D haLLlNuhE

e\perlence multlple and relatl\el> u ho appear most I~hel\ IO benefit

B hLlLI( K and P HEIM

enduring llte problem, It IS the latter two group5 from ps\chologlcal Inter\entlons ruch as the stresb

management training described abobe Thus we found (a) 21 responders \\lth specltls problem5 Patients In this categor\ contrquenses of clearl! dlscernlble Ilte events llhrl marital c‘rI\es, unemplo\ment

Patient,

\ho\\lnp

elevated

butter tram bereavement

BP levels as a re5ult ot neurotic

the or

disorders

(wch a> social anwtlrs or lath ot astertiLe behailour, re$ultlnp among other problem\ III permanent o\er\\orL, extreme competltl\enesr etc ) are also Included In thl, group (b) 59 wponder\ \rrth a \arwt\ ot dltterenr problem3 afiectlnp them at the same time These patients generally she\\ a farnil) hlstorv of hlpertenslon, and their BP re\pond> to man! \ItuatIon\ III thrlr prl\att: and profewonal IILC\ In contra?st to patwntz needing some bpecltlc soun5elllng or treatment. the\e hlpertrn>l\e\ sxm to be In nerd ot a more general problem-hoI\ Rlobt patient> Mlth ps\shologvzall> Induced BP \arlablhty,

and In analyslng

111g >trateg\

BP \arlatlons

the ps\chologlcal

condltlons

succeed In understandIng producmg

upward

BP

rungs \\ Ith this ‘dvnamls concept ot BP III mind. patient, trained to cope L\lth the stre\s 5ltuatlonb ot e\ervday llte showed both decreases In ca>ual mea>urcment, that compare well lath the rebultb ot other author>. and maintenance of BP reductlonb up to one iear atter treatment The\ turther Nho\\ed a >urprlslngl\ good compllancs o\er a length\ period ot ~IITK (A reflected b\ the patients’ \\llllngne,\ to attend bath-up SWJOII~, to dnb\\er qur\tlonnalres etc 1 Casual mea,urrment~ are being Insrearlnpl\ disputed for their lath ot reprswntatl\enes> ot BP Ie\el\ III e\rrvdab llte [IO~I?] Treatment result> In this \rud! Mere >upplemented b\ melt-mca,urcment~ In the patient\’ natural en\ Ironmrnt,, and recnrdlng, treatment LIS\

The

under Idborator\ stw\ conditions Tahlny these mra5ure\ Into account. re>ultz \\ere 5t1ll synltlcant but les\ Imprew\r tram a cllnlslan’~ point ot corrclatlon\ bet\rern the three outcome crlterla pro\ed IO be poor

(r = 0 00-o In

\ICW

Interlndl\ldual

ot

40) the hetcrogenelti ot e5~entlal h>perten,l\eb. and dlttcrenser III treatment responbe, more than one

the consIderable form ot psvcho-

logical treatment beem> to be nec:55sar\ Not\\lthstandlng the need for dl\errltlcatlon p!zshologlsal Inter\entlon$ the potential adiantager ofsomb~n~np p>\chologtcal and drug treatments III thlb multl~actorlal dlvzase condition xhould be further explored [ 121 III

REFERENUC ES

Trearmenr

5

ot essenllal hbpertenslkes

549

FRUNKIN k, NATHAN RJ, PROUT hlF, COHEN hlC Non-pharmacologic control of essential h\pertensron in man a crltxal re\le\r of the etperlmental hrerarure Psychosom Med 1978. 40 294-3 I9 6 ~ALLINKE D Psbchologl>che hlethoden zur Hochdruckrherapie In Arzr und HJperronrker AIlgememorzrhche 4spehreder Zumrwnenurberr (Edlred b\ Borh KD er a/ ) Essener Hjpertonre-kolloqulum 17 18 I I 1978 Braunschwelg. ii’lesbaden Vleweg, 1979 7 SHAPIRO 4P Behablor modlflcatlon can II control h!perrerwon7 I Curdrorusculur Mud 1980. 3 1075-1079 8 hRoNici B Blurdruck \urrubrlrrur her Hothdruckkrunken Heidelberg Hurhrg Verlag. 1976 9 CLEMENT DL edlror Blood Pressure ~urrclhrhry Lancaster England MTP Press, 1979 IO ~BETEL G In&e[ du profll rsnslonel Schwefz Wed Uschr 1980 110 1935-193X I I S~KOLOU hl Dara obtamed Huh the arnbulatorv Mood pressure recorder In Blood Pressure Iurrubrlr~t (Edited bv CLEMENT DL) Lancab[er hlTP Pres>, 1979 I2 SOKOLO\\ hl ClInIcal applica[lons 01 ambularorl blood pressures, l979b In Blood Pressure C’urrubrOn (Edlred b) CLEMENT DLI Lancaster hlTP Press. 1979 therap) and high blood pressure 13 TAILOR CB F~RQCIHAR J\\, NEL\ON E, ~GRAS S Rrlavarwn 4rch Gen Ps\thrur 1977.34 339-3-12