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Psychophysiological aspects of blood pressure regulation: A clinicians view
J. chron. Dis. 1964, Vol. 17, pp. 599-607.
Pergamon Press Ltd. Printed
PSYCHOPHYSIOLOGICAL REGULATION:
in Great Britain
ASPECTS OF BLOOD PRESSURE A CLINICIANS VIEW”?
CAROLINE BEDELL THOMAS, M.D.$ The Johns Hopkins University School of Medicine (Received
17 September
1963)
THE TITLE of this morning’s session raises antithetical images : the first, concerned with forces regulating blood pressure, demands rigid proof based on inductive reasoning; the second, embodying a clinical appraisal based on deduction and inference, is more permissive. Certainly the clinician’s view is not wholly scientific, for he sees through a glass darkly. Yet our whole concept of blood pressure regulation may depend upon the meaning of the interwoven strands making up the life story of the hypertensive patient, which the clinician witnesses as it unfolds. I am therefore delighted with this assignment, for it allows me to abandon the limitations imposed by statistics and the computer for the time being and to consider certain aspects of the story of hypertension. There are almost an infinite number of incidents and circumstances in the life of a hypertensive patient which may be important or even crucial in affecting or inhibiting his emotional and reflex development. Overt hypertension may exist for decades, and if, as the psychiatrist suspects, the submerged origins extend back into the dim recesses of childhood, hypertension should be studied for a lifetime, No one, however, be he psychiatrist, pediatrician or internist, has had the temerity to set up a prospective study of hypertension beginning in infancy. Until this is done, a retrospective view of early events, combined with the clinician’s continuing observations, must serve as our best guide. Fortunately, the path is illuminated by many beacons: 1. Freud’s emphasis on the significance of infantile, parent-directed hatred and fear, repressed to the subconscious level. 2. Cannon’s demonstration that fear and rage are the dominant emotions characteristically expressed in the sympathetic division of the autonomic nervous system. 3. Pavlov’s establishment of the conditional reflex as the basis of certain types of behavior. 4. The production of experimental hypertension by Heymans and by Goldblatt: one neurogenic, the other renal, both demonstrated that chronic vasoconstriction, generalized or local. could lead to hypertension. *Read at the Conference on Psychophysiologic Aspects of Cardiovascular Timberline Lodge, Oregon, 27 June 1963. iSupported by Grant HE-01891 from the National Heart Institute. SAssociate Professor of Medicine. 599
Disease,
held at
600
CAROLINE BEDELL THOMAS
5. The Russian experiments with monkeys suggesting that chronic frustration of primitive urges may also produce hypertension. 6. The recognition by Dunbar and others that hypertension is a psychosomatic disorder; its psychodynamic structure has been described by Alexander as one in which there is “a very pronounced conflict between passive, dependent, feminine, receptive tendencies and over-compensatory, competitive, aggressive hostile impulses which lead to fear and increase a flight from competition towards the passive dependent attitude.” 7. The tremendous expansion of knowledge, including the discoveries of angiotensin, aldosterone and other corticosteroids, the chemical transmission of nerve impulses, the relationship of amines to behavior, cortico-hypothalamic control mechanisms, cybernetics and the nature and enormous capacity of the genetic material. These are the scientific landmarks forming the background of my presentation, which deals with the patient himself as seen through the eyes of an internist. Long-term observations on the characteristics of several hundred hypertensive patients, as yet unsupported by statistical proof, form the wellspring of my conviction that psychological factors, as well as physiological and metabolic traits, are important precursors of hypertension, and that the severity of the disorder depends upon the particular configuration of the individual’s psychobiological heritage interacting with environmental stresses. In our prospective study of medical students, we have emphasized the importance of the family history, particularly the parental history, in elucidating the genetic aspects of hypertension, and have pointed out that hypertension, coronary disease, obesity and diabetes are probably not separate entities, but interlocking patterns of inheritance with certain genes in common and other genes, unshared, making each disorder distinctive. Today, I should like to call attention to the importance of another facet of the parental history and to submit that a major part of the answer to the riddle of hypertension lies in the parent-child relationship. If a physician takes time to explore the life histories of hypertensive patients, he will almost always find evidence of something strange, unusually intense and disturbing in the parent-child relationship over a long period of time. The clue may be so subtle that it is easily missed: for example, a married woman with a family, who had had her share of adversity, when asked what had been hardest in her life, instantly replied, “Oh, my mother’s death,” and burst into tears. Yet her mother had died nearly 30 years before ! A hypertensive man of 41, referring to his birth, said quietly, “My mother was single at the time.” Raised by his grandmother until age 11, he then went to live with his 25-year-old mother, who was later a diabetic. A switchboard operator was refused insurance at 21 because her blood pressure was 220. Her mother had had hypertension from her early 40’s until her death at 74. The patient, still hypertensive at 56, is active in her life-time job. She recently said, “No one ever pleased mama. She worked and thought the house should be spotless.” In these instances one can only speculate as to the unresolved emotional conflicts involved. The following story gives us a more penetrating glimpse: The patient’s father died when she was three; she was an only child. From then on she and her mother lived ‘peacefully’ together, so attuned that they would
Psychophysiological
Aspects of Blood Pressure Regulation
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laughingly state they were actually one individual, although she refers to her childhood as ‘unhappy’. Her mother was constantly ambitious for her-to go to college, to obtain a Master’s degree, to become a teacher. The patient did not want to do this-she said she was not brilliant and had to study excessively; she only did it because of her mother’s dominance over her. While teaching, she registered for a Ph.D. but found this too much strain; she had a nervous breakdown and gave it up. She continued to teach, however, living with her mother, who performed all the household duties. At 40 she married, although she had always considered sex disgusting. Her lawyer husband promptly went overseas in the Army for four years. On his return, she remained with her mother while he went to a new post. Three years later, when he put pressure on her, she finally moved, with her mother, to join him. At her mother’s death after a heart attack, she was separated from her mother for the first time in 52 years. The patient was prostrated. Not only was the apartment filled with her mother’s memory, but she hated housework and could not cope with it after an exhausting day of teaching; they went out to a restaurant every night for dinner. She had an ‘anniversary reaction’ a year after her mother’s death, reliving the past, with nightmares, guilt feelings and anxiety, and once wet the bed. She blamed herself for not feeling well enough to visit her mother in the nursing home the week of her death. She has been well aware of her hypertension for about ten years, ever since a series of examinations for getting jobs called it to her attention. She knows her blood pressure is higher in the doctor’s office, and often takes a barbiturate before she goes. She has read up about it, trying to care for herself by climbing stairs very slowly, stopping every tenth step, and so on. Despite her problems, at 53 she was considering adopting a child. She saw no incongruity in the fact that she had been utterly unable to establish a home for herself and her husband, who was something of an alcoholic. She somehow believed that if she adopted a little girl, everything would come out all right. The following year, while stationed in Germany, they actually did adopt a little 6-year-old girl. Last seen briefly two years later, she cried “I’m a mess.” Her husband did not like the child and had taken more and more to drink; she planned to separate from him if she could ‘get herself together.’ When abroad, she was no longer a working woman, and she hated housework. Her blood pressure had flown up at times. Army doctors had treated her for anxiety and depression as well as hypertension. On meprobamate, phenobarbital and chlorothiazide her blood pressure was 176/ 108. My note reads: “I can’t imagine a worse pair of parents. Mrs. D. is 58, has never had anything to do with housekeeping and is so much of a problem to herself that she could not possibly be a stable, out-giving mother. Her troubles are now compounded by the fact that she and her husband are completely at odds and her husband is becoming more and more of a heavy drinker.” This story is not unique: it exemplifies situations which, in my experience, have recurred in different guises in the life histories of many hypertensive patients : 1. The apparent submissiveness and passivity under the domination of a parent. 2. The anniversary reaction, with feelings of guilt, anxiety, and depression apparently stemming from chronic, hostile, unsuccessful, nearly conscious rebellion against the dominating parent.
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3.
The unrealistic marriage, which, even though unsatisfactory, seldom evokes as much deep emotional disturbance as the parent-child relationship. 4. The desire to adopt a child under bizarre circumstances. Another example of a disturbed parent-child relationship in which suppressed rage and fear play clearcut roles is seen in the following case: J.L. was first seen at 42 for severe hypertension. His father had survived a coronary occlusion at 58. His mother died at 40; her mother died of a stroke at 65. The patient had known that he had elevated blood pressure since he was 19, but believed his trouble began between the ages of 9 and 12. He had a very unhappy childhood. During the depression his family was extremely poor; his father was unemployed and became a heavy drinker. His father would come home and beat up his mother. They were so poor they could not even have electricity in their house. He said, “In my childhood, there was always an unseen fear, either that my father would come home drunk and beat my mother, or that a bill collector would knock on the door, or a car would hit me”, etc. He felt unwanted and inferior to his classmates. These feelings have persisted despite great personal success. He was married at 21, and started working for a construction company with jobs all over the country so that he was constantly moving; he said, “My wife has just made her thirtieth move.” He had risen steadily and was now a supervisor. His job was hard, with difficult decisions to make. He had had no vacations at all. He was paid for vacations but did not take them, except for two or three days between jobs. He was very limited as to recreation; he said he never reads at all and cannot sit down-he always has to be moving. He occasionally plays bridge and enjoys fishing from a boat, but never dares go fishing for fear he could not get to a doctor. He worries every minute of the day and night about his health, car accidents, tunnels caving in, etc. His youngest son does the same. He envisages this 12-year-old boy as having hypertension like himself. He worries particularly about his own high blood pressure and the possibility of a stroke or a heart attack; these conditions are never off his mind. He often feels as though he would inwardly explode. He takes it out on his wife: he said, “She has become my personal whipping boy.” Although elevated blood pressure was discovered at 19, it was 15 years later that symptoms of headache and fatigue took him to a doctor. The next year, he had retinal hemorrhages; dorso-lumbar sympathectomy was performed in Boston when he was 35. Two years later an episode of projectile vomiting and vertigo put him in bed for eight weeks. For the next five years, he was treated with increasingly strong combinations of antihypertensive agents, most of which disagreed with him. When first seen in Baltimore, he was taking only a sympathetic blocking agent. He complained of intermittent blurred vision, a sense of fullness and pains in his chest, and some staggering. He had no ambition and had to drive himself; he felt all the time as though he were going to be sick and wanted to be alone. He was intensely concerned about his blood pressure; in the morning, it was as low as 140/100 but went up to 260/ 150 by noon unless he took a morning dose of the drug, in which case it would only be 180/ 120. The highest reading of the day was at 5 o’clock. He would rush home from work, immediately take
Psychophysiological
Aspects of
Blood Pressure Regulation
603
his pressurz and, when he found it high, jump into a hot shower and think of all the additional things he could do to bring his pressure down. On examination his recumbent pressure was 228/168; standing it was 193/158. The retinal arteries and arterioles showed moderate smooth narrowing with occasional irregularity and one subsiding exudate; there were no hemorrhages or papilloedema. His heart was enlarged to the left; electrocardiogram showed left ventricular strain. Cholesterol was high-375 mg per 100 ml. Recent renal function studies in Boston were ‘satisfactory.’ With reassurance and reeducation his symptoms disappeared. His blood pressure pattern remained essentially unaltered over the next 14 months, however, despite attempts to improve his antihypertensive drug regime. He never had time for extensive tests or hospital study. When last seen he was off to Texas on a new job. He looked the picture of health, active and alert. Recumbent pressure was 262/ 170, standing 220/ 152, an hour before the next dose of blocking agent was due. He had been working ‘harder than ever.’ He said, “I love to work-1 thrive on it-1 find it challenging.” Here was a man with a driving, restless personality who vividly recalled many early fears. The circumstances of his childhood suggest that they were linked with repressed rage directed toward his drunken, cruel father. As an adult, severe chronic anxiety, obsessive-compulsive trends, inferiority feelings, sadistic impulses directed toward his wife, and some depression were evident. He had had hypertension for at least 23 of his 42 years, and he suspected that it had existed even longer. Despite thoraco-lumbar sympathectomy seven years before, he continued to have a stream of sympathicotonic impulses which could be partially blocked by pharmacological means, yet every morning his pressure was normal. His blood pressure pattern and that of the previous patient were in some ways reminiscent of experimental neurogenic hypertension. The final patient is of special interest because he has been observed from an early age. A private patient of Dr. Henry M. Thomas Jr.‘s, he has kindly allowed me to study him and to make use of his records in conjunction with ours. A 21-year-old Jewish ex-college student was first studied in 1948 as a result of a blind spot in one eye. His father had high blood pressure ‘due to emotional problems’ discovered at 43 and a heart attack at 54, a year before the patient was first seen. The father had battled obesity since childhood: all four paternal aunts and uncles and both paternal grandparents were obese: the grandmother also had diabetes. His father was a professional man who was distant and aloof and not particularly interested in his only child. His mother, who ‘almost died’ at his birth, was socially ambitious. When he was 9, his parents were divorced. In the following years, his interpersonal relationships were extraordinarily complex and ambivalent: his father, his stepmother, his governess, his own mother and her admirers formed a cast of characters worthy of a Eugene O’Neill play. At the age of 11, he became a Catholic like his governess, who for a time became a substitute mother. Later, he returned to his own mother who dominated him: he was at times hostile and sadistic toward her. At 17, in college, his own emotions became increasingly confused, with strands of homosexuality and heterosexuality intermingled. He changed from being a Catholic to being an agnostic, and dropped out of college.
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At the age of 7 the patient suffered a blow on the head; his blood pressure was thought to be slightly elevated at that time and on numerous subsequent occasions. At age 14 he weighed over 200 lb, gradually gaining to 250 lb at 17. At 18 he was examined for the Navy, but was rejected because his blood pressure was 212/96. He was very tense at the examination, as he did not want to be drafted. A week later his systolic pressure was 135. The present episode began when he was going to see a new friend-the first girl who had really attracted him. He had decided in his own mind that he would have sexual relations with her, and was extremely tense. On the doorstep of her house he suddenly noted a black spot in front of the left eye and, on fundoscopic examination, it was found that he had several large retinal hemorrhages, with minimal hypertensive changes otherwise. During the next two months the hemorrhages gradually disappeared; blood pressure readings varied from 190/104 to 146180. At the end of the two months he bad ‘gotten nowhere’ with his girl friend, so he determined to pick up some other woman and have intercourse. He actually did pick up a girl and sat talking to her in the park, under constant strain. He began to feel dizzy and went to a doctor who found his blood pressure 200 and his NPN 79 mg per 100 ml. He was admitted to a hospital where the high NPN was substantiated. X-rays of the skull were normal, but there was calcification of the choroid plexuses. Chest X-rays showed no evidence of disease of the heart or great vessels. Flat plate of the abdomen, intravenous and retrograde pyelograms were all normal. In a few days, his blood pressure fell to 130/80. Eight days later he was first seen in Baltimore. Studies revealed smooth narrowing of the entire retinal arterial tree, recorded in retinal photographs; blood pressure was in the range of 14~130/95-80; heart and renal function were normal, as was the NPN (29 mg per 100 ml). His cold pressor test was positive (t 24/ + 26). Skin resistance studies revealed almost the greatest sympathetic hyperreactivity ever seen in Dr. Curt Richter’s laboratory. The Fourneau and histamine tests were negative. Medically, he was considered to have a marked vasospastic reaction to anxiety which precipitated bouts of elevated pressure, retinal hemorrhages, and, in one instance, nitrogen retention. After consultation with a psychiatrist, he was referred to a psychoanalyst, who saw him two days a week for over two years. His analyst reported him to be “a latent schizophrenic; several times he has been transiently psychotic. There is a great deal of dissociated primitive aggression. From about the age of five he controlled this by assuming a feminine and passive role. Criticism, rebuff or failure always have aroused intense anxiety. At such times he barely manages to keep the killing aggression out of awareness by shifting to the less, frightening thought that he is a fairy. When upset, he frequently has accused his analyst of wanting to make him a homosexual and of ‘planting fairies outside to get him.’ For a while he carried a stiletto with which to kill them.” Toward the end of his analysis, shortly after starting graduate school at night, his blood pressure was 130/90. In 1954, five and a half years after he was first seen and 9 months after marriage, his blood pressure was 145/90, and his retinal arteries appeared less constricted although still slightly narrow. Check-ups in 1956 and 1957 revealed blood pressures of 125/84 and 130/86. The retinal arteries were straight, with no arterio-venous compression, and appeared perfectly normal. He
Psychophysiological
Aspects of Blood Pressure Regulation
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weighed 194 lb and his cholesterol level was 325 mg per 100ml. At present he is 36 and is leading a normal life, although reported to be compulsive in his drive to succeed in his chosen profession. This patient took three Rorschach tests: one at the beginning of his analysis and another a year later given by the same psychologist at the request of his analyst. Three months after the first test, the patient was also tested by one of the psychologists for the Study of Precursors of Hypertension and Coronary Disease, who had no access to the previous Rorschach protocol or interpretation. This patient was studied as an ‘abnormal control’ for the healthy medical student subjects, as he was of similar age, intelligence and background. The two independent early Rorschach reports emphasized almost identical features: despite indications of very high intelligence, he functions at a mediocre level in the test situation. He has a very poor concept of reality and of the nature of other people. He is often so preoccupied with his inner world that he becomes somewhat confused dealing with the outer world. He is obsessive in his attention to details, and quite stubborn and negativistic in many of his attitudes. He has strong introversive trends and shows little emotional stability in his relationship with others. His sexual preoccupation is marked: he shows much uncertainty about his sexual identity, having a deep fear that he is an unsatisfactory female, and an unconscious wish that he might be both male and female. There are evidences of oral sadism, sexual inferiority and infantilism. Despite a certain surface aggressiveness, he is extremely passive in his significant relations with others. He assumes that he cannot do anything real on his own and that he cannot compete with other men. This assumption persists no matter how much his achievements may prove the contrary to be true. The passivity goes along with important attitudes of hostile dependency upon key individuals, probably beginning with the mother. His strongly derogatory attitudes toward people, especially women, seem to have their chief roots here. The patient is potentially very anxious indeed but seems to have various techniques for keeping the anxiety as such out of awareness most of the time. He seems able to deal with painful feelings by simply denying them. He may be so used to doing this that he does not recognize the tension and strain which it forces upon him, as if he always had to maintain his equilibrium by straining in a difficult position. Over-all, the test shows that the patient is a markedly disturbed person, having many tensions and conflicts which he attempts to handle in a compulsive manner and with an impersonal intellectualization. He gives evidence that he perceives and handles his outer world differently from others: the record resembles that of an ambulatory schizophrenic. The third Rorschach test, after a year of analysis, showed that although still a very schizoid person, the patient’s attitude toward himself was much more courageous, open, constructive and hopeful than it had been previously. Since the initial test the livelier, more personal, emotional elements had increased, and the more objective, controlled elements decreased. Test II, performed independently by the research psychologist, fell between Tests I and III in a number of respects: for example, total R rose from 88 to 101 to 210 on the three successive tests. The content was also intermediate. In the initial test, all the human figures perceived
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were women, while in the final test there were a number of men, albeit often hunched or leaning; in Test II, the psychologist reported that about one-third of the human figures were ‘weak’ men-two archbishops back-to-back, a sad little man astraddle, a fat man, etc.-while one-third were undifferentiated people and one-third were unpleasant females-women arguing, vomiting, or with sour expressions. Animal figures were ‘dragging along’ in Test I, ‘walking’ or ‘looking’ in Test II and ‘pushing themselves up’ in Test III. There was greater accuracy of form perception and increasing conscious acceptance of himself as a male rather than as a vaguely female or undifferentiated figure. In the first test the patient saw ‘a penis voiding’, in the second, ‘a penis sticking out’ and in the third, ‘a penis with an erection’, indicating his gradual acceptance of the male role. This case seems to represent an instance of deeply disturbing, unconscious psychosexual conflicts erupting in the form of vasospastic crises as the patient emerged from adolescence. To some extent the paroxysmal attacks of hypertension resembled those of phaeochromocytoma, a diagnosis which was seriously considered. Not only were the specific tests for that disorder negative, however, but also the improvement noted after psychoanalysis and the absence of paroxysmal attacks for 15 years excludes the presence of a medullary tumor. Psychoanalysis apparently acted as a stabilizing force to this man in a period of transition. However, he has a heritage of the four closely interrelated disorders: hypertension, coronary disease, diabetes and obesity, and has himself shown some of the early physiological and metabolic traits of a highly susceptible individual: marked sympathetic hyperreactivity, obesity, and hypercholesteremia. It seems likely that, despite his present ‘good health’ which allows him to evade medical and psychiatric counsel, with his continuing compulsive drives he will again develop trouble in this area. The material presented this morning points to the importance of conflicts in childhood, with parents as the central focus. It does not identify the initial trauma nor is it possible for us to trace back the sequence of events into infancy in these cases. The last patient was said to have “a schizophrenogenic mother and a cold, remote or intimidated, passive father” by the patient’s psychoanalyst, whose interest is focused there, whereas mine centers on the fact that the father had hypertension, coronary disease and obesity, disorders which the mother has thus far escaped. Perhaps all of these elements were necessary to produce the particular personality and blood pressure patterns shown by this subject. In considering parental influence, we are usually dealing with both hereditary and environmental factors which are so intertwined that it may take infinite patience to unravel the strands. My conclusions are confined to a few brief comments : 1. The cases described are examples of a large number I have on record which attest to the extraordinary nature of the life histories of many hypertensive patients, particularly in the area of interpersonal relationships. 2. In general, my independent observations as an internist confirm those of the early psychosomatic group as to the hypertensive personality structure. 3. In the patient with hypertensive crises, the Rorschach test and the psychoanalytical material agree as to his psychodynamic personality structure: both indicate early parentxhild conflicts as possible sources of the increased sympathetic outflow. This supports the view that projective tests may provide a valuable source of psychological information in predicting the development of hypertension.
Psychophysiological
Aspects of Blood Pressure Regulation
607
4. In two of these patients, objective information derived from retinal photographs, skin resistance studies, thoraco-lumbar sympathectomy and sympathetic ganglionic blocking agents all indicates the positive association of heightened vasoconstriction and hyperactivity of the sympathetic nervous system with elevated blood pressure. 5. It seems possible that alterations in the cerebral feed-back mechanisms and in the formation of conditional reflexes may provide the link between early psychic traumata and later increases in sympathetic outflow. 6. It seems likely that thresholds of vulnerability to special forms of psychic trauma as well as thresholds of sensitivity to physiological control mechanisms are mediated by the genetic code.
Pergamon Press Ltd. Printed
PSYCHOPHYSIOLOGICAL REGULATION:
in Great Britain
ASPECTS OF BLOOD PRESSURE A CLINICIANS VIEW”?
CAROLINE BEDELL THOMAS, M.D.$ The Johns Hopkins University School of Medicine (Received
17 September
1963)
THE TITLE of this morning’s session raises antithetical images : the first, concerned with forces regulating blood pressure, demands rigid proof based on inductive reasoning; the second, embodying a clinical appraisal based on deduction and inference, is more permissive. Certainly the clinician’s view is not wholly scientific, for he sees through a glass darkly. Yet our whole concept of blood pressure regulation may depend upon the meaning of the interwoven strands making up the life story of the hypertensive patient, which the clinician witnesses as it unfolds. I am therefore delighted with this assignment, for it allows me to abandon the limitations imposed by statistics and the computer for the time being and to consider certain aspects of the story of hypertension. There are almost an infinite number of incidents and circumstances in the life of a hypertensive patient which may be important or even crucial in affecting or inhibiting his emotional and reflex development. Overt hypertension may exist for decades, and if, as the psychiatrist suspects, the submerged origins extend back into the dim recesses of childhood, hypertension should be studied for a lifetime, No one, however, be he psychiatrist, pediatrician or internist, has had the temerity to set up a prospective study of hypertension beginning in infancy. Until this is done, a retrospective view of early events, combined with the clinician’s continuing observations, must serve as our best guide. Fortunately, the path is illuminated by many beacons: 1. Freud’s emphasis on the significance of infantile, parent-directed hatred and fear, repressed to the subconscious level. 2. Cannon’s demonstration that fear and rage are the dominant emotions characteristically expressed in the sympathetic division of the autonomic nervous system. 3. Pavlov’s establishment of the conditional reflex as the basis of certain types of behavior. 4. The production of experimental hypertension by Heymans and by Goldblatt: one neurogenic, the other renal, both demonstrated that chronic vasoconstriction, generalized or local. could lead to hypertension. *Read at the Conference on Psychophysiologic Aspects of Cardiovascular Timberline Lodge, Oregon, 27 June 1963. iSupported by Grant HE-01891 from the National Heart Institute. SAssociate Professor of Medicine. 599
Disease,
held at
600
CAROLINE BEDELL THOMAS
5. The Russian experiments with monkeys suggesting that chronic frustration of primitive urges may also produce hypertension. 6. The recognition by Dunbar and others that hypertension is a psychosomatic disorder; its psychodynamic structure has been described by Alexander as one in which there is “a very pronounced conflict between passive, dependent, feminine, receptive tendencies and over-compensatory, competitive, aggressive hostile impulses which lead to fear and increase a flight from competition towards the passive dependent attitude.” 7. The tremendous expansion of knowledge, including the discoveries of angiotensin, aldosterone and other corticosteroids, the chemical transmission of nerve impulses, the relationship of amines to behavior, cortico-hypothalamic control mechanisms, cybernetics and the nature and enormous capacity of the genetic material. These are the scientific landmarks forming the background of my presentation, which deals with the patient himself as seen through the eyes of an internist. Long-term observations on the characteristics of several hundred hypertensive patients, as yet unsupported by statistical proof, form the wellspring of my conviction that psychological factors, as well as physiological and metabolic traits, are important precursors of hypertension, and that the severity of the disorder depends upon the particular configuration of the individual’s psychobiological heritage interacting with environmental stresses. In our prospective study of medical students, we have emphasized the importance of the family history, particularly the parental history, in elucidating the genetic aspects of hypertension, and have pointed out that hypertension, coronary disease, obesity and diabetes are probably not separate entities, but interlocking patterns of inheritance with certain genes in common and other genes, unshared, making each disorder distinctive. Today, I should like to call attention to the importance of another facet of the parental history and to submit that a major part of the answer to the riddle of hypertension lies in the parent-child relationship. If a physician takes time to explore the life histories of hypertensive patients, he will almost always find evidence of something strange, unusually intense and disturbing in the parent-child relationship over a long period of time. The clue may be so subtle that it is easily missed: for example, a married woman with a family, who had had her share of adversity, when asked what had been hardest in her life, instantly replied, “Oh, my mother’s death,” and burst into tears. Yet her mother had died nearly 30 years before ! A hypertensive man of 41, referring to his birth, said quietly, “My mother was single at the time.” Raised by his grandmother until age 11, he then went to live with his 25-year-old mother, who was later a diabetic. A switchboard operator was refused insurance at 21 because her blood pressure was 220. Her mother had had hypertension from her early 40’s until her death at 74. The patient, still hypertensive at 56, is active in her life-time job. She recently said, “No one ever pleased mama. She worked and thought the house should be spotless.” In these instances one can only speculate as to the unresolved emotional conflicts involved. The following story gives us a more penetrating glimpse: The patient’s father died when she was three; she was an only child. From then on she and her mother lived ‘peacefully’ together, so attuned that they would
Psychophysiological
Aspects of Blood Pressure Regulation
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laughingly state they were actually one individual, although she refers to her childhood as ‘unhappy’. Her mother was constantly ambitious for her-to go to college, to obtain a Master’s degree, to become a teacher. The patient did not want to do this-she said she was not brilliant and had to study excessively; she only did it because of her mother’s dominance over her. While teaching, she registered for a Ph.D. but found this too much strain; she had a nervous breakdown and gave it up. She continued to teach, however, living with her mother, who performed all the household duties. At 40 she married, although she had always considered sex disgusting. Her lawyer husband promptly went overseas in the Army for four years. On his return, she remained with her mother while he went to a new post. Three years later, when he put pressure on her, she finally moved, with her mother, to join him. At her mother’s death after a heart attack, she was separated from her mother for the first time in 52 years. The patient was prostrated. Not only was the apartment filled with her mother’s memory, but she hated housework and could not cope with it after an exhausting day of teaching; they went out to a restaurant every night for dinner. She had an ‘anniversary reaction’ a year after her mother’s death, reliving the past, with nightmares, guilt feelings and anxiety, and once wet the bed. She blamed herself for not feeling well enough to visit her mother in the nursing home the week of her death. She has been well aware of her hypertension for about ten years, ever since a series of examinations for getting jobs called it to her attention. She knows her blood pressure is higher in the doctor’s office, and often takes a barbiturate before she goes. She has read up about it, trying to care for herself by climbing stairs very slowly, stopping every tenth step, and so on. Despite her problems, at 53 she was considering adopting a child. She saw no incongruity in the fact that she had been utterly unable to establish a home for herself and her husband, who was something of an alcoholic. She somehow believed that if she adopted a little girl, everything would come out all right. The following year, while stationed in Germany, they actually did adopt a little 6-year-old girl. Last seen briefly two years later, she cried “I’m a mess.” Her husband did not like the child and had taken more and more to drink; she planned to separate from him if she could ‘get herself together.’ When abroad, she was no longer a working woman, and she hated housework. Her blood pressure had flown up at times. Army doctors had treated her for anxiety and depression as well as hypertension. On meprobamate, phenobarbital and chlorothiazide her blood pressure was 176/ 108. My note reads: “I can’t imagine a worse pair of parents. Mrs. D. is 58, has never had anything to do with housekeeping and is so much of a problem to herself that she could not possibly be a stable, out-giving mother. Her troubles are now compounded by the fact that she and her husband are completely at odds and her husband is becoming more and more of a heavy drinker.” This story is not unique: it exemplifies situations which, in my experience, have recurred in different guises in the life histories of many hypertensive patients : 1. The apparent submissiveness and passivity under the domination of a parent. 2. The anniversary reaction, with feelings of guilt, anxiety, and depression apparently stemming from chronic, hostile, unsuccessful, nearly conscious rebellion against the dominating parent.
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3.
The unrealistic marriage, which, even though unsatisfactory, seldom evokes as much deep emotional disturbance as the parent-child relationship. 4. The desire to adopt a child under bizarre circumstances. Another example of a disturbed parent-child relationship in which suppressed rage and fear play clearcut roles is seen in the following case: J.L. was first seen at 42 for severe hypertension. His father had survived a coronary occlusion at 58. His mother died at 40; her mother died of a stroke at 65. The patient had known that he had elevated blood pressure since he was 19, but believed his trouble began between the ages of 9 and 12. He had a very unhappy childhood. During the depression his family was extremely poor; his father was unemployed and became a heavy drinker. His father would come home and beat up his mother. They were so poor they could not even have electricity in their house. He said, “In my childhood, there was always an unseen fear, either that my father would come home drunk and beat my mother, or that a bill collector would knock on the door, or a car would hit me”, etc. He felt unwanted and inferior to his classmates. These feelings have persisted despite great personal success. He was married at 21, and started working for a construction company with jobs all over the country so that he was constantly moving; he said, “My wife has just made her thirtieth move.” He had risen steadily and was now a supervisor. His job was hard, with difficult decisions to make. He had had no vacations at all. He was paid for vacations but did not take them, except for two or three days between jobs. He was very limited as to recreation; he said he never reads at all and cannot sit down-he always has to be moving. He occasionally plays bridge and enjoys fishing from a boat, but never dares go fishing for fear he could not get to a doctor. He worries every minute of the day and night about his health, car accidents, tunnels caving in, etc. His youngest son does the same. He envisages this 12-year-old boy as having hypertension like himself. He worries particularly about his own high blood pressure and the possibility of a stroke or a heart attack; these conditions are never off his mind. He often feels as though he would inwardly explode. He takes it out on his wife: he said, “She has become my personal whipping boy.” Although elevated blood pressure was discovered at 19, it was 15 years later that symptoms of headache and fatigue took him to a doctor. The next year, he had retinal hemorrhages; dorso-lumbar sympathectomy was performed in Boston when he was 35. Two years later an episode of projectile vomiting and vertigo put him in bed for eight weeks. For the next five years, he was treated with increasingly strong combinations of antihypertensive agents, most of which disagreed with him. When first seen in Baltimore, he was taking only a sympathetic blocking agent. He complained of intermittent blurred vision, a sense of fullness and pains in his chest, and some staggering. He had no ambition and had to drive himself; he felt all the time as though he were going to be sick and wanted to be alone. He was intensely concerned about his blood pressure; in the morning, it was as low as 140/100 but went up to 260/ 150 by noon unless he took a morning dose of the drug, in which case it would only be 180/ 120. The highest reading of the day was at 5 o’clock. He would rush home from work, immediately take
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his pressurz and, when he found it high, jump into a hot shower and think of all the additional things he could do to bring his pressure down. On examination his recumbent pressure was 228/168; standing it was 193/158. The retinal arteries and arterioles showed moderate smooth narrowing with occasional irregularity and one subsiding exudate; there were no hemorrhages or papilloedema. His heart was enlarged to the left; electrocardiogram showed left ventricular strain. Cholesterol was high-375 mg per 100 ml. Recent renal function studies in Boston were ‘satisfactory.’ With reassurance and reeducation his symptoms disappeared. His blood pressure pattern remained essentially unaltered over the next 14 months, however, despite attempts to improve his antihypertensive drug regime. He never had time for extensive tests or hospital study. When last seen he was off to Texas on a new job. He looked the picture of health, active and alert. Recumbent pressure was 262/ 170, standing 220/ 152, an hour before the next dose of blocking agent was due. He had been working ‘harder than ever.’ He said, “I love to work-1 thrive on it-1 find it challenging.” Here was a man with a driving, restless personality who vividly recalled many early fears. The circumstances of his childhood suggest that they were linked with repressed rage directed toward his drunken, cruel father. As an adult, severe chronic anxiety, obsessive-compulsive trends, inferiority feelings, sadistic impulses directed toward his wife, and some depression were evident. He had had hypertension for at least 23 of his 42 years, and he suspected that it had existed even longer. Despite thoraco-lumbar sympathectomy seven years before, he continued to have a stream of sympathicotonic impulses which could be partially blocked by pharmacological means, yet every morning his pressure was normal. His blood pressure pattern and that of the previous patient were in some ways reminiscent of experimental neurogenic hypertension. The final patient is of special interest because he has been observed from an early age. A private patient of Dr. Henry M. Thomas Jr.‘s, he has kindly allowed me to study him and to make use of his records in conjunction with ours. A 21-year-old Jewish ex-college student was first studied in 1948 as a result of a blind spot in one eye. His father had high blood pressure ‘due to emotional problems’ discovered at 43 and a heart attack at 54, a year before the patient was first seen. The father had battled obesity since childhood: all four paternal aunts and uncles and both paternal grandparents were obese: the grandmother also had diabetes. His father was a professional man who was distant and aloof and not particularly interested in his only child. His mother, who ‘almost died’ at his birth, was socially ambitious. When he was 9, his parents were divorced. In the following years, his interpersonal relationships were extraordinarily complex and ambivalent: his father, his stepmother, his governess, his own mother and her admirers formed a cast of characters worthy of a Eugene O’Neill play. At the age of 11, he became a Catholic like his governess, who for a time became a substitute mother. Later, he returned to his own mother who dominated him: he was at times hostile and sadistic toward her. At 17, in college, his own emotions became increasingly confused, with strands of homosexuality and heterosexuality intermingled. He changed from being a Catholic to being an agnostic, and dropped out of college.
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At the age of 7 the patient suffered a blow on the head; his blood pressure was thought to be slightly elevated at that time and on numerous subsequent occasions. At age 14 he weighed over 200 lb, gradually gaining to 250 lb at 17. At 18 he was examined for the Navy, but was rejected because his blood pressure was 212/96. He was very tense at the examination, as he did not want to be drafted. A week later his systolic pressure was 135. The present episode began when he was going to see a new friend-the first girl who had really attracted him. He had decided in his own mind that he would have sexual relations with her, and was extremely tense. On the doorstep of her house he suddenly noted a black spot in front of the left eye and, on fundoscopic examination, it was found that he had several large retinal hemorrhages, with minimal hypertensive changes otherwise. During the next two months the hemorrhages gradually disappeared; blood pressure readings varied from 190/104 to 146180. At the end of the two months he bad ‘gotten nowhere’ with his girl friend, so he determined to pick up some other woman and have intercourse. He actually did pick up a girl and sat talking to her in the park, under constant strain. He began to feel dizzy and went to a doctor who found his blood pressure 200 and his NPN 79 mg per 100 ml. He was admitted to a hospital where the high NPN was substantiated. X-rays of the skull were normal, but there was calcification of the choroid plexuses. Chest X-rays showed no evidence of disease of the heart or great vessels. Flat plate of the abdomen, intravenous and retrograde pyelograms were all normal. In a few days, his blood pressure fell to 130/80. Eight days later he was first seen in Baltimore. Studies revealed smooth narrowing of the entire retinal arterial tree, recorded in retinal photographs; blood pressure was in the range of 14~130/95-80; heart and renal function were normal, as was the NPN (29 mg per 100 ml). His cold pressor test was positive (t 24/ + 26). Skin resistance studies revealed almost the greatest sympathetic hyperreactivity ever seen in Dr. Curt Richter’s laboratory. The Fourneau and histamine tests were negative. Medically, he was considered to have a marked vasospastic reaction to anxiety which precipitated bouts of elevated pressure, retinal hemorrhages, and, in one instance, nitrogen retention. After consultation with a psychiatrist, he was referred to a psychoanalyst, who saw him two days a week for over two years. His analyst reported him to be “a latent schizophrenic; several times he has been transiently psychotic. There is a great deal of dissociated primitive aggression. From about the age of five he controlled this by assuming a feminine and passive role. Criticism, rebuff or failure always have aroused intense anxiety. At such times he barely manages to keep the killing aggression out of awareness by shifting to the less, frightening thought that he is a fairy. When upset, he frequently has accused his analyst of wanting to make him a homosexual and of ‘planting fairies outside to get him.’ For a while he carried a stiletto with which to kill them.” Toward the end of his analysis, shortly after starting graduate school at night, his blood pressure was 130/90. In 1954, five and a half years after he was first seen and 9 months after marriage, his blood pressure was 145/90, and his retinal arteries appeared less constricted although still slightly narrow. Check-ups in 1956 and 1957 revealed blood pressures of 125/84 and 130/86. The retinal arteries were straight, with no arterio-venous compression, and appeared perfectly normal. He
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weighed 194 lb and his cholesterol level was 325 mg per 100ml. At present he is 36 and is leading a normal life, although reported to be compulsive in his drive to succeed in his chosen profession. This patient took three Rorschach tests: one at the beginning of his analysis and another a year later given by the same psychologist at the request of his analyst. Three months after the first test, the patient was also tested by one of the psychologists for the Study of Precursors of Hypertension and Coronary Disease, who had no access to the previous Rorschach protocol or interpretation. This patient was studied as an ‘abnormal control’ for the healthy medical student subjects, as he was of similar age, intelligence and background. The two independent early Rorschach reports emphasized almost identical features: despite indications of very high intelligence, he functions at a mediocre level in the test situation. He has a very poor concept of reality and of the nature of other people. He is often so preoccupied with his inner world that he becomes somewhat confused dealing with the outer world. He is obsessive in his attention to details, and quite stubborn and negativistic in many of his attitudes. He has strong introversive trends and shows little emotional stability in his relationship with others. His sexual preoccupation is marked: he shows much uncertainty about his sexual identity, having a deep fear that he is an unsatisfactory female, and an unconscious wish that he might be both male and female. There are evidences of oral sadism, sexual inferiority and infantilism. Despite a certain surface aggressiveness, he is extremely passive in his significant relations with others. He assumes that he cannot do anything real on his own and that he cannot compete with other men. This assumption persists no matter how much his achievements may prove the contrary to be true. The passivity goes along with important attitudes of hostile dependency upon key individuals, probably beginning with the mother. His strongly derogatory attitudes toward people, especially women, seem to have their chief roots here. The patient is potentially very anxious indeed but seems to have various techniques for keeping the anxiety as such out of awareness most of the time. He seems able to deal with painful feelings by simply denying them. He may be so used to doing this that he does not recognize the tension and strain which it forces upon him, as if he always had to maintain his equilibrium by straining in a difficult position. Over-all, the test shows that the patient is a markedly disturbed person, having many tensions and conflicts which he attempts to handle in a compulsive manner and with an impersonal intellectualization. He gives evidence that he perceives and handles his outer world differently from others: the record resembles that of an ambulatory schizophrenic. The third Rorschach test, after a year of analysis, showed that although still a very schizoid person, the patient’s attitude toward himself was much more courageous, open, constructive and hopeful than it had been previously. Since the initial test the livelier, more personal, emotional elements had increased, and the more objective, controlled elements decreased. Test II, performed independently by the research psychologist, fell between Tests I and III in a number of respects: for example, total R rose from 88 to 101 to 210 on the three successive tests. The content was also intermediate. In the initial test, all the human figures perceived
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were women, while in the final test there were a number of men, albeit often hunched or leaning; in Test II, the psychologist reported that about one-third of the human figures were ‘weak’ men-two archbishops back-to-back, a sad little man astraddle, a fat man, etc.-while one-third were undifferentiated people and one-third were unpleasant females-women arguing, vomiting, or with sour expressions. Animal figures were ‘dragging along’ in Test I, ‘walking’ or ‘looking’ in Test II and ‘pushing themselves up’ in Test III. There was greater accuracy of form perception and increasing conscious acceptance of himself as a male rather than as a vaguely female or undifferentiated figure. In the first test the patient saw ‘a penis voiding’, in the second, ‘a penis sticking out’ and in the third, ‘a penis with an erection’, indicating his gradual acceptance of the male role. This case seems to represent an instance of deeply disturbing, unconscious psychosexual conflicts erupting in the form of vasospastic crises as the patient emerged from adolescence. To some extent the paroxysmal attacks of hypertension resembled those of phaeochromocytoma, a diagnosis which was seriously considered. Not only were the specific tests for that disorder negative, however, but also the improvement noted after psychoanalysis and the absence of paroxysmal attacks for 15 years excludes the presence of a medullary tumor. Psychoanalysis apparently acted as a stabilizing force to this man in a period of transition. However, he has a heritage of the four closely interrelated disorders: hypertension, coronary disease, diabetes and obesity, and has himself shown some of the early physiological and metabolic traits of a highly susceptible individual: marked sympathetic hyperreactivity, obesity, and hypercholesteremia. It seems likely that, despite his present ‘good health’ which allows him to evade medical and psychiatric counsel, with his continuing compulsive drives he will again develop trouble in this area. The material presented this morning points to the importance of conflicts in childhood, with parents as the central focus. It does not identify the initial trauma nor is it possible for us to trace back the sequence of events into infancy in these cases. The last patient was said to have “a schizophrenogenic mother and a cold, remote or intimidated, passive father” by the patient’s psychoanalyst, whose interest is focused there, whereas mine centers on the fact that the father had hypertension, coronary disease and obesity, disorders which the mother has thus far escaped. Perhaps all of these elements were necessary to produce the particular personality and blood pressure patterns shown by this subject. In considering parental influence, we are usually dealing with both hereditary and environmental factors which are so intertwined that it may take infinite patience to unravel the strands. My conclusions are confined to a few brief comments : 1. The cases described are examples of a large number I have on record which attest to the extraordinary nature of the life histories of many hypertensive patients, particularly in the area of interpersonal relationships. 2. In general, my independent observations as an internist confirm those of the early psychosomatic group as to the hypertensive personality structure. 3. In the patient with hypertensive crises, the Rorschach test and the psychoanalytical material agree as to his psychodynamic personality structure: both indicate early parentxhild conflicts as possible sources of the increased sympathetic outflow. This supports the view that projective tests may provide a valuable source of psychological information in predicting the development of hypertension.
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4. In two of these patients, objective information derived from retinal photographs, skin resistance studies, thoraco-lumbar sympathectomy and sympathetic ganglionic blocking agents all indicates the positive association of heightened vasoconstriction and hyperactivity of the sympathetic nervous system with elevated blood pressure. 5. It seems possible that alterations in the cerebral feed-back mechanisms and in the formation of conditional reflexes may provide the link between early psychic traumata and later increases in sympathetic outflow. 6. It seems likely that thresholds of vulnerability to special forms of psychic trauma as well as thresholds of sensitivity to physiological control mechanisms are mediated by the genetic code.