In Part I, I discussed how decades of psychosomatic research focused on factors such as anger, anxiety and day-to-day stress have not helped us in understanding or managing hypertension. In Part II, I will describe a very different, and fascinating, understanding of the mind/body link in hypertension, which I have written about in papers and in my books, Hypertension and You, and Healing Hypertension, and which may be relevant as well in other medical conditions whose link to emotions is suspected but not well understood. As I mentioned before, I believe that in most cases, hypertension is not driven by emotional factors, but in about 15 percent of cases, it is. This blog is about that 15 percent. I am presenting it briefly here; more detail is available in my books.
A different perspective on the mind/body connection in hypertension
In essence, my observations and studies indicate that the mind/body link in hypertension is nearly the opposite of what most suspect. Yes, our anger and anxiety and stress can raise our blood pressure in the moment, but this does not lead to development of persisting hypertension. Instead, it is the emotions that we don't feel, and aren't aware of, that can contribute to hypertension. It is the patient who is very even-keeled, or always up, no matter what he has been through, who is more prone to hypertension than the one who is aware of his anger, anxiety and pain. This relates in particular to survivors of abuse or trauma, many of whom are successful survivors, who have moved on, are not suffering psychologically, and even view the trauma as having had no lasting effect on them.
The psychological term often used to describe this handling of emotion is repression, the blocking of emotions from awareness, without our even knowing we are blocking it. Many survivors of severe trauma repress the emotion, move on, and don't suffer psychologically. They don't seek counseling because they are not suffering psychologically. This is different than consciously suppressing emotions we are aware of, often avoiding them by occupying our minds with other things.
A key point is that in many cases repression, even if contributory to hypertension, is not psychopathology. It is a valuable psychological defense, particularly if we have been through a lot. We all repress emotion; we couldn't live our lives if we were aware of everything we were feeling. But the link to hypertension is more extreme, the repression of emotion related to severe trauma, or the unconscious burden left by being even-keeled all the time.
Nearly all studies investigating the mind/body link of hypertension have focused on perceived anger, anxiety and stress. Reviews indicate that these don't lead to hypertension. Fewer studies investigate the role of repressed emotion, both because it is a concept that most people don't really get, and because it is much easier to measure the emotions we feel than those that we don't.
In my studies, as summarized in my books, I have found and reported that patients with severe hypertension are more likely to be emotionally defensive than those with milder hypertension, with no difference in measures of anger or anxiety. Patients with a history of abuse or trauma during childhood are less likely than others to respond to the usual blood pressure drugs (diuretics and ACE inhibitors). And most important are my papers that describe a successful treatment approach, based on the mind/body connection, for patients with otherwise unexplained severe paroxysmal (episodic) hypertension.
In whom would I suspect that hypertension is at least partly psychologically driven? I believe that ordinary mild hypertension that is easily controlled with medication usually is not related to psychological factors. Here, genetics (family history) and lifestyle (diet, weight, salt intake, lack of exercise) usually explain the hypertension. Yes, emotions can raise blood pressure from time to time, and, in many patients, anxiety in the doctor's office leads to a misleading diagnosis of hypertension, but they are not responsible for sustained hypertension. My experience and studies also tell me that the nervous, anxious person usually is not the hypertension-prone person, but is the one prone to misdiagnosis of hypertension, and unnecessary treatment, due to elevated readings in the doctor's office. And of course the nervous, anxious person can still have hypertension caused by genetic factors or lifestyle.
I find that certain clues are a tip off of a mind/body connection:
- A very even-keeled personality.
- A past history of trauma or abuse.
- A pattern of hypertension that differs from the usual: unexplained severe hypertension, resistant hypertension (hypertension that does not respond to the usual drugs, labile or paroxysmal (episodic) hypertension.
This understanding of the mind/body connection is not just intellectual fodder. It is extremely relevant in treating hypertension, to selection of the right drug and non-drug therapy. I will delve more specifically with the very real treatment implications of this understanding in Part III, which truly integrates psychology and medicine.
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