Hypertension

Some individuals are more susceptible to exaggerated cardiovascular changes, including blood pressure (BP) changes, in response to physical or psychological stress. The so-called 'reactivity hypothesis' suggests that such susceptibility contributes to cardiovascular pathology over time. Consistent findings in the literature on hypertension include greater cardiovascular responses to stress in hypertensive patients than normal controls and reports that the children of hypertensive parents respond to stress with greater elevations in blood pressure (Lane, Carroll & Lip, 2001).

The impact of antihypertensive medication on coronary heart disease has been less than expected, however, most likely because of the influence of adverse side effects and poor compliance. There has led to renewed interest in the non-pharmacological management of hypertension, with the aim of reducing stress by focusing on cognitive and behavioural stress coping strategies and reducing sympathetic arousal. Psychological interventions to date have tended to focus on either one or a combination of biofeedback, relaxation and stress-management techniques. An early meta-analysis purporting to assess the efficacy of cognitive behavioural techniques for hypertension included biofeedback, meditation and relaxation as forms of CB therapies, concluding that there was a lack of support for such interventions (Eisenberg et al., 1993). However, Linden and colleagues have suggested that there is such a varied interpretation of the term 'stress management', ranging from transcendental meditation to cognitive behaviour therapy that comparisons of such studies are not meaningful at present (Ong, Linden & Young, 2004). In a previous meta-analysis of hypertension treatments by Linden & Chambers (1994), the impact of individualised psychological therapy was found to match the effects of drug treatments on blood pressure. Similarly, a meta-analysis of behavioural interventions for hypertension found a beneficial impact of group counselling on blood pressure levels (Boulware et al., 2001) but has been criticised in a Cochrane structured review for a lack of clarity in the statistical methods and study designs included (Database of Abstracts of Reviews of Effects DARE-20012344).

It is worth looking in more detail at some selected studies such as that of Shapiro et al. (1997), albeit involving small numbers. They considered the impact of a true cognitive behavioural intervention as an adjunct to drug treatment of mild to moderate hypertension. Thirty-nine patients were randomised to either CBT (n = 22) administered by a clinical psychologist in six weekly group sessions lasting an hour-and-a half or an attention control group (n = 17), which had contact with a nurse practitioner. All patients were treated with a standardised antihypertensive drug regime, followed by gradual withdrawal of medication after the six-week period and follow-up to one year. The authors reported that the CBT intervention was twice as effective in reducing medication, with 73 % of the treatment group requiring lower levels of medication than at the start of the study, compared to 35 % of the control group at the one-year follow-up. They have usefully outlined the 10 components of their CBT intervention, including an emphasis on progressive muscle relaxation, cue-controlled relaxation and imagery and cognitive-behavioural techniques for stress and anger management. It is worth commenting that the positive effect of the intervention was achieved in this study despite a lack of impact on levels of anxiety, depression, health habits or quality of life. However reductions in hostility and defensiveness were significantly associated with reduction of medication in both the treatment and control groups and the authors suggest training in anger and hostility management may be of particular relevance in future treatment programmes.

Other studies have also considered the role of anger management training. A previous study of 97 patients compared cognitive group therapy for anger management with heart rate biofeedback and routine treatment control groups (Achmon et al., 1989). They found that both interventions significantly reduced blood pressure, with greatest impact on blood pressure from the biofeedback intervention and greatest anger control in the cognitive group.

Linden's group aimed to address a number of the potential weaknesses of previous research in this area (Linden, Lenz & Con, 2001). Their inclusion criteria of, firstly, ambulatory and, secondly, relatively high BP levels reduced the potential impacts of 'white-coat hypertension' and possible floor effects of low base-line blood pressure levels. They randomised 60 patients to a treatment group and offered 10 hours of an individualised cognitive-behavioural intervention or standard care. Their attention to the inclusion criteria was supported by the outcome finding that high initial BP levels were strongly predictive of degree of change. The study also emphasised the delivery of the intervention by psychotherapists with specific training in CBT for psychosomatic patients, using techniques of proven efficacy in general psychotherapeutic practice. The components of therapy used most frequently focused on management of anger/hostility, autogenic training and discussion of relationship/existential issues, with less use of cognitive therapy for anxiety or depression. Blood pressure was significantly reduced by the CBT, including the waiting list control group when subsequently offered treatment. Additionally, the impact of treatment increased during the six-month follow-up, with reduced psychological distress and improved anger management suggested as the likely mediators of improvement.

Blumenthal et al. (2002) have critically reviewed the current literature on non-drug treatments for hypertension, as well as suggesting some possible pathopyhsiological mechanisms of relevance. They comment that more recent studies of biofeedback therapy are less encouraging than those prior to the mid-1990s, with reductions of BP failing to show a significant difference for placebo or sham biofeedback therapy and that the literature supporting relaxation techniques is equally weak. However, they conclude that there is evidence of a significant impact of CBT if it is applied in an individualised multicomponent treatment package in the treatment of patients with hypertension.

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