Biopsychological Barriers to the Behavioral Treatment of Hypertension

  • Wolfgang Linden
Part of the The Plenum Series in Behavioral Psychophysiology book series (SSBP)


This chapter has three osbjectives:
  1. 1.

    To review briefly review the presently used behavioral modes of treatment for essential hypertension (EH), outline their rationales, and provide a summary of research on their long-term effectiveness.

  2. 2.

    To delineate the physiology of normal and abnormal blood pressure regulation with an emphasis on self-regulatory mechanisms and their interactions.

  3. 3.

    To contrast rationales for presently used treatment modes with the currently available knowledge on pressure regulation mechanisms, noting where rationales are appropriate and sufficient or where they may be inadequate.



Essential Hypertension Psychosomatic Medicine Cognitive Reappraisal Hypertension Detection Servo Controller 


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  1. Agras, W. S. (1983). Relaxation therapy in hypertension. Hospital Practice, 19, 129–137.Google Scholar
  2. Alderman, M. H., & Madhavan, S. (1981). Management of the hypertensive patient: A continuing dilemma. Hypertension, 3, 192–197.PubMedGoogle Scholar
  3. Ambrosioni, E., Costa, F. V., Borghi, C., Montebugmoli, L., Giordani, M. F. & Magnani, B. (1982). Effects of moderate salt restriction on intralymphocytic sodium and pressor response to stress in borderline hypertension. Hypertension, 4, 789–794.PubMedGoogle Scholar
  4. Barefoot, J. C., Dahlstrom, W. G., & Williams, R. B. (1983). Hostility, CHD incidence, and total mortality: A 25-year follow-up study of 255 physicians. Psychosomatic Medicine, 45, 59–63.PubMedGoogle Scholar
  5. Becker, M. H., & Maiman, L. A. (1975). Sociobehavioral determinants of compliance with health and medical care recommendations. Medical Care, 13, 10–24.PubMedCrossRefGoogle Scholar
  6. Benson, H. (1975). The relaxation response. New York: William Morrow.Google Scholar
  7. Charlesworth, E. A., Williams, B. J., & Baer, P. E. (1984). Stress management at the worksite for hypertension: Compliance, cost-benefit, health care and hypertension-related variables. Psychosomatic Medicine, 46, 387–397.PubMedGoogle Scholar
  8. Chobanian, A. V., Gavras, H., Gavras, I., Bresnahan, M., Sullivan, P., & Melby, J. C. (1978). Studies on the activity of the sympathetic nervous system in essential hypertension. Journal of Human Stress, 4, 22–28.PubMedCrossRefGoogle Scholar
  9. Conway, J. (1984). Hemodynamic aspects of essential hypertension in humans. Physiological Reviews, 64, 617–660.PubMedGoogle Scholar
  10. DeClue, J. W., Guyton, A. C., Cowley, A. W., Jr., Coleman, T. G., Norman, R. A., Jr., & McCaa, R. E. (1978). Suppressor angiotension infusion, renal sodium handling, and salt-induced hypertension in the dog. Circulation Research, 43, 503–512.PubMedGoogle Scholar
  11. Dembroski, T. M., MacDougall, J. M., Williams, R. B., Haney, I. L., & Blumenthal, J. A. (1985). Components of type A, hostility and anger in relationship to angiographic findings. Psychosomatic Medicine, 47, 219–233.PubMedGoogle Scholar
  12. Dimsdale, J. E., Hackett, T. P., Hutter, A. M., Block, P. C., Catanzaro, D. M., & White, P. J. (1979). Type A behavior and angiographic findings. Journal of Psychosomatic Research, 23, 273–276.PubMedCrossRefGoogle Scholar
  13. Dustan, H. P. (1982). Physiologic regulation of arterial pressure: An overview. Hypertension 4 (Suppl. 3), 62–67.Google Scholar
  14. Dworkin, B. R., Filewich, R. J., Miller, N. E., & Craigmyle, N. (1979). Baroreceptor activation reduces reactivity to noxious stimulation: Implications for hypertension. Science, 205, 1299–1301.PubMedCrossRefGoogle Scholar
  15. Elbert, T., Pietrowsky, R., Kessler, M., Lutzenberger, W., & Birbaumer, N. (1985). Stimulation of baroreceptors decreases cortical excitability and increases pain sensation threshold in borderline hypertensives (Abstract). Psychophysiology, 22, 588.Google Scholar
  16. Esler. M., Julius, S., Zweifler, A., Randall, O., Harburg, E., Gardner, H, & DeQuatio, V. (1977). Mild high-venin essential hypertension. New England Journal of Medicine, 296, 405–412.PubMedCrossRefGoogle Scholar
  17. Falkner, B., Onesti, G., Angelakos, E. T., Fernandes, M., & Langman, L. (1979). Cardiovascular response to mental stress in normal adolescents with hypertensive parents. Hypertension, 1, 23–30.PubMedGoogle Scholar
  18. Feuerstein, M., & Linden, W. (1984). Psychobiological aspects of health and disease. In H. E. Adams & P. Sutker (Eds.), Comprehensive handbook of psychopathology (pp. 809–839 ). New York: Plenum Press.Google Scholar
  19. Folkow, B. (1975). Vascular changes in hypertension and recent animal studies. In G. Berglund, L. Hansson, & Werkö, E. (Eds.), Pathophysiology and management of arterial hypertension. Göteborg: Lindgren & Soener.Google Scholar
  20. Folkow, B. (1982). Physiological aspects of primary hypertension. Physiological Reviews, 62, 347–504.PubMedGoogle Scholar
  21. Fredrikson, M., & Engel, B. F. (1985). Cardiovascular and electrodermal adjustments during a vigilance task in patients with borderline and established hypertention. Journal of Psychosomatic Research, 29, 235–246.PubMedCrossRefGoogle Scholar
  22. Fredrikson, M., Dimberg, U., Frisk-Holmberg M., & Stroem, G. (1985). Arterial blood pressure and general sympathetic activation in essential hypertension during stimulation. Acta Medica Scandinavica, 217, 309–317.PubMedCrossRefGoogle Scholar
  23. Frohlich, E. D., Tarazi, R. C., Ulrych, M., Dustan, H. P., & Page, I. H. (1967). Tilt test for investigating a neural component in hypertension: Its correlation with clinical characteristics. Circulation, 36, 387–393.PubMedGoogle Scholar
  24. Frohlich, E. D., Tarazi, R. C., & Dustan, H. P. (1969). Hyperdynamic beta-adrenergic circulatory state: Increased beta receptor response. Archives of Internal Medicine, 123, 1–7.PubMedCrossRefGoogle Scholar
  25. Frumkin, K., Nathan, R. J., Prout, M. F., & Cohen, M. C. (1978). Nonpharmacologic control of essential hypertension in man: A critical review of the experimental literature. Psychosomatic Medicine, 40, 294–320.PubMedGoogle Scholar
  26. Fujita, T., Noda, H., & Ando, K. (1984). Sodium susceptibility and potassium effects in young patients with borderline hypertension. Circulation, 69, 468–476.PubMedCrossRefGoogle Scholar
  27. Giese, J. (1976). The renin angiotension system and the pathogenesis of vascular disease in malignant hypertension. Clinical Science and Molecular Medicine, 51 (Suppl. 3), 145.Google Scholar
  28. Glasgow, M. S., Gaarder, K. R., & Engel, B. (1982). Behavioral treatment of high blood pressure. II. Acute and sustained effects of relaxation and systolic blood pressure feedback. Psychosomatic Medicine, 44, 155–170.PubMedGoogle Scholar
  29. Goldby, F. S., & Benin, L. J. (1974). The evolution and healing of arteriolar damage in renal-clip hypertension in the rat: An electron microscope study. Journal of Pathology, 114, 139–148.PubMedCrossRefGoogle Scholar
  30. Goldman, H., Kleinman, K. M., Snow, M. Y., Bidus, D. R., & Korol, B. (1974). Correlation of diastolic blood pressure and signs of cognitive dysfunction in essential hypertension. Diseases of the Nervous System, 35, 571–572.PubMedGoogle Scholar
  31. Guyton, A. C. (1980). Circulatory physiology: III. Arterial blood pressure and hypertension. Philadelphia: W. G. Saunders.Google Scholar
  32. Guyton, A. C., Cowley, A. W., & Coleman, T. (1972). Interaction between the separate pressure control systems in normal arterial pressure regulation and in hypertension. In J. Genest & E. Koiw (Eds.) Hypertension. Berlin: Springer.Google Scholar
  33. Guyton, A. C., Coleman, T. G., Cowley, A. W., Jr., Manning, R. D., Jr., Norman, R. A., Jr., & Ferguson, J. D. (1974). A systems analysis approach to understanding long-range arterial blood pressure control and hypertension. Circulation Research, 35, 159–176.Google Scholar
  34. Harburg, E., Blakelock, E. H., Jr., & Roeper, P. J. (1979). Resentful and reflective coping with arbitrary authority and blood pressure. Psychosomatic Medicine, 41, 789–202.Google Scholar
  35. Hokanson, J. E., & Edelman, R. (1966). Effects of three social responses on vascular processes. Journal of Personality and Social Psychology, 3, 442–447.PubMedCrossRefGoogle Scholar
  36. Holden, R. A., Ostfeld, A. M., Freeman, D. H., Jr., Hellenbrand, K. D., & D’Atri, D. A. (1983). Dietary salt intake and blood pressure. Journal of the American Medical Association 250, 365–369.PubMedCrossRefGoogle Scholar
  37. Hypertension Detection and Follow-up Program Cooperative Group. (1979). Five-year findings of the Hypertension Detection and Follow-up Program. I. Reduction in mortality of persons with high blood pressure, including mild hypertension. Journal of the American Medical Association, 242, 2562–2571.CrossRefGoogle Scholar
  38. Hypertension Detection and Follow-up Program Cooperative Group. (1985). Five-year findings of the Hypertension Detection and Follow-up Program. Hypertension, 7, 105–112.Google Scholar
  39. Jacob, R. G., Kraemer, H. G., & Agras, W. S. (1977). Relaxation therapy in the treatment of hypertension: A review. Archives of General Psychiatry, 34, 1417–1427.PubMedCrossRefGoogle Scholar
  40. Jorgensen, R. S., Houston, B. K., & Zurawski, R. M. (1981). Anxiety management training in the treatment of essential hypertension. Behavioral Research and Therapy, 19, 467–474.CrossRefGoogle Scholar
  41. Julius, S., Esler, M. D., & Randall, O. S. (1975). Role of the autonomic nervous system in mild human hypertension. Clinical Science and Molecular Medicine, 48, 243–252.Google Scholar
  42. Kaplan, N. M. (1978). Clinical hypertension. Baltimore: Williams & Wilkins.Google Scholar
  43. Kasl, S. V. (1978). A social-psychological perspective on successful community control of high blood pressure: A review. Journal of Behavioral Medicine, 1, 347–381.PubMedCrossRefGoogle Scholar
  44. Kawasaki, T., DeLea, L. S., Bartter, I. C., & Smith, H. (1978). The effect of high-sodium and low-sodium intakes on blood pressure and other related variables in human subjects with idiopathic hypertension. American Journal of Medicine, 64, 195–198.CrossRefGoogle Scholar
  45. Keys, A., Taylor, H. L., Blackburn, H., Brozek, J., Anderson, J. T., & Somonson, E. (1971). Mortality and coronary heart disease among men studied for 23 years. Archives of Internal Medicine, 128, 201–214.PubMedCrossRefGoogle Scholar
  46. Lacey, J. I. (1967). Somatic response patterning and stress: Some revisions of activation theory. In M. H. Apley Sr R. Trumbull (Eds.), Psychological stress. New York: AppletonCentury-Crofts.Google Scholar
  47. Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common-sense representation of illness danger. In S. J. Rachman (Ed.), Medical psychology (Vol. 2, pp. 7–30 ). New York: Pergamon Press.Google Scholar
  48. Libo, L. M., & Arnold, G. E. (1983). Relaxation practice after biofeedback therapy: A longterm follow-up study of utilization and effectiveness. Biofeedback and Self-Regulation, 8, 217–227.PubMedCrossRefGoogle Scholar
  49. Light, K. C., Koepke, J. P., Obrist, P. A., & Willis, P. J., IV. (1983). Psychological stress induces sodium and fluid retention in man at high risk for hypertension. Science, 220, 429–431.PubMedCrossRefGoogle Scholar
  50. Linden, W. (1984). Psychological perspective of essential hypertension: Etiology, maintenance and treatment. Basel/New York: S. Karger.Google Scholar
  51. Linden, W., & Feuerstein, M. (1983). Essential hypertension and social coping behavior: Experimental findings. Journal of Human Stress, 9, 22–31.PubMedCrossRefGoogle Scholar
  52. Linden, W., & Frankish, J. (1984). Cardiovascular reactivity as a function of a repressive psychometric pattern. Paper presented at the annual meeting of the American Psychological Association, Toronto.Google Scholar
  53. Louis, W. J., Doyle, A. E., & Anavekar, S. (1973). Plasma norepinephrine levels in essential hypertension. New England Journal of Medicine, 288, 599–601.PubMedCrossRefGoogle Scholar
  54. Luborsky, L., Crits-Christoph, P., Brady, J. P., Kron, R. E., Weiss, T., Cohen, M., & Levey, L. (1982). Behavioral versus pharmacological treatments for essential hypertension-A needed comparison. Psychosomatic Medicine, 44, 203–213.PubMedGoogle Scholar
  55. MacDougall, J. M., Dembroski, T. M., Dimsdale, J. E., & Hackett, T. P. (1985). Components of Type A, hostility and anger: Further relationships to angiographic findings. Health Psychology, 4, 137–152.PubMedCrossRefGoogle Scholar
  56. Maland, L. J., Lutz, L. J., & Castle, C. H. (1983). Effects of withdrawing diuretic therapy on blood pressure in mild hypertension. Hypertension, 5, 539–544.PubMedGoogle Scholar
  57. Mancia, G., Ferrari, A., Gregorini, L., Ludrouk, J., & Zanchetti, A. (1978). Baroreceptor control of heart rate in man. In P. J. Schwartz, A. J. Brown, A. Malliani, & A. Zanchetti (Eds.), Neural mechanisms in cardiac arrhythmias. New York: Raven Press.Google Scholar
  58. Manuck, S. B. Kaplan, J. R., & Clarkson, T. B. (1983). Behaviorally induced heart rate reactivity and atherosclerosis in cynomolgus monkeys. Psychosomatic Medicine, 45, 95–108.PubMedGoogle Scholar
  59. Matthews, K. A., Glass, D. C., Rosenuran, R. H., & Bortner, R. W. (1977). Competitive drive, pattern A, and coronary heart disease: A further analysis of some data from the Western Collaborative Group Study. Journal of Chronic Diseases, 30, 489–498.PubMedCrossRefGoogle Scholar
  60. McCubbin, J. W., Green, J. H., & Page, I. H. (1956). Baroreceptor function in chronic renal hypertension. Circulation Research, 4, 205–210.PubMedGoogle Scholar
  61. Meyer, D., Leventhal, H., & Gutmann, M. (1985). Common sense models of illness: The example of hypertension. Health Psychology, 4, 115–136.PubMedCrossRefGoogle Scholar
  62. Miller, R. E., Shapiro, A. P., King, H. E., Gincherean, E. H., & Hosutt, J. A. (1984). Effect of antihypertensive treatment on the behavioral consequences of elevated blood pressure. Hypertension, 6, 202–208.PubMedGoogle Scholar
  63. Moehring, J., Moehring, B., Petri, M., Haack, D., & Hackenthal, E. (1975). Studies on the pathogenisis of malignant hypertension in rats. Kidney International, 8, 174.Google Scholar
  64. Morrison, R. L., Bellack, A. S., & Manuck, S. B. (1985). Role of social competence in borderline essential hypertension. Journal of Consulting and Clinical Psychology, 53, 248–255.PubMedCrossRefGoogle Scholar
  65. Sapira, J. D., Scheib, E. T., Moriarty, R., & Shapiro, A. P. (1971). Difference in perception between hypertensive and normotensive populations. Psychosomatic Medicine, 33, 239–250.Google Scholar
  66. Pennebaker, J. W. (1982). The psychology of physical symptoms. New York: Springer-Verlag.CrossRefGoogle Scholar
  67. Sapira, J. D., Scheib, E. T., Moriarty, R., & Shapiro, A. P. (1971). Difference in perception between hypertensive and normotensive populations. Psychosomatic Medicine, 33, 239–250.PubMedGoogle Scholar
  68. Schwartz, G. E. (1976). Self-regulation of response patterning: Implications for psychophysiological research and therapy. Biofeedback and Self-Regulation, 1, 7–30.PubMedCrossRefGoogle Scholar
  69. Seer, P. (1979). Psychological control of essential hypertension: Review of the literature and methodological critique. Psychological Bulletin, 86, 1015–1043.PubMedCrossRefGoogle Scholar
  70. Shapiro, A. P., Schwartz, G. E., Ferguson, D. L. E., Redmond, D. P., & Weiss, S. (1977). Behavioral methods in the treatment of hypertension. A review of their clinical status. Annals of Internal Medicine, 86, 626–636.Google Scholar
  71. Shekelle, R. B., Gale, M., Ostfeld, A. M., & Paul, D. (1983). Hostility, risk of coronary heart disease, and mortality. Psychosomatic Medicine, 45, 109–114.PubMedGoogle Scholar
  72. Shimada, K., Kitazumi, T., Sadakane, N., Ogura, H., & Ozawa, T. (1985). Age-related changes of baroreflex function, plasma norepinephrine, and blood pressure. Hypertension, 7, 113–117.PubMedGoogle Scholar
  73. Sleight, P., Robinson, J. L., Brooks, D. E., & Rees, P. M. (1975). Carotid baroreceptor resetting in the hypertensive dog. Clinical Science and Molecular Medicine Supplementary, 2, 261–263.Google Scholar
  74. Smithwick, R. H., & Robertson, G. W. (1973). Survival rates following splanchnicectomy for essential and malignant hypertension. In G. Onesti, K. E. Kim, & J. H. Moyer (Eds.), Hypertension: Mechanisms and management (pp. 847–865 ). New York: Grune & Stratton.Google Scholar
  75. Southam, M. A., Agras, W. S., Taylor, C. B., & Kraemer, H. C. (1982). Relaxation training: Blood pressure lowering during the working day. Archives of General Psychiatry, 39, 715–717.PubMedCrossRefGoogle Scholar
  76. Swales, J. (1980). Dietary salt and hypertension. Lancet, 1, 1177–1179.PubMedCrossRefGoogle Scholar
  77. Thailer, S. A., Friedman, R., Harshfield, G. A., & Pickering, T. G. (1985). Psychological differences between high, normal, and low reran hypertension. Psychosomatic Medicine, 47, 294–297.PubMedGoogle Scholar
  78. Thomas, G. W., Ledingham, J. G., & Beilin, L. J. (1976). Renin responses to intravenous Irusemide in essential hypertension. Clinical Science and Molecular Medicine, 50, 19 p.Google Scholar
  79. Veterans Administration Cooperative Study Group on Antihypertensive Agents. (1970). Effects of treatment on morbidity in hypertension. Part 2. Journal of the American Medical Association, 213, 1143–1152.CrossRefGoogle Scholar
  80. Veterans Administration Cooperative Study Group on Antihypertensive Agents. (1972). Effects of treatment on morbidity in hypertension. Part 3. Circulation, 45, 991–1004.Google Scholar
  81. Walker, J. R., & Guyton, A. C. (1967). Influence of blood oxygen saturation on pressureflow curve of dog hindleg. American Journal of Physiology, 212, 506–509.PubMedGoogle Scholar
  82. Weinstein, M. L., & Stason, W. B. (1976). Hypertension: A policy perspective. Cambridge, MA: Harvard University Press.Google Scholar
  83. Wilber, J. A., & Barrow, J. C. (1972). Hypertension: A community problem. American Journal of Medicine, 52, 653–663.PubMedCrossRefGoogle Scholar
  84. Wilkie, F., & Eisdorfer, C. (1971). Intelligence and blood pressure in the aged. Science, 172, 959–962.PubMedCrossRefGoogle Scholar
  85. Williams, R. B., Haney, T. L., Lee, K. A., Wong, Y., Blumenthal, J. A., & Whalen, R. E. (1980). Type A behavior, hostility, and coronary atherosclerosis. Psychosomatic Medicine, 42, 539–549.PubMedGoogle Scholar
  86. Williams, R. B., Barefoot, J. C., & Shekelle, R. B. (1985). The health consequenes of hostility. In M. A. Chesney, S. E. Goldston, Sr R. H. Rosenman (Eds.), Anger, hostility and behavioral medicine. New York: Hemisphere/McGraw-Hill.Google Scholar
  87. Wilson, N. V., & Meyer, B. M. (1981). Early prediction of hypertension using exercise blood pressure. Preventive Medicine, 10, 62–68.PubMedCrossRefGoogle Scholar
  88. Wood, D. L., Sheps, S. G., Elveback, L. R., & Schirger, A. (1984). Cold pressor test as a predictor of hypertension. Hypertension, 6, 301–306.PubMedGoogle Scholar

Copyright information

© Plenum Press, New York 1988

Authors and Affiliations

  • Wolfgang Linden
    • 1
  1. 1.Department of PsychologyUniversity of British ColumbiaVancouverCanada

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