354 Coronary Heart Disease and Hypertension
Four areas of Detroit were categorized as •high stressŽ or
•low stressŽ based on socioeconomic status, crime rates, pop-
ulation density, residential mobility, and marital breakup
rates. Researchers found that blood pressure levels were
highest among African American high-stress males, while
Caucasian areas and African American low-stress areas had
comparable blood pressure levels. Krieger and Sidney•s
(1996) data support this “nding and suggest that racism may
be linked to higher blood pressure in African Americans.
However, the simple notion that social stress and cultural
change are causally linked to hypertension has also been
criticized as being inconsistent with other data available
(Syme & Torfs, 1978).
Other research has shown that individuals in highly stress-
ful occupations, such as air traf“c controllers, have over four
times the prevalence of hypertension than age-matched peers
in other less stressful occupations (Cobb & Rose, 1973).
Pickering et al. (1996) found an association between high job
strain (using Karasek•s previously described de“nition) and
ambulatory blood pressure in blue-collar workers. This study
was limited however to males who consumed alcohol. As
with other cardiovascular disorders, hypertension may occur
more frequently in occupations that are demanding yet offer
little opportunity or ”exibility to deal with those stressful de-
mands (Karasek, Russel, & Theorell, 1982).
Personality and Essential Hypertension
Early clinical studies observed that many patients with
chronic hypertension exhibited certain personality traits (e.g.,
Aymann, 1933). Over the years, interest has risen in “nding
which personality traits may play a role in the development
of hypertension. Many traits have been associated with
and/or prospectively predictive of hypertension, including
suppressed anger and hostility (Dunbar, 1943; Johnson,
Gentry, & Julius, 1992), neuroticism and anxiety (Markovitz,
Matthews, Kannel, Cobb, & D•Agostino, 1993), and submis-
siveness (Esler et al., 1977). There has been speculation,
however, over the validity of many of these early “ndings, for
many of the studies used selected or convenience samples
and had other methodological ”aws. In addition, hyperten-
sion may not be a heterogeneous disease, but a number of dis-
orders with differing pathophysiology that progress over
years (Weiner & Sapira, 1987).
Recently, there has been growing research into the role
that the psychological trait of defensiveness might play in hy-
pertension development. Rutledge and Linden (2000) studied
127 initially normotensive male and female adults and
looked for a variety of hypertension risk factors. Three
years later, participants were measured for hypertension and
defensiveness. Twenty percent of patients who were initially
found to be highly defensive had developed hypertension,
while only 4.5% of those with low defensiveness developed
the condition. Statistical adjustment for many general risk
factors (including smoking, exercise levels, alcohol con-
sumption, and body fat) revealed that membership in the
highly defensive group was associated with more than a
sevenfold risk of developing hypertension over the three-
year period.
Various researchers differ in their views of the association
between personality trait differences/emotions and hyperten-
sion. Early investigators (Alexander, 1939; Dunbar, 1943)
and some more recent researchers (Jern, 1987) have hypoth-
esized a causal role for personality traits in the development
of hypertension. Some researchers (Esler et al., 1977; Weder
& Julius, 1987) have postulated mechanisms by which cer-
tain personality traits elicit excessive central and sympathetic
nervous system arousal, predisposing one to hypertension.
Another possibility is that the differences reported on psy-
chological tests between hypertensives and normotensives
are the result of the label and medical attention accompanied
by the diagnosis of hypertension. In support of this latter no-
tion, Irvine, Garner, Olmsted, and Logan (1989) found that
hypertensives who were aware of their condition scored sig-
ni“cantly higher than normotensives and even hypertensives
who were not aware of their condition on measures of
state and trait anxiety, neuroticism, and self-reported Type-A
behavior. However, Markovitz et al. (1993) reported a
prospective relationship between anxiety in apparently
normal individuals and the subsequent development of
hypertension„an association that labeling could not create.Treatment of Essential HypertensionThe goal in treating hypertension, according to guidelines set
forth by consensus committees including the Joint National
Committee on Prevention, Detection, Evaluation, and Treat-
ment of High Blood Pressure (JNC, 1997) and the World
Health Organization-International Society of Hypertension
(WHO-ISH, 1999) is to reduce the risk for cardiovascular dis-
eases and therefore reduce morbidity and mortality. JNC IV
treatment guidelines begin with vigorous lifestyle changes for
those individuals who present with moderate hypertension but
no CVD risk and no organ damage (i.e., renal failure) as a
result of hypertension. Lifestyle changes include weight loss,
increased physical activity, moderation of alcohol consump-
tion, dietary modi“cations, cessation of smoking, and stress
reduction (Carretero & Oparil, 2000b). These lifestyle
changes will be discussed in further detail. If blood pressure
control is not achieved in this population or in those with