356 Coronary Heart Disease and Hypertension
pressures remained unchanged from pretrial. Also, those in
the control group who later underwent the biofeedback bene-
“tted from the treatment, with decreases in overall blood
pressure reading during rest and smaller responses to mental
stressors. The researchers propose that biofeedback may be
especially bene“cial to those who have marked increases in
blood pressure to stress. These techniques are appealing be-
cause they seem to have produced reductions in blood pres-
sure without the use of medications and without any known
side effects.
However, despite some promising “ndings, the results of
other studies and meta-analyzes of an extensive body of re-
search have revealed that the effects of stress management on
hypertension appear to be minimal, and may be attributable
to nonspeci“c effects or habituation to repeated blood pres-
sure measurements over the course of the trials (Dubbert,
1995; Eisenberg et al., 1993; Jacob, Chesney, Williams, &
Ding, 1991). In a very tightly controlled study, Johnston et al.
(1993) studied the effects of stress management on resting
and ambulatory blood pressure and on left ventricular mass
(a clinically signi“cant consequence of hypertension).
Ninety-six individuals with mild hypertension underwent an
extensive baseline evaluation to habituate them to blood pres-
sure measurement. Each was then assigned to either 10 weeks
of stress management and relaxation training or to 10 weeks
of a nonaerobic stretching condition control. The study indi-
cates that blood pressures fell during the habituation period,
but blood pressures remained unchanged during the ambula-
tory and resting phases of treatment. However, patients had
smaller blood pressure increases during a stressful interview
if they had received the stress management training. Thus, the
balance of research indicates that stress management appears
not to be effective in lowering resting blood pressure
(Dubbert, 1995; Eisenberg et al., 1993; Johnston et al., 1993).
Adherence to Treatment
As hypertension is frequently an asymptomatic condition that
requires treatment including modi“cation in lifestyle and/or
expensive medications with side effects (e.g., fatigue, impo-
tence, frequent urination), nonadherence to treatment is a
common problem. Dunbar-Jacob, Wyer, and Dunning (1991)
found fewer than 33% to 66% of patients were complying
with their treatment plans. To improve medication adherence,
the JNC VI recommends health care providers consider the
cost of the medications. Newer drugs are usually more ex-
pensive than the older and more reliable diuretics and beta-
blockers. Also, adherence is improved with once-a-day
drugs. Making and maintaining lifestyle changes is often
dif“cult because long-time habits need to be changed. The
utilization of a team health care approach, community re-
sources (doctors, nurses, nutritionist, physical therapists),
and family to provide long-term assistance in education and
support is bene“cial (JNC VI, 1997).SummaryBehavioral factors that are important in the development of
essential hypertension include obesity, lack of physical exer-
cise, stress, and personality traits such as anger and anxiety.
However, the effectiveness of so-called •cognitiveŽ behav-
ioral intervention techniques, such as stress management and
biofeedback, in lowering blood pressure have been rather
minimal, and many believe, clinically insigni“cant. Behav-
ioral interventions such as weight loss and dietary changes,
which confer direct physiological changes, have proven to
be effective adjuncts to pharmacological interventions for
treating hypertension. Finally, patient nonadherence to anti-
hypertensive medication regimens is a prevalent and very
signi“cant problem that warrants further investigation.CONCLUSIONThere are many environmental, behavioral, and physiological
variables that interact in the development of cardiovascular
disorders. Many of the standard CHD risk factors have im-
portant behavioral components, and increasing evidence sug-
gests important psychosocial risk factors for CHD, including
occupational stress, hostility, and physiologic reactivity to
stress. In cardiac patients, the presence of acute stress, low
social support, lack of economic resources, and psychologi-
cal depression also appear to be important psychosocial risk
factors. The identi“cation of psychosocial risk factors for
coronary disease have led to several promising behavioral
and psychosocial interventions to aid in the treatment and
prevention of coronary disease in high risk individuals.
There also appear to be important biobehavioral in”u-
ences in the development and treatment of essential hyper-
tension. These include obesity, dietary salt intake, and stress.
Evidence also indicates that genetic and environmental fac-
tors interact in the development of hypertension. However,
the modest effects of cognitive stress-reducing techniques
such as relaxation training, biofeedback, and meditation in
lowering blood pressure have proven disappointing. Never-
theless, the important necessity for the involvement of health
psychologists in the treatment of essential hypertension is un-
derscored by the potential ef“cacy of weight loss, dietary
modi“cation, and exercise conditioning, as well as the need
to ensure that patients adhere to medication regimens in order