0
November 24, 1993, Vol 270, No. 20 >
ARTICLE | November 24, 1993

Psychological Predictors of Hypertension in the Framingham Study: Title and subTitle BreakIs There Tension in Hypertension? FREE

Jerome H. Markovitz, MD, MPH; Karen A. Matthews, PhD; William B. Kannel, MD; Janet L. Cobb, MPH; Ralph B. D'Agostino, PhD
[+] Author Affiliations

Presented in part at the American Heart Association Council on Epidemiology and Prevention, Santa Fe, NM, March 18, 1993.

Reprint requests to Division of Preventive Medicine, The University of Alabama School of Medicine, 1717 11th Ave S, Seventh Floor, Birmingham, AL 35205 (Dr Markovitz).


JAMA. 1993;270(20):2439-2443. doi:10.1001/jama.1993.03510200045030
Text Size: A A A
Published online
Article
References

Objective.  —To test the hypothesis that heightened anxiety, heightened anger intensity, and suppressed expression of anger increase the risk of hypertension, using the Framingham Heart Study.

Design.  —A cohort of men and women without evidence of hypertension at baseline were followed up for 18 to 20 years. Baseline measures of anxiety (tension), anger symptoms, and expression of anger (anger-in and anger-out) were taken, along with biological and behavioral predictors of hypertension (initial systolic blood pressure, heart rate, relative weight, age, hematocrit, alcohol intake, smoking, education, and glucose intolerance).

Participants.  —A total of 1123 initially normotensive persons (497 men, 626 women) were included. Analyses were stratified by age (45 to 59 or ≥60 years) and gender.

Main Outcome Measures.  —Hypertension was defined as either taking medication for hypertension or blood pressures higher than 160/95 mm Hg at a biennial examination.

Results.  —In univariate analyses, middle-aged men who went on to develop hypertension had greater baseline anxiety levels than men who remained normotensive (P=.04). Older hypertensive men had fewer anger symptoms at baseline (P=.04) and were less likely to hold their anger in (P=.01) than normotensives. In multivariate Cox regression analysis including biological predictors, anxiety remained an independent predictor of hypertension in middle-aged men (P=.02). Among older men, anger symptoms and anger-in did not remain significant predictors in the multivariate analysis. Further analysis showed that only middle-aged men with very high levels of anxiety were at increased risk (relative risk, 2.19; 95% confidence interval, 1.22 to 3.94). No psychological variable predicted hypertension in middle-aged or older women in either univariate or multivariate analyses.

Conclusions.  —The results indicate that among middle-aged men, but not women, anxiety levels are predictive of later incidence of hypertension.(JAMA. 1993;270:2439-2443)

REFERENCES

1 +
Alexander F.  Emotional factors in essential hypertension. Psychosom Med . 1939;;1:175-179.
2 +
Diamond EL.  The role of anger and hostility in essential hypertension and coronary heart disease. Psychol Bull . 1982;;92:410-435.
3 +
Sommers-Flanagan J, Greenberg RP.  Psychosocial variables and hypertension: a new look at an old controversy. J Nerv Ment Dis . 1989;;177:15-24.
4 +
Kahn HA, Medaalie JH, Neufeld HN, Riss E, Goldbourt U.  The incidence of hypertension and associated factors: the Israeli Ischemic Heart Disease Study. Am Heart J . 1972;;84:171-182.
5 +
Rose RM, Jenkins CD, Hurst MW. Air Traffic Controller Health Change Study: A Prospective Investigation of Physical, Psychological and Work-Related Changes . Boston, Mass: Boston University School of Medicine; 1978;. A report to the Federal Aviation Administration on research performed under contract DCT-FA73WA-3211.
6 +
McCelland DC.  Inhibited power motivation and high blood pressure in men. J Abnorm Psychol . 1979;;88:182-190.
7 +
Jenkins CD, Sooervell PD, Hames CG.  Does blood pressure rise with age?... or with stress? J Hum Stress . 1983;;9:4-12.
8 +
Sparrow D, Garvey AJ, Rosner B, Thomas HE.  Factors in predicting blood pressure change. Circulation . 1982;;65:789-794.
9 +
Pernini C, Muller FB, Buhler FR.  Suppressed aggression accelerates early development of essential hypertension. J Hypertens . 1991;;9:499-503.
10 +
Markovitz JH, Matthews KA, Wing RR, Kuller LH, Meilahn EN.  Psychological, health behavior, and biological predictors of blood pressure change in middle-aged women. J Hypertens . 1991;;9:399-406.
11 +
Haynes SG, Levine S, Scotch N, Feinleib M, Kannel WB.  The relationship of psychosocial factors to coronary heart disease in the Framingham Study, I: methods and risk factors. Am J Epidemiol . 1978;;107:362-383.
12 +
SHEP Cooperative Research Group.  Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA . 1991;;265:255-264.
13 +
Staessen J, Amery A, Fagard R.  Isolated systolic hypertension in the elderly. J Hypertens . 1990;; 8:393-405.
14 +
Eaker ED, Pinsky J, Castelli WP.  Myocardial infarction and coronary death among women: psychosocial predictors from a 20-year follow-up of women in the Framingham Study. Am J Epidemiol . 1992;;135:854-864.
15 +
Matthews HA, Kelsey SF, Meilahn EN, Kuller LH, Wing RR.  Educational attainment and behavioral and biological risk factors for coronary heart disease in middle-aged women. Am J Epidemiol . 1989;;129:1132-1144.
16 +
Pernini C, Muller FB, Buhler FR.  Suppressed aggression and hyperdynamic cardiovascular regulation in normotensive offspring of essential hypertensive patients. J Cardiovasc Pharmacol . 1988;; 12( (suppl 3) ):S130-S133.
17 +
Schneider RH, Egan BM, Johnson EH, Drobny H, Julius S.  Anger and anxiety in borderline hypertension. Psychosom Med . 1986;;48:242-248.
18 +
Pernini C, Mailer FB, Rauchfleisch U, Battegay R, Hobi V, Buhler FR.  Psychosomatic factors in borderline hypertensive subjects and offspring of hypertensive parents. Hypertension . 1990;;16:627-634.
19 +
Goldstein HS, Edelbery R, Meier CF, Davis L.  Relationship of resting blood pressure and heart rate to experienced anger and expressed anger. Psychosom Med . 1988;;50:321-329.
20 +
Spielberger CD, Johnson EH, Russell SF, Crane RJ, Worden TJ.  The experience and expression of anger.  In: Chesney MA, Rosenman RH. Anger and Hostility in Cardiovascular and Behavioral Disorders . Washington, DC: Hemisphere/McGraw Hill; 1985;:5-30.
21 +
Irvine MJ, Gaaner DM, Olmsted MP, Logan AG.  Personality differences between hypertensives and normotensive individuals: influence of knowledge of hypertension diagnosis. Psychosom Med . 1989;;51:537-549.
22 +
Rostrup M, Ekbery O.  Awareness of high blood pressure influences in psychological and sympathetic responses. J Psychosom Res . 1992;;36:117-123.
23 +
Robbins MA, Elias MF, Schultz NR.  The effects of age, blood pressure, and knowledge of hypertensive diagnosis in anxiety and depression. Aging Res . 1990;;16:199-207.
24 +
Intersalt Cooperative Research Group.  Intersalt: an international study of electrolyte excretion and blood pressure: results for 24 hour urinary sodium and potassium excretion. BMJ . 1988;;297: 319-328.
25 +
Langford HG.  Potassium and its role in the etiology and therapy of hypertension.  In: Blaufox MD, Langford HG. Bibliotheca Cardiologica: Non-Pharmacologic Therapy of Hypertension . Basel, Switzerland: S Karger AG; 1987;;41:57-68.
26 +
Havlik RJ, Garrison RJ, Feinleib M, Padgett S, Castelli WP, McNemara PM.  Evidence for additional blood pressure correlates in adults 20-56 years old. Circulation . 1980;;61:710-715.
27 +
Reaven GM, Hoffman BB.  A role for insulin in the aetiology and course of hypertension? Lancet . 1987;;2:435-437.
28 +
Yalow RS, Rose HG, Bauman WA.  Hyperinsulinemia. Am J Med . 1988;;85( (suppl A) ):22-30.
29 +
Henry JP.  Stress, salt, and hypertension. Soc Sci Med . 1988;;26:293-302.
30 +
Miller SB.  Affective moderators of the cardiovascular response to stress in offspring of hypertensives. J Psychosom Res . 1992;;36:149-157.
31 +
Katon W.  Panic disorder: epidemiology, diagnosis, and treatment in primary care. J Clin Psychiatry . 1986;;10( (suppl) ):21-27.
32 +
Wells KB, Golding JM, Burnam MA.  Affective, substance use, and anxiety disorders in persons with arthritis, diabetes, heart disease, high blood pressure, or chronic lung conditions. Gen Hosp Psychiatry . 1989;;11:320-327.
33 +
Wells KB, Golding JM, Burnam MA.  Chronic medical conditions in a sample of the general population with anxiety, affective and substance use disorders. Am J Psychiatry . 1989;;146:1440-1446.
34 +
Noyes R, Clancy J, Hoenk PR, Slymen DJ.  Anxiety neurosis and physical illness. Comp Psychiatry . 1978;;19:407-413.
35 +
Jacob RG, Chesney MA, Williams DM, Ding Y, Shapiro AP.  Relaxation therapy for hypertension: design effects and treatment effects. Ann Behav Med . 1991;;13:5-17.
36 +
Spielberger CD, Gorsuch RL, Lushene RE. STAI Manual for the State-Trait Anxiety Inventory . Palo Alto, Calif: Consulting Psychologists Press; 1970;.
37 +
Wadden TA.  Predicting treatment response to relaxation therapy for essential hypertension. J Nerv Ment Dis . 1983;;171:683-689.
38 +
Cottier C, Shapiro K, Julius S.  Treatment of mild hypertension with progressive muscle relaxation. Arch Intern Med . 1984;;144:1954-1958.
39 +
Blanchard FB, McCoy CC, Berger M, et al.  A controlled comparison of thermal biofeedback and relaxation training in the treatment of essential hypertension, IV: prediction of short-term clinical outcome. Behav Ther . 1989;;20:405-415.
40 +
McGrady A, Higgins JT.  Prediction of response to biofeedback-assisted relaxation in hypertensives: development of a hypertensive predictor profile (HYPP). Psychosom Med . 1989;;51:277-284.
41 +
Egan KJ, Ban HN, Garber A, Jarrett M.  The impact of psychological distress on the control of hypertension. J Hum Stress . 1983;;9:4-10.
42 +
Roberts J, Rowland M.  Hypertension in adults 25-74 years of age: United States 1971-1975. Vital Health Stat 11 . 1981;;No. (221) .
43 +
Johnson EH, Schork NJ, Spielberger CD.  Emotional and familial determinants of elevated blood pressure in black and white adolescent females. J Psychosom Res . 1987;;31:731-741.
44 +
Anderson NB, Myers HF, Pickering T, Jackson JS.  Hypertension in blacks: psychosocial and biological perspectives. J Hypertens . 1989;;7:161-172.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Alexander F.  Emotional factors in essential hypertension. Psychosom Med . 1939;;1:175-179.
2 +
Diamond EL.  The role of anger and hostility in essential hypertension and coronary heart disease. Psychol Bull . 1982;;92:410-435.
3 +
Sommers-Flanagan J, Greenberg RP.  Psychosocial variables and hypertension: a new look at an old controversy. J Nerv Ment Dis . 1989;;177:15-24.
4 +
Kahn HA, Medaalie JH, Neufeld HN, Riss E, Goldbourt U.  The incidence of hypertension and associated factors: the Israeli Ischemic Heart Disease Study. Am Heart J . 1972;;84:171-182.
5 +
Rose RM, Jenkins CD, Hurst MW. Air Traffic Controller Health Change Study: A Prospective Investigation of Physical, Psychological and Work-Related Changes . Boston, Mass: Boston University School of Medicine; 1978;. A report to the Federal Aviation Administration on research performed under contract DCT-FA73WA-3211.
6 +
McCelland DC.  Inhibited power motivation and high blood pressure in men. J Abnorm Psychol . 1979;;88:182-190.
7 +
Jenkins CD, Sooervell PD, Hames CG.  Does blood pressure rise with age?... or with stress? J Hum Stress . 1983;;9:4-12.
8 +
Sparrow D, Garvey AJ, Rosner B, Thomas HE.  Factors in predicting blood pressure change. Circulation . 1982;;65:789-794.
9 +
Pernini C, Muller FB, Buhler FR.  Suppressed aggression accelerates early development of essential hypertension. J Hypertens . 1991;;9:499-503.
10 +
Markovitz JH, Matthews KA, Wing RR, Kuller LH, Meilahn EN.  Psychological, health behavior, and biological predictors of blood pressure change in middle-aged women. J Hypertens . 1991;;9:399-406.
11 +
Haynes SG, Levine S, Scotch N, Feinleib M, Kannel WB.  The relationship of psychosocial factors to coronary heart disease in the Framingham Study, I: methods and risk factors. Am J Epidemiol . 1978;;107:362-383.
12 +
SHEP Cooperative Research Group.  Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension: final results of the Systolic Hypertension in the Elderly Program (SHEP). JAMA . 1991;;265:255-264.
13 +
Staessen J, Amery A, Fagard R.  Isolated systolic hypertension in the elderly. J Hypertens . 1990;; 8:393-405.
14 +
Eaker ED, Pinsky J, Castelli WP.  Myocardial infarction and coronary death among women: psychosocial predictors from a 20-year follow-up of women in the Framingham Study. Am J Epidemiol . 1992;;135:854-864.
15 +
Matthews HA, Kelsey SF, Meilahn EN, Kuller LH, Wing RR.  Educational attainment and behavioral and biological risk factors for coronary heart disease in middle-aged women. Am J Epidemiol . 1989;;129:1132-1144.
16 +
Pernini C, Muller FB, Buhler FR.  Suppressed aggression and hyperdynamic cardiovascular regulation in normotensive offspring of essential hypertensive patients. J Cardiovasc Pharmacol . 1988;; 12( (suppl 3) ):S130-S133.
17 +
Schneider RH, Egan BM, Johnson EH, Drobny H, Julius S.  Anger and anxiety in borderline hypertension. Psychosom Med . 1986;;48:242-248.
18 +
Pernini C, Mailer FB, Rauchfleisch U, Battegay R, Hobi V, Buhler FR.  Psychosomatic factors in borderline hypertensive subjects and offspring of hypertensive parents. Hypertension . 1990;;16:627-634.
19 +
Goldstein HS, Edelbery R, Meier CF, Davis L.  Relationship of resting blood pressure and heart rate to experienced anger and expressed anger. Psychosom Med . 1988;;50:321-329.
20 +
Spielberger CD, Johnson EH, Russell SF, Crane RJ, Worden TJ.  The experience and expression of anger.  In: Chesney MA, Rosenman RH. Anger and Hostility in Cardiovascular and Behavioral Disorders . Washington, DC: Hemisphere/McGraw Hill; 1985;:5-30.
21 +
Irvine MJ, Gaaner DM, Olmsted MP, Logan AG.  Personality differences between hypertensives and normotensive individuals: influence of knowledge of hypertension diagnosis. Psychosom Med . 1989;;51:537-549.
22 +
Rostrup M, Ekbery O.  Awareness of high blood pressure influences in psychological and sympathetic responses. J Psychosom Res . 1992;;36:117-123.
23 +
Robbins MA, Elias MF, Schultz NR.  The effects of age, blood pressure, and knowledge of hypertensive diagnosis in anxiety and depression. Aging Res . 1990;;16:199-207.
24 +
Intersalt Cooperative Research Group.  Intersalt: an international study of electrolyte excretion and blood pressure: results for 24 hour urinary sodium and potassium excretion. BMJ . 1988;;297: 319-328.
25 +
Langford HG.  Potassium and its role in the etiology and therapy of hypertension.  In: Blaufox MD, Langford HG. Bibliotheca Cardiologica: Non-Pharmacologic Therapy of Hypertension . Basel, Switzerland: S Karger AG; 1987;;41:57-68.
26 +
Havlik RJ, Garrison RJ, Feinleib M, Padgett S, Castelli WP, McNemara PM.  Evidence for additional blood pressure correlates in adults 20-56 years old. Circulation . 1980;;61:710-715.
27 +
Reaven GM, Hoffman BB.  A role for insulin in the aetiology and course of hypertension? Lancet . 1987;;2:435-437.
28 +
Yalow RS, Rose HG, Bauman WA.  Hyperinsulinemia. Am J Med . 1988;;85( (suppl A) ):22-30.
29 +
Henry JP.  Stress, salt, and hypertension. Soc Sci Med . 1988;;26:293-302.
30 +
Miller SB.  Affective moderators of the cardiovascular response to stress in offspring of hypertensives. J Psychosom Res . 1992;;36:149-157.
31 +
Katon W.  Panic disorder: epidemiology, diagnosis, and treatment in primary care. J Clin Psychiatry . 1986;;10( (suppl) ):21-27.
32 +
Wells KB, Golding JM, Burnam MA.  Affective, substance use, and anxiety disorders in persons with arthritis, diabetes, heart disease, high blood pressure, or chronic lung conditions. Gen Hosp Psychiatry . 1989;;11:320-327.
33 +
Wells KB, Golding JM, Burnam MA.  Chronic medical conditions in a sample of the general population with anxiety, affective and substance use disorders. Am J Psychiatry . 1989;;146:1440-1446.
34 +
Noyes R, Clancy J, Hoenk PR, Slymen DJ.  Anxiety neurosis and physical illness. Comp Psychiatry . 1978;;19:407-413.
35 +
Jacob RG, Chesney MA, Williams DM, Ding Y, Shapiro AP.  Relaxation therapy for hypertension: design effects and treatment effects. Ann Behav Med . 1991;;13:5-17.
36 +
Spielberger CD, Gorsuch RL, Lushene RE. STAI Manual for the State-Trait Anxiety Inventory . Palo Alto, Calif: Consulting Psychologists Press; 1970;.
37 +
Wadden TA.  Predicting treatment response to relaxation therapy for essential hypertension. J Nerv Ment Dis . 1983;;171:683-689.
38 +
Cottier C, Shapiro K, Julius S.  Treatment of mild hypertension with progressive muscle relaxation. Arch Intern Med . 1984;;144:1954-1958.
39 +
Blanchard FB, McCoy CC, Berger M, et al.  A controlled comparison of thermal biofeedback and relaxation training in the treatment of essential hypertension, IV: prediction of short-term clinical outcome. Behav Ther . 1989;;20:405-415.
40 +
McGrady A, Higgins JT.  Prediction of response to biofeedback-assisted relaxation in hypertensives: development of a hypertensive predictor profile (HYPP). Psychosom Med . 1989;;51:277-284.
41 +
Egan KJ, Ban HN, Garber A, Jarrett M.  The impact of psychological distress on the control of hypertension. J Hum Stress . 1983;;9:4-10.
42 +
Roberts J, Rowland M.  Hypertension in adults 25-74 years of age: United States 1971-1975. Vital Health Stat 11 . 1981;;No. (221) .
43 +
Johnson EH, Schork NJ, Spielberger CD.  Emotional and familial determinants of elevated blood pressure in black and white adolescent females. J Psychosom Res . 1987;;31:731-741.
44 +
Anderson NB, Myers HF, Pickering T, Jackson JS.  Hypertension in blacks: psychosocial and biological perspectives. J Hypertens . 1989;;7:161-172.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Response

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems