Cardiovascular Reactivity of Patients With Essential and Renal Hypertension in an Emotion-Triggering Interview

Hans-Christian Deter, MD; Angela Blecher, MD; Cora S. Weber, MD

Blood pressure reactivity to mental stress in hyperten.sives is much higher than in nornwtensives. The authors'aim in this study was to examine whether different cardiovascular responses can he induced hy various stimuli in hypertensive subgroups. The authors matched 10 essential hypertensives (EHs), 10 renal hypertensives (RHs). and 10 normotensives (Ns) according to age and gender, examined them during an emotion-stimulating interx'iew. and measured blood pressure (BP) and heart rate (HR) during the pha.ses ofthe interview. They observed differences in BP reactivity between EHs/RHs and Ns under some stimuli hut not between EHs and RHs. as well as a marked difference in the product of systolic BP (SBP) and HR between both hypertensive groups in the anger/rage phase fp = .028) and the baseline 2 (p = .02). This shows a higher cardiovascular activation under mental stress and a iower recovery in EHs and more sensitivity to perturbation or higher central tension compared with RHs. Index Terms: cardiovascular reactivity, emotion, essential hypertension, interview, renal hypertension

Essential hypertension (EH) has received much attention for many years. Genetic and environmental aspects play a major role in this context.''^ Menial and psychophysiological reactivity may both contribute to the development of EH.'''^ Results from psychosomatic studies have emphasized tbe role of cardiovascular reactivity to mental stress and the social environment as a possible stressor as well as certain personality traits'' that may have a particularly strong influence on the stress experience.^ Substantiated risk factors for EH seem to be an increased reactivity to mental stress and a positive family history of EH compared with tbose without tbis genetic component.** Psychosomatic findings bave repeatedly indicated open or latent personaliDrs Deter. Blecher. and Weber are with fhe Department ofPsychosamalic Medicine ami Psychnlherapy. Chariite Universiidtsmedizin. Bfrlin. Germany. Copyright 2007 Heldref Publications

ty traits, such as increased aggression, anger, and bostility'^iR and have suggested that these traits are associated with increased cardiovascular reactivity during mental stress. Researchers in various studies""'^ have demonstrated that certain emotions trigger blood pressure (BP) reactions. Addressing this issue in tbe present study, we aimed to analyze (I) wbetber emotions, such as aggression and anger, represent a specific stress stimulus for essential hypertensives (EHs), as assumed earlier'*''*''' and (2) whether these emotions are generally observed circulation-activating triggers that occur with the same intensity in normotensives (Ns) and subjects with otber types of hypertension and are therefore not specific in tbe etiopathogenesis of EH.'* Psychological tests to identify anger traits or bostility groups can be done using standardized questionnaires."'' Tbese examinations can also be performed under laboratory conditions by inducing anger and frustration or by stimulating emotions via specific interviewing tecbniques. such

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as tbe anger-recall technique.'^ Tbe interviewing technique bas a long tradition'''-" but bad fallen into some dispute because of unethical arrangements; bowever, this emotiontriggering technique has been revived in recent years because it is far superior to other tecbniques witb regard to the level of beart rate and BP reactions.-' This technique has become establisbed in the testing of 1 or 2 emotions-^ but bas thus far not been able to cover the whole range of several emotional responses, because it is difficult to provoke tbem validly in a sbort time. Zander et al'*^ had attempted tbis in a structured interview and found interesting specific reaction patterns tbat seemed to confirm an emotional reaction specificity in EHs. Stemmler's^^ laboratory findings concerning reaction specificity also indicate an emotional reaction specificity. An earlier study reported that, in contrast to psychosomatic inpatients and controls. EHs had stronger BP reactions in a structured interview witb emotional exposure to rage and anger as well as to questions concerning their occupational situation.^ The question was whether this applies to all hypertensives or only to the specific group of patients witb EH. We wanted to make a more precise analysis of the disease-reactive factors of hypertension by comparing EHs. in whicb environmental factors are repeatedly held responsible for tbe development of tbe disease, with renal hypertensives (RHs), in whom BP increases bave a clearly somatic (ie. nepbrogenic) cause. We speculated that tbis would enable us to differentiate between factors of reactivity to varying stimuli developing from tbe high-pressure disease itself and otber etiopatbological factors caused by tbe social environment or personality. Our aim in tbis study was to examine whether different affects would induce different cardiovascular reactions in EHs and RHs during an emotion-stimulating interview. In accordance with earlier psycbosomatic literature.^''' we expected that EHs would bave (I) stronger BP reactions than RHs and normotensive (N) controls to the rage and anger affect (HI), (2) stronger reactions in a psycbosocial situation triggering negative emotions (H2). and (3) stronger reactions to thoughts about tbeir occupational situation (H3). In a descriptive analysis, we wanted to examine if emotions sucb as anxiety, envy, and grief were effective in triggering a bigber cardiovascular reaction in EHs. METHODS Subjects We conducted tbis study in the Departments of Psycbosomatic Medicine and Nephrology at tbe Charite Campus Benjamin Franklin. Universitatsmedizin Berlin. Tbe study included hypertensive and N patients aged 20 to 60 years; wbo bad a good command of the German lan-

guage; and had no neurological or psychiatric diseases, cardiovascular diseases, otber independent severe organic diseases, or alcohol or drug abu.se. We recruited the RHs from the nephrology consultation service with the following diagnoses; fibromuscular renal arterial stenosis {n = 2) and polycystic kidney disease (n = 8). We selected 10 age- and sex-matcbed EHs from 18 EHs of tbe bypertension clinic at our hospital. We matched 10 of 22 Ns for age and sex recruited through intemal blackboard notices to be included in this study. We obtained tbe internal examination data from tbe patients' medical records, from consultation with the family pbysician, and from anamnestic questionnaires filled out by all patients. The 3 groups consisted of 3 x 7 men and 3 x 3 women witb no significant differences between groups regarding age. body mass index (BMI), and occupational status (Table 1) or smoking and sports activities. Compared witb the RH group, tbe EH group reported stronger subjective stress reactions, more frequent occupational activities, and longer durations of hypertension. RHs smoked more frequently, participated in more sports, and possessed more family histories of cardiovascular diseases than did tbe EHs. Mean serum creatinine and target organ damage were comparable between EHs and RHs. None of tbe patients had taken any medication 24 hours before the test. Seven in eacb hypertensive group took antibypertensive drugs before tbe test, wbich were: EH group calcium antagonists (4), diuretics (2). and ACE (angiotension converting enzyme) inhibitors (5) and RH groupcalcium antagonists (6), diuretics (2), and ACE inhibitors (2). A Ionger interruption of drug administration would have been ethically unjustifiable. Thus, we performed tbe study despite antihypertensive tberapy because the 2 groups received comparable medication, witb tbe exception of ACE inhibitors. It was not expected tbat reactions to the provoked affects would be systematically distorted by possible side effects of the drugs. Study Design After filling out psycbological questionnaires, we performed a first baseline and a standardized mental stress examination (results not reported here). After a 15-minute resting period and measurement of initial baseline values, we subjected patients to a structured .'iO-minute interview tbat addressed the following areas in a random order: complaints, occupational situation, life situation in which anger and rage were experienced, partnership, life situation in whicb anxiety was experienced, life situation in wbicb envy was experienced, life situation in which grief was experi-

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enced, life situation with a strong feeling of well-being, and the most important negative affect triggered by a stressful psycbosocial situation. Tbe second resting period, duration 3 minutes, started after tbe end of the interview. HCD. an experienced scientist and physician trained in depth psychology, conducted tbe interview, recorded it on sound carrier, and transcribed it. We tben blinded the transcripts (without knowledge of the physiological data). Two raters, members of tbe research group, independently defmed tbe 9 sections in the transcripts and we discussed and coordinated the differences. We subsequently assessed the individual sections of the transcripts witb respect to BP and HR. Measuring Instruments During the interview, we recorded HRs using a bipolar extremity lead in a .standard electrocardiogram (ECG). We measured BP at 1-minute intervals using an automatically inflatable cuff placed over tbe bracbial artery of tbe left arm. We recorded BP witb Bosomat 11 (Boscb and Son. Jungingen. Germany, wbicb were validated and used in former studies'); we recorded the ECG with an amplifier (Scbwarz: Munich. Germany) on registration paper and with an electronic evaluation program (Par Electronics: Berlin, Germany). Statistical Methods Because of the low sample size in this first pilot study in which we examined cardiovascular reactivity in EH and RH, we did not apply multivariate testing but instead focused on tbe bypotbesis derived from tbe literature. We calculated tbe BP differences between tbe 3 groups with tbe H test (Kruskal-Wallis test) for tbe tbree samples. We caicuiated the differences in mm Hg between baseline

systolic BP (SBP) and diastolic BP (DBP) and SBP and DBP in tbe individual phases of tbe interview. We recorded BP as well as HR and tbe product of HR and SBP We calculated tbe differences between 2 unrelated samples with Mann-Whitney's V test. Tbe significance level was p < .05 for the 3 hypotheses and, as adjustment for multiple comparisons (Bonferroni), p < .02 for tbe 3 fields of tbe descriptive analysis and p < .01 for the other variables. RESULTS EH compared witb RH had higher initial SBP, but comparable DBP before the experiment (difference not significant). We obtained these initial baseline values. Baseline 1 SBP: EH = 156.5; RH = 143.9; N = 125.6; DBP: EH = 103.3; RH = 98.3; N = 84.9 mm Hg, (Table 1), prior to completing tbe standardized mental stress examination (data not reported bere). The BP values did not return to this level in tbe subsequent interview. Wben starting tbe interview, BP levels for EHs and RHs were not statistically different, SBP: EHs = 165.5: RHs = 164.3; Ns = 129.9; DBP: EHs = 108.4; RHs = 110.2; Ns = 87.8 mm Hg. SBP and DBP increased strongly during the interview. The mean maximal SBP increase per phase was 30.2 mm Hg for EHs, as bigb as 44.7 mm Hg for RHs, and 28.6 mm Hg in Ns (Table 2). DBP increased by 23.9 mm Hg in EHs. by 26.1 mm Hg in RHs. and by 19.0 mm Hg in Ns. Tbe intragroup comparison of values in the interview situation and the initial baseline yielded significant to highly significant values for all groups in each interview pbase. As we had assumed, there were no statistically significant differences in SBP and DBP behavior between RHs and EHs witb respect to anger/rage (HI), psychosocial sit-

TABLE 1. General Patient Characteristics Essential hypertensives {n = 10) Characteristic Age Body Mass Index Sex Male Female Occupation Worker Employee/civil servant Unemployed/student/reiiree
n M

SD

Renal hypertension (n = 10) n M SD 41.6 24.6 7 3 9.8 3.5

Normotensives (n = 10) n M SD 43.0 24.5 7 3 0 6 4 10.2 2.4

44.8 25.9 7 3 1 7 2

9.7 2.6

0
5

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TABLE 2. Blood Pressure in Essential Hypertensives (EHs), Renal Hypertensives (RHs), and Normotensives (Ns) During the Individual Phases of the Interview

EHs
Interview phase M SD M

RHs SD M

Ns SD

Systolic blood pressure (mm Hg) Initial baseline Start of interview Complaints Occupation Anger/rage Partnership Anxiety Envy Grief Well-being Strong negative emotion End baseline 156.5 165.6 180.4 180.6 188.8 180.2 181.1 184.5 188.3 183.4 182.8 174.6 20.5 27.2 24.1 17.8 22.7 18.8 17.8 27.9 23.3 25.6 19.6 16.2 Dialostic 11.9 14.1 13.5 10.8 12.1 10.1 13.5 14.1 143.9 164.3 173.5 179.5 182.7 183.5 183.9 186.2 184.2 188.6 184.0 168.8 11.6 10.6 15.7 13.6 18.4 21.3 19.7 25.3 18.3 15.7 17.5 16.2 125.6 129.9 141.3 150.8 154.2 154.4 150.3 149.0 149.8 151.9 184.0 140.9 15.4 20.9 19.4 16.2 20.0 23.4 20.7 21.9 18.9 20.5 17.5 17.0

initial baseline Start of interview Complaints Occupation Anger/rage Partnership Anxiety Envy Grief Well-being Strong negative emotion End baseline

103.3 108.4 119.4 120.1 127.0 120.6 120.8 126.3 128.1 123.8 125.6 113.4

n.o
13.1 12.1 10.7

blood pre.ssure (mm Hg) 98.3 11.6 84.9 110.2 14.5 87.8 119.2 10.5 97.7 121.3 11.8 101.4 119.8 13.3 101.2 123.5 13.8 104.8 119.8 10.8 102.1 119.8 14.5 99.7 120.5 16.4 103.3 125.4 19.0 103.9 122.7 15.5 102.9 110.2 10.9 92.9

12.3 II.3 11.5 12.3 12.6 12,2 11.7 10.7 8.8 15.3 9.1 8.9

Initial baseline Start of interview Complaints Occupation Anger/rage Partnership Anxiety Envy Grief Well-being Strong negative emotion End baseline

84.7 88.6 92.9 93.6 93.6 92.3 91.0 90.4 90.1 88.0 91.9 83.5
10.

17.3 16.5 U.I 11.6 11.2 11.2 10.1 12.3 9.9 11.7 10.8 10.7

Heart rate (bpm) 76.0 15.9 72.4 12.4 80.6 15.0 80.1 16.3 80.8 14.6 79,4 13.5 77.4 14.7 78.1 14.7 78.0 12.9 79.7 12.1 79.9 15.9 71.2 12.2

72.8 72.7 74.1 75.9 75.2 75.2 74.8 76.4 76.9 73.3 74.8 69.8

12.2 10.7 13.3 13.6 12.7 12.7 12.2 10.8 14.7 11.9 12.8 11.5

Note. EUs: n = iO;RHs:n=]O; Ns:n=

uation triggering negative emotions (H2), and occupational situation (H3). In these areas, mean reactions compared with baseline I were higher in RHs than in EHs.

In contrast to our expectations, RHs had stronger SBP reactions than did EHs at the start of the interview {p = .046) and in the situations that stimulate anxiety (p = .052)

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and well-being (p = .08), DBP reactivity did not differ significuntly between the 3 groups; EHs reacted (as a statistic tendency) stronger than did Ns in the phase focusing on feelings of anger/rage. EHs versus Ns, p = .09] (Table 3). EHs had the highest and RHs the second highest initial HR values {Table 2). We found this succession in all interview phases except the starting one. in which Ns had slightly higher values than did RHs. As anticipated, EHs had the highest values for anger/rage and occupation but not for the psychosocial situation triggering negative emotions. Likewise, RHs had also the strongest reaction (on a lower level) to anger/rage, whereas Ns had the highest values for envy and grief. In all 3 groups, the HR dropped below the initial level at the end of the interview, with the least marked decrease for EHs.

We also examined whether the product on SBP and HR induced by the items discussed in the interview (anger/rage, psychosocial situation triggering negative emotions, and occupation) was stronger in EHs than it was in RHs (Figure 1). The 3 samples could be clearly differentiated by the absolute values of this variable. EHs had the highest initial and final values, which clearly exceeded those of the other 2 groups during the entire interview. RH had higher initial and final values than did Ns in all interview phases. In contrast to Ns, EHs and RHs had clearly increa.sed values in the course ofthe interview and a steep decline thereafter. However, the values in all 3 groups remained above the initial level. We found significant differences between the 3 groups in all interview areas including initial and the baseline after the interview. The differences between the 2

TABI.K 3, Systolic and Diastulic Blood Pressure Differences to Initial Baseline in Essential Hypertensivei (KHs), Renal Hyperten.sives (RHs), and Normotensives (Ns; Controls) Ns (" = iO) Interview phase M SD EHs (n = 10) M SD Systolic 9.1 23.9 25.3 28.5 24.8 24.6 28.4 30.2 29.2 26.3 18.1 Diastolic 5.7 17.5 20.5 21.9 20.4 18.4 21.9 23.0 20.5 22.2 9.8 RHs (n = 10) M SD

Ns/EHs
p*

Ns/RHs EHs/RHs
p* p*

Start ai interview Complaints H3: Occupation HI: Anger/rage Partnership Anxiety Envy Grief Well-being H2: Strong negative emotion End baseline

4.6 15.7 25.2 28.6 27.1 24.7 24.3 24.2 26.3 26.2 \5.:i

10.8 13,3 10.6 13.1 14.6 16.2 15.7 14.8 13.6 13.1 10.8

blood pressure differences (nun Hg) 12.5 14.4 NS 8.9 12.6 29.6 8.0 NS 15.4 35.6 6.8 NS 18.0 38.8 9.8 NS 15.1 12.6 39.6 NS 14.7 40.0 12.1 NS 17.8 42.3 20.0 NS 15.5 40.3 18.5 NS 17.0 13.3 44.7 NS 13.9 39.9 13.7 NS 14.7 24.9 8.8 NS blood pressure differences (mm 4.5 6.9 6.8 6.9 19.6 8.0 10.2 21.4 8.3 9.4 5.6 20.6 6.3 9.2 22.9 8.7 20.2 7.9 3.2 9.0 21.3 12.6 2.8 22.3 6.1 26.1 11.8 4.3 21.6 12.3 10.4 5.9 12.2 Hg) NS NS NS .091 NS NS .028 NS NS NS NS

NS .028 .019 NS NS .041 .066 .046 .019 .085 .083

.046 NS NS NS .080 .052 NS NS .080 NS NS

Start (tf interview Complaints Occupation Anger/rage Partnership Anxiety Envy Grief Well-being Strong negative emotion End baseline
Nole. NS = not significant. *Witcoxon's rank sum test.

3.3 12.8 16.5 16.3 16.9 17.2 15.1 18.4 19.0 18.4 8.0

4.7 7.6 7.2 8.9 9.7 9.2 5.7 8.6 9.0 10.4 6.9

NS .085 NS NS NS NS .042 NS NS NS NS

NS NS NS NS NS NS NS NS NS NS NS

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Essential hypertensives Renal hypertensives Nomiotensives

166 141210-

Ititerview Phases

-v"

FIGURE 1. Medians of the product from sy.stolic blood pressure (SBP) and heart rate (HK) in the individual interview phases with essential hypertensives, normotensives, and renal hypertensives.

hypertensive groups were highly significant in the category anger/rage in terms of our expectations (p = .028) but not for the other prognosed categories (occupation and psychosocial situation with negative emotions). The grief phase (p = .011) and the second resting phase after the interview (p < .02) were also different between the 2 hypertensive groups (Table 4). COMMENT As anticipated, both hypertensive groups had stronger mean SBP and DBP reactions to the stress interview than did the N controls. The hypertensive groups differed in their initial SBP (EH > RH) on the day of the experiment, but not in the previous ciinical examination. The BP differences became les.s pronounced during the interview. The varying initial conditions led to a maximal SBP increase of 29.2 mm Hg in EHs and 44.7 mm Hg in RHs in the highest phase (wellbeing). Thus, our resting values may have already been changed by the behavior of EHs who had a higher level of stress anticipation accompanied by an increased HR than did other groups. This must be kept in mind when inter-

preting the calculations of differences between baseline value and various values ofthe interview phases. Interesting differences between the hypertensive groups are the higher reaction values of RHs at the start of the interview and during the phase in which the test subjects had to recall an anxiety situation; however, these differences were not within the anticipated range with respect to anger/rage, occupation, and the negative emotion phase. Comparing BP values within groups, both Ns and tbe 2 hypertensive groups had significantly higher levels during the individual interview phases than at baseline. Analysis of HR showed that already in the resting phase, EHs had 12 more beats/min than Ns had and 8 more beats/min than RHs had. In the psychodiagnostic study of these patients, we did not detect any differences between EHs and RHs in anxiety and depression (Deter et a!). EHs had a total maximum increase of 9 beats/min (occupation, anger phases) and RHs had a maximum increase of 4 beats/min (anger phases). Ns only had a maximum increase of 4 beats/min (grief phase). Even though these differences are not significant, they demonstrate that EHs could be acti-

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TABLE 4. Differences Between Normotensives (Ns), Essential Hypertensives (EHs), and Renal Hypertensives (RHs) in the Product of Systolic Blood Pressure (SBP) and Heart Kate (HRl in the Individual Phases of the Interview (Absolute Values)

Ns/EHs/RHs* Interview phases Initial baseline Start of interview Complaints H3: Occupation H1: Anger/rage Partnership Anxiety Envy Grief H2; Strong negative emotion End baseline P

Ns/EHst P .006 .018 .007 .007 .011 .018 .005 .011 .011 .007 .005

Ns/RHst P

EHs/RHst
P

.018 .040 .004 .007 .011 .018 .003 .002

.(X)l .007 .001

.028 .046 .010 .066 .020 .028 .015 .011 .028 .017 .015

.085 .079 .068

NS

.028
NS

.066
NS

.011
NS

.020

Note. NS = nol significant. Tlie p values represent the differences between groups product of SBP x HR. Friedman test. tWilcoxon's test.

vated to a higher degree than could the other 2 groups. This finiJing can be statistically confirmed by the product of SBP and HR. There were significant differences between EHs and RHs with respect to the interview phases in which we stimulated anger/rage and grief. As anticipated, emotional stimulation of anger/rage produced cardiovascular activation that was stronger in EHs than il was in RHs and extended beyond the interview period in EHs but not in RHs. The findings obtained in the present study have to be considered in the light ofthe disproving of our initial hypotheses (SBP and DBP reactivity to anger/rage provocation is enhanced in EHs compiu-ed with RHs). Both RHs and normal controls have similar BP reactions as do EHs to specific interpersonal conditions (feelings of anger/rage, experience of the occupational situation, and psychosocial situations triggering strong negative emotions). On the one hand, we were unable to confirm our hypothesis formulated in agreement with the specificity hypothesis of Alexander^ and a number of other authors"''^^* that EHs react in a specific manner to defined emotional conditions or conflicts.-^-'' On the other hand, our study clearly confirmed the previously reported finding of increased cardiovascular tension being more evident in EHs-^** than in RHs (measured by the product of SBP and HR). The findings in this pilot study that included RHs in a stress experiment also have to be carefully considered in the

light of the relatively small number of test subjects. EHs and RHs were representative for a clinical study population with hypertensive grade I and II with comparable BP levels in a clinical examination. We recruited the Ns from hospital personnel without any disease. We matched groups according to sex and age, but other possibly influencing factors couid not be evaluated.'" The main hypotheses (reaginic response to recalled emotional topics) seemed to be comparable between the 3 groups. The results may have been influenced by antihypertensive drug intake some days before the experiment. A longer interruption of drug administration would have been ethically unjustifiable and was therefore not possible in the 2 hypertensive groups; however, this possible effect may not have been very strong because the test subjects without medication had essentially the same subevaluation findings as did those with medication. The structured interview, in which we addressed different topics within 50 minutes, has to be critically examined because individual situations or emotional states may have been too strongly related or not experienced intensively enough in the interview situation.^' A provocation with 2 or 3 emotional areas in the experiment might have provided a better control for these conditions; however, this pilot study aimed particularly at determining whether the various possible emotions and life situations would yield different find-

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ings. Thus, it was very interesting that grief and anxiety elicited, in part, the same strong BP reactions as anger/rage. tt seemed to be a limiting factor to focus hypertension research only on the aggression-anger-hostility complex, and the results confirm earlier studies relating EH to the effects of grief or anxiety.^^-^^ After all, SBP reactions of up to 40 mm Hg per phase in RHs and maximal reactions of up to 60 mm Hg in individual patients have demonstrated that emotion-triggering interviews have a considerably stronger effect than do standardized stress situations, with clearly lower mean SBP reactions of 15-20 mm Hg.-' A possible source of bias in the study could be the interviewer, who knew the diagnosis at the time of the interview. The differences observed between EHs and RHs indicate that high BP alone is not responsible for all the reactions under stress in these patient populations. But the results presented here do not confirm the specificity hypothesis'-" that certain emotions trigger higher BP reactions in EHs. The EHs evidenced nonspecific characteristics indicative of higher cardiovascular activity"" and perhaps higher neurogenic tension; however, we showed that social environment and mental stress are important factors in both EHs and RHs. There is evidence that these are conditions for worsening of the disease and for developing EH-'*-^" in the long run, in addition to biological risk factors,^' certain personality traits (eg, anger or coping behavior), and social mechanisms (eg, life events or social support'^). Further analyses in high-risk Ns and other hypertensive groups are needed to gain a better understanding of the etiopathogenesis and long-term outcome of EH. NOTE For comment or further information, please address correspondence to H. C. Deter. MD. Department of Psychosomatic Medicine and Psychotherapy. Charite Universitatsmedizin. Campus Benjamin Franklin. Hindenburgdamm 30, 12200 Berlin, Germany (e-mail: deter@charite.de).

5. Julius S. Changing role of the autonomic nervous system in human hypertension. J Hypertens. 1990;8:59-65. 6. Jorgensen RS, Johnson BT, Kolodzlej ME. Schreer GE. Elevated blood pressure and personality: a meta-analytic review. Psydwl Bull. l996:l20f2):293-320. 7. Dimsdale JE. Pierce B, Schoenfeld D, Brown A, Zusman R, Graham R. Suppressed anger and blood pressure: the effects of race, sex, social class, obesity, and age. Psvchosom Med. 1986:48:430-436. 8. Frederikson M, Matthews K. Cardiovascular responses to behavioral stress and hypertension: a meta-analytic review. Ann Behav Med. 1990; 12:30-39. 9. Alexander F. Psvchosom Med. New York: Grune and Stratton; 10. Linden W, Chambers W, Maurice J. Lenz J. Sex differences in social support, self deception, hostility and ambulatory cardiovascular activity. Heallh P.sychol. I993;13:376-380. 11. Lai JY. Linden W. Gender, anger expression style, and opportunity for anger release determine cardiovascular reaction to and recovery from anger provocation. Psxchosom Med. !992;54:297-310. 12. Christensen AJ, Smith TW. Cynical hostility and cardiovascular reactivity during self disclosure. Psychosom Med. 1993:55:193-202. 13. Everson SA. Goldberg DE. Kaplan GA, Julkunen J. Salonen JT. Anger expression and incident hypertension. Psvchosom Med. 1998;60(6):730-735. 14. Weiner H. Psychobiology and Human Disease. New York; Elsevier: 1977. 15. Zander W. Engel RR, Kitscher M. Wiedemann G. Psychophysiologische Korrelationsuntersuchungen wahrend eines halbstandardisierten Interviews hei Patienten mil Ulcus duodeni und Hyperwnie. In: Zander W. ed. Experimentelle Forschungsergebnisse in der psychosomatischen Medizin. Gbttingen, Germany: Vandenhoeck & Ruprecht; 1981; 120-128. 16. Noll G. Wenzel RR, Schneider M. et al. Increased activation of sympathetic nervous system and endothelin by mental stress in normotensive offspring of hypertensive parents. Circulation. 1996:93(5):866-869. 17. Haeri SL, Mills PJ, Nelesen RA. el al. Acute psychologic stress reactivity in blacks versus whites: relationship to psychologic characteristics. Blood Press Monit. 1996; 1:27-32. 18. Ironson G, Taylor CB, Boltwood M, et al. Effects of anger on left ventricular ejection fraction in coronary artery disease. Am JCardiol. l992;7O:281-285. 19. Wolf S. Wolff H. A summary of experimental evidence relation life stress to the pathogenesis of emotional hypertension in man. In: Bell ET. ed. Hypertension. Minneapolis: University of Minnesota Press, 1951. 20. Tlieorell T. SchaiMng. D, Akerstedt T. Circulatory reactions in coronary patients during interviewa noninvasive study. Biol Psychol. 1977;5:233-243. 21. Dimsdale JE, Stem MJ, Dillon E. The stress interview as a tool for examining physiological reactivity. Psychosom Med.

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