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Unearthing the Causes of Hypertension
YOU ARE IN YOUR FORTIES. You are slim and go to the gym four times a week. You get along with your spouse and you have a good job.
You have one medical problem: high blood pressure. Tests could not find a cause for it, and, by default, like 95 percent or more of people with high blood pressure, you are considered to have "essential hypertension." You have been told you will have to take pills, possibly for the rest of your life. You might go to another doctor who will repeat some of the tests or manipulate the medications, but the end result will be the same: You have hypertension and no one can tell you why.
Scenarios like this are played out regularly in physicians' offices. No one can tell you why you have hypertension. Even people with severe hypertension arrive at this same dead end: pills and no explanation. Even worse, you may have been led to believe that this condition is your own fault, because you are too "hyper."
FIFTY MILLION AMERICANS have hypertension. It is responsible for more visits to the doctor than any other medical condition. As the leading risk factor for strokes and a leading risk factor for heart attacks, it is a major health concern. Billions of dollars are spent each year on drugs, doctor visits, and research. Yet, in case after case, the cause is still considered a mystery. My experience argues that this is wrong, that often we can understand why you have hypertension, and sometimes we can even cure it.
What Is Hypertension?
Hypertension, also known as high blood pressure, is a persisting elevation of the pressure of the blood circulating in the arteries throughout the body. Over time, it causes damage to the arteries and to organs that receive blood through them. Ultimately it leads to an increased risk of cardiovascular events such as strokes and heart attacks, and, in severe cases, to heart and/or kidney failure. The more severe the hypertension, the sooner and more likely the complications.
Hypertension is unlikely to cause physical symptoms that warn of its presence unless it is very severe. Most people who have hypertension do not have headaches or feel a pressure in their head or feel dizzy. Most feel perfectly well. This is why hypertension has been called the "silent time bomb." Generally it is found only by measuring the blood pressure.
The components of the blood pressure measurement are the systolic and diastolic pressures, which represent the rise and fall of blood pressure associated with each heartbeat. Just as a mechanical pump pushes fluid into a system of pipes, the heart pumps blood into the aorta and the arteries to circulate oxygen and nutrients throughout the body. The forceful contraction of the heart pushes blood forward and raises the pressure. This peak pressure is called the systolic pressure. Between heartbeats, the pressure in the arterial system falls to the level known as the diastolic pressure.
Blood pressure is typically recorded as the systolic pressure over the diastolic pressure. An example of a normal reading would be 120/80, read as "120 over 80." The number 120 represents 120 millimeters of mercury, as explained below.
Since blood pressure fluctuates from moment to moment, I usually check a patient's blood pressure several times over a minute or so, and record it either as an average value or as the range of the readings I have obtained. For example, if the systolic pressure varied between 120 and 130, and the diastolic between 75 and 85, I would record it as 120-130/75-85.
Blood pressure is measured by placing a cuff around the upper arm and inflating it with air, causing the cuff to tighten around the arm. The pressure with which it is compressing the arm is measured as the millimeters of height it raises a column of mercury, as depicted in Figure 1.1.
The cuff is inflated to a pressure higher than the blood pressure, at which point it will completely block the flow of blood through the brachial artery, the main artery in the arm. Then the cuff is slowly deflated and the column of mercury begins to fall. The cuff pressure at which blood begins to resume flowing through the artery with each heartbeat is detected by the appearance of a sound with each heartbeat, called a Korotkoff sound. The sound is caused by the turbulence of blood flowing through the now partially open artery. The height of the mercury column when these sounds first appear is called the systolic pressure.
As the cuff deflation continues, and the pressure compressing the arm and the artery falls further, it impedes the flow of blood less and less. Finally, when blood flow is completely unimpeded, the turbulence ceases and the sounds disappear. The height of the mercury column when the sounds disappear is called the diastolic pressure.
OUR BLOOD PRESSURE VARIES from moment to moment. If we lift a heavy package or rush down the street or get really angry, it increases. If we relax and do nothing, it falls. As reviewed in the recent report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (1997), or JNCVI, hypertension is diagnosed when your blood pressure averages above 140/90 while you are sitting quietly in your doctor's office. At home, your blood pressure is considered elevated if readings average above 130-135/85.
Hypertension is classified as mild, moderate, or severe, or more recently, according to the JNCVI, as Stage 1, 2, or 3, based on the height of the blood pressure. Table 1 shows the percentage of people with hypertension who fall into each category. The risk of suffering complications from hypertension is proportional to your usual blood pressure level. Therefore, there is no reason to believe that your risk at 141/91, which is considered to be in the hypertensive range, differs much from the risk at 139/89, which is not. Even so, if your readings approach 140/90, measures to reduce your blood pressure are worthwhile.
Our blood pressure level is determined by the force of contraction of the heart muscle, the volume of blood circulating within the arteries, and the state of contraction or relaxation of the arteries. These mechanisms are more thoroughly described in Chapter 13. As reviewed by Norman Kaplan in his textbook, Clinical Hypertension, it is believed that roughly 30 to 50 percent of hypertension is governed by genetic factors. The rest is governed by lifestyle factors such as weight, diet, emotions, alcohol consumption, and exercise. Recent reports also suggest that sleep apnea, a disorder marked by irregular breathing patterns during sleep, may be an important contributor to hypertension (see D. S. Silverberg, 1997). In any individual, hypertension may result primarily from either genetic or lifestyle factors, or a combination of both.
The Mind-Body Connection
If there ever was a condition believed to be tied to emotions and stress, it is hypertension. Yet surprisingly, decades of research have not shown that the emotional distress we feel is a major cause of hypertension or that relaxation techniques to reduce that distress can eliminate it. Contrary to popular expectations, research has not strongly supported the notion that people who have hypertension feel more tense or angry, or are under more stress, than people who don't.
In my experience as a physician specializing in the treatment of hypertension, I find the same thing. Most patients with hypertension, even if it is severe, do not claim to be particularly tense or angry. This seems very hard to believe. When I meet people socially and mention my specialty, many tell me they are "hypertense," (a word that does not exist, by the way), or say, "Boy, do I need to see you." Living in New York City, I hear this all the time, yet study results do not support this popular view of the mind-body relationship in hypertension.
However, my experience treating thousands of people with high blood pressure tells me there is a crucial connection with emotions, but one that is very different from what most people believe. It tells me that the emotions we feel, usually have less to do with hypertension than do the emotions we harbor but don't feel and often don't even know exist within us. I believe this view offers an explanation for hypertension where traditional views have failed and offers an approach to treatment that can lead to both physical and emotional healing. It enables some people to get off medication and provides a rationale for selecting the right antihypertensive drug for those who need drug treatment.
Emotions Are Not Always the Cause of Hypertension
I see many patients in whom emotions play a major role in causing hypertension and many others in whom they do not. Thus, I believe it is wrong to say that all hypertension is caused by emotions, as some mind-body practitioners might suggest, or to recommend emotion-based treatment for everyone who has high blood pressure.
It would be just as wrong to say that hypertension is related to emotions in no one and that emotional factors should be ignored, as many physicians and medical researchers might say. I have personally seen hypertension improve in many patients when its emotional basis was correctly identified and addressed.
Whether your hypertension is related to emotions or not, I believe Healing Hypertension can help you better understand both its origin and its treatment. As I'll discuss, there are clues that can clarify whether your hypertension is related to hidden emotions. These clues are then useful both in selecting the right antihypertensive drugs and in determining whether to consider emotion-based therapy.
If emotional factors are contributing to your hypertension, I hope to clarify how blocking your emotions has worked to protect you but has also contributed to your condition. With this understanding, a path to healing is available if you choose it.
The Link between Hidden Emotions and Health in Other Conditions
Despite the explosion in medical knowledge in recent decades, the causes of many medical conditions, such as irritable bowel syndrome, colitis, chronic fatigue syndrome, fibromyalgia, and migraine, remain a mystery. Researchers have discovered biochemical abnormalities related to some of these conditions and drugs have been developed to address some of them. However, the causes of those abnormalities remain unknown. Studies of the emotional distress people feel have also failed to clarify their origin.
Medications sometimes help control the above conditions and sometimes don't. However, one thing the pills cannot do is cure them.
Aside from these conditions, many people suffer from a variety of unexplained physical symptoms. In a study by Kurt Kroenke reported in the American Journal of Medicine in 1989, an explanation could not be found 74 percent of the time when people sought medical attention for physical symptoms such as chest pain, fatigue, dizziness, headaches, insomnia, and weight loss. In such ailments the role of hidden emotions is widely ignored. If you suffer from any of these conditions, I hope you will consider the relevance of the lessons I have learned from people with hypertension.
The Shortcomings of Medication
The goal of treating hypertension is to lower blood pressure to normal and to prevent its cardiovascular complications. Ideally, we would like to accomplish this goal with medications that address the cause of the hypertension, are inexpensive, have no side effects, and always work. If we had achieved these goals, there would be no reason to consider alternative methods of treatment.
However, we have not achieved these goals. Medications do not always work, they are usually expensive, and they often cause side effects. Many people either cannot remember to take pills every day or just don't want to. No one is particularly thrilled about taking pills every day for the rest of his life.
The shortcomings of treatment are evident in the findings of the National Health and Nutritional Examination survey, reported by Vicki Burt in the journal Hypertension in 1995. It found that only 69 percent of people with hypertension were aware of their condition and that it was controlled (blood pressure below 140/90) in only 27 percent. There is no question that the medication available today is more effective and has far fewer side effects than the medication available twenty years ago. However, it is also clear that we have far to go before we eliminate the health problems that result from hypertension.
Finally, as elegantly discussed by Stevo Julius in the journal Hypertension in 1993, the increased activation of the sympathetic nervous system that underlies hypertension in many people, and that is the likely link between emotions and hypertension, has many harmful effects other than just high blood pressure. It increases our coronary risk by altering hormone levels, blood clotting, and blood vessels through mechanisms other than hypertension. Lowering the blood pressure with pills does not eliminate these effects, which might explain why even perfect blood pressure control will not completely eliminate the excess risk of coronary disease associated with hypertension.
An Epidemic of Overdiagnosis
The diagnosis of hypertension is not always clear-cut. It is not like cancer, where usually someone either has it or doesn't. In many people, the systolic blood pressure is only minimally elevated, or might fluctuate above and below 140. In others, the blood pressure is elevated only while it is being measured and is normal at all other times.
These problems have led to an epidemic of overdiagnosis and unnecessary treatment for millions who do not truly have hypertension. As I shall discuss, there is considerable evidence that at least a quarter of those diagnosed with hypertension do not have it and do not require treatment. If you are in this category, I hope the book will help you get off unneeded medication and will reduce your concern that you are at high risk for suffering a stroke.
In order to understand the relationship between hidden emotions and hypertension, we must first be clear as to who truly has hypertension and who does not. I shall begin by first addressing this important issue.