ESSENTIAL HYPERTENSION: A PSYCHO-SOMATIC FEATURE OR A PSYCHO-SOMATIC DISEASE?
A DIFFERENTIAL ANALYSIS OF CASES IN TERMS OF SEARCH ACTIVITY CONCEPT

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Publication Date:
February 28, 2013

Dynamische Psychiatrie/Dynamic Psychiatry, 1981, 68: 129-140.

Since the publication of classical works by F. Alexander essential hypertension has been classed with the most typical psycho-somatic diseases. In its most general form a persistent rise in arterial pressure is regarded as a manifestation of a prolonged state of emotional tension and potential readiness for action that cannot show itself in behaviour due to the counteraction of the subject's social attitudes. Long-term observations have indicated, for instance, that suppressed aggressiveness, which has no behavioural manifestations and is conditioned by unsatisfied power motivation, leads to a rise in arterial pressure (McClelland, 1979). Similar findings have been obtained by other researchers (Bastiaans, 1969; Wolff, 1969). Presumably, a psycho-somatic disease represents the result of a transfer of a psychic conflict to the somatic sphere (Koch, 1980). Apparently, it can be held to be proved that behind the rise in arterial pressure stand asocial requirements unrealized in behaviour due to a high degree of self-control. However, whether all instances of essential hypertension should have this explanation remains an open question.

At present essential hypertension is diagnosed by the elimination of known types of secondary hypertension, which permits the determination of the aetiological factor. Writers have on multiple occasions questioned the assumption that essential hypertension forms a single aetiological and pathogenetic group. Dickinson (1965) identified within the framework of essential hypertension as one of the nosological forms what he termed neuro-genetic hypertension - the presence of persistently intensified impulsation in sympathetic fibres. An added reason for these doubts is the absence of a specific psychological characteristic of patients with an essential rise in arterial pressure. More and more researchers have been assuming that several diseases (or states) have been grouped together on the basis of one phenomenological principle. If this is the case differentiation should help in choosing an adequate therapy. However, no adequately convincing alternative to the' above psycho-somatic concept has been suggested to this day.

In the opinion of Pickering (1955), essential hypertension is a disease characterized by quantitative rather than qualitative deviations from the normal state. This is what constitutes its difference from other forms of hypertension, which are underlain by specific organic changes in the kidneys (or renal vessels), adrenal glands and other organs. Such an approach merits greater attention: it is implied that high arterial pressure can be a variant of the normal state. This, however, leaves obscure the nature of high arterial pressure offering no convincing methods of distinguishing such a variant of the normal state from a psycho-somatic disease: at certain stages of the latter's progress subjective sensations and, still more, complications, can also be found missing.

The authors assume that the disclosure of the basic and most general mechanisms of psycho-somatic disturbances alone can help distinguish hypertension of the psycho-somatic genesis from the specific features of psychosomatic relations. Simultaneously, an insight into the latter's aetiology can be achieved. The present article constitutes an attempt in this direction undertaken in terms of the search activity concept (Rotenberg, Arshavsky, 1979).

By search activity is understood an activity oriented to changing the situation or an attitude to it in the absence of a definite forecast of the results of such activity.

In animals search activity assumes the forms of active defence behaviour (flight or fight) and of self-stimulation of the cerebral zones of positive reinforcement. In man search activity frequently manifests itself only at the psychic level (in the forms of planning and anticipation of a situation). Irrespective of the sign of attending emotion, search behaviour intensifies the body's resistance to noxious effects preventing the development of various experimentally induced forms of pathology (epilepsies, Parkinson-like syndromes, anaphylactic shock, cardiac arrhythmias, myocardial infarctions, gastrointestinal ulcers) (Miller, 1976; Arshavsky, Rotenberg, 1979; Vainstein, Simonov, 1979). The concept of search activity largely corresponds to that of constructive aggressiveness (Ammon, 1979): the latter also ensures purposeful behaviour underlying creative activity and reducing the risk of somatic diseases. In contrast, the state of renunciation of search in a situation that does not suit the subject diminishes the body's resistance. As a result, all the above forms of pathology develop rapidly and can have a lethal conclusion. The state of giving-up, which was noted by Engel and Shmale (1967) in psycho-somatic patients directly before the disease in the author's opinion, reflects renunciation of search. Learned helplessness (Seligman, 1975) represents a special case of an identical state also provoking various forms of pathology. In animals renunciation of search in behaviour assumes the form of imaginary death or freezing, which can be accompanied by vegetative components of fear or anxiety (simply a passive expectation of a catastrophe without any attempt to overcome the situation). In man this state takes the form of a neurotic anxiety or depression. In terms of the suggested concept the suppression or repression of the motive is regarded as a renunciation of search for ways of satisfying this motive and of ways of integrating it with other behavioural orientations.

Thus, in keeping with the search activity concept, the state of renunciation of search forms the basic non-specific prerequisite for the development of psycho-somatic diseases, search activity itself exercising a protective function.

The above concept has also enabled its authors to demonstrate that the state of renunciation of search enhances the REM sleep requirement and substantiate the hypothesis saying that during the REM sleep and dreams proceeds search activity that compensates for the state of renunciation of search in waking. Pronounced search activity in waking reduces the body's REM sleep requirements and its proportion in sleep time. Thus, the degree of requirement in, and the proportion of, REM sleep indicate the presence or absence of search activity.

At the same time, vegetative components of behaviour do not permit such differentiation. Search behaviour is marked by the activation of the sympathetic nervous system but similar activation is also possible in the state of renunciation of search (Afanasjeva, Beshimov, 1974). Correspondingly, arterial pressure can be raised in the cases of both behavioural forms but, in accordance with the above, only the arterial hypertension which accompanied the state of renunciation of search (in terms of the classical concepts of F. Alexander, renunciation of ways of satisfying suppressed motives and of open realization of emotional tension) can be categorized as a psycho-somatic disease whereas the rise in arterial pressure which accompanies search behaviour reflects specific psychophysiological relations within the normal state.

Experiments on animals have demonstrated (Kozlovskaya, 1977) that in the case of active defense behaviour (during aggressive reaction) arterial pressure exhibits a fairly significant rise but shortly after the aggression stops gets back to normal. In the case of a passive defense reaction, in the state of freezing, arterial pressure also goes up but, although it does not reach equally high levels, it drops much more slowly when the aversive influence is removed. Obviously, in the former instance, unlike the latter, the rise in arterial pressure bears an adaptive character forming a component of physiological mobilization. However, what will happen if this mobilization becomes stable and is determined by high search activity and increased search requirement inherent in the individual rather than a passing external situation, as in the said experiments on animals?¹ Perhaps in this situation, at least in some cases, an arterial pressure can stabilize at a level which formally transcends the bounds of the normal state? And perhaps only the rise in pressure concomitant to the state of renunciation of search when physiological mobilization is of no adaptive importance to the body should be categorized as pathological?

Now these theoretical questions can have some experimental solution. One of the authors (Alexeyev, 1980) studied the reaction to stress (emotional and intellectual simultaneously) in 12 sufferers from the initial stages of essential hypertension. A careful clinical and para-clinical examination eliminated the symptomatic character of the disease. The examined patients were 25-40 years old (average age 34). Emotional stress was induced on lines of the classical level-of-aspiration experiment suggested by K. Levin. The discrimination of the level of aspiration which was arbitrarily carried out by the experimenter led to the realization of objectionably reduced level of the subjects intellectual training creating the situation of an emotional stress. The experiment was preceded and followed by polygraphic registration of the frequency of cardiac contractions, shin rheovasography and measurements of the arterial pressure. On the nights which came before and after the emotional stress were performed polygraphic sleep studies (the pre-stress-control night was preceded by an adaptive night). The patients were examined with the aid of an MMPI psychological test.

In some patients (first group) emotional stress was followed by longer delta-sleep, in others (second group) by REM sleep. Table 1 compares the stress-induced changes in the sleep structure and haemodynamic indices in these two groups. Aware that arterial pressure is a resultant, the authors concentrated on an analysis of the mechanisms of its rise, the subjects of analysis being the dynamics of values of haemodynamic indices under the influence of stress rather than their absolute values.

Table 1. Basic Types of Psycho-Physiological Changes in Response to the Action of Emotional Stress in Individuals with a Rise in Arterial Pressure.

Group	General peripheral resistance (dyn-sec-cm5)	Minute volume (litres)	Heart output (mm3)	Delta sleep %	REM sleep %	VI scale MMPI
2nd	-173.6	+ 1.0	+ 14.0	+0.1	+ 5.0	57
1st	+265.8	-0.34	-2.6	+ 12.0	-6.7	49
	p< 0.05	p< 0.05	p<0.05	p<0.01	p<0.01	p< 0.025

As follows from the Table, this approach has disclosed two types of reaction to emotional-intellectual stress in sufferers from essential hypertension. In both instances stress led to a rise in the arterial pressure compared to the background value but in the first group this was due to a rise in the general peripheral vascular resistance with a relative drop in the cardiac output and the minute blood volume. In the second group this resulted from an expansion in the cardiac output accompanied by some drop in the peripheral vascular resistance. It is highly significant that the rise in arterial pressure was accompanied by a rise in the minute cardiac volume only in the second group patients. In the first group patients the minute volume did not register a significant post-stress change. On the post-stress night their delta-sleep time grew longer and their REM sleep time shorter. The second group patients exhibited a longer REM sleep time, a shorter delta-sleep time and a negative REM-delta sleep correlation (r=0.47). Both groups showed a negative correlation between the delta-sleep time and scale D and a positive correlation between the REM sleep time and scale Pa MMPI (r=+0.83) (see Fig 1) .

A control group of eight subjects, in whom the third night was registered without previous stress, did not exhibit the above sleep structure changes. These two types of sleep change strikingly resemble two types of reaction of healthy students to examination stress disclosed in studies of Rotenberg and Arshavsky (1979). Directly before the examination all students exhibited a rise in the arterial pressure, pulse frequency and facial muscle tension - evidence of emotional tension. Following success in the examinations in some of the students all these indices got back to the control level in the first 30 minutes (Group A) whereas the others (Group B) even exhibited a trend toward their increase although the stressful situation was gone. (It would be pertinent to recall here Kozlovskaya's data on persistent hypertension following an aversive situation in animals which reacted to this situation on lines of renunciation of search). In Group A students, who showed a typical rapid normalization of all indices, the subsequent sleep had an increased proportion of delta-sleep (compared to the control night unaffected by examination stress) whereas in Group B students it showed a longer REM sleep time, REM sleep having a negative correlation with delta-sleep. It was assumed that Group B was characterized by unproductive anxiety-type pre-examination tension similar to the state of renunciation of search, which conditioned the stabilization of physiological indices even after the successful ending of the aversive situation, leading to a rise in the REM sleep requirement. Indirect evidence of the above was the fact that on the post-examination evening the second group students poorly coped with intellectual problems - worse than in the control study, worse than on the morning after a sleep with a prolonged REM period and worse than the first group students. Meanwhile, the increase in the delta-sleep proportion in Group A students could be due to their high intellectual and perceptive load of the previous day. Some data indicate that such a load increases the delta-sleep requirement (Home, Wormsley, 1976). This also stands in good agreement with the experimental evidence of the role of delta-sleep in the organization and retention of learned material (Latash, Manov, 1975).

Figure 1.

Correlations between Physiological and Psychological Indices in Individuals with a Rise in Arterial Pressure

Comparing the results of the study of emotional stress in healthy students and individuals with initial forms of essential hypertension the authors feel bound to recall that in the latter category stress also bore a mixed (emotional and intellectual) character. It was directly addressed to the intellect and mnestic functions (the students were offered to resolve problems or recall data which for a long time had not been restored in their immediate memory). The authors therefore have every reason to believe that the increase in the delta-sleep period in the first group of individuals with high arterial pressure reflects an intensification of the intellectual search activity corresponding to a normal reaction to the intellectual load of the healthy Group A students. It follows that the rise in arterial pressure also represents not more than a component of psychophysiological mobilization necessary in solving intellectual problems - a physiological component of search activity. This assumption is also confirmed by the specific features of post-stress haemo-dynamics: a moderate rise in peripheral vascular resistance constitutes an adequate reaction of healthy individuals to stress if the cardiac output grows smaller and the minute volume remains at a permanent level in the process. Such a reaction of the cardiovascular system reveals the normal functioning of the reflex mechanism of autoregulation, when a rise in the blood pressure through the carotid sinus system activates the bulbar mechanisms of regulation of the cardiovascular system (which in the experiment, incidentally, led to a rise in the blood pressure during the REM sleep (Averill et al., 1970)). Meanwhile, the rise in arterial pressure in the second group of examined patients formed a physiological concomitant to the maladaptive reaction that proceeded on lines of renunciation of search. Consequently, only these subjects can be regarded as psycho-somatic patients. This assumption is supported by a number of facts:

1. The REM sleep phase, which compensates for the state of renunciation of search, grew longer only in this group.

2. The above hypothesis is also supported by the post-stress haemodynamic changes proper in this group of patients: the arterial pressure rises predominantly due to cardiac output whereas the total peripheral resistance tends towards a drop. Incidentally, precisely such a change in haemodynamic indices was detected in dogs exposed to a chaotic administration of electric shocks (Anderson, Jingling, 1978) - a widespread method of inducing experimental neurosis, learned helplessness and in general all states which the authors group as renunciation of search. The dog's behaviour exactly corresponded to this state being marked by falls on their front paws and freezing - in the periods between the irregularly supplied conditional signal and electric shock as well as outside this set of stimuli. Anderson and Jingling believe it important that the acute aversive situation leading to a rise in arterial pressure and pulse frequency does not necessarily result in a rise in general peripheral resistance.

In the examined second group patients the increase in the heart output was attended, despite a drop in the peripheral resistance, by an increase in the minute volume - a prognostically unfavorable symptom revealing that the mechanisms of auto-regulation of the cardiovascular system are upset. A group of researchers led by Brod (1960) assumes that the increase in the minute volume of, and the bloodstream passing through, the muscles is accompanied by a decrease in the bloodstream passing through the kidneys. In this case there is no increase in the general resistance to the bloodstream (Feifar, Widimsky, 1960) - a phenomenon observed at later stages of essential hypertension. The reason for such a type of reaction of the haemodynamic system is acute emotional stress (Brod, 1963). The majority of modern researchers, basing themselves on the theory suggested by Guyton et al. (1974), assume that such a hyperkinetic variant of arterial hypertension eventually passes into hypertension with high peripheral vascular resistance because of the protective myogenetic stenosis of the arterioles in response to the increase in the blood inflow to the organs and in the oxygen pressure in the tissues, which exceeds metabolic requirements. This secondary rise in peripheral vascular resistance furnishes evidence of a severe decompensation, is related to the activation of the humoral factors that maintain high arterial pressure and is fraught with severe somatic complications. This makes it important to observe that humoral regulation in ontogeny is formed before neuro-reflex (partly repeating phylogeny) whereas the state of renunciation of search is regarded by the authors as regressive - a reversion to an ontogenetically earlier type of behavioural reaction to stress. If one also is to consider that all second group patients had histories of early-age psychogenies it could be assumed that these diseases had promoted the retention (on lines of imprinting) of, first, a behavioural reaction to stress on the principle of renunciation of search and, second, of the attending rise in arterial pressure predominantly due to factors of humoral regulation.

It can thus be assumed that the rise in arterial pressure stemming mostly from a rise in peripheral resistance with a stable minute volume is typical of search behaviour and of mobilization manifesting itself in activity. Meanwhile, a rise in blood pressure because of an increase in cardiac output and minute volume, even in the case of a drop in peripheral resistance at the early stages is typical of unproductive emotional tension, which accompanies the state of renunciation of search.

These assumptions were found to be almost coincidental with the clinico-psychological correlates disclosed by Danies and Moses (cited from Schors, 1970).

1. An excessive rise in arterial pressure conditioned by an increase in peripheral vascular resistance and the frequency of cardiac contractions is accompanied by a predominant reaction of the fury type.

2. Manifest anxiety represents the basic concomitant to a moderate rise in arterial pressure, which is related to an increase in peripheral resistance with normal stroke volume and frequency of cardiac contractions.

3. Suppressed anxiety is characterized by a lesser rise in arterial pressure, which stems from an increase in stroke volume and frequency of cardiac contractions with normal peripheral resistance.

Apparently, the first two behavioural types, which are characterized by a rise in peripheral resistance, can be regarded as ones which include components of search activity.

The above leads the authors to assume that hypertension proper as a psychosomatic disease is only the rise in arterial pressure which accompanies renunciation of search and is characterized, at least at the early stages of the disease, by a relative predominance of minute volume (hyperkinetic type) over peripheral resistance.

The rise in blood pressure that goes with search behaviour should be considered to be a variant of normal psychophysiological component of search behaviour rather than a pathology.

However, the identification of two polar types, far from excluding, emphasizes the existence of a third (intermediate or mixed) type. Its presence is confirmed by correlations between the analyzed indices.

Continued analysis should disclose whether some instances of stable high blood pressure, resistant to therapy and not leading to complications for many years, should be classed with the normal state. As is known, rises in arterial pressure are not infrequently discovered in members of particularly responsible trades or professions (traffic controllers, flyers, etc.) whose functioning requires for success an ability for stable concentration. In many instances the treatment of such subjects happens to be ineffective and if, in spite of all this, the doctors succeed in bringing down their blood pressure this fairly often exercises a negative effect on the physical state and vocational adequacy of these people. A question arises: Doesn't the pressure in such cases drop due to a drop in necessary (and, on the whole, useful for the individual) search activity? If this is the case such subjects can be treated very carefully or not treated at all. However, the problem owes its complexity to the fact that the individuals in whom high blood pressure is a normal physiological correlate of search activity can, in certain circumstances, also contract hypertension as an actual psycho-somatic disease. This is why differentiation of these two forms of rise in arterial blood pressure - normal and pathological - is of topical interest. At the present stage such differentiation will be facilitated by a study of sleep structure. Future researchers, however, will attempt to find other stable criteria for identifying these forms.

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