Detecting white coat and reverse white coat effects in clinic settings using measures of blood pressure habituation in the clinic and patient self-monitoring of blood pressure.

To examine the utility of blood pressure (BP) habituation within and across multiple clinic visits and patient-determined home BP monitoring for detecting white coat (WCE) and reverse white coat effects (RWCE) commonly observed in medical settings, 54 patients undergoing evaluation for hypertension in an internal medicine group practice were categorized according to the magnitude of differences between systolic BP (SBP) and diastolic BP (DBP) obtained in the clinic and through ambulatory BP monitoring. BPs were measured four times during three separate clinic visits, during a 1-week home BP monitoring period, and during a single 24-h ambulatory monitoring period. Patients whose mean clinic and average daytime BPs were within +/-5 mm Hg were categorized as having stable BP; patients whose clinic BPs were >5 mm Hg of their daytime BPs were categorized as showing a WCE and patients whose average daytime BPs were >5 mm Hg of their clinic BPs were categorized as showing a RWCE. Results revealed that degree of habituation occurring between the first and third clinic visits significantly predicted magnitude of both the WCE and RWCE for SBP, with greater habituation being associated with the WCE and lesser habituation associated with the RWCE. Greater SBP habituation within clinic visits was associated with the WCE for SBP and greater DBP habituation within clinic visits was associated with the WCE for DBP. Lesser DBP habituation within clinic visits was associated with the RWCE for both SBP and DBP. Home BP monitoring did not contribute to predicting either WCE or RWCE.

Psychophysiological arousal in older adults: a critical review.

In spite of the relatively high prevalence rates of anxiety disorders (AD) and related symptoms, very little is known about the experience, presentation, and assessment of anxiety in later life. Because the physiology of the autonomic nervous system changes with age, an enhanced understanding of how these developmental changes affect the somatic-physiological response patterns to anxiety-evoking stimuli among older adults may help explain whether we can generalize current assessment and treatment practices and procedures for AD from younger to older adults. In this paper, we describe and critically evaluate studies that have employed psychophysiological recording of autonomic arousal to anxiety-arousing or stressful stimuli among samples of younger and older adults. The conclusions one can draw from the review are quite limited by both the paucity of relevant literature and the methodological limitations of the published studies.

Changes in hemodynamic response to mental stress with heart rate feedback training.

This study was designed to examine underlying hemodynamic changes that accompany observed reductions in heart rate (HR) response to mental stress following HR feedback training. Twenty-five college males, assigned to either a HR feedback training group (FB+) or a control group (FB-), were presented with a videogame and mental arithmetic challenge, as HR, blood pressure, and impedance cardiography-derived measures of hemodynamic functioning were recorded. During training, the FB+ group received HR feedback and the FB- group was not provided with HR feedback while playing a videogame. At posttraining, results revealed that the FB+ group exhibited significantly lower HR, systolic blood pressure, stroke volume, and total peripheral resistance responses to the videogame compared to that at pretraining. There was no evidence that the acquired skills generalized to a mental arithmetic task. These results suggest that HR feedback training is an effective method for reducing cardiovascular and hemodynamic responses to a mental stressor; however, the generalizability of this effect remains questionable.

Biobehavioral responses to interpersonal conflict during anger expression among anger-in and anger-out men.

To examine whether typical modes of anger expression (ie., anger-in, anger-out) were related to cardiovascular, affective, behavioral, and cognitive responses to interpersonal conflict, 20 anger-in and 20 anger-out undergraduate men participated in 2 role plays, one in which they were instructed to exhibit their anger overtly and the other in which they inhibited their anger Results showed that anger-in individuals used significantly more repression self-statements than anger-out individuals across both role play interactions (p <.01). Anger-out persons showed exaggerated diastolic blood pressure response in contrast to anger-in participants, but only during the exhibited anger role play (p <.04). When the anger exhibition role play followed anger inhibition, diastolic bloodpressure responses were more intense (p <. 05), and heart rate recovery was significantly slower (p <.03) among anger-outparticipants in contrast to anger-in participants. These findings indicate that modes of anger expression (trait) and contextual demands of the interaction (state) interact in complex ways to influence biobehavioral reactions to anger provocation.

Effects of gender of observer and fear of negative evaluation on cardiovascular reactivity to mental stress in college men.

This study investigated the relation between mere observation, the gender of a confederate observer and cardiovascular reactivity to two laboratory challenges, a math task and verbal anagrams, in both individuals with high and low social fear (e.g. fear of negative evaluation). Forty-eight undergraduate males completed the Fear of Negative Evaluation Scale and were categorized as either high or low social fear based on a median split. Sixteen subjects were tested alone, 16 subjects were observed by a male confederate during task performance and 16 subjects were observed by a female confederate during task performance. Cardiovascular measures of heart rate and blood pressure were measured during both tasks and intervening rest periods. Results revealed subjects with high social fear exhibited higher heart rate reactions to the math task and higher diastolic blood pressure reactions to the anagram challenge than low social fear participants, but only when observed by a female confederate. In addition, participants in the male and female observation conditions exhibited greater SBP responses to the anagram task than participants in the alone condition. No group differences on task performance were observed. Cardiovascular reactivity to the two tasks used in this study was impacted by both contextual laboratory factors (i.e. gender of observer) and dispositional attributes of the participant (i.e. social fear).

Cardiovascular and behavioral response to social confrontation: measuring real-life stress in the laboratory.

Laboratory investigations of cardiovascular reactivity to mental stress often ignore concomitant differences in cognitive, affective, and behavioral responses that are commonly observed among study participants. To provide a more systematic laboratory methodology to examine relations among cardiovascular, behavioral, and self-report measures of cognitive and affective responses to stress, we developed and tested a social confrontation procedure involving standardized interactions during two scenes. Results of three investigations are presented to illustrate the utility of the social confrontation procedure. In the first two studies, this multidimensional assessment strategy produced results which may foster research projects that bridge separate areas of psychological inquiry. In one application, persons with hypertensive parents, in contrast to persons with normotensive parents, exhibited characteristic negative behavioral responses during both interactions as well as the more commonly-observed exaggerated blood pressure reactions. In the other study, students from less functional families (regarding cohesion and adaptability) were shown to exhibit exaggerated blood pressure reactions in addition to their commonly-reported negative cognitive and behavioral coping styles. Finally, a third study examined how a simple instructional set regarding the expression or suppression of anger influenced participants' responses. Significant differences were observed across response domains, with anger expression resulting in a more intense response than anger suppression. In sum, the social confrontation procedure represents an important methodological development for exploring the relation between response domains, the relation between cardiovascular response to stress and psychosocial risk for cardiovascular disease, and the physiological and behavioral distinction between anger expression and anger suppression.

Anger management training with mild essential hypertensive patients.

Casual blood pressures and measures of cardiovascular and behavioral reactions to neutral and confrontive interactions were obtained from 13 essential hypertensive patients who received training in anger management and 9 no-treatment control patients. At pre- and posttraining, heart rate (HR) and blood pressure (BP) were measured (a) at rest and (b) during role-play interactions consisting of neutral and confrontation scenes. Behavioral responses were also coded for each interaction. For treatment subjects, a 6-week program in anger management was conducted, which included relaxation training, self-statement modification, and role-play assertiveness training. Treatment subjects exhibited significantly lower casual DBPs at posttraining (M = 90.2 mm Hg) than control subjects (M = 95.7 mm Hg). Posttreatment casual SBPs for treatment and control subjects were not significantly different. Treatment subjects exhibited significantly more assertive skill and lesser DBP reactivity at posttreatment than their control counterparts during the confrontive interaction but not during the neutral role-play interaction.

Women, anger, and cardiovascular responses to stress.

Cardiovascular reactivity (CVR) to stressful stimuli is predictive of future development of cardiovascular disease (CVD). Anger appears to be an important mediator of this relationship. Unfortunately, the majority of research in this area has utilized predominantly male subjects, leaving the relationship between CVD and anger in females largely unexplored. To address the dearth of research among females, the present study examined the relationship between Anger-In, as well as Anger-Out, and CVR to stressors among women. Females reporting moderate levels of Anger-Out exhibited lower blood pressure reactions to a mental arithmetic stressor than females reporting high and low levels of Anger-Out. Females reporting moderate levels of Anger-Out also exhibited lower heart rate reactions than individuals reporting high levels of Anger-Out. Anger-In was not related to CVR in the present study.

Behavioral and cardiovascular responses to interpersonal challenges among male offspring of essential hypertensives.

Behavioral, cardiovascular, and self-report of cognitive and affective responses to 2 interpersonal challenges were examined among 20 men with a positive (FH+) and 20 with a negative (FH-) family history of hypertension. Heart rate (HR) and blood pressure (BP) were measured throughout the laboratory session; Ss were requested to self-report positive and negative cognitions, state anger, and state anxiety that occurred during interactions with a male and female confederate. Behavioral responses to interpersonal tasks were videotaped, coded, and categorized into 4 major groupings (positive verbal, positive nonverbal, negative verbal, and negative nonverbal). FH+ individuals exhibited significantly higher resting HR and systolic BP (SBP) reactivity to both interactions than FH- counterparts. Analyses of behavioral responses for both interactions revealed significantly more negative verbal and nonverbal behavior and less positive nonverbal behavior among FH+ as compared with FH-Ss.

The effect of social support and physical touch on cardiovascular reactions to mental stress.

To examine the effects of social support on cardiovascular reactions to behavioral stress, the present study tested the relative contribution of three elements of social support: the presence of another person in the laboratory; the presence of a person considered to be a friend; and physical touch. Sixty undergraduate females were assigned to one of the following groups: alone (A); friend present-touch (FT); friend present-no touch (FNT); stranger present-touch (ST); and stranger present-no touch (SNT). Heart rate (HR), systolic blood pressure (SBP), and diastolic blood pressure (DBP) measures were obtained across baseline phases and during presentation of two behavioral challenges (mental arithmetic, mirror-tracing). The findings suggest that neither the presence of a stranger nor physical touch are related to attenuated cardiovascular reactions to stress; rather, if the extent of cardiovascular reactivity is related to social support, the presence of a friend may be the important mediating variable.

Reducing heart rate reactivity to stress with feedback. Generalization across task and time.

Heart rate (HR) reactions to two behavioral stressors (videogame and mental arithmetic) were measured in 8 experimental subjects who received biofeedback training and 8 matched control subjects during three assessment periods: pretraining, posttraining, and one-week follow-up. Experimental subjects exhibited significant reductions in HR following a training session in which they received ongoing HR feedback while playing a videogame. Control subjects, who played the same number of videogames without HR feedback, showed smaller HR reductions. During the training session, all subjects were instructed to reduce HR while maximizing game performance. In comparison to controls, experimental subjects (a) maintained lower HRs during videogame presentations after a one-week period and (b) generalized these HR reductions to the mental arithmetic challenge at follow-up. Performance on the videogame declined from posttraining to follow-up for experimental subjects but not for control subjects. No group difference in mental arithmetic performance was observed.

Treatment of paruresis with in vivo desensitization: a case report.

In vivo desensitization was employed with a patient exhibiting chronic paruresis. Measures of urination delay, and subjective units of distress were obtained at pre-training, during training, at a generalization trial, and at a follow-up assessment. Urine volume was also measured at pre- and post-training. There was shorter delay in urination, greater urine output, and less subjective anxiety following treatment. These effects were also demonstrated during a generalization post-test in which the patient was exposed to an unknown observer. A follow-up trial involving exposure to a second unknown observer indicated that treatment effects were maintained at 7.5 months following treatment.

Assessment of cardiovascular reactivity across laboratory and natural settings.

The purpose of this investigation was to examine the stability of heart rate and blood pressure reactions of individuals across laboratory challenges and a challenge in the natural environment. Undergraduate musicians' heart rates and blood pressures were measured during anticipation and in response to a mental arithmetic challenge and a visual-verbal concepts challenge in the laboratory and anticipation of a musical performance jury in the natural environment. Results revealed that systolic blood pressure reactivity measured in anticipation of laboratory challenges, but not during these tasks, was related to systolic blood pressure levels measured in anticipation to the musical performance jury. Generalization of heart rate and diastolic blood pressure reactivity across settings was not supported. Systolic blood pressure, diastolic blood pressure, and heart rate reactions were stable across laboratory tasks.

Cognitive response to a cold pressor challenge in high and low blood pressure reactive subjects.

To examine the relationship between cognitive and cardiovascular reactions to a cold pressor challenge, 20 high and 20 low blood-pressure-reactive males were identified. Subjects were trained using a think-aloud procedure and asked to report their thoughts aloud during task presentation. In comparison to low-reactors, high-reactive subjects exhibited greater increases in systolic and diastolic blood pressure, but not heart rate, in response to the task. High-reactive subjects reported fewer distracting self-statements than low-reactors during the task. No group differences in positive, neutral, or negative self-statements were observed. These findings corroborate the importance of distraction strategies in mediating acute cardiovascular reactions to stress.

Predicting treatment outcome to progressive relaxation training in essential hypertensive patients.

Nineteen borderline essential hypertensive patients participated in (a) a pretreatment assessment of sympathetic nervous system activity (SNS), (b) a progressive muscle relaxation training program, and (c) a posttreatment assessment of SNS functioning. During both pre- and posttreatment assessments, each subject participated in a laboratory session during which cardiovascular responses to two behavioral challenges were measured, a 24-hr urine collection for catecholamine analysis and the completion of relevant self-report questionnaires. Results revealed that subjects who improved the most with relaxation training (showed the greatest reduction in blood pressure) were individuals who, at pretreatment, (a) were less reactive to laboratory challenges, (b) possessed lower levels of resting epinephrine, and (c) scored lower on measures of trait anger and higher on assertiveness. Posttreatment assessment results showed that relaxation training did not affect cardiovascular reactivity to laboratory tasks or self-report of anger and assertion.

The effect of feedback-assisted reduction in heart rate reactivity on videogame performance.

In 67 male volunteers, we examined the reduction of cardiovascular responsivity to a psychomotor challenge (videogame) achieved by use of heart rate (HR) feedback and effects of these procedures on concomitant behavioral performance. Each subject participated in a pretraining assessment of his cardiovascular responses to the videogame, a training condition, and a posttraining assessment identical to the initial evaluation. During training, subjects were assigned to one of four conditions: (a) a habituation control group receiving no instructions to alter HR (HC); (b) an instructions-only control group receiving instructions to maintain a low or unchanged HR during videogame presentations (IC); (c) a feedback group receiving instructions to reduce HR using ongoing HR feedback (FB-); or (d) a feedback group receiving instructions to lower HR and given HR feedback plus a score contingency in which total game score was jointly determined by subjects' game performance and success at HR control (FB+). Subjects receiving feedback (FB+, FB-) exhibited greater reductions in HR response to the videogame in the posttraining assessment than control (HC, IC) subjects; FB+ subjects showed greater HR reductions than subjects in any other group. FB+ and FB- subjects showed a lower SBP at posttraining relative to the two control groups, but no reduction in task-induced blood pressure reactivity. There were no group differences in videogame performance, either before or following training.

Persistent sympathetic nervous system arousal associated with tethering in cynomolgus macaques.

The swivel-tether system has been used extensively in biomedical research involving nonhuman primates, yet there has been little or no investigation into potential adverse influences of this form of restraint on research results. In the study described here, a portable electrocardiographic telemetry system was used for continuous monitoring of the heart rate of 26 cynomolgus monkeys while: (a) pair-caged, 8 weeks prior to tethering; (b) singly-caged, tethered; (c) singly-caged, tethered, administered propranolol (30 mg/kg/day) in the diet; (d) group-housed (five monkeys per group), 1 week after group formation; and (e) group-housed (five monkeys per group), 4 weeks after group formation. Tethering resulted in persistent elevations in heart rate relative to the other conditions. Administration of propranolol, a beta-adrenergic antagonist, resulted in an abrupt, sustained decrease in heart rate indicating that the increase in heart rate associated with tethering was due to persistent stimulation of the sympathetic nervous system. Since multiple aspects of cardiovascular function are influenced by the sympathetic nervous system, and other organs and systems (e.g., pituitary-gonadal) also may be affected, investigators using the swivel-tether system should be cognizant of these potential effects when designing experiments and interpreting the results.

Validation of a simple method of assessing cardiac preejection period: a potential index of sympathetic nervous system activity.

Traditional noninvasive assessment of sympathetic nervous system (SNS) activity in cardiovascular functioning has been confounded by concurrent parasympathetic influences. Analyses of specific intervals of the cardiac cycle have indicated that the systolic preejection period (PEP) may serve as a reliable index of SNS activity independent of parasympathetic inhibition. In the present study, PEP values derived from a technique employing peripheral pulse wave tracings were compared to values obtained from simultaneous impedance cardiograph recordings. Recordings were made on 15 male subjects who were instructed to rest quietly sitting in an upright position. Results indicated that values obtained from both methods were highly correlated and not significantly different when measurement adjustments on total systole were taken into account. These findings support the validity of the fingertip peripheral-pulse method in obtaining measures of systolic time intervals under resting conditions.

The neurobiology of the narcoleptic syndrome.

Relevant electroencephalographic, psychopharmacologic, and genetic research reports are described in support of a neurobiological explanation of the narcoleptic syndrome. Despite increased support in this realm, no single neurobiological theory has won unanimous approval among sleep researchers, which has led toward speculation that the condition may be heterogeneous in nature. A multifactorial perspective, including psychological as well as neurobiological influences, appears to be the most productive model for research. Future investigation of sleep disorders utilizing such a model may enhance the understanding of neurobiological correlates of behavioural disorders.