Pharmaceuticals 2009, 2, 82-93; doi:10.3390/ph2030082 OPEN ACCESS
pharmaceuticals ISSN 1424-8247 www.mdpi.com/journal/pharmaceuticals Article
Obsessive-Compulsive and Post Traumatic Avoidance Symptoms Influence the Response to Antihypertensive Therapy: Relevance in Uncontrolled Hypertension Anna Realdi 1,*, Angela Favaro 2, Paolo Santonastaso 2, Marco Nuti 2, Emanuela Parotto 1, Giulia Inverso 1, Matteo Leoni 1, Luisa Macchini 1, Francesca Vettore 1, Lorenzo Calo 1 and Andrea Semplicini 3 1
2
3
Clinica Medica 4, Department of Clinical and Experimental Medicine, Policlinico Universitario, Via Giustiniani 2 35128 Padova, Italy; E-Mails:
[email protected] (E.P.);
[email protected] (G.I.);
[email protected] (M.L.);
[email protected] (L.M.);
[email protected] (F.V.) ;
[email protected] (L.C.) Psychiatric Clinic, Department of Neuroscience, University of Padua, Policlinico Universitario, Via Giustiniani 2 35128 Padova, Italy; E-Mails:
[email protected] (A.F.);
[email protected] (P.S.);
[email protected] (M.N.) Division of General Medicine, SS. Giovanni e Paolo Hospital, Campo SS. Giovanni e Paolo, Castello 6777–30122 Venezia, Italy; E-Mail:
[email protected] (A.S.)
* Author to whom correspondence should be addressed; E-Mail:
[email protected]; Tel.: +39+3396992201; Fax: +39+0498212264. Received: 22 September 2009; in revised form: 9 November 2009 / Accepted: 13 November 2009 / Published: 16 November 2009
Abstract: Aim: To investigate the association of uncontrolled hypertension with psychological factors associated with high cardiovascular morbidity and mortality (type D personality, depression, posttraumatic stress-related symptoms). Methods: 205 consecutive outpatient hypertensives completed three questionnaires evaluating Type D personality (DS 16), post traumatic symptoms (revised Impact of Events Scale), symptoms of anxiety, hostility, depression and obsessive-compulsive traits (subscales of the Symptom Checklist). Uncontrolled hypertension was diagnosed when clinic sitting blood pressure was above 140/90 mmHg (130/80 in the presence of diabetes or nephropathy), despite reported adherence to treatment with at least three antihypertensive medications, including a diuretic. Results: Uncontrolled hypertension (39%), was predicted by lower scores at Symptom Checklist obsessive-compulsive subscale and higher number of post traumatic
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avoidance symptoms, older age, diabetes, higher systolic pressure at first visit and longstanding hypertension. Type D personality correlated with depression, hostility, anxiety, compulsiveness, history of malignancy, and older age, but not with uncontrolled hypertension. Conclusions: Uncontrolled hypertension is associated with low obsessionality and avoidance symptoms, which reduce compliance to treatment. On the contrary, type D personality is not correlated with uncontrolled hypertension, as it includes compulsiveness, which improves compliance. A multidisciplinary approach to the hypertensive patient is mandatory to establish if the psychological profile affects compliance. Keywords: avoidance symptoms; compliance; uncontrolled hypertension; type D personality
obsessive-compulsive
symptoms;
Introduction Resistant hypertension is becoming a clinical entity due to its large prevalence and high associated cardiovascular risk [1-3]. It is defined by blood pressure above 140/90 mmHg (130/80 in patients with diabetes or renal disease), despite adherence to an appropriate three drug regimen, including a diuretic. The inability to lower blood pressure stems from secondary hypertension, lifestyle factors and ingestion of substances that elevate blood pressure. White coat effect, poor compliance, inadequate dose or blood pressure measurement, physician selection of inappropriate drugs all affect blood pressure control and may cause what should be better named as “pseudoresistant” hypertension [1,3]. Recently, Alderman stressed the difficulty of distinguishing “resistant” from “pseudoresistant” hypertension and that, in the absence of rigorous therapeutic criteria of resistant hypertension, the term of “uncontrolled hypertension” should be preferred [4]. Many studies have pointed out the role of psychological factors in hypertension, such as defensiveness, alexithymia, negative affectivity, expression of anger, anxiety and depression [5,6], but very few explored the impact of psychological factors in resistant or uncontrolled hypertension. Anxiety and inability to channel anger were more frequent in resistant hypertension [7,8], but others showed no correlation with psychological variables [9,10]. The aim of our study was, therefore, to evaluate the psychological correlates of uncontrolled hypertension. In particular, we explored the presence of recent stressful and traumatic life events, of posttraumatic stress-related symptoms, the general psychopathology and if ‘type D personality’, which describes patients who experience increased negative emotions and tend to inhibit the expression of emotions in social interactions [11-13], has some role in increasing the risk of uncontrolled hypertension. Results In the whole sample (205 patients), 184 (90%) were diagnosed as having essential hypertension and 21 (10%) as secondary hypertension (eight idiopathic hyperaldosteronism due to bilateral adrenal hyperplasia, two aldosterone producing adenoma, four renovascular hypertension, three chronic renal insufficiency, one adult polycystic kidney disease, one aortic coarctation, one Cushing syndrome and
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one polycythemia vera). The two groups did not differ for clinical and demographic characteristics (age, sex, blood pressure at first and last visit, BMI, number of outpatient consultations, duration of known hypertension, number of antihypertensive drugs, total vascular events, diabetes, malignancy, use of antidepressants or benzodiazepines, data not shown), but the number of cardiovascular events (history of myocardial infarction or angina) was more frequent among the patients with secondary hypertension (3/21 vs. 4/184, χ2 = 8.38; p < 0.005). One hundred and twenty six hypertensives were classified as controlled (61.5%), and 79 as uncontrolled (38.5%). Uncontrolled hypertensives were older, had higher baseline systolic blood pressure, longer duration of hypertension, greater number of outpatient consultations, larger prevalence of diabetes and cardiovascular events than responders (Table 1). By definition, uncontrolled hypertensives had also higher blood pressure values at the last visit and were taking a greater number of antihypertensive drugs. Table 1. Demographic and clinical characteristics of “responder” and “resistant” hypertensives.
Age (yrs) Male gender Diagnosis of hypertension Essential hypertension Secondary hypertension BP at first visit Systolic BP (mmHg) Diastolic BP (mmHg) BP last visit Systolic BP (mmHg) Diastolic BP (mmHg) Outpatient consultations Duration of hypertension (yrs) Antihypertensive drugs BMI Diabetes Vascular diseases Ischemic heart disease History of malignancy
Responder (n = 126)
Resistant (n = 79)
p Value
53 (±12) n = 60 (47.6%)
62 (±13) n = 35 (44.3%)
.000 NS
n = 115 (92 %) n = 11 (8%)
n = 69 (86 %) n = 10 (14 %)
NS
155 (±19) 96 (±12)
167 (±21) 99 (±14)
.001 NS
132 (±10) 82 (±8) n = 6 (±5) 8 (±7)
153 (±16) 88 (±12) n = 10 (±10) 12 (±8)
.000 .001 .003 .000
n = 2 (±1) 27 (±5) n = 10 (8%) n = 12 (10%) n = 0 (0%) n = 12 (10%)
n = 4 (±1) 28 (±4) n = 21 (26%) n = 13 (16%) n = 7 (8%) n = 7 (9%)
.000 NS .000 NS .001 NS
NS = not significant; BMI: body mass index (weight (Kg)/ height (m2)); BP = blood pressure values; vascular diseases (angina, myocardial infarct, heart failure, stroke, transitory ischemic accident).
Type D personality and other psychopathological aspects One hundred and sixty six patients returned the questionnaires (81%). The clinical and demographic characteristics (age, sex, blood pressure at first and last visit, BMI, number of outpatient
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consultations, known duration of hypertension, number of antihypertensive drugs, use of antidepressant drugs, type of hypertension, rate of response to treatment, diabetes, malignancy) were similar between the patients who returned the questionnaire and those who did not (data not shown). However, those who returned the questionnaires had fewer total vascular events (16/166 versus 9/39 patients; p= 0.026), history of malignancy (12/166 versus 7/39; p = 0.045) and use of benzodiazepine (14/166 vs. 8/39; p = 0.034). Another 19 subjects were excluded from subsequent analyses because they returned incomplete questionnaires. In the final sample (n = 147), the prevalence of type D personality was 37 % (n = 54). Type D patients were significantly older than non-type D patients (59.6 ± 12.0 yrs vs. 55.2 ± 12.2; p < 0.04), but did not differ for gender, blood pressure at first and last visit, number of consultations, duration of hypertension, number of drugs, BMI, type of hypertension, blood pressure response to antihypertensive treatment, history of diabetes, previous cardiovascular events, use of benzodiazepines or antidepressants. Type D personality was associated with history of malignancy (14% vs. 3%; χ2 = 6.44; p < 0.02; OR = 5.1, 95% C.I. 1.3-20.2). Type D patients scored significantly higher than non Type D patients at H-SCL obsessivecompulsive (1.3 ± 0.9 vs. 0.7 ± 0.6; p
