Combined behavioral and pharmacological treatment of essential hypertension

Fifty-two pharmacologically treated hypertensive patients were randomized to one of four treatment groups: (1) diastolic blood pressure biofeedback, (2) progressive deep muscle relaxation training, (3) self-directed relaxation training, or (4) medication alone. Data collection occurred during baseline, treatment, and 1-year follow-up phases in a laboratory, a medical clinic, and the patient's own home. Patients from all four groups combined showed mean blood pressure reductions of –10.2/–5.5 mm Hg on clinic recordings and –2.4/–.7 mm Hg on home recordings, which were maintained throughout the follow-up period. There were no significant differences among the four groups in terms of blood pressure reduction. Patients given adjunctive behavioral treatment showed significantly larger reductions in medication usage compared to patients treated with medication alone, but there were no significant differences among the three behaviorally treated groups. Patients who showed medication reductions did not show subsequent blood pressure elevation. The results suggest that combined behavioral and pharmacological therapy may be superior to pharmacological therapy alone in the treatment of essential hypertension.This research was supported in part by NIH research grant number HL27698. The contribution of Jacquelyn Bain is gratefully acknowledged. We thank Merrell-National Laboratories for providing Metahydrin that was used by some of the patients in this study.     

The relationship of expectancies to outcome in stress management treatment of essential hypertension: Results from the joint USSR-USA behavioral hypertension project

Outcome expectancy and efficacy expectancy measures were made during the course of a cross-cultural comparison of thermal biofeedback and autogenic training as treatments for mild essential hypertension. There were no differences between groups at either pre- or posttreatment, and expectancy measures were not related to initial success or failure at the completion of treatment. However, both outcome and efficacy expectations were related to relapse over the three months immediately following the completion of treatment. Treatment failures had lower ratings for both outcome and efficacy expectations at the posttreatment assessment in comparison to treatment successes. Implications of these results are discussed.The American portion of this research was supported by grant No. HL-31189 from the NHLBI. We express appreciation to the late Academician Igor Shkvatsabaya and Professor Vadim Zaitsev at the USSR Cardiology Research Center for their scientific and administrative support.     

An incremental model to isolate specific effects of behavioral treatments in essential hypertension

To prove clinical effectiveness of behavioral treatments in essential hypertension, an incremental repeated measures design was combined with findings that positive expectancies (placebo factors) potentiate specific effects. If positive expectancy effects were maximized in a Baseline Control Phase (6–26 weeks of BP stabilization), specific effects might be isolated as well as potentiated in a Learning Phase (2a, 6 weeks, twice/week; 2b, 6 weeks, once/week—fading). Follow-up Phase 3 was six weeks, once/week; six months, once/month; and at 12 months. To equalize groups across seasons over 12 years of regular clinical work, 117 volunteer outpatient veterans with borderline to moderate essential hypertension (130–170/90–110) were assigned in order of entry (10–20 each year) to one of four Treatments: R, simple relaxation; REMG, R + EMG biofeedback; BP, BP biofeedback only; RBP, R + BP; or to an inert Control Group (TA, reading about transactional analysis without skills training). The four treatment groups showed modest but consistent BP decreases during Phase 2 (p range from .0001 to .01). Control Phase placebo effects matched those in the Control Group (no BP decrease after Baseline). With a two-way mixed ANOVA design, Learning Phase 2 isolated specific effects of behavioral treatments, while the Control Phase 1 with liberal placebo factors potentiated specific effects during regular clinical work.This research was supported in part by NIH Research grant No. R01-HL27220; by the Hypertension Investigation Pooled Project of the National Heart, Lung and Blood Institute of NIH; and by the VA Medical Research, Va Hines Hospital, Hines, Illinois. The contributions of the following Medical and Nursing staff members are gratefully acknowledged: Javier Clemente, David Weber, Peter Kraut, Ali Kheirbek, David Leehey, Alan Reich, Gloria Lorenz, Della Herzog, Geraldine Stroka.     

Interaction of biofeedback-assisted relaxation and diuretic in treatment of essential hypertension

Thirty patients with essential hypertension participated in a study designed to compare two treatments: diuretic medication alone (n=10) and biofeedback assisted relaxation combined with diuretic (n=20). One of 10 patients lowered BP with diuretic alone and 11 of 20 patients lowered BP with diuretic combined with biofeedback-assisted relaxation. The addition of the behavioral intervention to the diuretic therapy produced a decrease in blood pressure beyond that associated with the diuretic alone. The decreases in BP mediated by diuretic were related to high entry levels of BP, low anxiety, forehead muscle tension, anger expression and plasma renin activity. The BP decrease mediated by combined diuretic and biofeedback-assisted relaxation was associated with high pretreatment BP, anger controlled, low finger temperature and high/normal plasma renin activity.This work supported by the Northwestern Ohio Heart Association under grant No. 93132 to Dr. McGrady.     

Neuroscience of behavioral and pharmacological treatments for addictions

Although substantial advances have been made in behavioral and pharmacological treatments for addictions, moving treatment development to the next stage may require novel ways of approaching addictions, particularly ways based on new findings regarding the neurobiological underpinnings of addictions that also assimilate and incorporate relevant information from earlier approaches. In this review, we first briefly review theoretical and biological models of addiction and then describe existing behavioral and pharmacologic therapies for the addictions within this framework. We then propose new directions for treatment development and targets that are informed by recent evidence regarding the heterogeneity of addictions and the neurobiological contributions to these disorders.     

Biobehavioral treatment of essential hypertension: A group outcome study

In a group outcome and follow-up study of 77 patients with essential hypertension, significant reductions were seen in systolic and diastolic blood pressure (BP) and in hypotensive medication requirement. A multimodality biobehavioral treatment was used which included biofeedback-assisted training techniques aimed at teaching self-regulation of vasodilation in the hands and feet. Of the 54 medicated patients, 58% were able to eliminate hypotensive medication while at the same time reducing BP an average of 15/10 mm Hg. An additional 19 (35%) of the medicated patients were able to cut their medications approximately in half while reducing BP by 18/10 mm Hg. The remaining 4 (7%) medicated patients showed no improvement in either BP or medication requirement. Similar reductions in BP were seen in initially unmedicated patients. Seventy percent of the 23 unmedicated patients achieved average pressures below 140/90 mm Hg, with an additional 22% of these patients making clinically significant reductions in pressure without becoming normotensive, and with 8% unsuccessful at lowering pressures to a clinically significant extent. Follow-up data available on 61 patients over an average of 33 months indicated little regression in these results with 51% of the total patient sample remaining well-controlled off medication, an additional 41% partially controlled, and 8% unsuccessful in lowering either medications and/or blood pressures to a clinically significant extent.This research was partially supported by grant HL-32136. The Authors wish to thank Sarah Bremer for her assistance in preparing this article.     

Biobehavioral treatment of essential hypertension: a group outcome study

In a group outcome and follow-up study of 77 patients with essential hypertension, significant reductions were seen in systolic and diastolic blood pressure (BP) and in hypotensive medication requirement. A multimodality biobehavioral treatment was used which included biofeedback-assisted training techniques aimed at teaching self-regulation of vasodilation in the hands and feet. Of the 54 medicated patients, 58% were able to eliminate hypotensive medication while at the same time reducing BP an average of 15/10 mm Hg. An additional 19 (35%) of the medicated patients were able to cut their medications approximately in half while reducing BP by 18/10 mm Hg. The remaining 4 (7%) medicated patients showed no improvement in either BP or medication requirement. Similar reductions in BP were seen in initially unmedicated patients. Seventy percent of the 23 unmedicated patients achieved average pressures below 140/90 mm Hg, with an additional 22% of these patients making clinically significant reductions in pressure without becoming normotensive, and with 8% unsuccessful at lowering pressures to a clinically significant extent. Follow-up data available on 61 patients over an average of 33 months indicated little regression in these results with 51% of the total patient sample remaining well-controlled off medication, an additional 41% partially controlled, and 8% unsuccessful in lowering either medications and/or blood pressures to a clinically significant extent.     

Metabolic consequences of atenolol and propranolol in treatment of essential hypertension.

A six-month study of triglyceride, cholesterol, free fatty acid (FFA), glucose, insulin, growth hormone, and glucagon concentrations was carried out in asymptomatic hypertensive normal-weight men randomly allocated to treatment with atenolol or propranolol. A highly significant increase in the basal plasma triglyceride concentration was observed in propranolol-treated patients after three and six months'' treatment, with a smaller but significant increase in atenolol-treated subjects after six months'' treatment. The changes in triglyceride concentration could not be ascribed to variations in plasma insulin, growth hormone, or glucagon concentrations. Basal FFA concentrations were reduced during the first three months of treatment in both groups but returned to pretreatment levels after six months. Plasma cholesterol concentrations were unchanged by either agent.     

Interaction of biofeedback-assisted relaxation and diuretic in treatment of essential hypertension.

Thirty patients with essential hypertension participated in a study designed to compare two treatments: diuretic medication alone (n = 10) and biofeedback assisted relaxation combined with diuretic (n = 20). One of 10 patients lowered BP with diuretic alone and 11 of 20 patients lowered BP with diuretic combined with biofeedback-assisted relaxation. The addition of the behavioral intervention to the diuretic therapy produced a decrease in blood pressure beyond that associated with the diuretic alone. The decrease in BP mediated by diuretic were related to high entry levels of BP, low anxiety, forehead muscle tension, anger expression and plasma renin activity. The BP decrease mediated by combined diuretic and biofeedback-assisted relaxation was associated with high pretreatment BP, anger controlled, low finger temperature and high/normal plasma renin activity.     

Ethnic variations in the pharmacological and nonpharmacological treatment of hypertension: biopsychosocial perspective.

Blood pressure regulation is a complex, dynamic process influenced by psychosocial, behavioral, and cultural factors. Integrative theories of cross-population differences in the prevalence of hypertension and response to treatment include physiological, social, and genetic perspectives. Ethnic differences in salt sensitivity, calcium regulation of sodium flux, vascular reactivity to psychosocial stress, and drug metabolism are integral components of observed cross-cultural variations in hypertension. In general, pharmacological treatment of hypertension in blacks is most consistently achieved through diuretics and calcium-channel blockers; angiotensin-converting enzyme inhibitors and beta-blockers are more efficacious in whites. These stereotypical patterns are consistent with the higher prevalence of salt sensitivity, stress-induced vasoconstriction and slower natriuresis, and alpha-adrenergic receptor mediated vascular reactivity observed in blacks compared with whites. Some antihypertensive agents produce adverse glucose metabolic side effects, thus contraindicating their use in individuals with high sympathetic tone, insulin resistance, or obesity. Cross-population differences in adopted guidelines for treating hypertension exist but are not likely a factor in observed ethnic differences in rate of treatment or control. Attitudes toward nontraditional treatment options (e.g., herbal medicine), political and individual responsibilities in health care, and adaptations to acculturation and urbanization stress differ between and within societies and thus play a role in observed cross-cultural differences in hypertension as well. The value of regular exercise in controlling hypertension is widely recognized, and reductions in blood pressure reactivity to behavioral stress following acute exercise have been documented; however, empirical studies of ethnic differences in exercise-related blood pressure control are lacking. Overall, increased awareness of the multifactorial nature of hypertension by both the physician and the patient will facilitate treatment of this disease on an individual basis.     

Evaluation of a minimal-therapist-contact thermal biofeedback treatment program for essential hypertension

We compared a clinic-based regimen of 16 individual sessions (2 per week) of thermal biofeedback with a largely home-based regimen of 5 sessions (spread over 8 weeks) for the treatment of essential hypertension in patients who required at least two drugs to maintain control of blood pressure (BP). On the basis of the clinical end point of being successfully withdrawn from the second stage medication while BP remained under control, the clinic-based regimen (5 of 9) was superior (X<(1)=4.0,p<.05) to the home-based regimen (1 of 9). Internal analyses point to more frequently obtaining a hand temperature of at least 95° F by the office-based patients as possibly the reason for the difference.This research was supported by a grant from NHLBI, HL-27622.     

Evaluation of a minimal-therapist-contact thermal biofeedback treatment program for essential hypertension

We compared a clinic-based regimen of 16 individual sessions (2 per week) of thermal biofeedback with a largely home-based regimen of 5 sessions (spread over 8 weeks) for the treatment of essential hypertension in patients who required at least two drugs to maintain control of blood pressure (BP). On the basis of the clinical end point of being successfully withdrawn from the second stage medication while BP remained under control, the clinic-based regimen (5 of 9) was superior (chi less than (1) = 4.0, p less than .05) to the home-based regimen (1 of 9). Internal analyses point to more frequently obtaining a hand temperature of at least 95 degrees F by the office-based patients as possibly the reason for the difference.     

Biofeedback treatments of essential hypertension

Fifteen years of research in the self-regulatory treatment of hypertension by the author is summarized. A model relating expectations, task performance, home practice, and biochemical variables to the thermal biofeedback treatment of hypertension is presented.     

Biofeedback treatments of essential hypertension

Fifteen years of research in the self-regulatory treatment of hypertension by the author is summarized. A model relating expectations, task performance, home practice, and biochemical variables to the thermal biofeedback treatment of hypertension is presented.Essentially, all of the research reported herein was supported by various grants from NHLBI: HL-14906, HL-18814, HL-27622, and HL-31189.