Prevention of Cardiovascular Diseases
from a Psychosomatic Point of View
Dr. K. Nespor, Czechoslovakia
Psychosomatic factors, such as the aggressive, assertive and competitive
behaviour pattern known as 'type A', in conjunction with a chronically
stressful lifestyle, are important in the etiology of cardiovascular diseases,
such as hypertension and ischemia (deficiency of the blood supply to the
heart due to obstruction or constriction of the coronary arteries). They
influence various high risk factors associated with these diseases, including
high serum lipid levels, high blood pressure and heavy smoking. Therefore,
psychosomatic techniques should be used in both the prevention and treatment
of cardiovascular diseases.
Relaxation techniques are being successfully used in the therapy of hypertension,
and yoga practices which emphasize relaxation and appear to change the
neurohumoral reaction to stress, seem very suitable in the rehabilitation
of patients after myocardial infarction. The ideal approach to the treatment
of hypertension and ischemic heart disease should integrate the methods
of internal medicine with yoga and relaxation techniques, including yoga
nidra, as well as systematic psychotherapy and guided self-analysis.
'Type A' behaviour pattern
Psychosomatic factors are very important in the etiology of cardiovascular
disease. The relative risk of developing clinical ischemic heart disease
(IHD), associated with the presence of 'type A' behaviour patterns, was
found to be four times greater in those with such behaviour. *1 According
to Rosenman "the 'type A' behaviour pattern is a particular action-emotion
complex which is exhibited by an individual who is engaged in a relatively
chronic and excessive struggle to obtain a usually unlimited number of
things from his environment in the shortest period of time or against
the opposing efforts of other things or persons in the same environment."
*2 Rosenman also states that "the healthy subject exhibiting the
fully developed form of 'type A' behaviour pattern is usually the individual
who exhibits the same biochemical derangements, e.g. hypercholesterolemia,
hyperlipemia, hyperinsulinemia and excess discharge of noradrenalin, so
frequently observed in patients with IHD." *2 According to Harrel,
"findings suggest that the 'type A' coronary prone behaviour pattern
is related to blood pressure levels, and there is some evidence that personality
may be related to blood pressure levels in certain physiological subtypes
of essential hypertensives." *3 IHD with normal coronary arteries,
which do not exhibit any of the above mentioned symptoms, is also interesting
from a psychosomatic point of view. Massed et al. showed that coronary
vasospasm is a possible major cause of myocardial infarction. *4
The majority of known risk factors can be favourably influenced by psychosomatic
methods, and they should be used in the prevention.
Hypertension and its treatment by relaxation techniques
It is well known that blood pressure levels react to stress. For example,
the author knew an officer with normal blood pressure at his garrison
but with 'hypertension' during visits in a hospital. Benson (*5) quotes
Ostfeld and Shekelle, who found that "black migrants living in a
Chicago slum who viewed their neighbors as undesirable had higher blood
pressures than those with neutral or positive attitudes." According
to Stamler, "a greater prevalence of elevated blood pressure was
noted in white-collar workers with less education than their colleagues."
*5 Osti et al. found that "patients with hypertension were exposed
to undesirable life events before disease onset and exhibited alexithymic
traits significantly more than a control group." Alexithymia is a
relatively new concept introduced by Sifneos to describe the impoverished
fantasy life of psychosomatic patients resulting in a utilitarian way
of thinking and characteristic inability to use appropriate words to describe
their emotions. *6
Because the relationship between the onset of hypertension and chronic
stress seems proven, it is only logical to use relaxation techniques which
create an antagonistic state to stress. In the course of relaxation, heart
rate, respiratory rate, blood pressure and metabolism decrease, and a
predominance of alpha rhythm appears on EEG.
A number of investigations dealing with the use of relaxation techniques
in the treatment of hypertension have been published in recent years.
Datey et al., using yogic relaxation, found an improvement in essential
and renal hypertension but not in arteriosclerotic. *7 Yogic relaxation
and biofeedback were successfully used in a controlled study by Patel
and North (*8) and decreased blood pressure levels were measured during
relaxation treatment by Agras et al. This work is especially important
for the prevention of cardiovascular disease because blood pressure was
found to be significantly lower during those days and nights when the
relaxation technique was applied than during the days and nights when
it was not. *9 Results of the relaxation treatment of hypertension are
summarized in the articles by Jacob et al. (*10) and Benson (*5).
We are aware of only one study in which relaxation techniques were found
generally ineffectual. Frankel et al. used diastolic blood pressure and
EMG biofeedback with autogenic relaxation training. Out of 14 subjects,
only one responded with prolonged improvement while in others practically
no changes were observed. *11 From our own experience with the use of
yogic relaxation in psychiatric patients, we recognize that the efficacy
of treatment is influenced not only by the patient's condition and personality,
but also by the particular technique used, the therapeutic relationship
and the patient's willingness to collaborate in the treatment.
Relaxation training lowers risk factors
Cholesterol and lipids
An increase in serum lipids in response to situational stress has been
found during race car driving, public speaking and scholastic examinations.
*12 Cooper and Aygen found a decrease of serum cholesterol levels in hypercholesterolemic
subjects practising the relaxation technique of Transcendental Meditation.
*13 Patel found a decrease of serum cholesterol and lipids in normal and
hypertensive subjects. *12 A decrease in total serum lipids was also observed
after the practice of yogic postures by Udupa et al. (*14) but this study
did not make use of a control group.
Smoking
Some psychiatrists consider the number of cigarettes smoked as a reliable
tension scale. From this point of view, Hyner's case report (*15) is understandable
as well as Patel's finding that the number of cigarettes consumed fell
after the inclusion of a relaxation technique into the daily routine.
*12 In Czechoslovakia, Rehulkova used autogenic training, including autosuggestion,
in the treatment of cigarette abuse in patients with respiratory conditions,
while Merhaut found that during long term practice of yoga the number
of cigarettes smoked decreased in normal subjects. *16
Psychosomatic factors
It is well known that excessive physical or emotional stress may provoke
an attack of angina pectoris. Stress endangers patients even during sleep.
According to Nowlin et al. (*17) episodes of chest pain were significantly
associated with dreaming in REM sleep, and dream content was also important.
After myocardial infarction, fear of death and the dramatic change of
lifestyle exert a strong negative influence upon the patient's psychic
and neurohumoral balance. Supportive psychotherapy and relaxation are
both indicated. Autogenic training (*18) and group psychotherapy (*19)
have also proved effective. Neuhof et al. investigated the effect of relaxing
music on patients in an intensive care unit; the majority of them felt
that their wellbeing was improved. *20 Tulpule et al. used yogic practices
in both uncontrolled and controlled studies of the rehabilitation of patients
after myocardial infarction with good results. *21, *22 Correctly performed,
yoga is unforced, relaxing and enjoyable, and among the vast number of
yogic practices, many suitable exercises can be found for both cardiac
and geriatric patients.
Approaches to the treatment of IHD
Physical training
Lack of physical activity is considered to be an important risk factor
in IHD. Blumenthal et al. found that the coronary risk factor score decreased
after a 10 week physical training program in subjects with coronary prone
behaviour patterns ('type A') but remained unchanged in subjects with
the more relaxed, less aggressive, 'type B' behaviour pattern. *23
Pharmacological approach
According to Sigg the most suitable drugs against cardiac stress are
barbiturates, benzodiazepines and propandiols. However, long term use
of these drugs is associated with an increasing risk of drug dependence
and harmful side effects. Blockage of stressful adrenergic stimuli on
the heart by beta-blocking agents may also be useful, but it is not yet
known if prolonged treatment with these drugs can prevent pathological
changes in the heart due to chronic exposure to stress factors. *24
Group psychotherapy
Psychotherapy in hypertensives, and in psychosomatic patients, is generally
more difficult than in purely neurotic subjects. *25 One reason is alexithymia
as mentioned previously. On the other hand, group psychotherapy has been
successfully used in patients after myocardial infarction. *19
Yogic treatment
Tulpule et al. state that "it is a very common observation in India
that people who practise yogic exercises regularly maintain a very good
state of circulation." *21 However, they do not present any statistical
data to justify this observation. Nevertheless, relatively strong indirect
evidence exists to support the preventive value of yoga. *26 Relaxation
is an important component of yoga. A high degree of relaxation was observed
both in yogic postures (*27) and meditative practices (*28). In addition,
there are many yogic practices such as yoga nidra, which are specifically
intended to induce a state of physical, mental and emotional relaxation.
Maybe it is this very relaxation which, by creating the counterbalance
to the chronic stress of 20th century living, is partially responsible
for the increasingly widespread practice of yoga throughout the world
today.
Lowered cigarette and drug consumption in people practising Transcendental
Meditation seems to be also related to decreased tension, even if other
factors may also operate here. According to Dostalek, during some yogic
practices, systematic stimulation of reflexogenic areas (from which vegetative
autonomic reflexes arise) occurs. As a result, the organism ceases to
react rashly and inadequately to external stimuli, and in this way the
mobilization of energetic reserves decreases during conflict situations.
*29 Metabolic changes induced by emotional stressors, e.g. the increase
of serum levels of noradrenalin and lipids, probably damage the cardiovascular
system. *30 Lepicovska and Dostalek have also demonstrated marked effects
of some yogic practices on ECG records of cardiac activity. *31
Other investigations indicate that neurohumoral reactivity to stress
changes in people practising meditation. *32, *33
The diet recommended by yoga is highly advantageous from the point of
view of prevention of cardiovascular disease. It contains little animal
fat, plenty of vitamin C, and is not so nutritious as to impose a heavy
burden on the digestive and eliminative organs.
Practical applications
One suitable application would be the provision of lessons on relaxation
techniques in industrial corporations. *34 Tie removal of immoderate tension
increases productivity and improves working relationships. Sucharebsky
suggests that relaxation and autoregulation techniques increase creative
potential, and he recommends their incorporation into our educational
systems. *35 Yoga nidra, the yogic relaxation technique (*36) which we
use for psychiatric patients, is not very demanding on the therapist's
time, as a well motivated patient is able to practise on his own after
several 15-20 minute group training sessions.
Relaxation techniques are also most suitable for the secondary prevention
of IHD in those people with increased risk. The ideal approach to the
treatment of hypertension and IHD should integrate the methods of internal
medicine with those of yoga and relaxation techniques, together with systematic
psychotherapy aimed at social, dietary and lifestyle modification where
necessary.
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