Hypertension & Coronary Artery Disease

 

A Current Case of Hypertension

 

By: William G. Barton, MBA, MA, Ph.D.

www.biobill.org or e-mail: biobill@pacbell.net

 

            I first entered the mental health field in 1972 and obtained my Masters in clinical psychology while working on the “locked unit” of Walnut Creek Hospital.  I was hired without any experience but the staff liked my height and strength!  I was soon looking for a niche to make a better living than two dollars an hour and “health education” via the deliverance of clinical biofeedback was an attractive avenue for me as I had come from and experimental psychology background at Hamilton College in New York.  At Gladman Memorial Hospital, I met Dr. Arthur Gladman who rapidly became my mentor and who was largely responsible for “bringing” biofeedback to the Bay Area from his experiences with Elmer Green at the Menninger Clinic in Topeka, Kansas.  I became a pioneer of group biofeedback at his hospital and augmented my income in those days before becoming licensed with this tool and technique.  Today, biofeedback applications amount to some 40% to 50% of my practice. 

I seem to always have at least four or five clients working on hypertension control and a number of patients with panic disorder, phobia, chronic pain, TMJ, anxiety disorder, and insomnia where the biofeedback and self-regulation provide specific skill training helpful to the individual. I come from a Humanistic and Existential orientation and embrace Jungian ideas but often work behaviorally with specific goals to treatment with the biofeedback. The following is an example of an ongoing case involving anxiety and hypertension.

G.P. on her first visit had an initial blood pressure of 160/90 and at the end of the session was 160/82.  She is a fifty-year-old retired professional that has been in psychoanalysis intensively for over fourteen years.  She became aware of her hypertension four years ago and had concomitant panic attack episodes and rampant anxiety. Increasingly she had tachycardia and very irregular heartbeats. Her anxiety and physical symptoms along with elevated blood pressure had gotten markedly worse as she worked on and approached termination with her analyst. Her medication regimen that was begun four years ago included Valium, Toprol, Inderal, Claritin, and Pindolol.  She knew very little about biofeedback but was referred to me by her internist.  I suggested to her that she suspend any judgement about the biofeedback training and its potential efficacy for four or five sessions to see how it goes.  I felt that I would know by then if this held promise for her.  I have been using the Bio Integratorä system for fifteen years or so.

At her third session her initial reading was 170/90, and she was clearly quite anxious.  Her exit blood pressure was 150/86, and she and I were both hopeful and optimistic.  By the fifth session she was reporting considerable compliance with daily home practice consisting of fifteen to twenty minutes of replicating her training in the office, albeit without any feedback but using my auditory program “Relax to Relax” which incorporates soothing music, ocean sounds, and Autogenic suggestion.  Let me turn to some general statements about hypertension and then show GP’s results.

 

Physicians occasionally make referrals for biofeedback therapy and training for individuals that want help in specific skills training to reduce blood pressure. Referrals seem to be generated by the insistence of the patient for something more than control through drugs. Many of these people benefit from learning skills of self-regulation of the mind/body reactions to stressors, anxiety, and tension, often referred to as “fight or flight” responses that take a physical toll over time. Many of the more “high risk” referrals are people who have had a stroke or cardiac episode.  Some of these individuals could be classified as “Type A” personality types that can begin practicing and implementing specific behavioral changes in their lifestyles for additional benefits to the self-regulation or biofeedback training. 

 

What is Hypertension? :  Hypertension is a complex disease that is characterized by chronic sustained elevations in systolic blood pressure (SBP) and or diastolic blood pressure (DBP).  The American Heart Association states that nearly 1 in 3 adults in the United States has high blood pressure.  This is a staggering number of people and nearly 1/3rd of this group is undiagnosed and are unaware that they have it.  High blood pressure is the major risk factor for the incidence of stroke, heart attack, heart failure, and kidney failure.  Sustained elevated blood pressure correlates with a shortened life span.  Amazingly, 90 to 95% of all cases of hypertension are of “unknown origin”.  This type of hypertension is sometimes called “essential”, “primary”, or “idiopathic”. 

What are the Numbers of Hypertension and its Categories?

Greater than or equal to 140 mmHg. systolic

Greater than or equal to   90 mmHg. diastolic

 Normal = less than 120 mmhg. systolic and less than 80 mmHg. diastolic

       Pre-hypertensive =  120 to 129 mmHg. systolic and 80 to 89 mmHg. diastolic

High Blood Pressure: Stage I: 140 to 159 systolic or 90 to 99 diastolic

  High Blood Pressure: Stage II: 160 or higher systolic or 100 or higher diastolic             

 

How Blood Pressure is Measured: Blood pressure is measured with a sphygmomanometer and is usually taken from the left arm and taken while the individual is sitting. The device is a cuff that is placed around the biceps area of the arm. The cuff is inflated with a small hand pump that contains a meter that reads pressure in millimeters of mercury (mmHg.) and that has a valve to allow the release of the pressure. The cuff is inflated usually to a level about 20 mmHg. above the systolic level. This pressure closes the brachial artery that runs down the arm. As opening the valve slowly backs off the pressure, the first pulse of blood that comes through can be heard by a stethoscope or can be heard by an electronic pick-up sensor. This is the systolic blood pressure and is an indicator of how hard the heart organ is contracting to get blood through the arterial system. As the valve is opened more, the beat to beat pulses of blood is heard all the way down to a point that it is now longer heard. This level where there is no longer resistance is the diastolic blood pressure. There are a wide variety of blood pressure units on the market. There are units that are battery powered and can read blood pressure from the wrist and others that can read it from the finger. These instruments are easy to use but are notorious for giving quite variable readings. There are easy to use instruments available with built in stethoscopes that can be self-applied on the biceps and that provide quite reliable blood pressure readings.


Biofeedback and Self-Regulation Training: It is important to emphasize that the biofeedback training is an important adjunct to an individual’s medical treatment and is not meant to replace medical treatment. For an individual taking any variety of medications to “control” hypertension, it is often possible that their physician may chose to reduce medication as one gains self regulation skills and makes positive life-style changes that are contributing to lowered blood pressure. Physicians and cardiologists are generally quite conservative and slow to reduce medication! Usually within three or four biofeedback sessions, it is very apparent whether biofeedback training will be useful in helping an individual control and modify his or her hypertensive reactions to stress and anxiety. We all have fluctuations in blood pressure throughout the day and certainly elevations with exercise, and emotional interactions, and work stress are common. One of the hallmarks of hypertension, however, is the inability or slowness to recover to a “safe” blood pressure after a stressor. It is not unusual to see significant drops in blood pressure from mastering biofeedback techniques. Within a session as much as a twenty to thirty point drop in blood pressure can be typical.


The training proceeds as follows. I take a blood pressure reading “pre” and “post” biofeedback training. Depending on the individual, in the first or second session data will be taken on several physiological modalities. Recording may include hand and foot temperature, the muscle tension of key muscle groups (eg.trapezius and frontalis), basal skin resistance (eccrine sweat gland activity, also called BSR and formerly GSR) as recorded off of the fingers or palmer surface of the hand, respiration activity and heart rate variability. Brain wave training may also be useful to help train pathways toward a mentally quiet state or meditative state. The patient trains in a relaxed, semi-reclining position and is guided by the therapist (often with the use of Autogenic Training and Progressive Relaxation) and by the physiological feedback via tones or video screen feedback into a deeply relaxed state. This state, broadly speaking, consists of learning peripheral vasodilatation (warm hands and warm feet), slowing of heart rate coupled with relaxed slow diaphragmatic breathing, low muscle tension, low “arousal” as evidenced by less sweat activity in the hands, and a quiet mind. The state can be learned and mastered with practice. As the patient gains some skill, I like to practice “interval” training during a session. After relaxing for five or six minutes, I may pause the training and “reactivate” or stress the patient by discussing current issues in their lives, followed by another interval of relaxation. I may do this three or four times in a session. Post blood pressure readings are taken at the conclusion of the last relaxation interval. As a person gains mastery and skill of reducing blood pressure in the office, the next challenge is to begin to integrate these skills into ones day to day life activities. Integration can be promoted initially by practicing the biofeedback skills daily for a set time interval of fifteen minutes. With further mastery an individual can gradually shift from having a specific meditative-type or biofeedback “time out” to more integrated “micro” breaks that include deliberate, conscious shifts to ones physiology throughout the day designed to lower and regulate blood pressure and curtail “fight or flight” behavioral patterns. I often provide home training devices for more specific learning along with audio support.


 

GP has been a pleasure to work with and has really applied herself to learning biofeedback skills.  She works each session initially with some heart rate variability and then moves into eyes closed training where her focus is on increasing peripheral blood flow to hands and feet, increased BSR (drier hands with emotional quieting), increased percent alpha, and lowered EMG frontalis (less muscle tension).  As she goes eyes closed she initially is fed back frontalis with the goal of getting under one microvolt.  Generally she gets there in four of five minutes.  She receives a lower pitch tone as she achieves greater relaxation.  I typically finish the training with six or seven minutes of alpha feedback.  She gets a “reward” tone anytime her alpha is above a particular threshold.  She goes away from nearly every session feeling a bit more confident in her self regulation skills and her ability to reduce her blood pressure.  Here is a summary of her pre and post blood pressure readings during the sessions.  Her sessions were at the same time each week.  She intends to periodically “check-in” for booster sessions. 

 

 

Date

PRE

POST

 

Date

PRE

POST

1/03/05

162 / 88

162 / 82

 

3/28/05

132 / 90

122 / 84

1/10/05

150 / 92

138 / 86

 

4/04/05

Didn’t want

130 / 88

1/19/05

170 / 90

150 / 86

 

4/18/05

132 / 86

118 / 78

1/24/05

152 / 90

146 / 84

 

4/25/05*

122 / 82

118 / 78

2/07/05

144 / 92

132 / 88

 

5/02/05**

130 / 86

120 / 80

2/14/05

138 / 86

130 / 84

 

5/16/05

124 / 84

118 / 78

2/21/05

144 / 100

130 / 84

 

5/23/05

138 / 92

122 / 82

2/28/05

138 / 98

122 / 82

 

6/06/05

128 / 84

118 / 80

3/07/05

138 / 88

118 / 82

 

6/13/05

126 / 84

116 / 74

3/09/05

136 / 86

No take

 

6/27/05

124 / 84

112 / 80

3/14/05

150 / 98

130 / 88

 

7/11/05

124 / 90

118 / 80

3/21/05

132 / 94

118 / 84

 

7/25/05

130 / 86

122 / 82

3/23/05

128 / 94

122 / 84

 

    8/8/05***

    128 / 82

118 / 80

 

* Discontinued Inderol, Beta Blocker

** Reduced Toprol by ½ the dose, 25 mg. down to 12.5 mg

*** Discontinued Toprol

 

The following graph depicts the patient’s progress over time on her basal skin resistance.  This measure is one of my favorites as it is a window into a person’s emotions.  Higher skin resistance (drier hands) generally indicates less anxiety, less vigilance, greater calmness, and greater sense of security, confidence, and safety.  Medications such as anxiolytics certainly effect the readings and can cloud the picture (artificially induce drier hands).  Despite titrating out some of the Beta Blockers, the patient shows tremendous progress.

           

I have been using the biofeedback tool for over thirty years and find it very helpful in giving a person a sense of “control” back in their lives.  They become and active participant in health maintenance.  If my practice were solely biofeedback based, I would burn out and be bored by it.  I am not at all!  Also, I am not asking patients to do something that I have not practiced myself.  It has been a great tool for me and I maintain

my own skill levels via micro self-regulation breaks throughout the day.    A clinician is really not ready to use biofeedback with patients until they have mastered self regulation skills for themselves and until the technology is no longer a distraction away from client centered therapy.  A basic level of competence in biofeedback is achieved by practitioners whom have gained certification from the Biofeedback Certification Institute of America located in Wheat Ridge, Colorado.  I am a Senior Fellow of the B.C.I.A. which likely means I am old and competent!

 

 



Home /Psychotherapy & Counseling/What is Biofeedback? /Dental and Myofacial Pain/ Hypertension & Coronary Artery Disease / Chronic Pain & Headaches / Anxiety, Phobias & Panic Attacks / EEG, Brainwaves & Neurofeedback / Biofeedback Links /TMJ Photos /ADHA Article / Academic Performance / Attention Training / IM Links /Bill's Bio/ E-Mail/ Directions / Forms/ Testimonials