Journal of Human Hypertension (1997) 11, 171–176
 1997 Stockton Press. All rights reserved 0950-9240/97 $12.00
Relationship between self-perceived stress
and blood pressure
PM Suter, R Maire, D Holtz and W Vetter
Department of Internal Medicine, Medical Policlinic, University Hospital, Zürich, Switzerland
Objective: The importance of stress in the pathogenesis
of essential hypertension is controversial. In this study
we wanted to evaluate the relation between self-perceived stress and the blood pressure (BP) in a asymptomatic healthy population.
Subjects and methods: A total of 1666 guests (mean ±
s.d. age 50 ± 16 years) attending the air show AIR94 in
Buochs, Switzerland volunteered to participate in a
cross-sectional study. Using a self-administered questionnaire and visual analogue scales the individual
stress perception and other cardiovascular risk
behaviours/factors were assessed. BP, body weight,
height, and the waist:hip ratio were measured.
Results: Individual stress perception was inversely
related with the systolic BP (SBP) (r = −0.12, P , 0.001).
The relationship was found in both men and women and
was independent of age and/or body weight. No relation
was found between the diastolic BP (DBP) and stress
perception. Subjects with high normal BP according the
JNC V classification showed a lower stress perception
than did subjects with normal BP. In a multiple
regression model the stress score was fourth most predictive of the SBP after body mass index, waist:hip ratio,
and age followed by alcohol and fat intake.
Conclusion: In this study we found an inverse association between the self-perceived stress and SBP. We
suggest that the inverse association between BP and
the self-perceived stress reflects a neuroendocrine and
biochemical setting characterized by inadequate stress
handling associated with a higher fat and alcohol intake
and more abdominal fat tissue leading to a higher BP.
Our data suggest that stress denial in combination with
abdominal obesity, alcohol consumption, and smoking
may be proxy for a high stress level.
Keywords: blood pressure; self-perceived stress; stress control; stress coping
Introduction
Subjects and methods
The importance of psychological stress in the pathogenesis of essential hypertension is controversial.1–7
The controversy is due to methodological problems
in the definition and assessment of stress8 and the
large variability in stress responses according to the
individual personality and the type of stress.9 While
it is generally accepted that acute stressors (such as
fear, anger, anxiety and other physical stressors such
as noise or accidents) are associated with a short
term increase in blood pressure (BP) (‘reactivity
hypothesis’), it is less clear whether a continuous
stressor will lead over time to a ‘fixed’ hypertension.3 A high BP reading is often interpreted to be
caused at least in part by stress. Different stress situations leading to increased BP have been identified.
Everybody is exposed to stress factors which may be
of importance in the pathogenesis of different diseases, however, the stress perception and the
response to stress are very heterogeneous.6 Thus, it
comes as no surprise that the literature on the
relation between self-perceived stress and BP is
inconclusive.6,10,11 In this study we wanted to evaluate the relation between self-perceived stress and BP
in a free living healthy population.
In this cross-sectional study, 1666 guests attending
the AIR94 air show at the Swiss Air Force Base in
Bouchs (Nidwalden/Switzerland) were studied. The
participation was voluntary. Upon obtaining their
agreement to participate in the study, subjects were
asked to complete a self-administered questionnaire
and visual analogue scales assessing various issues
related to cardiovascular risk factors (eg, family history of hypertension, diabetes, coronary artery disease, overweight, smoking habits). Alcohol consumption was evaluated by asking about alcohol
intake (yes/no) and four consumption frequency categories (less than once per week, 1–2 times/week,
3–4 times/week, daily). With the help of visual analogue scales the levels of self-perceived stress
(high/low), physical activity (high/low), fat content
of the diet (high/low), health perception (good/bad)
and self-judged body weight status (too light/too
heavy) were assessed. No grading or marks on the
visual analogue scales were used. Further the intake
of antihypertensive drugs (yes/no) was noted. The
questionnaire was pretested in patients of the Medical Policlinic of the University Hospital in Zürich.
The procedure of the data collection was as follows: Initially, body weight (in light summer clothing with shoes) was measured with a mechanical
scale (SecaTM, Germany) and height to the nearest
0.5 cm with a fixed stadiometer. Then, fat distribution was assessed by the measurement of the largest circumference at the waist and at the level of the
hip. The body mass index (BMI, kg/m2) and the
Correspondence: Professor Dr W Vetter, Department of Internal
Medicine, Medical Policlinic, University Hospital, Rämistrase
100, CH 8091 Zürich, Switzerland
Received 20 July 1996; revised 31 December 1996; accepted 2
January 1997
Self-perceived stress and blood pressure
PM Suter et al
172
waist:hip (W/H) ratio were computed. Following
these anthropometric measurements, the subjects
were asked to complete the questionnaire as well as
the visual analogue scales. The completion of the
questionnaire took about 8–10 min. Next, resting BP
measurements were performed with an appropriately sized cuff using a semi-automatic device
(Visomat OZ2TM, Hestia Pharma GmbH, Mannheim,
Germany). Two BP measurements were taken by
trained health workers. In the analysis, the mean
value of the two measurements was used. Hypertension was defined according the World Health
Organization criteria 12 as well as the criteria of the
5th US NJC for the Detection of Hypertension. 13
Only three subjects were found to have Stage III
hypertension. As they could not be statistically
evaluated as a separate group, they were omitted
from the final analysis (Table 1).
The responses of the self-perceived stress were
reverse-scored for the final analysis so that 10 equals
the highest stress level. Since only the overall stress
perception was assessed using one single visual analogue scale, no distinction between different stressors (eg, job related stress or private stress, etc) could
be made. During the pretesting of the questionnaire,
all subjects indicated that the term ‘stress’ is viewed
as an integral term for all types of stress in daily life.
In the following sections, the terms self-perceived
stress will be used interchangeable with stress score
or with stress perception.
To study the relation between the stress score and
BP as well as other variables, simple logistic
regression models were computed. For differences
between means of non-paired data, one-way analysis
of variance and Student’s t-test procedure were
used. Differences in frequency were assessed by x2
statistics. As the univariate analysis revealed that
several variables confounded the parameters of
interest due to colinearity, we applied a stepwise
multivariate procedure for the further analysis of the
data (F . 2.247, P , 0.001).
The data processing was done on a personal computer using the StatViewTM statistical software package (Abacus Concepts, Berkeley, CA, USA). All
values are presented as mean ± s.d. unless otherwise stated.
Table 1 Mean ± s.d. stress score according according systolic and
DBP status using the NJC criteria for the entire population (see
text)
n
Stress score ± s.d.
Systolic
Normal
High Normal
Stage I
Stage II
ANOVA for trend
1067
233
224
73
4.5 ± 0.09
4.9 ± 0.2
3.6 ± 0.2
3.7 ± 0.4
P = 0.0002
Diastolic
Normal
High Normal
Stage I
Stage II
ANOVA for trend
1189
142
180
90
4.3 ± 0.9
3.8 ± 0.3
4.1 ± 0.2
4.1 ± 0.3
P = 0.24 (ns)
Blood pressure group
Results
Characteristics of the population
All subjects were of Caucasian origin. The characteristics of the subjects and the mean scores of the visual analogue scales for all subjects and separately by
gender are listed in Table 2.
A family history of hypertension was present in
32% of the subjects. A family history of diabetes,
overweight, or coronary artery disease was present
in 12%, 33% and 17%, respectively.
The mean (±s.d.) systolic (SBP) and diastolic BP
(DBP) of the population was 124 ± 19 mm Hg and
77 ± 13 mm Hg, respectively. Based upon the mean
of two resting BP measurements, 17% showed a systolic and 16% a diastolic hypertension according to
the WHO criteria. Fifteen per cent of the subjects
were on an antihypertensive medication. The BP of
the subjects on antihypertensive medication was significantly higher than in the subjects without antihypertensive medication (mean BP 135/84 mm Hg
vs 121/76 mm Hg, P , 0.001).
The mean ± s.d. stress score for the whole population was 4.2 ± 3.1, the distribution of the stress
score was normal without any significant skewness
or curtosis. There was no gender difference in the
stress perception (men 4.32 ± 0.09 and 4.15 ± 0.14
women, ns). Since there was no gender difference
in the stress score, the data for men and women were
pooled for the final analysis. Subjects with systolic
hypertension and a lower stress score than the normotensive subjects (3.6 ± 0.2 vs 4.4 ± 0.1, P , 0.001).
There was no significant difference in the stress
score in diastolic hypertensive subjects as compared
to diastolic normotensive subjects (P = 0.45). Subjects on antihypertensive medication had a lower
stress score than did subjects without antihypertensive medication (3.7 ± 0.2 vs 4.5 ± 0.1, P , 0.01). The
stress scores were practically identical in subjects
with and without a family history of hypertension
(4.3 ± 0.1 vs 4.4 ± 0.1, P = 0.49). The stress score was
neither affected by the family history of coronary
artery disease, diabetes mellitus, and/or overweight.
With increasing alcohol consumption the W/H ratio
increased (ANOVA for trend P , 0.0001). The stress
score of the daily alcohol consumers was lower than
the score of the less than once per week consumers
(4.0 ± 0.23 vs 4.4 ± 0.15, P = 0.23). The stress score in
smokers was higher than in the non-smokers
(4.6 ± 0.2 vs 4.2 ± 0.1, P , 0.05).
Univariate correlations
The univariate correlation coefficients of the different parameters with the stress score are summarized
in Table 3 for the entire population and according
antihypertensive therapy.
The univariate correlation showed an inverse
association between the SBP and the stress score
(r = −0.12, P , 0.0001). This relation was found to be
independent of age, sex and/or body weight. This
relationship was not found for the DBP (r = −0.02,
P = 0.27). There was an inverse relation between the
pulse pressure and the stress score (r = −0.15,
p , 0.05).
Self-perceived stress and blood pressure
PM Suter et al
173
Table 2 Characteristics of the entire study population and according gender
Parameter
Age (years)
BMI (kg/m 2)
Waist (cm)
Hip (cm)
W/H ratio
Weight change since age 20 years (kg/year)
Weight change last 2 years (kg)
Alcohol consumption (%)
Alcohol consumption frequency
,1×/week
1–2×/week
3–4×/week
daily
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)
Pulse pressure (mm Hg)
Stress score
Nervousness score
Health score
Physical activity score
Fat score
Smoking (%)
All
(n = 1410–1601)
Men
(n = 1104)
Women
(n = 497)
P for sex
difference
50 ± 16
25 ± 4
92 ± 13
103 ± 29
0.893 ± 0.087
3±5
81
51 ± 0.5
26 ± 0.1
95 ± 0.4
104 ± 0.9
0.925 ± 0.002
0.5 ± 0.03
2.9 ± 0.1
86
47 ± 0.7
24 ± 0.2
82 ± 0.5
100 ± 1.4
0.818 ± 0.003
0.4 ± 0.05
3.3 ± 0.2
71
,0.0001
,0.0001
,0.0001
,0.05
,0.0001
,0.05
ns
,0.001
34
36
16
14
124 ± 19
77 ± 13
47 ± 13
4.2 ± 3.1
3.7 ± 3
8.8 ± 1.7
5.7 ± 3
3.9 ± 2.6
23
28
38
19
15
127 ± 0.6
79 ± 0.4
48 ± 0.4
4.3 ± 0.9
3.6 ± 0.9
8.8 ± 0.05
5.8 ± 0.9
4.3 ± 0.08
23
52
33
6
9
117 ± 0.8
72 ± 0.6
45 ± 0.6
4.2 ± 0.1
4.1 ± 0.1
8.8 ± 0.08
5.6 ± 0.1
3.1 ± 0.2
23
,0.0001
,0.0001
,0.001
ns
,0.01
ns
ns
,0.0001
ns
Table 3 Univariate correlations of the stress perception with different parameters in the entire population according antihypertensive therapy (AT). Each figure represents the correlation coefficient (r) for the stress core with the corresponding parameter
Parameter
Stress Score
All
Without With AT
(n = 1410– AT
(n = 173–
1601) (n = 1035– 229)
1283)
Systolic blood pressure (mm Hg)
Diastolic blood pressure (mm Hg)
Pulse Pressure (mm Hg)
Age (years)
Body weight (kg)
BMI (kg/m 2)
Waist (cm)
Hip (cm)
Waist/Hip ratio
Weight at age 20 (kg)
Weight change since age 20 (kg)
Weight change since 2 years (kg)
Alcohol intake (yes/no)†
Alcohol consumption frequency†
Nervousness score
Health score
Physical activity score
Fat intake score
Smoking†
−0.12***
−0.03
−0.15*
0.25***
0.01
−0.04
−0.07**
0.04
−0.07**
0.06*
0.03
0.05
0.02
0.05
0.43***
−0.14***
0.02
0.08**
0.06*
−0.10*** −0.12
−0.02
0.01
−0.12*** −0.18***
−0.21*** −0.41***
0.03
0.00
−0.01
−0.01
−0.05
−0.06
−0.03
0.04
−0.00
0.13
0.07* −0.40***
0.04
0.16
0.06
−0.07
0.02
0.00
0.05
0.06
0.44*** 0.34***
0.15*** −0.16*
0.00
0.07
0.6*
0.11
0.05
0.09
*P , 0.05; **P , 0.01, ***P , 0.001.
†by ANOVA.
The health score was found to be significantly
related to the stress perception (r = −0.14, P , 0.001)
and the effect was independent of the antihypertensive therapy. Higher levels of stress were associated
with higher fat intake (r = 0.08, P . 0.01). There was
no difference in the fat score contingent on the
hypertension status. Age was a very strong determinant of the stress score (r = −0.25, P , 0.0001).
There was a significant inverse correlation
between the W/H ratio and the stress score
(r = −0.07, P , 0.01). The higher the abdominal fat
mass the lower the stress score and the higher the
alcohol intake (ie, alcohol consumption frequency).
There was no significant relation between the
health score and alcohol intake (ie, frequency of
consumption). The self-judged fat intake was significantly higher in those who consumed alcohol
more frequently (r = 0.13, P , 0.01).
The univariate analysis revealed that several parameters might confound the association between the
individual stress-perception and BP. Therefore we
tested in a stepwise multiple regression model the
variables which may have influenced the association
of interest.
Multivariate analysis
The following twelve factors were included in a
stepwise multiple regression model: health status,
age, gender, W/H ratio, BMI, physical activity score,
smoking, family history of diabetes, family history
of coronary artery disease, family history of hypertension, ethanol consumption, BP and the self-perceived stress. We included into the model only 1007
subjects in which all parameters of interest were
available and who did not take any antihypertensive
drugs. The major determinants for the SBP were the
BMI, the W/H ratio and age. The fourth most
important contributor to the systolic pressure was
the self-judged stress perception followed by alcohol
and fat intake (Table 4). The R2 for the whole model
for the SBP was 0.21 (P , 0.001).
Age, the health score, SBP and the fat score were
the major determinants for the individual stress perception (Table 5). A positive family history of coronary artery disease was a determinant of the systolic
(F value = 7, P , 0.01) and diastolic (F value = 6,
P , 0.05) BP.
Self-perceived stress and blood pressure
PM Suter et al
174
Table 4 Multiple regression analysis of the contribution of different parameters to the variability of the systolic pressure (the nonsignificant variables are not shown)
Systolic blood
pressure
Diastolic blood
pressure
F value
Partial
correlation
F value
Partial
correlation
163
129
101
13
6
5
0.37†††
0.34†††
0.30†††
0.11†††
0.087†
0.074†
139
119
58
0.023
6
6
0.35†††
0.33†††
0.23†††
0.005 (ns)
0.08†
0.08†
BMI (kg/m2 )
W/H ratio
Age (years)
Stress score
Ethanol intake
Fat score
† for these variables P , 0.05.
†† for these variables P , 0.01.
††† for these variables P , 0.001.
ns = not significant.
Table 5 Multiple regression analysis of the contribution of different parameters to the variability of the individual stress perception (the nonsignificant variables are not shown)
STRESS SCORE
F value
Age
Health score
Systolic blood pressure
Fat score
60
12
12
7
Partial correlation
0.24†††
0.11†††
0.11†††
0.083††
†† for these variables P , 0.01.
††† for these variables P , 0.001.
The described relations were found to be independent of the order of entry of the parameters into
the model.
Discussion
The role of stress in the pathogenesis of hypertension is controversial.3–7 There is, however, evidence
suggesting that the control of certain forms of stress
can be of great therapeutic value in the control and
prevention of essential hypertension.6,14,15 In this
study we found an inverse relationship between the
self-perceived stress and SBP. This relationship was
found in men and in women. The association was
independent of age and/or body weight. Subjects
with antihypertensive therapy did not show this
relation. No relation was found between the DBP
and the stress score.
Many different factors may determine the
response and the self-judged perception of stress.
The response may vary according the stressor16 and
personality traits. Using a stepwise multiple
regression procedure, age, the self-judged health
status and the SBP were the most important determinants of the self-perceived stress score (Table 5) followed by the fat intake as the fourth most important
factor modulating the stress perception. On the
other site the BMI, the W/H ratio, age, the stress
score, alcohol and fat intake were the most
important determinants of the SBP. The coefficient
of correlation of the association between the stress
score and the SBP in our population was rather
small, and one may be inclined to dismiss any relevance of this association. Nevertheless in view of
the great pathophysiological association between
small BP changes and cardiovascular mortality,13,17
the described relation may be of great public
health importance.
There is no ideal validated tool for the assessment
of stress, however, the use of various self-administered scales (such as visual analogue scales), and
questionnaires remain most useful for epidemiological studies. While systematic over- or underestimation of the perceived stress may occur,8 this would
probably not strongly affect the present dataset. The
inverse relationship between stress perception and
SBP seems to be surprising but is in agreement with
other studies.10,11,18 Winkleby et al11 reported a
negative relation between SBP and a subjective
stress index based upon different job problems.
Other studies, however, reported a positive association between these two parameters.19–22 These contradictory results may be caused by several factors
such as characteristics (especially psychosocial
traits) of the populations studied, the type of stress,
the duration of the stressor, and by the method of
stress assessment.11 Chronic low-impact stressors of
daily life are handled differently than acute highimpact life threatening stress factors.21 Continuous
exposure to a stressor often leads to habituation and
adaptation or even ‘stress denial’,23 which may partially explain our findings. Further, any suppressed
perception of a stress factor or emotion may lead to
hostility and often also higher BP.10,24–26 The theory
of repressed hostility as a potentially important
element in the modulation of BP and cardiovascular
risk has been proposed26–29 and may have contributed to the higher BP in our subjects.
After classifying our population according the JNC
BP categories (Table 1),13 we found that subjects
with high normal systolic and/or DBP do show a significantly lower stress score than subjects with normal BP. This suggests that subjects with a high normal BP may be psychologically and/or metabolically
different from subjects with normal BP. This is also
in agreement with the findings that subjects with
borderline hypertension and with prehypertension
are hyperreactive to various stressors as compared
to normotensive subjects, thought to be caused by
specific personality traits (including increased hostility14,28,30,31 and eventually also specific metabolic
characteristics predisposing to hypertension.32–36
In addition, high prevalence of the inability to
express emotions (alexithimia) has been found in
subjects with various cardiovascular diseases
including hypertension and prehypertension.8,37
Accordingly, hypertension may be associated more
often with a low capability to express emotions.38
This constellation may then lead to a underreporting
of stress factors such as job problems, private problems and also of potentially stressful life events.39
This may also be one reason for the postulated
underreporting of stress in our population. Further
it is possible that the behvaiour described in our
population corresponds at least in part to the
Self-perceived stress and blood pressure
PM Suter et al
recently described distressed personality type D
characterized by the tendency to suppress emotional
distress, which has been identified as an independent potential predictor of long-term mortality
in coronary artery disease.40,41
Beside these psychophysiological factors, other
stress coping strategies may further enhance the
development of a higher BP. Some of these coping
mechanisms, especially smoking, alcohol consumption, and overeating may in part and temporally
help to control stress, however, at the expense of a
higher risk to develop hypertension.42 In our study
an increased stress score was associated with an
increased fat intake, suggesting that stressed subjects
try to control their stress by an increased fat consumption and respectively a higher energy intake.
The latter is supported by the strong positive correlation between the BMI and the fat score (r = 0.15,
P , 0.0001). There was a tendency for increased
alcohol consumption with increasing stress perception, however, the trend did not reach significance.
The lack of significance may be due to difficulties in
assessing alcohol consumption correctly. A higher
alcohol intake was, however, associated with a
higher fat intake (ANOVA P , 0.001). The latter is,
however, an unfavourable constellation, since alcohol suppresses lipid oxidation thus enhancing the
development of a positive energy balance and thus
obesity, further enhancing the development of
frank hypertension.
Our data do not allow us to interpret the lacking
relation between the stress perception and the DBP.
However, it is known that the stress effects on systolic and DBP vary according the type of the stress
factor.31
In this study we found an inverse association
between the self-perceived stress and the SBP. We
suggest that the inverse association between BP and
self-perceived stress reflects a psychological and
metabolic setting characterized by inadequate stress
handling predisposing to a higher BP.
Acknowledgements
Industrade Computer Company Dietlikon Zürich for
borrowing two computer hardware systems. Mr J
Bollhalder and Ch. Mazenauer for the data entry.
SERVIER Suisse SA, Geneva, for a financial support
of the study. Special thanks are expressed to the
Samaritans of the Kanton Nidwalden and the members of the military medical corps of the AIR94
(SanKp 36) for their excellent contribution in the
data collection and infrastructure as well as overall
assistance. The critical comments of Professor A
Zeichner, Department of Psychology (University of
Georgia, Athens, USA) are appreciated.
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