Differences in Emotion Processing in Patients With Essential and Secondary Hypertension
AMERICAN JOURNAL OF HYPERTENSION |
Differences in Emotion Processing in Patients With Essential and Secondary Hypertension
Silla M. Consoli 1 2
Cédric Lemogne 2
Bernard Roch 1 2
Stéphane Laurent 1 5 6
Pierre-François Plouin 1 4
Richard D. Lane 3
0 CNRS USR 3246, Pitié-Salpêtrière Hospital , Paris , France
1 Paris Descartes University of Medicine , Paris , France
2 a ssistance Publique-Hôpitaux de Paris, Department of C-L Psychiatry, European Georges Pompidou Hospital , Paris , France
3 Department of Psychiatry
4 a ssistance Publique-Hôpitaux de Paris, Department of Hypertension, European Georges Pompidou Hospital , Paris , France
5 INSERM U 970 , Paris , France
6 a ssistance Publique-Hôpitaux de Paris, Department of Pharmacology, European Georges Pompidou Hospital , Paris , France
Bacgkround a n impaired ability to experience and express emotions, known as alexithymia, has previously been associated with hypertension. a lexithymia and related emotion-processing variables, however, have never been examined as a function of the type of hypertension, essential (EH) or secondary (SH).
alexithymia; blood pressure; emotional awareness; hypertension; questionnaires; psychosomatic model
a fter controlling for confounding variables, LEa S score was lower in
EH than SH (estimated means: 46.4 vs. 52.0; P = 0.028; effect size 0.52).
Hypertension has historically been considered a psychosomatic
disease.1–3 Consequently, several studies have searched for
differences in emotion processing between normotensives
and hypertensives, as well as between normotensives with
and without a family history of hypertension. Increased
blood pressure reactivity to mental stressors as well as several
emotion-processing abnormalities, such as suppressed anger,
anxiety, depression, or job stress, have been associated with
hypertension.4–14 A few studies focused on the presence of a
global impairment in processing emotions in hypertensives.
Such impairment, named alexithymia, was originally defined
as a difficulty in identifying and describing feelings. The
association of alexithymia with several classic psychosomatic
diseases was described by Sifneos15 and Nemiah et al.16 in the
1970s. The construct of alexithymia was further developed by
Using the 20-item Toronto Alexithymia Scale (TAS-20), the
most widely used measure of alexithymia to date, Todarello
et al.25 found hypertensive patients to be more frequently
alexithymic: 55% of alexithymic individuals in a hypertension
group, compared with a rate of 33% in a psychiatric control
sample, and 16% in a normal control sample. Jula et al.26 also
found higher TAS-26 scores in newly diagnosed, uncomplicated
and as yet untreated hypertensive men and women, compared
with normotensive controls (TAS-26 is an earlier version of the
TAS-20, which correlates highly with it). Gage and Egan27 and
Lyshova et al.28 observed more severe disease (i.e., presence of
target organ damage) or longer duration of the disease in
alexithymic vs. nonalexithymic hypertensive patients.
Psychometric data available in hypertensive patients are
therefore compatible with impaired emotion-processing in
hypertension. Nevertheless, studies published on this topic
generally compared hypertensive patients with
normotensive controls, and it cannot be excluded that the observed
results may simply reflect the psychological impact of having a
chronic somatic disease or the consequences of some
subclinical brain damage due to a longstanding hypertensive disease.
This study was based on the hypothesis that if dysregulated
emotional processes play a key neurobiological role in primary
or essential hypertension (EH), they would be less present
in hypertension due to specific medical causes or
secondary hypertension (SH). In other words, we thought that even
if EH and SH share common emotion-processing alterations
as results of a similar clinical condition, a more pronounced
impairment in emotion processing should be expected in
EH. In fact, no study has ever compared emotion processing
between the two forms of hypertension. This study was thus
designed to compare emotion-processing scores in EH vs. SH,
taking into account the presence of potential confounding
variables. Two complementary tools were used for measuring
emotion processing: the TAS-20, for measuring alexithymia,
and the Levels of Emotional Awareness Scale (LEAS),29 for
measuring “emotional awareness”, i.e., the capacity to
represent, discriminate, and elaborate both one’s own and others’
emotional experience in a given context. Emotional awareness
has never been studied in hypertensive patients. Higher
levels of alexithymia and/or lower levels of emotional awareness
were expected in EH compared with SH.
Subjects. The study population consisted of consecutive
hypertensive patients admitted to a hypertension clinic (Broussais
Hospital, Paris, France), typically for pharmacological
readjustment or extensive clinical work-up. Subjects completed a
battery of questionnaires (see below). Sociodemographic and
clinical data were obtained from medical records.
Psychometric measures. Alexithymia was measured by the
French version of the TAS-20 (ref. 30). This is a self-report
questionnaire that involves rating 20 statements on a 5-point
Likert scale for a minimum score of 20 and a maximum score
of 100. Although alexithymia is a dimensional construct,
cutoff scores have been proposed (≥56 for the French population)
for selecting alexithymic subjects when using a categorical
approach. The three factorial components of the scale were
also computed: difficulty identifying feelings (DIF) or Factor 1,
difficulty describing feelings (DDF) or Factor 2, and externally
oriented thinking (EOT) or Factor 3 (ref. 31).
Emotional awareness was measured by the French version
of the Levels of Emotional Awareness Scale (LEAS).32 This
is a written, projective instrument that asks the subject to
describe his or her anticipated feelings and those of another
person in each of 20 scenes described in two to four
sentences and constructed to elicit four types of emotion (anger,
fear, happiness, and sadness).33 Each scene is followed by two
questions: “How would you feel?” and “How would the other
person feel?” The construct of LEAS is based on a
cognitivedevelopmental model of emotional experience related to
Piaget’s model of intelligence. In this model, the experience
of emotion is hypothesized to undergo structural
transformation in a hierarchical developmental sequence of progressive
differentiation and integration;29 alexithymia is thought to be
associated with lower level function on this continuum. Thus,
each response to a scene receives a score of 0–5, according to
five levels of increasing complexity, 0 corresponding to
nonemotion responses, e.g., cognitive terms, 1 to an awareness of
physiological cues, 2 to undifferentiated emotions or action
tendencies, 3 to differentiated emotions or feelings, 4 to a blend
of differentiated emotions, and 5 to differentiated emotions
attributed to self and other that are nonidentical. The
maximum possible score on the LEAS is 100. Self and other LEAS
subscores are also generally computed. We will report only the
results for total LEAS scores as this is the most reliable
measure. A glossary of words and phrases at each level was created
by Lane and Schwartz to guide scoring. Inter-rater reliability of
LEAS total score is high with intraclass r = 0.84 for the English
version33 and r = 0.96 for the French version.32
In addition to these two main emotion-processing measures,
subjects also completed the French version of the 27-item Ways
of Coping Checklist, which provides three scores:
problemfocused coping, emotion-focused coping, and seeking social
support.34,35 Emotion-focused coping includes items
addressing minimization (Tried to forget the whole thing),
avoidance (Wished that the situation would go away or somehow
be over with), or self-blame (Criticized or lectured myself). No
hypothesis was formulated regarding a difference in coping
mechanisms between EH and SH, but coping measures were
considered as potential covariates of the two
emotion-processing measures. Actually, emotion-focused coping was found in
several studies to be a good predictor of depression, negative
affect, or emotional distress.36
Statistical analysis. Student t-tests for unpaired groups, Mann–
Whitney nonparametric tests, and χ2-tests were, respectively,
used for comparing means or ranks of continuous or ordered
variables (e.g., educational level, duration of the disease), or
distributions of categorical variables. Associations between
quantitative variables were tested calculating Pearson r
productmoment or Spearman ρ rank correlation coefficients for ordered
variables (e.g., correlation between psychometric measures and
educational level). Effect sizes were computed for indicating the
magnitude of differences in psychometric measures between EH
and SH (Cohen’s d for continuous variables and the coefficients
of contingency for categorical ones (categorical alexithymia)).
Post hoc power estimates with α = 0.05 were also computed.
Multivariate analyses of continuous variables (i.e., the
TAS-20 total score and subscores and the LEAS score) were
performed for comparing EH and SH, using a general linear
model, with all potential confounding variables (i.e.,
sociodemographic or clinical variables found to be associated with the
type of hypertension in univariate analyses) as covariates.
Finally, a multivariate binary logistic regression was performed
for predicting the type of hypertension (EH vs. SH) according to
psychometric measures and controlling for sociodemographic or
clinical variables found to be associated with the type of
hypertension in univariate analyses. Only the variables with a
statistical level of significance <0.10 were kept into the model.
May 2010 | VOLUME 23 NUMBER 5 | AMERICAN JOURNAL OF HYPERTENSION
a ge (years)
SBP (mm Hg)
DBP (mm Hg)
a CE inhibitors
Educational level (
a ngiotensin II receptor
Calcium channel blockers 98
Duration of HT (years)
BMI ≥30 kg/m2
t able 1 | s ociodemographic and clinical characteristics
of the study population
Except for categorical variables, results correspond to means ± s.d. P is the comparison
between EH and SH (Student t-test for continuous variables, Mann–Whitney test for
ordered variables (educational level, duration of HT, number of antihypertensive drugs
prescribed) and χ2-test for categorical variables).
ACE, angiotensin-converting enzyme; BMI, body mass index; CV, cardiovascular;
DBP, diastolic blood pressure; EH, essential hypertension; HT, hypertension; SBP, systolic
blood pressure; SH, secondary hypertension.
A total of 98 hypertensive patients were included in the study.
Two subsets of hypertensives were defined based on medical
diagnosis: 73 patients suffering from EH and 25 patients from
SH; 13 of the latter were attributed to renal artery stenosis, 1
to primary nephropathy, 9 to primary aldosteronism, and 2 to
The sociodemographic and clinical characteristics of
the study population are described in Table 1. EH differed
from SH patients in having a higher body mass index (BMI)
and a higher percentage of patients suffering from obesity
(BMI ≥30 kg/m2) or hypercholesterolemia. Given the
nonnormal distribution of the duration of the disease, this variable
was log-transformed before entering into statistical analyses. In
total, 13 patients (9 EH and 4 SH patients) presented with
associated clinical cardiovascular (CV) complications. The latter
consisted of coronary heart disease (n = 6), peripheral vascular
disease (n = 5), stroke (n = 4), and heart failure (n = 1), some
patients presenting with more than one CV complication.
Except for three EH patients, for whom the current blood
pressure measures were not reported in medical records, data
collected for the remaining 95 patients showed that systolic
and diastolic blood pressures did not differ between EH and
SH. The number of prescribed antihypertensive drugs was
greater in EH; moreover, angiotensin II receptor antagonists
and, marginally, angiotensin-converting enzyme (ACE)
inhibitors were less prescribed in SH (Table 1).
c orrelation analyses
Total TAS-20 score and LEAS score were slightly
intercorrelated (r = −0.20, P = 0.047). LEAS was also correlated with
DDF score (r = -0.27, P = 0.008).
Ways of Coping Checklist emotion-focused coping was
positively correlated with TAS DIF subscore (r = 0.25; P = 0.013)
and, marginally, with total TAS-20 score (r = 0.18; P = 0.082),
but not with LEAS (r = 0.03).
TAS-20 was correlated with age (r = 0.20; P = 0.043) and
educational level (ρ = −0.32, P = 0.001). No significant association
was observed between LEAS scores and gender, age, or
educational level. No significant association was observed between
TAS-20 or LEAS scores and CV risk factors (smoking,
hypercholesterolemia, BMI, diabetes), except a positive correlation
between TAS-20 EOT subscore and BMI (r = 0.24; P = 0.017),
the log-transformed duration of hypertension since diagnosis
or the presence of CV complications. No association was found
between psychometric measures and the number of prescribed
antihypertensive drugs, but LEAS scores were lower in patients
receiving ACE inhibitors (43.0 ± 10.5 vs. 49.6 ± 10.9; P = 0.009).
u nivariate comparisons of psychometric measures between
eh and sh
The mean TAS-20 total score and LEAS score for the entire
sample of hypertensives were 51.4 ± 11.8 and 47.9 ± 11.2,
Univariate comparisons of psychometric measures between
EH and SH are presented in Table 2. EH differed from SH in
that it was associated with higher EOT scores (P = 0.033) and
lower LEAS scores (P = 0.009). Although a higher percentage
of alexithymia was found in EH (40%) in comparison to SH
(28%), according to French-recommended cutoff point (≥56;
ref. 30) the difference was not significant. The difference was
even narrower when applying international cutoff point (≥61;
ref. 20). Although TAS-20 total score, DIF, and DDF subscores
were not significantly different between EH and SH, values
were higher in EH, with effect sizes of 0.34, 0.27, and 0.07,
respectively, and a post hoc power estimate of 0.30 for TAS-20
No difference between the two types of hypertension was
found for Ways of Coping Checklist scores.
Regarding the TAS-20 total and factorial subscores (DIF, DDF,
and EOT scores), no effect of hypertension type (EH vs. SH)
was observed after controlling for BMI and
hypercholesterolemia and/or for emotion-focused coping.
Regarding the LEAS score, the difference observed in
univariate analysis between EH and SH persisted after controlling
t able 2 | Psychometric measures of the study population
for BMI, hypercholesterolemia, CV complications,
emotionfocused coping, and prescription of ACE inhibitors (P = 0.047).
Retaining within the model only those variables associated with
LEAS score at P < 0.10, LEAS was predicted both by the type of
hypertension (P = 0.028) and prescription of an ACE inhibitor
(P = 0.027). Estimated LEAS means for EH and SH were 46.4
and 52.0, respectively (effect size = 0.52). LEAS scores were
lower in hypertensive patients treated by ACE inhibitors.
We finally performed a descending hierarchical binary
logistic regression analysis for predicting SH vs. EH, entering
first into the model all the variables associated with the type
of hypertension. Three independent variables remained within
the model: the LEAS total score (P = 0.012), the BMI, and the
prescription of an angiotensin II receptor antagonist. SH was
thus predicted by higher LEAS scores, lower BMI, and no
prescription of an angiotensin II receptor antagonist (Table 3).
To our knowledge, this is the first study that examined two
complementary aspects of emotion processing, alexithymia,
and emotional awareness, in ES vs. SH, using both TAS-20
and LEAS measures. Our results confirmed the presence of
emotion-processing differences between EH and SH, even
after controlling for potential confounding variables. In
univariate as well as in multivariate analyses, emotional
awareness, as measured by the LEAS, strongly differentiated EH
from SH, according to our hypothesis, with significantly lower
emotional awareness in EH vs. SH. Although TAS-20 scores
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on 30 May 2018
t able 3 | Multivariate logistic regression analysis of the type
of hypertension (secondary vs. essential)
and subscores did not significantly differentiate EH from SH
in multivariate analyses, the differences found were in the
expected direction, with higher alexithymia scores in EH vs.
SH and a non-negligible effect size for TAS-20 total score.
interpretation of findings
Results are consistent with a higher emotion dysregulation in
EH than in SH, potentially playing a key neurobiological role
in the pathogenesis of EH, which corresponds to the classical
“psychosomatic” model of the disease. They are also consistent
with the existing literature suggesting that, in patients
suffering from paroxysmal hypertension, greater emotional
awareness may prevent emotional distress from contributing to
blood pressure elevation.37
LEAS proved to be more effective in discriminating between
EH and SH than did TAS-20. The latter measures the more
classical aspect of a deficit in emotion processing, i.e., the
presence of alexithymic characteristics. Only the EOT factor score
was higher in EH vs. SH, but this finding in univariate analysis
was not confirmed in multivariate analysis. Consistently, Jula
et al.26 showed a greater effect size between hypertensives and
normotensives using the TAS-26 Factor 4, which is very
similar to the TAS-20 EOT Factor score. Independent of
hypertension type (EH or SH), quite high levels of alexithymia and a
moderately high percentage of alexithymic individuals (40%
in EH and 28% in SH, when using the French-recommended
cutoff points, and, respectively, 25 and 20% with international
cutoffs) were observed in our study, in comparison with data
from the general populations (about 15% of alexithymics30,38).
Our results in EH, even with lower cutoffs, are nevertheless
lower than those of Todarello et al.25 and Jula et al.26, who,
respectively, found 55% of alexithymic subjects, and 57% of
alexithymic males and 46% of alexithymic females in their
samples, but we have to take into account that their
samples did not mix EH and SH as did ours. As regards
continuous TAS-20 scores, our results on EH subjects (52.4 ± 11.6)
are lower than those published by Todarello et al.25 (62.0 ±
13.0) but higher than US norms for nonclinical populations
(45.6 ± 11.4; ref. 39) or French norms for nonclinical
populations (46.2 ± 10.5; ref. 30). As regards our TAS-20 scores in
SH patients (48.4 ± 12.1), our results are still higher than US
or French norms. Our LEAS scores not only in EH subjects
(46.2 ± 11.5) but also in SH subjects (52.8 ± 8.4) are lower than
US norms (58.5 ± 11.0 for males and 64.3 ± 10.2 for females)38
or French norms (62.1 ± 8.5; ref. 32). These findings suggest
May 2010 | VOLUME 23 NUMBER 5 | AMERICAN JOURNAL OF HYPERTENSION
that some impairment in emotion processing exist even in SH
subjects and that emotion dysregulation observed in EH could
result from the same medical conditions leading to SH, thus
contributing to the null finding for the TAS-20 scores. It is now
documented that early-stage hypertension is associated with
cognitive deficits, altered cerebral blood flow support for
cognitive processing, and decreased gray matter in specific
cortical regions.40 Nevertheless, our findings do not support the
hypothesis that the differences in emotion processing between
the two types of hypertension could result from differences in
blood pressure measures between EH and SH, given that no
significant difference in blood pressure was found between the
two groups of subjects. On the other hand, the specificity of
the concept of alexithymia regarding somatic diseases has been
put into question, given that high rates of alexithymia were
also found in psychiatric patients, especially in post-traumatic
stress disorder.41 These findings raised the possibility of a
“secondary” alexithymia, reflecting an adaptive reaction to a
lifethreatening situation or severe medical condition, vs. or in
addition to a “primary” alexithymia, constituting a sustained
deficit in emotion processing and possibly contributing to the
onset of various psychosomatic diseases.
Our study took advantage of two complementary measures
of emotion processing: the TAS-20 and the LEAS. Several
limitations in the measurement of alexithymia (the reliance
on self-assessment, the association with depressive mood or
anxiety,42–45 false-negative, and false-positive issues)
highlighted the value of the construct of Levels of Emotional
Awareness by Lane and Schwartz,29 which constitutes a
complementary approach to emotion processing and offers an
alternative way of measuring an individual’s emotional
abilities. Emotional awareness has been investigated in various
normative and clinical populations and has been found to be
associated with actual emotion recognition ability and actual
differences in brain function during emotional arousal.38,46–49
It nevertheless had never been studied in patients suffering
In our study, we observed that only the LEAS score, but not
the more commonly used TAS-20 measure of alexithymic
characteristics, differentiated between EH and SH. One way of
understanding this is to consider that TAS-20 scores are based
on self-reported assessments of the ability to identify and
describe emotions, which are influenced by the respondent’s
level of distress, whereas the LEAS is a performance measure
of the ability to identify and describe emotions that does not
involve self-assessment and is not influenced by self-reported
distress. In previous studies, emotional awareness proved
to be a more robust and relevant construct than alexithymia
in patients presenting with somatoform disorder,47 eating
disorders,49 or psoriasis.48 Nevertheless, LEAS and TAS-20
findings are not opposed to each other, as the direction of the
nonsignificant difference of TAS scores between the two types
of hypertension is congruent with the significant LEAS
finding. Post hoc power estimates indicate that, due to sample size,
negative findings with TAS could also result from a lack of
To better examine the possible impact of the severity of
hypertension on emotion-processing variables (“secondary
alexithymia”), we considered clinically significant CV diseases,
in addition to hypertension (e.g., stroke or coronary heart
disease), and not simple asymptomatic target organ damage due
to hypertension, such as asymptomatic left ventricular
hypertrophy. Because it is often impossible to state that hypertension
is the only CV risk factor contributing to such organ
damage, we named them “associated CV complications”. Neither
TAS-20 total score nor LEAS score distinguished hypertension
with or without CV complications. Moreover, no
emotionprocessing measure was related to the duration of the disease.
This negative finding contrasts with the results previously
published by Gage and Egan27 and Lyshova et al.28 who observed
higher alexithymia scores in more severe hypertension or in
disease of longer duration. A possible explanation may be
related to the definition of the severity of hypertension, either
including only clinically relevant CV diseases, as in this study,
or including also asymptomatic target organ damage, as
previously reported by others.27,28
A surprising finding regarding LEAS and antihypertensive
treatment concerned the lower LEAS scores in hypertensives
treated by ACE inhibitors. Given that in our sample the latter
were more often prescribed in EH than in SH, we verified that
EH subjects still presented with lower emotional awareness
scores, even after controlling for the medication prescribed.
Such a side finding could be explained by cerebral
receptors and cognitive effects related to the renin–angiotensin
system.50,51 Further observational or intervention longitudinal
studies are warranted for exploring emotion-processing effects
of antihypertensive drugs acting on the renin–angiotensin
Our findings could also provide a rationale for therapeutic
nonpharmacological approaches in hypertension. Subic-Wrana
et al., collecting emotion-processing data from in-patients
of a psychosomatic ward at onset and at the end of
multimodal psychodynamic treatment, observed that LEAS scores
increased with treatment in the groups with somatoform
disorders and psychological factors related to somatic disorders,
and this change was independent of the negative affect.47 Thus,
patients suffering from EH and presenting with low emotional
awareness could represent a relevant indication for a specific
combination of psychotherapeutic techniques.
Our study presents several limitations. First, due to the
random nature of the consecutive recruitment of subjects, the two
types of hypertensives were not equal in number or balanced
regarding clinical characteristics. We therefore performed
multivariate analyses to control for these variables, as well as
for presence or absence of CV complications and the
antihypertensive drugs prescribed. Second, unlike TAS-20 scores,
LEAS scores were independent of sociodemographic variables,
a result that contrasts with other published data.52 The lack
of associations between LEAS scores and sociodemographic
variables in this study could be due to the more limited range
of LEAS scores in our clinical population compared to healthy
Third, due to its cross-sectional nature, no causal
interpretation can be proposed for the associations observed between
emotion-processing measures and the development of EH.
Emotion processing and EH could be two manifestations of
a unique underlying process. Indeed, lower emotional
awareness and some forms of blood pressure dysregulation may
share some neural bases, including aberrant activation of the
anterior cingulate cortex.53–55 One also cannot exclude that
an alteration in emotion processing could proceed from the
burden of a disease diagnosed several years previously, or even
from its pharmacological treatment and other
nonpharmacological constraints. Nevertheless, if this was the case, a
comparable impairment in emotion processing should have been
found, within our population study, in SH as well. A
prospective study should be undertaken with repeated measures of
emotion processing to test this hypothesis in recently
diagnosed and untreated hypertensives. Alexithymia scores and
emotional distress would be compared in successfully treated
hypertensives vs. uncontrolled hypertensives.
Another question is whether group differences in emotional
awareness could be explained by other emotional factors, such
as negative emotionality, previously linked to hypertension.
Actually, negative emotionality (e.g. anxiety or depressive
mood) was not directly measured in the study, but a proxy of
negative emotionality was available; thanks to the
emotionfocused coping score derived from the Ways of Coping
Checklist also completed by the participants to the study. No
difference was observed between EH and SH subjects as regards
emotion-focused coping. Moreover, as expected on the basis of
already documented data on emotion-processing measures and
negative affect, no association was observed between LEAS and
emotion-focused coping, but a significant positive correlation
with TAS DIF subscore (difficulty identifying feelings) and a
trend with total TAS score. Adjusting for emotion-focused
coping score did not change the association found between LEAS
and the type of hypertension, but lead to a nonsignificant
association between TAS EOT score and the type of hypertension,
even before entering into the model the clinical confounding
variables (BMI and cholesterol). Future studies should include
a direct assessment of emotional distress, as it may have clinical
implications regarding the management of hypertension.
Other limitations should be pointed out. Our study did not
include any neuropsychological assessment or neuroimaging
data. A contribution of a mild cognitive impairment in emotion
processing due to brain damage caused by a sustained history
of hypertension cannot be excluded. Nevertheless, neither the
TAS-20 nor the LEAS scores were correlated with the duration
of disease. In addition, even if the cause of SH can be
identified and treated (e.g., surgical treatment of a renal artery
stenosis), autonomic nervous system and endocrine deregulation
may persist. Such observations blunt the theoretical difference
between EH and SH. Finally, all hypertensive patients
completed the questionnaires during their hospitalization, which
itself can be stressful and could potentially blunt the differences
between the two types of hypertension. Moreover, a selection
bias of the type of hypertensive patients admitted in the
hypertension clinic is likely, given the overrepresentation in our
sample of patients suffering from SH relative to their rate in general
population. The referral of a hypertensive patient to such a
department is mainly due to the expertise of this department
in the etiological work-up and follow-up of SH and the
pharmacological management of resistant cases of hypertension;
these particularities could also potentially blunt the differences
between the two types of hypertension. The strong differences
found for LEAS scores between EH and SH, in spite of these
limitations, suggest that our findings are robust.
In conclusion, emotional awareness was lower in EH than
SH, whereas alexithymia scores did not significantly
differentiate EH from SH. Our results support a contribution of an
emotional or “psychosomatic” component in EH. They also
highlight the importance of using complementary measures of
emotion processing in medically ill patients.
Our findings suggest the importance of carrying out further
experimental studies to explore the relationships between
alexithymia and/or low emotional awareness and blood pressure
reactivity in response to stress, in hypertensives (both EH and
SH) and normotensives. Further longitudinal, observational,
as well as intervention studies are also needed to better
understand the predictive role of alexithymia and/or low emotional
awareness in relation to the onset of disease in people at risk for
hypertension and the evolution of a sustained hypertension, or
to examine whether treating impairments in emotional
awareness among those with EH impacts blood pressure control (or
vice versa). Finally, further studies addressing the neural bases
of the association between emotional awareness and EH, via
neuroimaging methods focused on anterior cingulate,
amygdala and medial pre-frontal cortex, are also recommended.
Disclosure: The authors declared no conflict of interest.
May 2010 | VOLUME 23 NUMBER 5 | AMERICAN JOURNAL OF HYPERTENSION
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