Does stress or anxiety cause high blood pressure?

The stress response is a term used to describe the numerous changes that take place in the body when a person is faced with a stressful situation.¹ Perceived stress may be caused by emotional, environmental, or physical threats, but the body’s protective response is predictable. Changes occur in the central nervous system and certain target organs when the stress hormones cortisol and adrenaline are released. The changes appear to serve the purpose of increasing a person’s arousal to focus attention on the perceived threat. Specifically, the heart rate and blood pressure (BP) increase to bring oxygen and nutrition to the heart, brain, and skeletal muscles to coordinate a “fight or flight” response. So, BP does rise in response to acute stress.

This BP rise is temporary. When the stressful situation is over, the BP returns to the pre-stress level.² This adaptation to stress might have been helpful for survival of the species in earlier times, but scientists are now studying the effect of the stress response in modern times, when a fight or flight response may not be as healthy an adaptation. The link between chronic stressors present in today’s world and elevated BP are still not completely understood.

The relationship between chronic stress and high blood pressure may be direct or indirect. There is some evidence that psychosocial factors might influence the development of hypertension.^3–6 There is also evidence that stress can lead to an increase in unhealthy behaviors, such as alcohol consumption, smoking, and poor dietary choices.^7,8 Excess alcohol, tobacco, and obesity are known to be associated with an increased risk for high blood pressure.^9–12

Sparrenberger et al conducted a systematic review of cohort and case-control studies that studied the relationship between psychosocial stress and hypertension through February 2007.⁵ Fourteen studies met their inclusion criteria including 52,049 participants. The quality of each study was assessed by the Newcastle-Ottawa Quality Assessment scale; the average quality being 6.6 ± 1.3 on a 9-point scale. Five out of seven studies found a significant and positive association between measures of chronic stress and hypertension, with risk ratios ranging from 0.8 to 11.1. The authors interpreted their results cautiously because of the high degree of variability among the definitions of psychosocial stressor but suggested that while acute stress was unlikely to be a risk factor for hypertension, chronic stress might cause sustained levels of elevated BP. Better quality studies were recommended.

Cuffee et al conducted a systematic literature review of publications between 2010 and 2017 that reported on associations between psychosocial stress and hypertension.³ Studies were included in their analysis if the psychosocial stressor was assessed by a stated measurement scale and the primary outcome measured was sustained high blood pressure or diagnosed hypertension. Cross-sectional studies, studies on children, and studies in which the stressor was induced in a laboratory setting were excluded. 21 studies were ultimately included in their review. The studies examined a variety of stressors including occupational stress, housing instability, social isolation or lack of social support, poor sleep quality, and mental health issues such as personality traits, exposure to traumatic events, or diagnosed depression. The authors determined that occupational stress (unemployment, job insecurity, low wages, and job strain), housing insecurity, lack of social support, and poor sleep quality consistently increased the risk of incident hypertension. The definition of the psychosocial stressors varied widely, limiting the interpretation of this meta-analysis. It is also difficult to draw conclusions about the duration of the high blood pressure many authors found to be incident with the stressor.

In a 2010 review article Spruill summarized results of previous work on the possible association between stressful environments and hypertension.⁶ Occupational stress or job strain has been shown to increase ambulatory BP at work, at home, and during sleep, and has also been shown to increase left ventricular mass suggesting sustained levels of high blood pressure.¹³ But the aspects of job strain that contribute to that risk are poorly understood. Women and men appear to have different BP responses to different types of job stress.^14,15 The duration of the stress also matters.¹⁶ In a study by Ohlin et al, people with greater social support at work appear to be less likely to have increased BP in response to job strain.¹⁵ Some studies have failed to show an association between job strain and elevated blood pressure.¹⁷

Social support can mitigate the negative effects of stress, and the lack of social support can itself be a source of stress.⁶ On the other hand, relationships can also be the source of conflict and stress.¹⁸ Grewen et al found men and women reporting high relationship quality had lower ambulatory blood pressure at home and at work than those without a partner, or couples reporting a low-relationship quality.¹⁹

Some epidemiologic studies have demonstrated an association between low socio-economic status (SES) and the risk of hypertension.^20,21 But it is not known if the correlation is explained by factors associated with low SES like poorer health behaviors, increased stress, fewer resources to cope with stress, or other factors. Access to safe walking environments, food security, perceived and real personal safety, and race, for example, are correlated in many analyses with SES, making it difficult to determine the extent to which each individual factor contributes to an increase in risk of hypertension.^22,23 African-Americans have higher rates of hypertension than black Africans and black Caribbeans.²⁴ BP rates within black populations vary between rural and urban populations, and according to some authors track directly with Western lifestyles.^25,26 The stress associated with racial discrimination has been proposed as an additional contributing factor.^27–29

Despite a growing body of support for the hypothesis that long-term exposure to stress can increase the likelihood of hypertension, it is difficult to prove a causal relationship. Prospective studies that control for as many confounding variables as possible will be needed.  

A meta-analysis of studies of stress-reduction strategies to lower blood pressure suggested that biofeedback, relaxation and other interventions to lower stress might have a blood-pressure lowering effect.³⁰ However, the authors felt that the results should be interpreted with caution because of methodological limitations in existing studies. National guidelines at present conclude that stress reduction is not sufficiently proven to lower blood pressure to recommend it as an antihypertensive strategy.¹²    

                                 ^References                                          

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