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.
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.
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.
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.
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
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.
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
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
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
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.
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.
*1. K. Orth-Gomer, A. Ahlbom and T. Theorell, 'Impact of pattern A behavior on ischemic heart disease when controlling for conventional risk indicators', J. Human Stress, 6: 6-13, 1980.
*2. R. H. Rosenman, 'The role of behavior patterns and neurogenic factors in the pathogenesis of coronary heart disease', in R.S. Eliot (ed.), Stress and the Heart, Futura, New York, 1974, pp. 123-141. 13
*3. J. P. Harrel,'Psychological factors and hypertension: a status report', Psychol. Bulletin, 87:482-501,1980.
*4. A. Masseri, A. L. Abbate, G. Baroldi et al., 'Coronary vasospasm as a possible cause of myocardial infarction', N. Engl. J. Med., 299: 1271-1277, 1978.
*5. H. Benson, J. B. Kotch and K. D. Crassweller, 'Stress and hypertension: interrelations and management', in G. Onesti and A. M. Brest (eds.), Hypertension: Mechanisms, Diagnosis and Treatment, Davis, Philadelphia, 1978, pp. 113-124.
*6. R. M. A. Osti, G. Trombini and B. Magnani, 'Stress and distress in essential hypertension', Psychother. Psychosom., 33 : 193-197, 1980.
*7. K. K. Datey, S. Deshmukh, L. Dalvi and S. L. Vinekar, 'Shavasana: a yogic exercise in the management of hypertension', Angiology, 20:325-333, 1969.
*8. G. Patel and W. R. S. North, 'Randomized controlled trial of yoga and biofeedback in management of hypertension', Lancet 2/7925:93-95, 1975.
*9. W. S. Agras, C. B. Taylor, H. C. Kraemer, R. A. Allen and J. A. Schneider, 'Relaxation training: twenty four hour blood pressure reductions', Arch. Gen. Psych., 37 : 859-863, 1980.
*10. R. G. Jacob, H. C. Kraemer and W. S. Agras, 'Relaxation therapy in the treatment of hypertension', Arch. Gen. Psych., 34:1417-1427, 1977.
*11. B. L. Frankel, D. J. Patel, D. Horwitz, W. T. Friedewald and K. R. Gaarder, 'Treatment of hypertension with biofeedback and relaxation techniques', Psychosom. Med., 40 :276-293, 1978.
*12. G. Patel, 'Coronary risk factor reduction through biofeedback. aided relaxation and meditation', J. Royal Coll. Gen. Pract. 27: 401-405, 1977.
*13. M. J. Cooper and M. M. Aygen, 'A relaxation technique in the management of hypercholesterolemia', J. Human Stress, 5 :24-27, 1979.
*14. K. N. Udupa, R. H. Singh and R. M. Settiwa.r, 'A comparative study on the effect of some individual yogic practices in normal persons', Ind. J. Med. Res., 63: 1066-1071, 1975.
*15. G. C. Hyner, 'Relaxation treatment for excessive cigarette and caffeine use', Psychol. Reports, 45 :531-534, 1979.
*16. B. Merhaut, 'Prevention of smoking and alcoholism by yoga', Veda a zivot, pp. xic-c, 1978 (Czech).
*17. J. B. Nowlin, W. G. Troyer, W. S. Collins et al, 'The association of nocturnal angina pectoris with dreaming', Ann. Int. Med., 63:l040-1046, 1965.
*18. J. Polackova, E. Bockova, M. Kucera et al., 'Autogenni trening jako soucast komplexni rehabilitacni pece o nemocne v poinfarktovem obdobi', Cas. Lek. ces., 116: 1580-1583, 1977.
*19. R. H. Rahe, H. W. Ward and V. Mayes, 'Brief group therapy in myocardial infarction rehabilitation: three to four year follow up of a controlled trial', Psychosom. Med., 51:229-242, 1979.
*20. H. Neuhof, B. F. Klapp, O. Gerlach et al., 'Die wirkung von "entspanugsmusik" auf patienten, arzte and pflagepersonal einer iternistischen intensivstation', Dtsch. Med. Wochenschr., 105 : 556-560, 1980.
*21. T. H. Tulpule, J. S. Shantilal, H. M. Shah and H. K. Haweliwala, 'Yogic exercises in the management of ischemic heart disease', Indian Heart J., 23: 259-264, 1973.
*22. T. H. Tulpule and A. T. Tulpule, 'Yoga- a method of relaxation for rehabilitation after myocardial infarction', Indian Heart J., pp. 1-7, Jan.-Feb. 1980.
*23. J. A. Blumenthal, R. S. Williams, R. B. Williams and A. G. Wallace, 'Effects of exercise in the type A (coronary prone) behavior pattern', Psychosom. Med., 42 : 289-296, 1980.
*24. E. B. Sigg, 'The pharmacological approaches to cardiac stress', in R. S. Eliot (ed.), Stress and the Heart, Futura, New York, 1974, pp. 263-278.
*25. G. V. Ford and K. D. Long, 'Group psychotherapy of somatizing patients', Psychother. and Psychosom., 28 : 294-3C4, 1977.
*26. K. Nespor, 'Joga a prevence kardiovaskularnich chorob', Cas. Lek. ces., 118:333-335, 1979.
*27. E. Gomes, 'Le yoga methode d'apprentissage du controle de relaxation differentielle et globale', Vie Med., 55 (Spec.) :57-61, 1974.
*28. R. K. Wallace, H. Benson and A. F. Wilson, 'A wakeful hypo-metabolic physiological state', Am. J. Physiol., 221: 795-799, 1971.
*29. G. Dostalek, 'Joga a nase lekarstvi (Yoga and our medicine)', Int. Conf. on the Use of Yoga in Rehabilitation, Kosice, 1978, Abstracts, pp. 80-83.
*30. J. Charvat, P. Dell and B. Folkow, 'Mental factors and cardiovascular diseases', Cardiology, 44 ; 124-141, 1964.
*31, V. L;picovska and G. Dostalek, 'EKG zmeny pri hathajogickych cvicenich (EGG changes during hatha yogic exercises)', Workshop of the Commission of the Use of Yoga in Rehabilitation, Praha, 23.9.1930.
*32. R. R. Michaels, J. Parra, D. S. McGan and A. J. Vender, Renin, cortisol and aldosterone during Transcendental Meditation', Psychosom. Med., 41: 50-54, 1979.
*33. M. West, 'Meditation', Brit. J. Psychiat., 135: 457-467, 1979.
*34. P. Carrington, G. H. Collings, H. Benson et al., 'The use of meditation-relaxation techniques for the management of stress in a working population', J. Occupational. Med.,22:A, 1980.
*35. L. M. Sucharebsky, 'On the stimulation of the creative potential of the unconscious', in Prangishvili et al. (eds.), Bessoznatjelnoje, Metsnierba (Tbilisi), 1978, pp. 776-780.
*36. 'Yoga Nidra', parts 1-4, Kriya Yoga Postal Sadhana Course, Part III, Sept.-Dec. 1976, Monghyr (India).