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Stroke. 2001;32:1712-1720

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(Stroke. 2001;32:1712.)
© 2001 American Heart Association, Inc.

Original Contributions

Adaptive Behavior in Stressful Situations and Stroke Incidence in Hypertensive Men

Results From Prospective Cohort Study "Men Born in 1914" in Malmö, Sweden

Lena André-Petersson, MS; Gunnar Engström, MD, PhD; Bo Hagberg, PhD; Lars Janzon, MD, PhD Gunilla Steen, MS

From the Division of Epidemiology, Department of Community Medicine (G.E., L.J.), Malmö University Hospital, Lund University, Malmö, Sweden; Department of Psychology (L.A.-P.), Lund University, Lund, Sweden; Gerontology Research Center (B.H.), Lund, Sweden; and Department of Geriatric Medicine (G.S.), Göteborg University, Göteborg, Sweden.

Correspondence to Lena André-Petersson, Gerontology Research Center, Karl XII gatan 1, S-222 20 Lund, Sweden. E-mail Lena.Andre-Petersson{at}psychology.lu.ses


*    Abstract
up arrowTop
 *Abstract
down arrowIntroduction
 down arrowSubjects and Methods
 down arrowResults
 down arrowDiscussion
 down arrowReferences
 down arrowCardiovascular and Behavioral...
 down arrowReferences 
 
Background and Purpose—— Although hypertension is a major risk factor for stroke, many hypertensive persons remain healthy. The aim of the present study was to analyze whether adaptation in a stressful situation was associated with the incidence of stroke in hypertensive men.

Methods—— Two hundred thirty-eight hypertensive men were followed from baseline in 1982/1983 until first stroke, death, or December 31, 1996. Adaptation to stress was studied with the serial Color-Word Test. In the Regression dimension, 4 patterns of adaptation could be distinguished according to mastering of the test. Successful mastering of the test was shown in stabilized patterns, increasing difficulty in cumulative patterns, fluctuating difficulty in dissociative patterns, and fluctuating difficulty that increased during testing in cumulative-dissociative patterns. The patterns were compared regarding stroke incidence.

Results—— Forty-three men experienced a stroke during follow-up. Stroke rates per 1000 person-years were 12.6 for men with stabilized patterns, 14.3 for men with cumulative patterns, 16.2 for men with dissociative patterns, and 31.2 for men with cumulative-dissociative patterns. Multivariate analysis, adjusted for relevant cerebrovascular risk factors, showed that the cumulative-dissociative pattern of the Regression dimension was associated with an increased risk of stroke during follow-up (relative risk 3.00, 95% CI 1.32 to 6.81).

Conclusions—— The specific behavior pattern, characterized by the greatest difficulties in managing the test, was associated with incidence of stroke in hypertensive men. One interpretation is that hypertensive men who chronically fail to find successful strategies in stressful situations are vulnerable to the damaging effects of stress and thereby at an increased risk of a future stroke.


Key Words: hypertension • neuropsychological tests • stress, psychological • stroke


*    Introduction
up arrowTop
 up arrowAbstract
 *Introduction
down arrowSubjects and Methods
 down arrowResults
 down arrowDiscussion
 down arrowReferences
 down arrowCardiovascular and Behavioral...
 down arrowReferences 
 
Stroke is associated with huge costs, both economically and in terms of human suffering. Hypertension has been acknowledged as the major risk factor for stroke.1 The associated risk can be assumed to be modified by interaction with several other factors, because not all hypertensive individuals experience a stroke.2 In the case of myocardial infarction, many research programs have been aimed at delineating the relationship between incidence, psychological stress, and personality.3–6 The effects of stress and personality factors on stroke incidence have attracted far less interest.

Studies have, however, reported associations between stress and stroke.7 Severe psychological stress or life-threatening events have been related to an increased risk of both nonhemorrhagic and hemorrhagic strokes.8–11 General difficulties in coping with stress,12 as well as specific features

See Editorial Comment, page 1718

of the type A behavior personality,13,14 have also shown associations with an increased risk of stroke.

So far, it has not been studied to what extent psychological stress and its management modify the risk of hypertension in association with stroke. The serial Color-Word Test (CWT)15 is a version of the original Stroop test.16 This test makes it possible to examine how an individual responds and adapts through repeated encounters to a conflicting and challenging mental task.

In the prospective cohort study "Men Born in 1914," the serial CWT was included, together with extensive medical examinations.17 Two dimensions of behavior can be studied; Regression and Variability. In each dimension, 4 adaptive patterns can be distinguished according to mastering of the test. The objective of the present study was to analyze whether adaptive behavior can be related to the incidence of stroke in hypertensive men.


*    Subjects and Methods
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 *Subjects and Methods
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Study Population
The cohort study "Men Born in 1914" concerns the epidemiology of cardiovascular and atherosclerotic diseases. In 1982/1983, 621 men, all born in an even-number month of 1914 and residing in the city of Malmö, Sweden, were invited to the combined medical and psychological examination. Of the 500 men who participated in the study, 294 (58.5%) men were hypertensive and 191 (38.2%) were normotensive. Data on blood pressure were missing for 15 (3%) men. Nonparticipation was related to lower socioeconomic background, being single, or being hospitalized.18 All hypertensive men with complete data in all the examinations constituted the study cohort.

The Ethical Committee of the Faculty of Medicine, Lund University, Sweden, approved the study.

Serial CWT
Background
The serial CWT is a semiexperimental way to differentiate between adaptive styles in a novel and conflicting situation. Stroop16 designed the original CWT for studies of interference. An individual is presented a written name of a color, which is printed in a divergent color. The task is to name the color of the print and not the written word. This method of studying interference, by presenting 2 conflicting stimuli simultaneously, causes the response to become slower. The serial CWT was chosen because it is experienced as frustrating and challenging. The Stroop CWT has been used to evoke stress reactions in studies of cardiovascular reactivity.3,5

The construction of the serial CWT was founded on a model in which perception and personality are considered a unit.19 Personality determines which strategies an individual uses when controlling needs, mediating between conflicting needs, or adjusting needs to reality. Through ontogenesis, certain strategies become preferred or habitual, and these characteristic strategies are also used when the individual has to adapt to new and conflicting demands. By the construction of a serial CWT, in which temporal aspects of behavior could be studied from start until final mastery, these strategies would become evident.

Administration, Scoring, and Classification
Four color words ("red," "green," "blue," and "yellow"), ordered randomly in a 10 wordsx10 rows design and printed on a sheet of cardboard, made up the test. The words were printed in an incongruent color. The men were asked to name the color of the print and to ignore the written word. A practice session established that the instructions were fully understood. Naming the color of the prints as quickly as possible was encouraged. The test was repeated 5 times with each repetition referred to as a "subtest."

Scoring of each subtest was made by the test administrator after 20, 40, 60, 80, and 100 responses and was expressed as time consumption in seconds.

For the description of situational behavior, a primary classification is determined from the individual’s most frequent pattern during testing. It is based on the regression (linear change) and the variability (nonlinear change) in each subtest and on how these values relate to the medians of the group. Reference medians were obtained from the test results of the 431 men who completed the test in 1982/1983.17 Detailed information about the test is found in the manual,15 presently revised and translated into English.20

In the secondary classification, on the other hand, the habitual adaptive behavior is reflected. Four patterns of adaptation are categorized according to linear change, the Regression dimension, and nonlinear change, the Variability dimension, obtained by renewed calculations of regression and variability for each subtest and compared with reference medians. The 4 patterns, which are equally labeled in both dimensions, describe adaptation as a process, from start until the end. Stabilized patterns show an even and stable time consumption through all the subtests. The cumulative patterns show increasing time consumption within subtests and from 1 subtest to the next. The dissociative patterns show a recurrently increasing and decreasing time consumption in all 5 subtests. The fourth pattern, the cumulative-dissociative, shows increasing time consumption from the first subtest until the last combined with intermittently increasing and decreasing time consumption in each subtest. More information on these adaptive patterns has been given in detail.21

Blood Pressure, Hypertension, and Treatment
Blood pressure was measured in a standardized way with the individual in a sitting position and after 15 minutes’ rest. The pressure was established to the closest 5 mm Hg level with the arithmetic mean calculated from 3 consecutive measurements.22 Hypertension was defined as systolic or diastolic blood pressure of >=160/95 mm Hg or if medication for hypertension had been prescribed.23 Antihypertensive treatment was recorded if drugs to lower the blood pressure had been prescribed. The use of anticoagulant medical drugs was also recorded separately.

Cerebrovascular Risk Factors
Hospital records, clinical examination by a neurologist, and answers from a questionnaire about previous diseases were used to establish history of stroke.24 Peripheral artery disease was defined at an ankle-brachial blood pressure index of <0.9 in 1 or both legs.25 Findings from 24-hour ambulatory ECG recordings were used to establish presence of atrial fibrillation.24 Prevalent ischemic heart disease was defined as angina pectoris according to the Rose questionnaire26 or if the individual had been hospitalized because of myocardial infarction. Diabetes mellitus was defined as a fasting blood glucose level of >=7.0 mmol/L or if medication for diabetes mellitus had been prescribed.

A structured questionnaire inquired about tobacco and alcohol habits. Tobacco habits were categorized as never smoked, former smokers (who had maintained current abstinence for at least the previous month), and current smokers. Similarly, alcohol habits were categorized as never uses alcohol, does not drink more than 250 g/wk, and drinks more than 250 g/wk.

Body mass index was measured as body weight in kilograms divided by height in meters squared. Plasma cholesterol level and triglyceride levels were measured according to standardized procedures and expressed in mmol/L.

Self-Reported Psychiatric Disorders
Before the examination, the men had been asked to fill in a questionnaire of medical history. One of the questions, "Has a doctor or a nurse told you that you have a psychiatric disease?" was used in this study as an indication of a psychiatric disorder. The answers were grouped according to how long the men had had a disease as never, <1 year, between 1 and 10 years, and >10 years.

Stroke and Follow-Up Data
All participants were followed from baseline examination until the first stroke occurring during follow-up, their death, or December 31, 1996. Mean follow-up time was 9.9 years (range 3.1 months to 14 years 3.4 months). A stroke incident was defined according to World Health Organization definitions.27 The following International Classification of Diseases, Ninth Revision (ICD-9) codes27 are encountered in the study: hemorrhagic stroke ICD-9 codes 430 (subarachnoid hemorrhage) and 431 (intracerebral hemorrhage) and nonhemorrhagic stroke ICD-9 codes 434 (ischemic stroke) and 436 (unspecified). The incidence of a stroke was obtained through the Stroke Registry of Malmö28 and hospital records. The ICD-9 codes 430, 431, and 434 were all verified by CT scanning.29 Data on mortality and cause of death have been continuously obtained from the Swedish National Bureau of Statistics. Stroke rates were calculated as stroke event per 1000 person-years of follow-up.

Statistical Methods
All hypertensive men with complete data from all the relevant examinations (n=243) were included in the present study. SPSS Advanced Statistics 6.1, 1994, was used for all computations. Stroke rates per 1000 person-years were calculated for the men when divided into the 4 patterns of adaptation in the serial CWT dimensions Regression and Variability. The Cox proportional hazards model was used to establish univariate relations between the serial CWT dimensions Regression and Variability and the incidence of stroke. The same procedure was used for univariate relations between each baseline variable and stroke rate. Variables with P<0.2 were chosen for the final analysis. The estimation of the relative influence of adaptive pattern on stroke incidence was made in a multivariate analysis (Cox proportional hazards model) with application of the forward, stepwise procedure. Probability of entry was <0.05, and probability of removal was >0.10. The influence of adaptive pattern was thus analyzed in relation to peripheral artery disease, atrial fibrillation, antihypertensive drug treatment, and smoking habits. In the regression analyses, the Regression and Variability dimensions of adaptation were entered as categorical variables. The stabilized pattern of each dimension was used as a reference category. Alcohol use, smoking habits, and psychiatric disorder were likewise entered as categorical variables when part of regression analyses. Confidence intervals were calculated at the 95% level.


*    Results
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 *Results
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During the follow-up, 43 (17.7%) men experienced a nonhemorrhagic stroke (ICD-9 codes 434 and 436), and 4 died within 7 days. Five (2.1%) men experienced a hemorrhagic stroke (ICD-9 codes 430 and 431), and 2 died within 7 days. Eleven (4.5%) men had a history of stroke at baseline, and 3 of them had another stroke during follow-up.

Serial CWT and Incidence of Stroke
The differential stroke rates for the men, categorized into the 4 adaptive patterns of the Regression dimension, are illustrated in the Figure. The 5 men who had hemorrhagic strokes are included in the Figure. Three of these men had an adaptive pattern in the Regression dimension categorized as dissociative, and the remaining 2 had cumulative-dissociative patterns. To confine the following analyses to the nonhemorrhagic strokes, the 5 men who had hemorrhagic strokes were excluded.



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  		Stroke-free survival in 68-year-old hypertensive men categorized according to adaptive pattern of the Regression dimension in the serial Color-Word Test.

The adaptive patterns in the serial CWT dimensions Regression and Variability were analyzed in relation to incidence of stroke (Table 1). Men whose behavior in the test situation was categorized as cumulative-dissociative in the Regression dimension had a significantly increased risk of stroke during follow-up (unadjusted relative risk 2.53, 95% CI 1.13 to 5.68, P=0.025). The stroke rate for men with a cumulative-dissociative pattern in the Regression dimension was more than twice as high (31.2 strokes per 1000 person-years) than the rate of stroke for men with a stabilized pattern (12.6 strokes per 1000 person-years). No pattern in the Variability dimension was associated with stroke during follow-up.


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  		Table 1. Univariate Analyses of Stroke Rate in 238 Hypertensive Men in Relation to Four Groups of Adaptive Patterns in the Variability Dimension and to Four Groups of Adaptive Patterns in the Regression Dimension of the Serial CWT

Stroke Rate in Relation to Baseline Risk Factors
Baseline characteristics of the study cohort are given in Table 2, distributed according to adaptive pattern of the Regression dimension. Among men with a stabilized pattern, only 32.8% had been prescribed antihypertensive drug treatment. This proportion was 43.8% among those with a cumulative-dissociative pattern. The prevalence of ischemic heart disease was the lowest among men with a cumulative-dissociative pattern. Anticoagulant medical therapy (not shown in the table) had been prescribed to 2 men, and both showed stabilized patterns. When asked about psychiatric disorders, 6 men confirmed disease with a duration of 1 to 10 years, and 15 men reported a duration of >10 years.


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  		Table 2. Baseline Characteristics of Study Cohort, 238 Hypertensive Men, Distributed According to Adaptive Patterns of the Regression Dimension of the Serial CWT and Univariate Analyses of Stroke Rate in Relation to Baseline Characteristics

The crude relative risk of each variable in association with stroke rate is also shown in Table 2.

Multivariate Analysis
Multivariate analysis was limited to stroke incidence in relation to the 4 adaptive patterns of the Regression dimension of the serial CWT, because no univariate associations were found between the Variability dimension and stroke incidence. The multivariate analysis included the 4 patterns of the Regression dimension, peripheral artery disease, atrial fibrillation, antihypertensive drug treatment, and smoking habits. The cumulative-dissociative pattern in the Regression dimension of the serial CWT was associated with stroke in a statistically significant way (relative risk 3.00, 95% CI 1.32 to 6.81, P=0.009) (Table 3). Associations were also present between stroke incidence and peripheral artery disease (relative risk 3.02, 95% CI 1.47 to 6.16, P=0.003) and atrial fibrillation (relative risk 2.91, 95% CI 1.02 to 8.34, P=0.046). Use of antihypertensive drugs or smoking habits were not associated with stroke rate.


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  		Table 3. Multivariate Analysis (Cox Proportional Hazards Model) of Stroke Rate in Relation to Peripheral Artery Disease, Four Groups of Adaptive Patterns in the Regression Dimension of the Serial CWT and Atrial Fibrillation


*    Discussion
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowSubjects and Methods
 up arrowResults
 *Discussion
down arrowReferences
 down arrowCardiovascular and Behavioral...
 down arrowReferences 
 
Hypertensive men form a heterogeneous group regarding smoking habits, drinking behavior, blood pressure level, and the extent to which arteriosclerotic disease has developed. These factors are all related to the incidence of stroke, but heterogeneity can also be proved regarding how hypertensive men adapt in stressful situations. The conclusion of the present study is that 1 distinct pattern of adaptation, the cumulative-dissociative pattern of the Regression dimension of the serial CWT, is associated with an increased incidence of stroke, independent of other risk factors. The specific behavior was characterized by difficulties that varied along the test situation, and for each new subtest, the linear change was accelerated. This is thought to imply that an initially tight control is exhausted by the end of the test as a result of repeated efforts and failures to find successful strategies to master the conflict.30

The pathophysiological mechanisms that could explain why individual difficulties in stressful situations would be related to a future stroke are not clear, but some established relations exist between stress and disease. Although individuals vary and behavior elicited by a stressor varies, the coping mechanisms measured on the behavioral level have been associated with specific physiological correlates. Active coping behavior has been related to increased catecholamine release and sympathetic activation, whereas passive behavior has been related to corticosteroid secretion.31

Cardiovascular reactivity (the manner in which the cardiovascular system responds to psychological stress) has been associated with carotid artery atherosclerosis and its progression,32 increased serum lipid concentrations, hemostatic factors, and blood viscosity.33 These factors are also related to stroke.13,34 An association between personality and cardiovascular reactivity has been suggested because individuals differ in reactivity when exposed to a mental stressor.3 It cannot be excluded that individuals whose adaptive behavior is characterized as cumulative-dissociative are more disposed to elevated blood pressure when met with stressful encounters.

McEwen and Seeman35 use the concepts of allostasis and allostatic load to describe both physiological and behavioral responses to stress. "Allostasis" has been defined as the ability of the organism to maintain stability through change. It is not the unique, stressful event that can be related to disease but rather the repeated and life-long exposure to stressful situations. Consequently, "allostatic load" refers to the accumulation of the wear and tear to which the different physiological systems have been exposed during a lifetime of allostasis, through either inefficient responses or having experienced many stressful events. The term is aimed at describing an individual’s total exposure to stressful events and consequences for the regulatory system. In view of this theory, it would be reasonable to assume that men with a cumulative-dissociative pattern would be exposed to greater levels of allostatic load than would men who show other adaptive patterns.

In an earlier work,21 based on the same study cohort of hypertensive men, the cumulative-dissociative pattern of the Variability dimension was associated with an increased risk of a cardiac event during follow-up. The aspect of control was considered important. Feelings of tension were thought to disturb the acquisition of a successful strategy to manage the stressful situation. The tension would cause intermittent breakdowns in the adaptive process and result in accumulated and enhanced nonlinear change in time consumption. In the cumulative-dissociative pattern of the Regression dimension, control is certainly of importance, but the pattern is such that control was executed only at the beginning of the test and is running short toward the end. Despite a growing familiarity with the character of the task, attempts to find new and durable strategies are accompanied by increasing difficulties through the complete test session.

The methodological aspects that must be considered in the present study concern the medical diagnoses, foremost that of stroke, and the use of the serial CWT. At baseline, history of stroke was established by a neurologist who based the diagnosis on a questionnaire of medical history, clinical examination, and hospital records.24 Strokes that occurred during follow-up 2involved patients with hospital records that provided CT and autopsy results. The serial CWT has previously been used mostly in clinical settings to increase the understanding of the adaptive strategies used by individuals with various psychiatric disorders.30,36 A consistent and general observation from those studies is that control subjects more often showed a stabilized or cumulative pattern, whereas more severe psychological disturbances were associated with a higher frequency of a dissociative or cumulative-dissociative pattern in either dimension.19,36,37 In the present study, however, psychiatric disorders were not more frequent among individuals whose behavior was categorized as cumulative-dissociative.

The semiexperimental method of the serial CWT was used as a stress-inducing task in the present study, and the results were related to stroke incidence in hypertensive men during a follow-up period of {approx}14 years. Other studies have used questionnaires to estimate experiences of stress. In a large cohort study of stroke incidence in >7000 middle-aged men,8 psychological stress was defined as feelings of tension and anxiety on a scale of 1 to 6. This single item was sufficient to show an independent relationship between stress and stroke during {approx}12 years of follow-up. The present study is focused on hypertensive men but is otherwise similar in design. Both studies show that indications of perceived stress at baseline can be associated with a future stroke. Another approach to analysis of the relationship between personality traits and stroke has been to compare individuals who had a stroke with healthy control subjects. Anger13 and the feature "high tenseness" of the type A personality14 have been associated with a higher prevalence of ischemic stroke. On interview of 32 men about their psychological history of stroke, Adler et al11 noted that the most commonly reported factor was personal failing.

The way in which a stressful situation is managed can be associated with the incidence of stroke. It is possible to identify a subgroup of individuals who are more vulnerable than others with the serial CWT. Hypertensive men whose behavior was categorized as cumulative-dissociative in the Regression dimension were vulnerable to stress and consequently had an increased risk for stroke.


*    Acknowledgments
 
This study was supported by grants from the Swedish Council for Social Research and from research foundations administered by Malmö University Hospital. The authors are indebted to Prof Gudmund Smith (Lund University, Lund, Sweden) for valuable support in preparation of the manuscript.

Received February 14, 2001; revision received May 10, 2001; accepted May 11, 2001.


*    References
up arrowTop
 up arrowAbstract
 up arrowIntroduction
 up arrowSubjects and Methods
 up arrowResults
 up arrowDiscussion
 *References
down arrowCardiovascular and Behavioral...
 down arrowReferences 
 

  1. Strandgaard S, Paulson OB. Cerebrovascular consequences of hypertension. Lancet. 1994; 344: 519–521.[Medline] [Order article via Infotrieve]
  2. Wolf PA, D’Agostino RB, Belanger AJ, Kannel WB. Probability of a stroke: a risk profile from the Framingham Study. Stroke. 1991; 22: 312–318.[Abstract/Free Full Text]
  3. Jennings JR, Kamarck T, Manuck S, Everson SA, Kaplan G, Salonen JT. Aging or disease? Cardiovascular reactivity in Finnish men over the middle years. Psychol Aging. 1997; 12: 225–238.[Medline] [Order article via Infotrieve]
  4. Rosenman RH, Brand RJ, Jenkins CD, Friedman M, Straus R, Wurm M. Coronary heart disease in the Western Collaborative Group Study: final follow-up experience of 81/2 years. JAMA. 1975; 233: 872–877.[Abstract]
  5. Rozanski A, Bairey N, Krantz DS, Friedman J, Resser KJ, Morell M, Hilton-Chalfen S, Hestrin L, Bietendorf J, Berman DS. Mental stress and the induction of silent myocardial ischemia in patients with coronary artery disease. N Engl J Med. 1988; 318: 1005–1012.[Abstract]
  6. Frasure-Smith N, Lespérance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation. 1995; 91: 999–1005.[Abstract/Free Full Text]
  7. Schneck MJ. Is psychological stress a risk factor for cerebrovascular disease? Neuroepidemiology. 1997; 16: 174–179.[Medline] [Order article via Infotrieve]
  8. Harmsen P, Rosengren A, Tsipogianni A, Wilhelmsen L. Risk factors for stroke in middle-aged men in Göteborg, Sweden. Stroke. 1990; 21: 223–229.[Abstract/Free Full Text]
  9. Kleinman Y, Korn-Lubetzki I, Eliashiv S, Abramsky O, Eliakim M. High frequency of hemorrhagic strokes in Jerusalem during the Persian Gulf War. Neurology. 1992; 42: 2225–2226.Abstract.[Free Full Text]
  10. House A, Dennis M, Mogridge L, Hawton K, Warlow C. Life events and difficulties preceding stroke. J Neurol Neurosurg Psychiatr. 1990; 53: 1024–1028.[Abstract]
  11. Adler R, MacRitchie K, Engel GL. Psychologic processes and ischemic stroke (occlusive cerebrovascular disease). Psychosomat Med. 1971; 33: 1–29.[Abstract/Free Full Text]
  12. Schneck MJ, Carano D, Hartman P, Page WF, Brass LM. Personality factors and stroke risk. Stroke. 1995; 26: 158.Abstract.
  13. Matsumoto Y, Uyama O, Shimizu S, Michishita H, Mori R, Owada T, Sugita M. Do anger and aggression affect carotid atherosclerosis? Stroke. 1993; 24: 983–986.[Abstract/Free Full Text]
  14. Kim JS, Yoon SS, Lee SI, Yoo HJ, Kim CY, Choi-Kwon S, Lee BC. Type A behavior and stroke: high tenseness dimension may be a risk factor for cerebral infarction. Eur Neurol. 1998; 39: 168–173.[Medline] [Order article via Infotrieve]
  15. Smith GJW, Nyman GE, Hentschel U. Manual till CWT: Serialt Färgordtest. Stockholm, Sweden: Psykologiförlaget AB; 1986.
  16. Stroop JR. Studies of interference in serial verbal reactions. J Exp Psychol. 1935; 18: 643–662.
  17. Steen G, Hagberg B, Johnson G, Steen B. Cognitive function, cognitive style and life satisfaction in a 68-year-old male population. Comprehens Gerontol B. 1987; 1: 54–61.
  18. Janzon L, Hanson BS, Isacsson S-O, Lindell S-E, Steen B. Factors influencing participation in health surveys: results from prospective population study "Men born in 1914" in Malmö, Sweden. J Epidemiol Commun Health. 1986; 40: 174–177.[Abstract]
  19. Kragh U, Smith GJW. Percept-Genetic Analysis. Lund, Sweden: Gleerups; 1970.
  20. Smith GJW, Nyman E, Hentschel U, Rubino IA. The Serial Color-Word Test (s-CWT). Leyden: Swets & Zeitlinger. In press.
  21. André-Petersson L, Hagberg B, Hedblad B, Janzon L, Steen G. Incidence of cardiac events in hypertensive men related to adaptive behavior in stressful encounters. Int J Behav Med. 1999; 6: 331–355.
  22. Ögren M, Hedblad B, Janzon L. Biased risk factor assessment in prospective studies of peripheral arterial disease due to change in exposure and selective mortality of high-risk individuals. J Cardiovasc Risk. 1996; 3: 523–528.[Medline] [Order article via Infotrieve]
  23. 1986 Guidelines for the treatment of mild hypertension: memorandum from a WHO/ISH meeting. J Hypertens. 1986; 4: 383–386.[Medline] [Order article via Infotrieve]
  24. Ögren M, Hedblad B, Isacsson S-O, Janzon L, Jungqvist G, Lindell S-E. Ten year cerebrovascular morbidity and mortality in 68 year old men with asymptomatic carotid stenosis. BMJ. 1995; 310: 1294–1298.[Abstract/Free Full Text]
  25. Ögren M, Hedblad B, Isacsson S-O, Janzon L, Jungqvist G, Lindell S-E. Non-invasively detected carotid stenosis and ischaemic heart disease in men with leg arteriosclerosis. Lancet. 1993; 342: 1138–1141.[Medline] [Order article via Infotrieve]
  26. Rose GA, Blackburn H. Cardiovascular survey methods. WHO Monogr Ser. 1968; 56: 1–188.
  27. World Health Organization. International Classification of Diseases, Ninth Revision (ICD-9). Geneva, Switzerland: World Health Organization; 1977.
  28. Jerntorp P, Berglund G. Stroke registry in Malmö, Sweden. Stroke. 1992; 23: 357–361.[Abstract/Free Full Text]
  29. Engström G, Hedblad B, Juul-Möller S, Tydén P, Janzon L. Cardiac arrhythmias and stroke: increased risk in men with high frequency of atrial ectopic beats. Stroke. 2000; 31: 2925–2929.[Abstract/Free Full Text]
  30. Rubino IA, Verucci M, Fortuna E. Microgenetic styles of regulation among two nonpsychotic psychiatric groups. Percept Mot Skills. 1993; 76: 1059–1069.[Medline] [Order article via Infotrieve]
  31. Steptoe A. Psychological coping, individual differences and physiological. stress responses.In Cooper CL, Payne R, eds. Personality and Stress: Individual Differences in the Stress Process. West Sussex, England: John Wiley & Sons; 1991: 205–233.
  32. Barnett PA, Spence JD, Manuck SB, Jennings JR. Psychological stress and the progression of carotid artery disease. J Hypertens. 1996; 15: 49–55.
  33. Muldoon MF, Herbert TB, Patterson SM, Kamaneva M, Raible R, Manuck SB. Effects of acute psychological stress on serum lipid levels, hemoconcentration, and blood viscosity. Arch Intern Med. 1995; 155: 615–620.[Abstract]
  34. Marmot MG, Poulter NR. Primary prevention of stroke. Lancet. 1992; 339: 344–347.[Medline] [Order article via Infotrieve]
  35. McEwen BS, Seeman T. Protective and damaging effects of mediators of stress: elaborating and testing the concepts of allostasis and allostatic load. Ann N Y Acad Sci. 1999; 896: 30–47.[Abstract/Free Full Text]
  36. Rubino IA, Del Monaco E, Rocchi MT, Pezzarossa B. Microgenetic styles of regulation in schizophrenia. Percept Mot Skills. 1994; 79: 451–457.[Medline] [Order article via Infotrieve]
  37. Rubino IA, Fedeli B, Zanna V, Fortuna E. A multivariate study of the serial Color-Word Test. Percept Mot Skills. 1997; 84: 275–282.[Medline] [Order article via Infotrieve]

Editorial Comment

Results From Prospective Cohort Study "Men Born in 1914" in Malmö, Sweden

Deirdre A. Lane, PhD; Douglas Carroll, PhD; Gregory Y.H. Lip, MD Guest Editors

University Department of MedicineCity Hospital Birmingham, UK
School of Sport and Exercise Sciences University of Birmingham BirminghamUK


*    Cardiovascular and Behavioral Reactions to Stress and Cerebrovascular Disease
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 up arrowResults
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 *Cardiovascular and Behavioral...
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Psychological stress has been implicated as both a precursor to cardiovascular disease1–3 and a significant risk factor for death in those with established coronary heart disease (CHD),3,4 although some counterexamples exist.5,6 There is also an extensive literature, again not all of it positive, concerning the role of behavioral factors, such as hostility and type A behavior, in the pathogenesis of CHD. In marked contrast, little attention has been paid to psychosocial factors in relation to stroke. There is preliminary evidence from one prospective study7 of a positive association between psychological stress and stroke and, from a variety of sources, 8–11 that psychological factors may be predictive of prognosis. Such research outcomes raise the question of what psychobiological and behavioral mechanisms underlie links between psychological stress, on the one hand, and subsequent health outcomes, such as cerebrovascular and cardiovascular disease, on the other.

A possibility here stems from the observation of marked and reasonably stable individual differences in the magnitude of cardiovascular reactions to a variety of mental and physical stress exposures. What has come to be called the "reactivity hypothesis" holds that exaggerated cardiovascular perturbations in response to such exposures contribute over time to the development of cardiovascular pathology. Cardiovascular reactivity has been defined as "an individual’s propensity to experience cardiovascular reactions of greater or lesser magnitude, in relation to those of other persons, when encountering behavioral stimuli experienced as engaging, challenging, or aversive."12 The earliest and most frequently evoked version of this reactivity hypothesis implicates cardiovascular reactions to psychological stress in the etiology of essential hypertension.13–16 Two consistent findings from cross-sectional research support the hypothesis: (1) individuals with borderline hypertension exhibit larger-magnitude cardiovascular reactions to stress than do normotensives,17 and (2) children of hypertensive parents appear to experience greater elevations in blood pressure in response to stress.18,19

However, there is some uncertainty about the exact nature of the risk conferred by excessive cardiovascular reactivity,2,15,20 as well as doubts expressed regarding the stability of individual differences in cardiovascular reactivity across time and different eliciting stimuli, as well as the generalizability of reactions to laboratory challenges to reactions to everyday life stress exposures.15,20 Nevertheless, empirical evidence attests that laboratory measures of cardiovascular reactivity exhibit acceptable temporal and intertask consistency and generalize reasonably well to real life reactivity.21–23

Several prospective studies have now examined the relationship between cardiovascular reactivity to a range of laboratory challenges and subsequent cardiovascular disease. Three main types of laboratory stress have been deployed: (1) the cold pressor test,24,25 (2) mental stress (for example, Raven’s matrices, Color-Word Test, mirror-image tracing), 26,27 and (3) the anticipation of exercise.28–30 In addition, a variety of disease outcomes have now also been examined, including carotid atherosclerosis, 31–33 left ventricular mass,34,35 cardiovascular disease,25,36 and more recently, stroke.30 However, given the original focus of the reactivity hypothesis it is perhaps hardly surprising that the bulk of studies targeted blood pressure and hypertension as outcomes.24,26,28,37

Two recent prospective studies in Stroke have examined cardiovascular reactions to stress in healthy men30 and behavioral adaptations to stress in hypertensive individuals in relation to incident stroke (discussed in the article preceding this editorial comment). Everson et al30 examined the association between blood pressure reactivity to the anticipation of bicycle exercise and subsequent incident stroke in 2303 men from the Kuopio Ischaemic Heart Disease Risk Factor Study in Finland. Men with elevated systolic blood pressure reactivity (>=20 mm Hg) had a 72% greater risk of any stroke and an 87% greater risk of ischemic stroke relative to less reactive men.

The more recent of these 2 studies, the preceding article by André-Petersson et al, explored in 238 hypertensive men born in 1914 in Malmö, Sweden, patterns of behavioral adaptation to a psychological stressor (Color-Word Test), a cognitive conflict task, and the subsequent incidence of stroke. Men who exhibited what the authors called a cumulative-dissociative pattern of behavior in response to the test had a more than 2-fold increased risk of suffering a stroke during follow-up. A cumulative-dissociative behavior pattern is described as "an initially tight control that, as a result of repeated efforts and failures to find successful strategies to master the conflict, is exhausted by the end of the test." An earlier study of the same cohort38 found that this cumulative-dissociative adaptation to stress was also associated with increased risk of cardiac events. Thus, healthy men with elevated cardiovascular reactions to stress and hypertensive men who adapt poorly to stressful situations may be more vulnerable to stroke.

The association between the magnitude of cardiovascular reactions to stress and behavioral adaptations to stress in this context remains to be determined. Furthermore, because the findings of these 2 studies have important theoretical and clinical implications, replication is important. The somewhat variable results that have emerged from the study of cardiovascular reactivity and other outcomes further reinforce the need to establish the robustness of the results for stroke.

The earliest studies of cardiovascular reactivity and hypertension employed the cold pressor test, a passive stress task. The pattern of results is best described as mixed; there are as many studies that have not found a relationship, including some on large cohorts, as studies that have.39 Prospective studies that have used active mental stress tasks provide somewhat more consistent evidence for the reactivity hypothesis. However, the effects tend to be variable, and in some cases of doubtful clinical prognostic significance; approximately 1% to 6% of the variance in follow-up blood pressure or blood pressure change is accounted for by blood pressure reactions to an active mental stress task, following adjustment for basal blood pressure at entry and other potential confounders.26,27,37 Effects of a similar order emerged from the Kuopio Study, in which blood pressure reactions were measured in response to anticipation of physical exercise. It is worth noting here that exercise anticipation is unlikely to be analogous to the usual laboratory mental stress tasks in terms of both psychological and physiological demands.40 Furthermore, the magnitude of such anticipatory cardiovascular reactions are related to physical training history, which will be reflected in variations in physical fitness. The association between fitness levels and cardiovascular pathology is very well documented. There are far fewer population studies of cardiovascular reactivity and subsequent cardiac events or cardiac mortality. The results are again mixed, with more studies failing to find a relationship than reporting one.25 The indications from studies of carotid atherosclerosis31–33 and left ventricular mass34,35 are promising, but the data are few and it is not at all clear that the latter outcome is related to the former and that it has significance for disease end points.

The findings from the 2 recent prospective studies published in Stroke which suggest, first, that the magnitude of cardiovascular reactions to a challenging exposure is associated with incident stroke in initially healthy men (Everson et al30), and second, that stroke incidence is related to the manner in which hypertensive patients behaviorally adapt in the face of a stressful mental challenge (Andre-Petersson et al), are exceedingly encouraging. The brief review above of cardiovascular reactivity studies using other disease outcomes, however, suggests caution. The history of studies implicating other behavioral adaptations to stress, such as type A behavior, in cardiovascular disease should act as a further warning that encouraging early indications in this field do not always stand the test of time and replication. Nevertheless, we hope that other researchers will react adaptively to the challenge of these data. Although substantially neglected, the issue of whether the patterns of cardiovascular and behavioral adjustments to psychological stress are implicated in stroke is far from trivial.


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  1. Greenwood DC, Muir KR, Packham CJ, Madeley RJ. Coronary heart disease: a review of the role of psychological stress and social support. J Public Health Med. 1996; 18: 211–231.
  2. Manuck SB. Cardiovascular reactivity in cardiovascular disease: "once more unto the breach." Int J Behav Med. 1994; 1: 4–31.
  3. Hemingway H, Marmot MG. Psychosocial factors in the aetiology and prognosis of coronary heart disease: systematic review of prospective cohort studies. Br Med J. 1999; 318: 1460-1-467.[Free Full Text]
  4. Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation. 1999; 2192–2217.
  5. Lane D, Carroll D, Ring C, Beevers DG, Lip GYH. Mortality and quality-of-life twelve months after myocardial infarction: effects of depression and anxiety. Psychosom Med. 2001; 63: 221–230.[Abstract/Free Full Text]
  6. Mayou RA, Gill D, Thompson DR, Day A, Hicks N, Volmink J, Neil A. Depression and anxiety as predictors of outcomes after myocardial infarction. Psychosom Med. 2000; 62: 212–219.[Abstract/Free Full Text]
  7. Harmsen P, Rosengren A, Tsipogianni A, Wilhelmsen L. Risk factors for stroke in middle-aged men in Göteborg, Sweden. Stroke. 1990; 21: 223–229.
  8. House A, Dennis M, Mogridge L, Hawton K, Warlow C. Life events and difficulties preceding stroke. J Neurol Neurosurg Psychiatry. 1990; 53: 1024–1028.
  9. House A, Knapp P, Bamford J, Vail A. Mortality at 12 and 24 months after stroke may be associated with depressive symptoms at 1 month. Stroke. 2001; 32: 696–701.[Abstract/Free Full Text]
  10. Everson SA, Roberts R, Goldberg D, Kaplan G. Depressive symptoms and increased risk of stroke mortality over a 29-year period. Arch Intern Med. 1998; 158: 1133–1139.[Abstract/Free Full Text]
  11. Morris PL, Robinson RG, Andrzejewski P, Samuels J, Price TR. Association of depression with 10-year poststroke mortality. Am J Psychiatry. 1993; 150: 124–129.[Abstract/Free Full Text]
  12. Manuck SB, Kasprowicz AL, Monroe SB, Larkin KT, Kaplan JR. Psychophysiologic reactivity as a dimension of individual differences.In: Schneiderman N, Weiss SB, Kaufmann P, eds. Handbook of Methods and Measurements in Cardiovascular Behavioral Medicine. New York, NY: Plenum; 1989: 365–382.
  13. Light KC. Cardiovascular responses to effortful active coping: implications for the role of stress in hypertension development. Psychophysiology. 1981; 18: 216–255.[Medline] [Order article via Infotrieve]
  14. Obrist PA. Cardiovascular Psychophysiology. New York, NY: Plenum; 1981.
  15. Manuck SB, Kasprowicz A, Muldoon MF. Behaviorally-evoked cardiovascular reactivity and hypertension: conceptual issues and potential associations. Ann Behav Med. 1990; 12: 17–29.
  16. Krantz DS, Manuck SB. Acute psychophysiological reactivity and risk of cardiovascular disease: a review and methodologic critique. Psychol Bull. 1984; 96: 435–464.[Medline] [Order article via Infotrieve]
  17. Fredrikson M, Matthews KA. Cardiovascular responses to behavioral stress and hypertension: a meta-analytic review. Ann Behav Med. 1990; 12: 30–39.
  18. Widgren BR, Wikstrand J, Berglund G, Andersson OK. Increased response to physical and mental stress in men with hypertensive parents. Hypertension. 1992; 20: 606–611.[Abstract/Free Full Text]
  19. Matthews KA, Rakaczky CJ. Familial aspects of the type A behavior pattern and physiologic reactivity to stress.In: Schmidt TH, Dembroski TM, Blumchen G, eds. Biological and Psychological Factors in Cardiovascular Disease. Berlin, Germany: Springer-Verlag; 1986: 228–245.
  20. Pickering T, Gerin W. Cardiovascular reactivity in the laboratory and the role of behavioural factors in hypertension: a critical review. Ann Behav Med. 1990; 12: 3–16.
  21. Kamarck TW, Debski TT, Manuck SB. Enhancing the laboratory-to-life generalizability of cardiovascular reactivity using multiple occasions of measurement. Psychophysiology. 2000; 37: 533–542.[Medline] [Order article via Infotrieve]
  22. McKinney ME, Miner MH, Ruddel H, McIlvain HE, Witte H, Buell JC, Eliot RS, Grant LB. The standardized mental stress test protocol: test-retest reliability and comparison with ambulatory blood pressure monitoring. Psychophysiology. 1985; 22: 453–463.[Medline] [Order article via Infotrieve]
  23. Kasprowicz AL, Manuck SB, Krantz DS. Reproducibility of individual differences in cardiovascular response to behavioural and physical challenge. Psychophysiology. 1988; 25: 461.
  24. Menkes MS, Matthews KA, Krantz DS, Lundberg V, Mead LA, Qaqish B, Liang KY, Thomas CB, Pearson TA. Cardiovascular reactivity to the cold pressor test as a predictor of hypertension. Hypertension. 1989; 14: 524–530.[Abstract/Free Full Text]
  25. Carroll D, Davey Smith G, Willemsen G, Sheffield D, Sweetman PM, Gallacher JE, Elwood PC. Blood pressure reactions to the cold pressor test and the prediction of ischaemic heart disease: data from the Caerphilly study. J Epidemiol Community Health. 1998; 52: 528–529.[Medline] [Order article via Infotrieve]
  26. Carroll D, Davey Smith G, Sheffield D, Shipley MJ, Marmot MG. Pressor reactions to psychological stress and prediction of future blood pressure: data from the Whitehall II study. Br Med J. 1995; 310: 771–776.[Abstract/Free Full Text]
  27. Markovitz JH, Raczynski JM, Wallace D, Chettur V, Chesney MA. Cardiovascular reactivity to video game predicts subsequent blood pressure increases in young men: the CARDIA study. Psychosom Med. 1998; 60: 186–191.[Abstract/Free Full Text]
  28. Everson SA, Kaplan GA, Goldberg DE, Salonen JT. Anticipatory blood pressure in middle-aged men. Hypertension. 1996; 27: 1059–1064.[Abstract/Free Full Text]
  29. Kamarck TW, Eränen J, Jennings JR, Manuck SB, Everson SA, Kaplan GA, Salonen JT. Anticipatory blood pressure responses to exercise are associated with left ventricular mass in Finnish men: Kuopio Ischemic Heart Disease Risk Factor Study. Circulation. 2000; 102: 1394–1399.[Abstract/Free Full Text]
  30. Everson SA, Lynch JW, Kaplan GA, Lakka TA, Sivenius J, Salonen JT. Stress-induced blood pressure reactivity and incident stroke in middle-aged men. Stroke. 2001; 32: 1263–1270.[Abstract/Free Full Text]
  31. Barnett PA, Spence JD, Manuck SB, Jennings JR. Psychological stress and the progression of carotid artery disease. Hypertension. 1997; 15: 49–55.
  32. Kamarck TW, Everson SA, Kaplan GA, Manuck SB, Jennings JR, Salonen R, Salonen JT. Exaggerated blood pressure responses during mental stress are associated with enhanced carotid atherosclerosis in middle-aged Finnish men: findings from the Kuopio Ischemic Heart Disease Study. Circulation. 1997; 96: 3842–3848.[Abstract/Free Full Text]
  33. Lynch JW, Everson SA, Kaplan GA, Cohen RD, Salonen R, Salonen JT. Low socioeconomic status potentiates the effects of heightened cardiovascular responses to stress on the progression of carotid atherosclerosis. Am J Public Health. 1998; 88: 389–394.[Abstract/Free Full Text]
  34. Georgiades A, Lemne C, de Faire U, Lindvall K, Fredrikson M. Stress-induced laboratory blood pressure in relation to ambulatory blood pressure and left ventricular mass among borderline hypertensive and normotensive individuals. Hypertension. 1996; 28: 641–646.[Abstract/Free Full Text]
  35. Allen MT, Matthews KA, Sherman FS. Cardiovascular reactivity to stress and left ventricular mass in youth. Hypertension. 1997; 30: 782–787.[Abstract/Free Full Text]
  36. Coresh J, Klag MJ, Mead LA, Liang KY, Whelton PK. Vascular reactivity in young adults and cardiovascular disease: a prospective study. Circulation. 1992; 19: 218–223.
  37. Matthews KA, Wood KL, Allen MT. Cardiovascular reactivity to stress predicts future blood pressure status. Hypertension. 1993; 22: 479–485.[Abstract/Free Full Text]
  38. André-Peterson L, Hagberg B, Hedblad B, Janzon L, Steen G. Incidence of cardiac events in hypertensive men related to adaptive behaviour in stressful encounters. Int J Behav Med. 1999; 6: 331–355.
  39. Carroll D, Davey Smith G, Sheffield D, Willemsen G, Sweetman PM, Gallacher JEJ, Elwood PC. Blood pressure reactions to the cold pressor test and the prediction of future blood pressure status: data from the Caerphilly study. J Hum Hypertens. 1996; 10: 777–780.[Medline] [Order article via Infotrieve]
  40. Carroll D, Davey Smith G. Socioeconomic status and cardiovascular response. Am J Public Health. 1999; 89: 415.[Free Full Text]



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