The Misdiagnosis of Hypertension The Role of Patient Anxiety
Department of Medicine, Columbia University/New York Presbyterian Hospital, New York, New York, USA. Archives of internal medicine
(Impact Factor: 17.33).
01/2009; 168(22):2459-65. DOI: 10.1001/archinte.168.22.2459
The white coat effect (defined as the difference between blood pressure [BP] measurements taken at the physician's office and those taken outside the office) is an important determinant of misdiagnosis of hypertension, but little is known about the mechanisms underlying this phenomenon. We tested the hypothesis that the white coat effect may be a conditioned response as opposed to a manifestation of general anxiety.
A total of 238 patients in a hypertension clinic wore ambulatory blood pressure monitors on 3 separate days 1 month apart. At each clinic visit, BP readings were manually triggered in the waiting area and the examination room (in the presence and absence of the physician) and were compared with the mercury sphygmomanometer readings taken by the physician in the examination room. Patients completed trait and state anxiety measures before and after each BP assessment.
A total of 35% of the sample was normotensive, and 9%, 37%, and 19% had white coat, sustained, and masked hypertension, respectively. The diagnostic category was associated with the state anxiety measure (F(3,237) = 6.4, P < .001) but not with the trait anxiety measure. Patients with white coat hypertension had significantly higher state anxiety scores (t = 2.67, P < .01), with the greatest difference reported during the physician measurement. The same pattern was observed for BP changes, which generally paralleled the changes in state anxiety (t = 4.86, P < .002 for systolic BP; t = 3.51, P < .002 for diastolic BP).
These findings support our hypothesis that the white coat effect is a conditioned response. The BP measurements taken by physicians appear to exacerbate the white coat effect more than other means. This problem could be addressed with uniform use of automated BP devices in office settings.
Available from: Mark Beauchamp
- "However, this may not always be the case as the current study shows that altered balance could be due to the presence of a clinical evaluator. Similar observations have been made with respect to " white-coat " effects on elevated blood pressure measures recorded in the presence of a clinician  and to changes in speech performance in stroke patients performing in the presence of a therapist . "
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ABSTRACT: While balance in young and older adults is known to change with the threat of standing on elevated surfaces, the potential for social anxiety to influence emotional states and balance performance during a clinical assessment is currently unknown.
Nineteen young and 19 older healthy female adults volunteered for the study. The effects of age and clinical assessment on balance performance were examined using a 2×2 between- and within-subjects factorial design. Balance performance measures were derived from forceplate recordings of three different postural tasks. Psychological measures included fear of negative evaluation, state anxiety, and fear related to the completed balance tasks.
There was a significant increase in state anxiety and fear when participants performed balance tasks while being assessed by an evaluator. Compared to the control condition, both age groups leaned significantly further forward during the functional reach task when being assessed. While being assessed, older adults had significantly larger amplitudes and frequencies of center of pressure (COP) displacement during two-legged stance with eyes closed (EC) and significantly less stance time during one-legged standing compared to the control condition. In contrast, balance performance in young adults during one-legged or two-legged stance tasks was unchanged by clinical assessment.
Social anxiety associated with the clinical assessment of balance can have a negative influence on both emotional states and balance control. As a result, clinicians need to recognize and account or control for potential social anxiety effects on clinical balance performance in young and older adults in particular.
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ABSTRACT: Patiënten met een hoge bloeddruk op het spreekuur en een normale bloeddruk in hun vertrouwde huiselijke omgeving komen elke
behandelaar bekend voor. Geschat wordt dat tussen de 10 en 20% van de mensen er last van heeft. Men kan wel iets bedenken
over de oorzaak van het wittejaseffect. Bij de dokter kom je toch omdat je denkt of bang bent dat er iets aan je mankeert.
Er bestaan twee hypothesen over angst in de spreekkamer als mogelijke verklaring voor het wittejaseffect. De ene theorie gaat
uit van angst als karaktertrek bij mensen die altijd een beetje gespannen of angstig zijn. De andere theorie gaat uit van
een zogenaamde geconditioneerde angstreflex, waarmee wordt bedoeld dat sommige mensen in bepaalde situaties met angst reageren.
Available from: Karina W Davidson
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ABSTRACT: The traditional reliance on blood pressure (BP) measurement in the medical setting misses a significant number of individuals with masked hypertension, who have normal clinic BP but persistently high daytime BP when measured out of the office. We suggest that masked hypertension may be a precursor of clinically recognized sustained hypertension and is associated with increased cardiovascular risk compared with consistent normotension. We discuss factors that may contribute to clinic-daytime BP differences as well as the changing relationship between these two measures over time. Anxiety at the time of BP measurement and having been diagnosed as hypertensive appear to be two possible mechanisms. The identification of individuals with masked hypertension is of great clinical importance and requires out-of-office BP screening. Ambulatory BP monitoring is the best established technique for doing this, but home monitoring may be applicable in the future.
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