Psychosocial demands and ambulatory blood pressure: a field assessment approach
Introduction
Numerous findings have linked psychosocial factors with increased cardiovascular disease (CVD) risk. Factors such as job stress, hostility and the Type A behavior pattern, depression, and social isolation have been significantly associated with CVD incidence in healthy individuals, and with worsened prognosis in patient samples [1]. Biological alterations associated with psychosocial demands might play an important role in explaining some of these results. For example, hemodynamic and neuroendocrine changes associated with recurrent or chronic activation of the sympathetic nervous system have been shown to trigger pathophysiologic processes relevant to CVD risk [2].
With the advent of ambulatory blood pressure (ABP) monitoring, we can reliably assess cardiovascular activity in the natural environment. ABP measures may allow us to capture some of these disease-relevant biological alterations, associated with acute and chronic psychosocial demands, during periods of daily life when the experience of demanding activities or experiences are most likely to occur [3].
A large body of evidence supports the prognostic utility of mean ABP measures as correlates of disease risk, with such measures showing independent predictive value over and beyond the effects of blood pressure measures taken in the doctor's office [4]. As an explanation for these findings, some have suggested that ABP may reflect the influence of psychosocial factors, such as job stress, that can only be captured in the field and are not represented in the clinic [5]. In an effort to understand such influences, we have adopted ecological momentary assessment methods, which permit us to measure ongoing behavior in real time and in the natural environment [6]. One goal of our work has been to identify dimensions of daily experience that are associated with acute and chronic alterations in ABP, and ultimately, with cardiovascular health.
In our lab, we have developed a computer-assisted self-report diary, designed to assess psychosocial processes occurring in the natural environment that are hypothesized to be related to ABP [7]. The use of an electronic diary is important, as research suggests that many paper diaries are not completed at the time indicated [8]. Our diary includes five scales measuring dimensions of daily experience that are assumed to be markers of adaptive demands: social conflict, assessing the presence of negative social interactions with others; task demand and decisional control, assessing effortful and uncontrollable activities during daily life; and negative affect and arousal, assessing fluctuations in emotional activation. We use the term “psychosocial demands” to refer, in the aggregate, to these measures.
In a previous sample of healthy young adults, we found that changes in negative affect and arousal were positively associated with fluctuations in both systolic and diastolic blood pressure (SBP and DBP, respectively) during daily life (“within-person” effects), after adjustment for posture, activity, and substance use. Similar findings of a smaller magnitude emerged for the measures of task demand and decisional control. The magnitude of association between psychosocial demands and blood pressure varied significantly across individuals in this sample, with some showing larger changes in ABP than others, across comparable changes in perceived psychosocial demands [9].
Although these initial results have implications for understanding the short-term influence of psychosocial demands on cardiovascular function, longer term influences, which one would expect to be associated with individual differences in mean ABP, might be more directly relevant to the literature on CVD risk. With this in mind, we designed the present report as a replication and extension of our initial findings. As in our previous study, we hypothesized that five dimensions of psychosocial demands would be associated with acute within-person fluctuations in ABP. As an extension of our previous findings, we hypothesized that individual differences in psychosocial demands (“between-person” effects) would be associated with mean ABP over and beyond their association with clinic blood pressure (CBP) measures. Such effects would reflect associations that are uniquely relevant to blood pressure in the natural environment. In testing these associations, we will be expanding our understanding of the potential links between psychosocial factors and CVD risk.
Section snippets
Participants
Participants were 340 older adults drawn from the Pittsburgh Healthy Heart Project, an ongoing investigation examining biobehavioral predictors of subclinical CVD progression in an asymptomatic, community-dwelling sample. This study received the approval of the Institutional Review Board at the University of Pittsburgh, and participants were paid US$200 for completion of this portion of the research. Recruitment involved targeted mailings and media postings in the Pittsburgh metropolitan area.
Data quality
An average of 112.2 diary interviews (82% of possible interviews during waking hours; range=76–161) were successfully completed by each subject, and an average of 114.0 (83% of possible; range=80–191) blood pressure readings were collected. The average participant in this sample had 106.1 valid observations (range=66–148 observations with valid interviews and blood pressure readings) across the two ambulatory monitoring periods.
Correlations between measures of psychosocial demands
Between- and within-person correlation coefficients were derived
Discussion
Using a field assessment approach, we have examined several measures of “psychosocial demands” in terms of their association with ABP in a sample of healthy older community adults. On a within-person basis, everyday fluctuations in negative affect, arousal, social conflict, task demand, and decisional control were each associated with changes in cardiovascular activity, as predicted, even after statistical adjustment for posture, activity, and substance use. On a between-person basis, those
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Perceived social support predicts lower cardiovascular reactivity to stress in older adults
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Saul Shiffman is cofounder and Chief Science Officer of invivodata, inc., which provides electronic diary methods like those reported here for use in clinical trials.