Various authors have noted that interethnic group and intraethnic group racism are significant stressors for many African Americans. As such, intergroup and intragroup racism may play a role in the high rates of morbidity and mortality in this population. Yet, although scientific examinations of the effects of stress have proliferated, few researchers have explored the psychological, social, and physiological effects of perceived racism among African Americans. The purpose of this article was to outline a biopsychosocial model for perceived racism as a guide for future research. The first section of this article provides a brief overview of how racism has been conceptualized in the scientific literature. The second section reviews research exploring the existence of intergroup and intragroup racism. A contextual model for systematic studies of the biopsychosocial effects of perceived racism is then presented, along with recommendations for future research.

Racism as a stressor for African Americans. A biopsychosocial model

To determine the prognostic significance of ambulatory blood pressure, we prospectively followed for up to 7.5 years (mean, 3.2) 1187 subjects with essential hypertension and 205 healthy normotensive control subjects who had baseline off-therapy 24-hour noninvasive ambulatory blood pressure monitoring. Prevalence of white coat hypertension, defined by an average daytime ambulatory blood pressure lower than 131/86 mm Hg in women and 136/87 mm Hg in men in clinically hypertensive subjects, was 19.2%. Cardiovascular morbidity, expressed as the number of combined fatal and nonfatal cardiovascular events per 100 patient-years, was 0.47 in the normotensive group, 0.49 in the white coat hypertension group, 1.79 in dippers with ambulatory hypertension, and 4.99 in nondippers with ambulatory hypertension. After adjustment for traditional risk markers for cardiovascular disease, morbidity did not differ between the normotensive and white coat hypertension groups (P = .83). Compared with the white coat hypertension group, cardiovascular morbidity increased in ambulatory hypertension in dippers (relative risk, 3.70; 95% confidence interval, 1.13 to 12.5), with a further increase of morbidity in nondippers (relative risk, 6.26; 95% confidence interval, 1.92 to 20.32). After adjustment for age, sex, diabetes, and echocardiographic left ventricular hypertrophy (relative risk versus subjects with normal left ventricular mass, 1.82; 95% confidence interval, 1.02 to 3.22), cardiovascular morbidity in ambulatory hypertension was higher (P = .0002) in nondippers than in dippers in women (relative risk, 6.79; 95% confidence interval, 2.45 to 18.82) but not in men (P = .91). Our findings suggest that ambulatory blood pressures stratifies cardiovascular risk in essential hypertension independent of clinic blood pressure and other traditional risk markers including echocardiographic left ventricular hypertrophy.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory blood pressure. An independent predictor of prognosis in essential hypertension.

1 Many human fetuses have to adapt to a limited supply of nutrients In doing so they permanently change their structure and metabolism 2 These 'programmed' changes may be the origins of a number of diseases in later life, including coronary heart disease and the related disorders stroke, diabetes and hypertension 3 This review examines the evidence linking these diseases to fetal undernutrition and provides an overview of previous studies in this area

In utero programming of chronic disease

OBJECTIVES: This study examined associations between blood pressure and self reported experiences of racial discrimination and responses to unfair treatment. METHODS: Survey data were collected in year 7 (1992/93) of the Coronary Artery Risk Development in Young Adults (CARDIA) study, a prospective multisite community-based investigation. Participants included 831 Black men, 1143 Black women, 1006 White men, and 1106 White women 25 to 37 years old. RESULTS: Systolic blood pressure among working-class Black adults reporting that they typically accepted unfair treatment and had experienced racial discrimination in none of seven situations was about 7 mm Hg higher than among those reporting that they challenged unfair treatment and experienced racial discrimination in one or two of the situations. Among professional Black adults, systolic blood pressure was 9 to 10 mm Hg lower among those reporting that they typically challenged unfair treatment and had not experienced racial discrimination. Black-White diff...

https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.86.10.1370

Racial discrimination and blood pressure: the CARDIA Study of young black and white adults.

Twenty-one percent of 292 patients with untreated borderline hypertension (clinic diastolic blood pressures persistently between 90 and 104 mm Hg) were found to have normal daytime ambulatory pressures (defined from a population of normotensive subjects). These patients were defined as having "white coat" hypertension, and they were more likely to be female and younger, to weigh less, and to be more recently diagnosed than patients whose pressure was elevated both in the clinic and during ambulatory monitoring. Patients with white coat hypertension did not show a generalized increase of blood pressure lability, nor an exaggerated pressor response while at work. The phenomenon is more pronounced when blood pressure is measured by a physician than by a technician. In such patients, the pressor response may be relatively specific to the physician's office and lead to significant misclassification of hypertension.

How common is white coat hypertension

During a survey of young subjects not receiving treatment for hypertension in Tecumseh, Michigan, clinic and self-monitored blood pressures taken at home (14 readings in 7 days) were obtained in 737 subjects (387 men, 350 women, average age 31.5 years). Hypertension in the clinic was diagnosed if the clinic blood pressure exceeded 140 mm Hg systolic or 90 mm Hg diastolic. In the absence of firm criteria for what constitutes hypertension at home, subjects whose average home blood pressure was in the upper decile of the whole population were considered to have hypertension at home. By these criteria, 7.1% of the whole population had "white coat" hypertension (i.e., high clinic but not elevated home readings). The prevalence of "sustained" hypertension (i.e., high readings in the clinic and at home) was 5.1%. Subjects with white coat and sustained borderline hypertension in Tecumseh were very similar. Both groups showed, at previous examinations (at ages 5, 8, 21, and 23 years), significantly higher blood pressure readings than the normotensive subjects. As young adults (average age 33.3 years), the parents of both hypertensive groups had significantly higher blood pressure readings than the parents of normotensive subjects. Both hypertensive groups had faster heart rates, higher systemic vascular resistance, and higher minimal forearm vascular resistance. Both hypertensive groups were more overweight, had higher plasma triglycerides, insulin, and insulin/glucose ratios than normotensive subjects. The white coat hypertensive group also had lower values of high density lipoprotein than the normotensive group. White coat hypertension is a frequent condition.(ABSTRACT TRUNCATED AT 250 WORDS)

"White coat" versus "sustained" borderline hypertension in Tecumseh, Michigan.

Of 691 healthy (untreated) villagers of Tecumseh, Michigan (average age 32.6 years), 99 had a clinical blood pressure exceeding 140/90 mmHg. Thirty-seven per cent of these borderline hypertensives had increased heart rate, cardiac index, forearm blood flow and plasma norepinephrine. These subjects had elevated self-determined home blood pressure (average of 14 measurements). The present hyperkinetic borderlines had elevated blood pressure at 5, 8, 21 and 23 years of age and their parents also had higher blood pressure. The prevalence of high blood pressure in Tecumseh, its long history, elevated blood pressure readings outside the physician's office and family background of hypertension, suggests that the hyperkinetic state is a significant clinical condition. Previous studies on hospital-based populations proved that the hyperkinetic state is caused by an excessive autonomic drive. The association of the hyperkinetic state with elevated norepinephrine in this study suggests that a sympathetic hyperactivity is present in a large proportion of unselected subjects with mild blood pressure elevation.

Hyperkinetic borderline hypertension in Tecumseh, Michigan.

Among 82 inpatients with psoriasis, 67% (55 patients) reported moderate or severe pruritus. The degree of depressive psychopathology discriminated between the mild, moderate, and severe pruritus groups at admission. Prospectively, the change in depression scores correlated with the change in pruritus pretreatment to posttreatment. Pruritus severity did not correlate significantly with stress due to life events, age at onset, ethyl duration of psoriasis, age, sex, marital status, and average reported daily alcohol (ethanol) consumption. Among the objective dermatologic measures, including extent and severity of lesions, only the degree of perilesional irritation discriminated between the mild, moderate, and severe pruritus groups at admission, and prospectively, change in this measure correlated with the change in pruritus pretreatment to posttreatment. This finding was most likely related to the self-excoriation associated with pruritus. Intrapsychic factors (eg, the severity of depression) rather than external psychosocial or well-defined dermatologic factors, were the most significant correlates of pruritus in psoriasis.

Pruritus in psoriasis. A prospective study of some psychiatric and dermatologic correlates.

Psychologic studies of hypertension have usually focused on the relationship of anger and anxiety to clinic or laboratory blood pressure (BP). Yet, average blood pressure outside of the clinic has proven to be a more important predictor of hypertensive complications. In this study, we have isolated two groups of borderline hypertensives--one group that maintained high blood pressure outside of the clinic and another whose average BP returned to normal at home. All 33 subjects were given psychometric instruments for measuring various components of anger and anxiety: Spielberger's State-Trait Personality Inventory, the Anger Expression Scale, and the State Anger Reaction Scale. The high home BP group reported greater intensity of anger, although they suppressed their expression of anger to a greater extent. The groups did not differ in anxiety. Also, blood pressure variability was not different between the two groups. It is suggested that the psychologic differences found in the group of higher-risk borderline hypertensives may, through autonomic arousal, contribute to the later development of established hypertension.

Anger and anxiety in borderline hypertension.

Julius, M. (U. of Michigan, School of Public Health, Ann Arbor, MI 48109- 2029), E. Harburg, E. M. Cottington, and E. H. Johnson. Anger-coping types, blood pressure, and all-cause mortality: a follow-up in Tecumseh, Michigan (1971-1983). Am J Epidemiol 1986; 124:220-33. This study examined prospectively (1971-1983) the relationship between anger-coping types, blood pressure, and all-cause mortality in a sample of men and women aged 30-69 ( n = 696) of the Tecumseh Community Health Study. Subjects who indicated that they were likely to suppress their anger in response to two hypothetical anger-provoking situations had 1.7 times the mortality risk of those who expressed their anger (95% confidence interval (CI) = 1.03-3.05). Subjects who suppressed their anger when unjustifiably confronted by their spouse had twice the mortality risk of those who expressed their anger (95% CI = 1.13-3.38). For high vs. low suppressed anger towards a policeman, the mortality risk was 1.24 (95% CI = 0.72-2.14). These relationships were invariant across age, sex, and education groups, even when medical risk factors were adjusted for, i.e., smoking, relative weight, blood pressure, coronary heart disease status, forced expiratory volume at one second (FEV 1 ), and chronic bronchitis. However, suppressed anger measures significantly interacted with elevated blood pressure to predict the highest mortality risk. These results suggest that persons with high mortality risk can be identified in part by how they cope with anger, and by the joint effect of anger-coping type (a behavioral trait) and elevated blood pressure (a biological trait). anger; blood pressure; follow-up studies; mortality The association between anger-hostility and health status has long been emphasized by researchers, with particular attention given to cardiovascular disorders such as coronary heart disease and hypertension (1-6), as well as to coronary heart disease complications of hypertension (7). Recent investigations have also indicated that anger-hostility may be the most important “coronary prone behavior” that underlies the confirmed relationship between the Type A behavior pattern and both the incidence of coronary heart disease in prospective studies (8) and the severity of basic coronary artherosclerosis (9, 10). The purpose of the present study was to examine the relationships between anger-coping types, blood pressure, and all-cause mortality. These anger types, namely keeping “anger in” or letting “anger out” were first suggested by Funkenstein et al. (3), by classifying behaviors to laboratory-induced provocation; later, a self-report measure was developed by Harburg et al.

Ernest H. Johnson

Papers

"White coat" versus "sustained" borderline hypertension in Tecumseh, Michigan.

Hyperkinetic borderline hypertension in Tecumseh, Michigan.

Pruritus in psoriasis. A prospective study of some psychiatric and dermatologic correlates.

Anger and anxiety in borderline hypertension.

Anger-coping types, blood pressure, and all-cause mortality: a follow-up in Tecumseh, Michigan (1971-1983)