Hostility and Differences Between Clinic, Self-Determined, and Ambulatory Blood Pressure LARRY D. JAMNER, PHD. DAVID SHAPIRO, PHD, KA KIT HUI, MD, MARK E. OAKLEY, PHD, AND MARCI LOVETT RN, NP This study examined the role of personality factors in differences between three methods of assessing blood pressure (clinic, self, ambulatory) in 45 patients with mild hypertension. The data were obtained after the patients were withdrawn from antihypertensive medications and had achieved stable clinic diastolic blood pressure levels of 95 to 110 mm Hg, averaged over three visits in 2 to 4 weeks. Significant differences were obtained in systolic blood pressure (SBP) and diastolic blood pressure (DBP) as a function of method of assessment. These differences in both systolic blood pressure (SBP) and diastolic blood pressure (DBP) were associated with individual differences in the total score and several subscales of the Buss-Durkee Hostility Inventory (Assault, Resentment, Guilt), but not in anxiety, depression, or other characteristics. High hostile subjects had consistently high blood pressure values in both clinic, self, and ambulatory recordings. Low hostile subjects were significantly lower in self-recorded blood pressure readings taken at home and in ambulatory recordings, compared with clinic values. Implications of these findings for "white coat hyperten- sion" are discussed. Key words: hypertension, blood pressure, hostility, personality, ambulatory, home, clinic, white coat. INTRODUCTION Compared with office or clinic assessments, blood pressure measurements obtained outside the physi- cian's office are more predictive of risk for devel- oping hypertension (1] and more closely associated with hypertension-related target organ damage (2- 5). Recognition of this fact has stimulated research on the identification of factors contributing to the blood pressure differences observed in various set- tings. Clinic or office systolic and diastolic blood pressure are higher on the average when compared with home or ambulatory blood pressure (ABPM) determinations in patients with established and bor- derline hypertension (6-11). In normotensive sub- jects, ABPM or home blood pressures remain at clinic levels (12). In one study of normotensive sub- jects, average clinic screening blood pressure was actually lower than ambulatory blood pressure re- corded at home and work (13). The degree of dis- crepancy between clinic and nonclinic blood pres- sure levels may be an individual characteristic. The From the Department of Psychiatry and Biobehavioral Sciences (L.D.J., D.S., M.O.), and Department of Medicine (K.K.H., M.L.), UCLA School of Medicine, Los Angeles, and the Department of Psychology and Social Behavior, University of California, Irvine (L.D.J). Address reprint requests to: David Shapiro, Ph.D., Department of Psychiatry and Biobehavioral Sciences, University of Califor- nia, Los Angeles, 760 Westwood Plaza, Los Angeles, CA 90024. Received for publication July 28, 1992; revision received No- vember 9, 1992 tendency for clinic blood pressure to be significantly higher than nonclinic levels is referred to as "office" or "white coat hypertension" (9). Individual differences in anger/hostility have been proposed as factors contributing to differences in observed blood pressure values obtained in the clinic/office and those obtained at home or during ambulatory monitoring. In a study of 33 untreated borderline hypertensives (clinic screening blood pressure >140/90 mm Hg with at least one subse- quent clinic visit <140/90 mm Hg), Schneider et al. (10) found that two-thirds of their subjects demon- strated normotensive blood pressures at home (de- fined in this study as <130/83 mm Hg). Subjects whose home and clinic blood pressure levels were both high scored significantly higher on measures of anger intensity and "anger-in" than subjects who were low both at home and in the clinic. It was hypothesized that anger served to maintain, or con- tribute to, consistently higher blood pressure levels at home by way of a form of sympathetic activation involving higher levels of plasma renin activity and plasma norepinephrine. In another comparison of clinic and home blood pressure, patients demon- strating the "white coat" effect had significantly lower scores on the SCL-90 hostility subscale and on the Spielberger Trait Anger Inventory (14). Hy- pertensive patients having clinic systolic blood pres- sure (SBP) or diastolic blood pressure (DBP) 10 mm Hg higher than their average awake ABPM levels reported significantly less anger and less overt anger expression on the Spielberger Trait Anger Inventory than hypertensives whose clinic and home blood Psychosomatic Medicine 55:203-211 (1993) 203 0033-3174/93/55O2-O2O3SO3 00/0 Copyright <B 1993 by the American Psychosomatic So