ann. behav. med.
(2014) 47:111–119
DOI 10.1007/s12160-013-9526-2
ORIGINAL ARTICLE
Emotional Dampening in Persons with Elevated Blood Pressure:
Affect Dysregulation and Risk for Hypertension
James A. McCubbin, Ph.D & James P. Loveless, M.Ed. & Jack G. Graham, B.S. &
Gabrielle A. Hall, B.S. & Ryan M. Bart, B.A. & DeWayne D. Moore, Ph.D. &
Marcellus M. Merritt, Ph.D. & Richard D. Lane, M.D. & Julian F. Thayer, Ph.D.
Published online: 25 June 2013
# The Society of Behavioral Medicine 2013
Abstract
Background Persons with higher blood pressure have emo-
tional dampening in some contexts. This may reflect inter-
active changes in central nervous system control of affect
and autonomic function in the early stages of hypertension
development.
Purpose The purpose of this study is to determine the indepen-
dence of cardiovascular emotional dampening from alexithymia
to better understand the role of affect dysregulation in blood
pressure elevations.
Methods Ninety-six normotensives were assessed for rest-
ing systolic and diastolic (DBP) blood pressure, recognition
of emotions in faces and sentences using the Perception of
Affect Task (PAT), alexithymia, anxiety, and defensiveness.
Results Resting DBP significantly predicted PAT emotion
recognition accuracy in men after adjustment for age, self-
reported affect, and alexithymia.
J. A. McCubbin : J. P. Loveless : J. G. Graham : D. D. Moore
Clemson University, Clemson, SC, USA
G. A. Hall
University of Florida, Gainesville, FL, USA
R. M. Bart
Gonzaga University, Spokane, WA, USA
M. M. Merritt
University of Wisconsin-Milwaukee, Milwaukee, WI, USA
R. D. Lane
University of Arizona, Maricopa, AZ, USA
J. F. Thayer
Ohio State University, Columbus, OH, USA
J. A. McCubbin (*)
Department of Psychology, Clemson University, Clemson,
SC 29634, USA
e-mail: jmccubb@clemson.edu
Conclusions Cardiovascular emotional dampening is inde-
pendent of alexithymia and affect in men. Dampened emo-
tion recognition could potentially influence interpersonal
communication and psychosocial distress, thereby further
contributing to BP dysregulation and increased cardiovascu-
lar risk.
Keywords Emotion recognition . Blood pressure .
Hypertension development . Central nervous system .
Stress . Alexithymia . Repressive coping . Defensiveness
Introduction
Central nervous system (CNS) regulation of blood pressure
appears to be intimately associated with CNS pathways
mediating expression of emotions, yet very little is known
about the interaction of these basic mechanisms in health and
disease. Recent work in our lab has shown that elevated
resting blood pressure is associated with dampened subjec-
tive assessment of: acute pain [1, 2], images of emotionally
meaningful scenes [3], and emotional content in facial ex-
pressions and written narratives [4]. The inverse relationship
between resting blood pressure and emotional responsivity
has been termed cardiovascular emotional dampening [4].
The purpose of the present study is to examine the potential
independence of cardiovascular emotional dampening from
alexithymia, a well-documented construct pertinent to affect
and cardiovascular risk. If cardiovascular emotional damp-
ening is independent of alexithymia, then the relationship
between elevated blood pressure and reduced perception of
affect represents a newly appreciated and potentially impor-
tant mechanism in the developmental etiology of essential
hypertension.
Historic theories of the interactions between blood pres-
sure regulation and perception of emotions suggest that the
causal pathways are complex and likely multifactorial [5, 6].
112
For example, visceral arousal has been viewed both as a
correlate and a contributor to the complex experience of
emotion. The classic work of the Laceys [7] emphasized
the role of visceral afferents on CNS mechanisms of sensory
intake or rejection. The role of baroreflex stimulation on
brain function has been described in several contexts with
different methodologies [8, 9]. While these studies clearly
demonstrate the effects of acute baroreceptor input to impor-
tant CNS mechanisms, more recent studies of baseline blood
pressure levels and emotional dampening suggest that CNS
control of chronic baroreflex set point may be intimately
linked to both visceral and emotional responsivity [4].
Clues to the interaction between CNS control of blood
pressure and emotional reactivity come from early studies of
the relationship between blood pressure and pain sensitivity
[10–13]. An inverse relationship between resting blood pres-
sure levels and indices of pain sensitivity has been consis-
tently found in both normotensive and hypertensive popula-
tions. For example, reduced pain sensitivity or increased pain
threshold has been observed in hypertensive animals and
humans [10]. Evidence that this pattern may represent a basic
biobehavioral mechanism rather than hypertension-induced
CNS pathology is provided by studies showing that the
BP/pain relationship extends throughout the normotensive
range in healthy, normal humans [1, 11] and in normoten-
sives with a positive family history of hypertension [12, 13].
A significant component of the response to pain is affective
in nature [14], suggesting that further study of the relation-
ship between blood pressure and regulation of emotion is
warranted.
More specific support for an inverse association between
blood pressure and subjective reactivity to aversive stimuli is
building. For example, Nyklicek and others [15, 16] report
that some hypertensive individuals show reduced subjective
self-report of stress. This led us to hypothesize that the data
on pain sensitivity may be only part of a more pervasive
dampening of affective responses in general. A subsequent
study from our laboratory [3] showed that mildly elevated
resting blood pressure was associated with reduced response
to emotionally evocative visual images, including items with
both positive and negative valence. More recently, we have
shown that this cardiovascular emotional dampening extends
to recognition of emotional meaning in facial expressions
and in written verbal narratives [4]. This cardiovascular
emotional dampening has been observed in young adults
and older populations, in both black and white individuals,
and appears to be independent of education and socioeco-
nomic status (SES).
Alexithymia is a personality trait that describes one’s in-
ability to recognize and describe emotional experience [17]
and has been related to both cardiovascular control and per-
ception of affect. The highest rates of alexithymia are found
among older men who are of low SES and have a limited
ann. behav. med. (2014) 47:111–119
education [18]. Some studies have noted a relationship be-
tween alexithymia and hypertension [19]. Alexithymia is as-
sociated with high blood pressure independent of sodium
levels, alcohol intake, body mass index, and physical fitness
[20]. Moreover, the mortality risk of those with cardiovascular
disease increases as alexithymia scores increase [21]. Finally,
high levels of alexithymia strongly correlate with symptoms
of metabolic syndrome such as high triglycerides, high blood
pressure, and type II diabetes [22]. Lane and others [17] have
hypothesized that alexithymia could be an indicator of a more
general emotional processing impairment. While many re-
searchers have explored possible neurobiological components
of alexithymia [23–26], other have noted the similarities be-
tween alexithymia and other constructs, including repressive
coping style and defensiveness [17, 27, 28]. Since both
alexithymia and cardiovascular emotional dampening are as-
sociated with impaired recognition of emotion, it is important
to determine the relationship, if any, between these two con-
structs linking emotion and blood pressure.
The present study was designed to determine the relation-
ship, if any, of cardiovascular emotional dampening to
alexithymia. If cardiovascular emotional dampening is shown
to be independent of alexithymia, then new lines of research
may further clarify the role of this potentially important link in
CNS regulation of both blood pressure and emotional
responsivity in risk for hypertension.
Methods
Participants
Participants were 96 normotensive young adults (45 male, 51
female) from 18–59 years of age (average=22.4±6.81 years).
The racial and ethnic background of study participants includ-
ed 15 % African American, 12 % Asian, 2 % Hispanic, and
71 % Caucasian. Exclusion criteria include a history of sig-
nificant cardiovascular, endocrine, or psychiatric disorder or
current use of cardiovascular or psychoactive medications.
Protocol
Written informed consent was received prior to the experi-
mental session for each participant. Then, participants were
assessed for resting systolic (SBP) and diastolic (DBP) blood
pressure manually, and with a calibrated GE Dinamap Pro100
(Medical Solutions, Minneapolis, MN). Resting blood pres-
sure was determined after a 5-min rest while sitting upright in a
comfortable arm chair. For analysis of resting blood pressure,
five automated readings of blood pressure and heart rate (HR)
were taken at 2-min intervals. The last three automated read-
ings were averaged for analysis. Participants were then given a
Perception of Affect Task (PAT) that required recognition of
112
For example, visceral arousal has been viewed both as a
correlate and a contributor to the complex experience of
emotion. The classic work of the Laceys [7] emphasized
the role of visceral afferents on CNS mechanisms of sensory
intake or rejection. The role of baroreflex stimulation on
brain function has been described in several contexts with
different methodologies [8, 9]. While these studies clearly
demonstrate the effects of acute baroreceptor input to impor-
tant CNS mechanisms, more recent studies of baseline blood
pressure levels and emotional dampening suggest that CNS
control of chronic baroreflex set point may be intimately
linked to both visceral and emotional responsivity [4].
Clues to the interaction between CNS control of blood
pressure and emotional reactivity come from early studies of
the relationship between blood pressure and pain sensitivity
[10–13]. An inverse relationship between resting blood pres-
sure levels and indices of pain sensitivity has been consis-
tently found in both normotensive and hypertensive popula-
tions. For example, reduced pain sensitivity or increased pain
threshold has been observed in hypertensive animals and
humans [10]. Evidence that this pattern may represent a basic
biobehavioral mechanism rather than hypertension-induced
CNS pathology is provided by studies showing that the
BP/pain relationship extends throughout the normotensive
range in healthy, normal humans [1, 11] and in normoten-
sives with a positive family history of hypertension [12, 13].
A significant component of the response to pain is affective
in nature [14], suggesting that further study of the relation-
ship between blood pressure and regulation of emotion is
warranted.
More specific support for an inverse association between
blood pressure and subjective reactivity to aversive stimuli is
building. For example, Nyklicek and others [15, 16] report
that some hypertensive individuals show reduced subjective
self-report of stress. This led us to hypothesize that the data
on pain sensitivity may be only part of a more pervasive
dampening of affective responses in general. A subsequent
study from our laboratory [3] showed that mildly elevated
resting blood pressure was associated with reduced response
to emotionally evocative visual images, including items with
both positive and negative valence. More recently, we have
shown that this cardiovascular emotional dampening extends
to recognition of emotional meaning in facial expressions
and in written verbal narratives [4]. This cardiovascular
emotional dampening has been observed in young adults
and older populations, in both black and white individuals,
and appears to be independent of education and socioeco-
nomic status (SES).
Alexithymia is a personality trait that describes one’s in-
ability to recognize and describe emotional experience [17]
and has been related to both cardiovascular control and per-
ception of affect. The highest rates of alexithymia are found
among older men who are of low SES and have a limited
ann. behav. med. (2014) 47:111–119
education [18]. Some studies have noted a relationship be-
tween alexithymia and hypertension [19]. Alexithymia is as-
sociated with high blood pressure independent of sodium
levels, alcohol intake, body mass index, and physical fitness
[20]. Moreover, the mortality risk of those with cardiovascular
disease increases as alexithymia scores increase [21]. Finally,
high levels of alexithymia strongly correlate with symptoms
of metabolic syndrome such as high triglycerides, high blood
pressure, and type II diabetes [22]. Lane and others [17] have
hypothesized that alexithymia could be an indicator of a more
general emotional processing impairment. While many re-
searchers have explored possible neurobiological components
of alexithymia [23–26], other have noted the similarities be-
tween alexithymia and other constructs, including repressive
coping style and defensiveness [17, 27, 28]. Since both
alexithymia and cardiovascular emotional dampening are as-
sociated with impaired recognition of emotion, it is important
to determine the relationship, if any, between these two con-
structs linking emotion and blood pressure.
The present study was designed to determine the relation-
ship, if any, of cardiovascular emotional dampening to
alexithymia. If cardiovascular emotional dampening is shown
to be independent of alexithymia, then new lines of research
may further clarify the role of this potentially important link in
CNS regulation of both blood pressure and emotional
responsivity in risk for hypertension.
Methods
Participants
Participants were 96 normotensive young adults (45 male, 51
female) from 18–59 years of age (average=22.4±6.81 years).
The racial and ethnic background of study participants includ-
ed 15 % African American, 12 % Asian, 2 % Hispanic, and
71 % Caucasian. Exclusion criteria include a history of sig-
nificant cardiovascular, endocrine, or psychiatric disorder or
current use of cardiovascular or psychoactive medications.
Protocol
Written informed consent was received prior to the experi-
mental session for each participant. Then, participants were
assessed for resting systolic (SBP) and diastolic (DBP) blood
pressure manually, and with a calibrated GE Dinamap Pro100
(Medical Solutions, Minneapolis, MN). Resting blood pres-
sure was determined after a 5-min rest while sitting upright in a
comfortable arm chair. For analysis of resting blood pressure,
five automated readings of blood pressure and heart rate (HR)
were taken at 2-min intervals. The last three automated read-
ings were averaged for analysis. Participants were then given a
Perception of Affect Task (PAT) that required recognition of
ann. behav. med. (2014) 47:111–119
positive and negative emotions in facial expressions and written
narrative sentences. This task has been normed with community-
based populations and has been shown reliable and sensitive
[17]. They also completed the Toronto Alexithymia Scale
(TAS-20) [17, 18], the Positive and Negative Affect Scale
(PANAS), and in a subgroup (n=51) the Spielberger State and
Trait Anxiety Inventory (STAI) and the Marlowe-Crowne Social
Desirability Scale. An additional 6-min rest period ensued after
task completion.
Sentences Sub-task
The experimenter gave the participant instructions for the
sentences sub-task as well as practice trials. The experiment-
er asked the participant to read 35 sentences and match the
perceived emotional response of the underlined character in
each sentence to one of the following response options:
happy, sad, fear, anger, disgust, surprise, and neutral emo-
tion. Five sets of sentences represented each of the seven
emotions. For example, one anger item from the PAT
sentences is: “Being sure that his players did nothing wrong,
a coach demands an explanation from the referee about the
penalty call.” After identification of the type of emotion,
participants then rated the intensity of emotional expression
on a 0 to 6 scale where 0 is defined as “no intensity” and 6 is
“extremely intense.”
Faces Sub-task
Participants were shown 35 photographs of faces with vary-
ing expressions and were asked to indicate which emotion
(of the seven options above) was the best match for the
expression in the face. Five sets of faces stimuli represented
each of the seven emotions. Intensity ratings were identical
to the sentences task.
The sentences and faces sub-tasks were counterbalanced
and have been normed in previous research with community-
based aging populations [17]. This task has proven to be
reliable and related to measures of emotion awareness, anx-
iety, defensiveness, and coping style [17]. After the protocol,
the experimenter debriefed the participant.
Analysis of PAT Recognition Accuracy
Recognition accuracy of emotions was determined as fol-
lows. Total Faces accuracy scores were calculated as the
percentage of correct responses for all face items. Total
Sentences accuracy scores were calculated as the percent-
age of correct responses for all sentence items. Total PAT
accuracy scores were calculated as the proportion of cor-
rect responses to total responses (collapsed across faces
and sentences).
113
PAT Valence Scores
Recognition accuracy scores were also computed for negative
and positive stimuli, collapsed across faces and sentences
tasks, in order to assess differences in emotion recognition
as a function of valence.
Emotion Intensity Scores
In a similar manner, average emotion intensity scores were
calculated as the mean of intensity scores of correctly recog-
nized emotions for total PAT, sentences, faces, positive and
negative items.
Statistical Analysis
Mean scores for resting systolic and diastolic BP and HR were
computed for the rest periods. Analyses were performed with
SPSS-PC software, and an alpha level of 0.05 was adopted for
all statistical tests. Statistical analyses included correlational
tests for demographic variables, cardiovascular levels, and the
various PAT scores. Initially, we assessed potential sex in-
teractions by a series of hierarchical regressions predicting
each PAT performance metrics by PANAS, TAS-20, sex,
and resting blood pressure (step 1), then the BP × sex inter-
action (step 2). SBP and DBP were each entered in separate
analyses. Where no significant sex interactions were ob-
served, we conducted a series of multiple regression tests
predicting PAT scores from the following independent vari-
ables: sex, age, total TAS-20 alexithymia scores, total PANAS
scores, and resting blood pressures. Thus, we tested the role of
each resting cardiovascular parameter on perception of affect
after adjustment for sex and other relevant demographic fac-
tors, alexithymia, and self-reported affect. Tests of skewness
and normalization transformations were also conducted to
confirm that skewness did not affect PAT results. In an ex-
ploratory analysis of a subgroup of subjects (n=51), regres-
sions were performed using the Marlowe-Crowne and STAI
scores for assessment of the role of defensiveness and repres-
sive coping [27, 28].
Results
Average (±SE) resting SBP was 113.7±1.21 mmHg, while
resting DBP was 67.7±0.70 mmHg across the entire sample.
Total PAT percentage correct accuracy was 92.2±0.84, with
no significant difference between performances on faces ver-
sus sentences. Average total PAT intensity was 4.29±.079,
with no significant intensity differences between faces and
sentences. Descriptive statistics for men and women are given
in Table 1. The range of SBP was 93.5–154 mmHg in men and
90–138.5 mmHg in women, while the range of DBP was 55–
114 ann. behav. med. (2014) 47:111–119

Table 1 Average (SE) of cardiovascular and affective measures in men and women

SBP (mmHg) DBP (mmHg) HR (bpm) PAT recognition PAT intensity TAS total PANAS total

Men n=45 118.0 (1.69) 68.5 (1.07) 72.8 (1.81) 90.7 (1.52) 4.23 (.119) 45.2 (1.65) 42.1 (1.71)
Women n=51 109.8* (1.53) 67.0 (0.90) 69.8 (1.90) 93.5 (0.79) 4.35 (.106) 42.0 (1.45) 38.2 (1.12)

SE standard error, SBP systolic blood pressure, DBP diastolic blood pressure, HR heart rate, PAT Perception of Affect Task, TAS Toronto Alexithymia
Scale, PANAS Positive and Negative Affect Scale
*p<.001 versus men

91.5 mmHg in men and 48–82 mmHg in women. The only
significant sex difference was in SBP, where men had signif-
icantly higher levels than women. Average total TAS score
was 43.5±1.1, with seven participants scoring >61.
Bivariate zero-order correlations were first calculated for
the entire sample. Resting DBP was inversely related to total
PAT accuracy score, r(93)=−.343, p=.001. There were no
significant correlations between SBP or HR with PAT total
accuracy or intensity scores. Interestingly, total alexithymia
scores were inversely related to total PAT accuracy,
r(88)=−.340, p=.001, but not total PAT intensity scores.
Total PANAS scores were positively correlated with PAT total
intensity scores, r(69)=.310, p=.009, but not with PAT total
accuracy, p>.1. To assess potential sex differences, correla-
tions are depicted separately for men and women in Table 2.
Interestingly, correlations between DBP and PAT scores show
significant negative correlations with PAT total accuracy and
total intensity in men, but not women.
To further assess the effects of sex on the relationship
between DBP and PAT performance, a series of hierarchical
multiple regressions were performed predicting PAT perfor-
mance from total TAS alexithymia scores, total PANAS
scores, DBP, age, and sex (step 1), and then the DBP × sex
interaction (step 2). The DBP × sex interaction was signifi-
cant for all tests of PAT accuracy and for PAT total and
negative intensity (see Table 3). Further analyses for PAT
accuracy and PAT total and negative intensity are conducted
separately for men and women.
PAT Recognition Accuracy and Intensity Regression
Analyses
A series of linear regression equations examined the possible
role of alexithymia in cardiovascular emotional dampening.
In these regression equations, calculated separately for men
and women, PAT accuracy was predicted from total PANAS

Table 2 Bivariate correlations with degrees of freedom among cardiovascular and affective measures in men (above diagonal) and women (below
diagonal)

Resting SBP Resting DBP Resting HR PAT accuracy PAT intensity TAS total PANAS total

Resting SBP – .581** .243 −.153 −.292 .298 −.099

45 45 .45 38 42 42

Resting DBP .588** – .260 −.521** −.367** .138 .044

51 45 45 38 42 44

Resting HR .283 .355* – .093 −.204 .181 −.070

51 51 45 38 42 44

PAT accuracy .127 −.015 .056 – .397* −.360* −.153

50 50 50 38 42 44

PAT intensity .208 .172 .217 −.030 – −.124 .254

37 37 37 36 35 37

TAS 20 total .050 .073 .090 −.284 −.159 – .188

49 49 49 48 35 41

PANAS total .209 .130 .209 .099 .544** −.210 –

48 48 48 47 34 46

SBP systolic blood pressure, DBP diastolic blood pressure, HR heart rate, PAT Perception of Affect Task, TAS Toronto Alexithymia Scale, PANAS
Positive and Negative Affect Scale
*p<.05, **p<.01 (two-tailed)
ann. behav. med. (2014) 47:111–119 115

Table 3 Hierarchical multiple regression results for sex × DBP inter- Skewness
action (model 1 with interaction term added)

Variable B SEB t R2 Adj. R2 Because of the high levels of PAT accuracy in both men and
women, additional analyses were conducted to determine the
PAT accuracy (sex × DBP interaction)a effects of skewness on results. Total PAT accuracy scores
PAT total 0.770 0.224 3.341** 0.362 0.312 show skewness=−3.212 in men and −1.888 in women.
PAT negative 0.909 0.267 3.399** 0.380 0.332 Subsequently, PAT accuracy scores underwent reflection
PAT positive 0.699 0.197 3.539** 0.334 0.283 and square root transformations, where skewness=1.631 in
PAT faces 0.472 0.192 2.464* 0.262 0.204 men and 0.164 in women. The transformed scores showed
PAT sentences 1.067 0.341 3.129** 0.305 0.251 correlation and regression results similar to untransformed
PAT intensity (sex × DBP interaction)b scores. For example, the correlation of DBP and transformed
PAT total 0.053 0.023 2.285* 0.273 0.196 PAT accuracy scores remain significant for men, r(43)=.464,
PAT negative 0.055 0.020 2.699** 0.307 0.232 and nonsignificant for women, r(48)=.068. Multiple regres-
PAT positive 0.047 0.026 1.815 0.247 0.168 sion on the transformed PAT total accuracy scores continued
PAT faces 0.053 0.027 1.916 0.249 0.170 to show significant, independent prediction by DBP in men,
PAT sentences 0.052 0.026 1.988 0.210 0.128 t(36)=2.271, p=.029, but not women. A scatter plot of the
relationship between resting diastolic blood pressure and
PAT Perception of Affect Task, DBP diastolic blood pressure
a
normalized Perception of Affect Task (PAT) accuracy scores
Residual df=78
b
in men and women is depicted in Fig. 1. Skewness was not
Residual df=58 found in combined PAT intensity scores for either men (.550)
*p<.05, **p<.01 or women (.212).

scores, total TAS alexithymia scores, age and, separately, Discussion

resting DBP, SBP, and HR. In men, both resting DBP,
t(36)=−2.922, p<.001, and total alexithymia scores, Results of the present study emphasize a new level of intimacy
t(36)=−2.173, p=.036, were significant independent predic- between CNS control mechanisms mediating blood pressure
tors of total PAT recognition accuracy scores. The effect of and perception of affect. In men, resting DBP significantly
DBP on PAT accuracy, independent of alexithymia, was also predicted PAT emotion recognition accuracy after adjustment
significant in men for PAT negative, t(36)=−2.99, p=.005; for age, self-reported affect, defensiveness, and alexithymia.
PAT positive, t(36)=−2.508, p=.007; PAT faces, These new data, at least in men, replicate and extend our
t(36)=−1.581, p=.036; and PAT sentences, t(36)=−2.663,
p=.012. In women, DBP did not significantly predict any
PAT accuracy scores (ps>.05).
Since there were no interactions between DBP and sex for
PAT positive, PAT faces, and PAT sentences intensity, the
multiple regressions were performed on the combined
dataset including both men and women. For men and women
combined, resting DBP was not significantly related to the
PAT positive, faces, and sentences intensity scores. Marginal
intensity effects were observed in men for PAT combined
intensity, p=.061, and PAT negative intensity, p=.064.
Additional regression analyses using PANAS negative
scores, defensiveness, and trait anxiety as predictors did not
substantially change the relationship between blood pressure
and perception of affect. For example, DBP remained a sig-
nificant, independent predictor of PAT total accuracy in men
after adjustment for alexithymia, affect, trait anxiety, and
social desirability/defensiveness, t(18)=−2.478, p=.024.
Bivariate correlations showed that only Marlowe-Crowne Fig. 1 Scatter plot of the relationship between resting diastolic blood
pressure and normalized Perception of Affect Task (PAT) accuracy
scores showed significant correlations with trait anxiety, scores in men (solid line) and women (dotted line). DBP significantly
r(49)=−.387, p=.005, with no significant relationship to predicted normalized PAT accuracy in men (p=.029) but not women.
blood pressure or PAT performance. The DBP × sex interaction is significant (p<.001)
116
previous emotional dampening findings [4] to a younger
sample of mixed race and ethnicity. Collectively, these find-
ings are consistent with other recent studies [29] and suggest
that cardiovascular emotional dampening, as indexed by the
inverse relationship between resting diastolic blood pressure
and perception of emotion, is not simply an effect of
alexithymia and self-reported affect on perception of emo-
tions. The implications of these findings are potentially im-
portant from the standpoint of both basic biobehavioral mech-
anisms and relevance to the early developmental etiology of
essential hypertension.
Interactions with Sex
The significant interactions between diastolic BP and sex
may further elucidate factors influencing the expression of
emotional dampening. In our previous study of mostly older
African American men and women [4], there were no sig-
nificant interactions between blood pressure and sex in pre-
diction of PAT scores. Differences between that study and the
current study include race and age. For example, average age
for women in the current study is 22.9 years, while the age of
women in the previous study was 55.1 years. One explana-
tion is that the cardiovascular emotional dampening may
emerge in women at an older age and/or may be influenced
by the presence or absence of estrogen. Additional research
is necessary to further address the sex differences observed
in the present study.
Relationship Between CNS Control of Blood Pressure
and Perception of Affect
The link between cardiovascular function and perception of
affect appears to be a characteristic of normal basic human
functioning. For example, the relationship between resting
blood pressure and affective response extends throughout
the normotensive range of blood pressures in healthy young
adult men, in older men and women, and in samples at both
high and low risk for cardiovascular disease [1, 4]. Moreover,
resting blood pressure predicts emotional responding to a
variety of modalities, including facial expressions [4], written
narrative passages [4], and from earlier studies, evocative
visual images [3] as well as responses to various types of
painful stimuli [1, 2]. The current design does not allow
verification of a direct causal relationship between blood
pressure levels and emotional dampening, and future studies
are recommended to bridge this gap. Taken together, however,
these findings suggest a potentially important intimacy in the
CNS mechanisms controlling chronic blood pressure levels
and perception of and/or response to emotionally meaningful
environmental stimuli.
These results suggest that the basic relationship between
CNS control of blood pressure and affect may have relevance
ann. behav. med. (2014) 47:111–119
for the developmental pathophysiology of essential hyperten-
sion. Although the present study was conducted in young
normotensives, longitudinal studies indicate that the level of
blood pressure in young men predicts both level of pressure
and incidence of hypertension later in life [30, 31]. Therefore,
younger men with the highest resting blood pressure in the
current sample show significant emotional dampening and are
also at statistically enhanced risk for development of hyper-
tension later in life.
The present study does not address the precise pathways by
which CNS regulation of blood pressure and affect are inte-
grated. Early pioneering work on CNS effects of visceral
afferents [7–9] shows the important inhibitory effects of phasic
baroreflex visceral afferent input to the CNS. That line of work
emphasizes the role of baroreflex sensitivity and momentary
stretch of carotid sinus baroreceptors projecting to nucleus
tractus solitarius and other structures on higher brain function.
However, the current research on cardiovascular emotional
dampening highlights the relationship between stable, resting
blood pressure and emotional responsivity in young men. In
the present study, the prediction of PAT accuracy from resting
DBP was independent of diastolic blood pressure levels during
the PAT task and changes in diastolic blood pressure during the
task. These data suggest that CNS mechanisms controlling
chronic baroreflex set point may be better predictors of the
current emotion perception task, may underlie cardiovascular
emotional dampening, and are consistent with findings of
Wilkinson and France [32]. Whether mediated by acute,
bottom-up visceral afferent influence on CNS control of emo-
tional responding or by top-down CNS regulation of both
emotional responsivity and baroreflex setpoint, the relationship
between perception of emotions and blood pressure control
may provide significant insight into CNS changes in the early
stages of hypertension development.
Independence from Alexithymia
Alexithymia, as measured by the TAS-20, was significantly
correlated with PAT accuracy in men (p=.019) and was mar-
ginally correlated in women (p=.051). Alexithymia scores
were marginally correlated with systolic blood pressure in
men but not women (p=.055). There were no significant
correlations between TAS-20 and DBP in either men or wom-
en. These findings suggest that, at least in men, TAS-20 scores
were sensitive to some behavioral and cardiovascular vari-
ables, and may be linked more directly to systolic blood
pressure via mechanisms separate and independent from dia-
stolic blood pressure regulation. Because of the complexity of
interpretation of self-reported alexithymia, we also assessed
self-reported affect via the PANAS scale. Although total
PANAS scores were significantly correlated with PAT inten-
sity ratings in women, there were no significant correlations
with PAT recognition accuracy or blood pressure. In multiple
ann. behav. med. (2014) 47:111–119
regression analyses in men, diastolic blood pressure scores
remained significant, independent predictors of PAT recogni-
tion accuracy scores. The significant relationship between
blood pressure and PAT accuracy was also independent of
negative affectivity as indexed by negative PANAS scores.
This suggests that some manifestations of cardiovascular emo-
tional dampening, i.e., the emotional dampening associated
specifically with basal diastolic blood pressure, operate inde-
pendently of alexithymia in men, even after adjustment for self-
reported affect assessed by the PANAS. Analysis of defensive-
ness and anxiety indicates that defensiveness and anxiety do
not alter the independent prediction of PAT scores from diastol-
ic blood pressure in men. Taken together, these data suggest
that cardiovascular emotional dampening operates indepen-
dently of the constructs of alexithymia, defensiveness, and
anxiety. Thus, the relationship between resting DBP and per-
ception of affect does not appear to be mediated by those
important personality dimensions, but additional research is
needed to more fully understand the role of these factors in
men and women. Cardiovascular emotional dampening may
thus demarcate a previously unappreciated biobehavioral
mechanism linking CNS regulation of blood pressure to brain
mechanisms involved in perception of affect. It is important to
point out, however, that the current sample included healthy
individuals who did not have a significant impairment in emo-
tion perception as the absolute level of PAT performance was
quite high. Moreover, most TAS-20 scores were in the non-
alexithymic range. Nevertheless, the independence of cardio-
vascular emotional dampening from alexithymia and defen-
siveness may point to CNS processes tied to more implicit/
automatic mechanisms of emotional responding.
Possible Relationship to Risk for Hypertension
This intimacy in regulation of diastolic blood pressure and
emotions has significant implications for the developmental
etiology of hypertension, and thus coronary heart disease,
stroke, and other associated cardiovascular diseases. The
extension of emotional dampening into the borderline and
prehypetensive ranges of blood pressure suggests that de-
creased accuracy of emotion recognition is comorbid with
elevated resting blood pressure. It is unclear at this point,
however, if primary emotional dampening precedes, results
from, or parallels the early stages of hypertension develop-
ment. First, emotional dampening could be a direct conse-
quence of mild blood pressure elevations on CNS function.
For example, mild blood pressure elevations, even within the
normotensive range, may directly influence brain function
through visceral afferent processes and/or subclinical CNS
microcirculatory damage. There is some evidence to support
both mechanisms [5–8]. Second, elevations in resting blood
pressure and emotional dampening may be linked indirectly
via common CNS mechanisms [33]. Finally, emotional
117
dampening may contribute, directly or indirectly, to chronic
blood pressure dysregulation. Importantly, these pathways
are not mutually exclusive.
Regardless of a direct, primary etiologic directionality, damp-
ening of emotional perception can likely produce secondary
communication challenges and dysfunction, thus initiating a
potentially pathogenic emotional dampening cascade of in-
creased psychosocial distress and sympathetic nervous system
activity, thereby contributing to further blood pressure eleva-
tions and increased risk for hypertension. Specifically, emotion-
al dampening can result in inappropriate responding in complex
social and occupational settings. Inappropriate responding can
contribute directly to social and work-related conflict, and there-
by increase psychosocial distress. Moreover, reduced perception
of affective cues may result in interpersonal misunderstanding
with potential increases in cynical mistrust and hostility. Several
studies support links among hostility, intimacy, social support,
and risk for subsequent cardiovascular disease [34–36],
suggesting that cardiovascular emotional dampening and its
associated reduced perception of affect may underlie, at least
in part, propensity for both hostility and circulatory risk.
Reduced recognition of emotional communication by others
may also undermine close personal relationships, thus decreas-
ing the quantity and quality of social support, contributing to
poor cardiovascular health through reduced social support and
increased stress [37]. Because emotional dampening can reduce
subjective self-report of affect, evidence for increased distress in
hypertensives requires reliance on more objective measures.
Importantly, the review by Nyklicek and co-workers [15] con-
cludes that higher blood pressure is associated with higher levels
of chronic stressor exposure, even in the face of reduced stress
appraisal and labeling. Therefore, high stress exposure, regard-
less of dampened subjective assessment, can increase sympa-
thetic nervous system activity, raising blood pressure and po-
tentially raising visceral afferent discharge, further dampening
CNS emotional responsivity. This pattern creates a hypothetical
positive feedback loop resulting in the gradual rise in blood
pressure and emotional dampening over time, contributing to
the elevation of blood pressure into the hypertensive range.
Overall, the theoretical causal link between emotional dampen-
ing and psychosocial distress suggests the potential efficacy of
new therapeutic strategies to improve perception of emotion as
an adjunct technique for stress management and improved
blood pressure control. Additional research is needed to more
directly test components of the emotional dampening cascade.
Dampening of Emotion Recognition Versus Emotion
Intensity
Diastolic blood pressure appears to be a more consistent
predictor of PAT recognition accuracy, while prediction of
intensity scores is less robust. Previous work with evocative
images suggests a significant correlation of blood pressure
118
with intensity indices [3]. Although the PAT was not devel-
oped to systematically assess a range of intensities, the current
study shows modest trends for intensity. Nevertheless, the
present results strongly suggest a significant dampening of
affect recognition accuracy in young men. In the present
study, this conceptual dampening is best characterized as
reduced perception or recognition of affect. Additional studies
are recommended to further assess the role of emotion
intensity.
Other Limitations
There are some limitations in the present study that merit
consideration. For example, the statistical power may have
been limited by truncation of the range in PAT scores. Eighty-
one percent of all participants scored at or above 90 % PAT
accuracy. A more difficult test of affect perception may have
yielded stronger results. Nevertheless, results remained robust
after normalization of PAT accuracy scores. Also, the results
show significant cardiovascular emotional dampening with
DBP, but not SBP. The reason for this is unclear, but may
relate to the significant role of total peripheral resistance in
emotional dampening. In our previous HANDLS study with
older, African American men and women [4], total peripheral
resistance was a significant predictor of adjusted PAT accura-
cy. Although both SBP and DBP correlated with indices of
PAT accuracy in that study, age-related changes in arterial
compliance in the older population may have altered the
relationship between DBP and SBP. Another limitation is that
the current PAT procedures cannot differentiate blunted affect
perception from blunted affect responding. Nevertheless, the
independence of cardiovascular emotional dampening from
both alexithymia and defensiveness begins to address this by
elimination of those constructs as mediating mechanisms.
There are also conceptual and practical limitations in the
assessment of alexithymia [38]. For example, persons with
alexithymia have difficulty communicating their emotions.
Our multiple regression approach allowed assessment of
TAS-20 scores independent of self-reported affect. While this
does address some limitations, the present alexithymia results
should be considered in light of limitations in measurement of
alexithymia. Finally, the present study addresses the role of
emotional dampening in risk for hypertension indirectly
through mildly elevated blood pressure. Multiple longitudinal
studies have shown the predictive utility of blood pressure
levels in young adults [30, 31], and moreover, this approach to
early cardiovascular risk assessment is especially important in
light of recent findings that point to emergence of subclinical
markers of cardiovascular disease early in life [39, 40].
Nevertheless, additional work is needed to more directly link
cardiovascular emotional dampening to risk for hypertension
development.
ann. behav. med. (2014) 47:111–119
Conclusions
In summary, the inverse relationship between resting blood
pressure and perception of affect suggests a potentially important
intimacy between CNS control of chronic levels of resting blood
pressure and brain mechanisms mediating perception of affect.
We recommend additional studies to further characterize the role
of sex, the specific nature and implications of emotional damp-
ening, and the functional and structural basis for its links to blood
pressure regulation and circulatory control. Detailed characteri-
zation of these important brain mechanisms may lead to better
understanding of the links between complex psychosocial pro-
cesses and blood pressure dysregulation during the early stages
of essential hypertension development. Although these data are
correlational and cannot establish cause and effect, we recom-
mend future studies of the effect of emotion discrimination
training on hostility, social support, and blood pressure. The
potential contributory role of emotional dampening to the psy-
chosocial distress cascade can provide a rationale for novel
therapeutic strategies aimed at normalization of emotion recog-
nition in young persons with elevated blood pressure before
progression to frank essential hypertension.
Conflict of Interest The authors have no conflict of interest to disclose.
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