Stress And Hypertension: Key Insights

Melissa Mondala, MD

I’m well. Thank you so much, Dr. Laurie. It’s always a pleasure to be here and share some tips with everyone here.

Laurie Marbas, MD, MBA

Excellent. We’ll just jump in. There are a lot of things that can contribute to hypertension, but I don’t think people quite appreciate the amount of stress and our mental health and thoughts can contribute. Can you talk a little bit about that? Either chronic stress, acute illness, or stressors—all of that is related to the things that we should be looking for.

Melissa Mondala, MD

Yes. Stress is a word that we haven’t heard before. It’s everywhere there’s it’s not just small s and big S or small T or big T. Small these little micro traumas and big T, big trauma. But as is the case, sometimes people approach situations with a positive outlook and feel okay, or they think it’s not, as I would say, harmful to them. But other times there are certain situations that can be alarming if it has to do with work-related stress, or sometimes as moms or family members where there’s conflict that can be high in someone’s nervous system to the point where they feel they’re having a panic attack, but may translate into someone feeling they might have a heart attack because of their blood pressure being so elevated and their nervous system being on overdrive. They might feel the chest pressure and the sweaty hands. It’s important to see that stress is something at all levels. Everyone defines stress differently, and everyone approaches stress in a way that depends on their cultural background, their family background, and their environment. They may have their brain perceive it in a way that’s manageable and where they can build a sense of what’s going to be okay versus what’s not okay. I feel threatened. 

When they feel threatened, that’s when their blood pressure can spike, just like when you go through natural stress, like going to the doctor’s office. When you go into the doctor’s office, that white coat, that hypertension—you very much feel that heightened sense. But things to watch out for is understanding that chronic stress means stress over a lifetime can be harmful when you’re not learning stress management techniques when you’re not able to understand that stress is the elephant in the room, and you have to address it first before even trying to take your medications because the medications only work so well. Or are you trying to eat healthy, but you’re still uptight because you’re stressed out? What do we know that other factors are pulling at?

Laurie Marbas, MD, MBA

Absolutely. That mind-body connection piece, could you speak to that a little bit on what that looks like? Is it the other nervous system, the imbalance? How do we even begin to know that it’s stress that’s inducing hypertension versus something else? Or how do we begin to peel back the layers of that?

Melissa Mondala, MD

Yes, absolutely. When it comes to the autonomic nervous system, it is the unconscious part of our brain where we do not have this ready wired in, where you have the sympathetic and the parasympathetic, the sympathetic not only release the cortisol, not just first thing in the morning, it weakens you up. But sometimes we feel on alert and in overdrive throughout the day because there’s a trigger for stress. Then there’s also the running out and running. That’s the other aspect where that works on the arteries and sometimes even the kidneys. There are layers of stress going not only through the receptors of our heart, our kidneys, the arteries, and sometimes even our brains; there’s also the brain connection. We might, when we’re stressed out, get that headache. 

If people call it a tension headache, it’s their blood pressure rising too. That’s one of the symptoms of hypertension; some people start getting headaches. They might feel there’s this sense of over-doomsday stress or that that’s the end of the world, which they might catastrophize in their minds. When we think about not just hypertension but also the nervous system and the release of hormones that are being impacted in the overall nervous system and bloodstream, we often feel overwhelmed. That’s the neurogenic component. There’s a neurogenic brain or vascular component and a hormonal component, and it’s multifactorial. That’s why we often have to talk about the big picture. Even when it comes to neurogenic aspects, if someone is having so much stress that they’re not sleeping well, it’s a bi-directional aspect because the sympathetic system is once again overactive.

Laurie Marbas, MD, MBA

Go ahead. Yes.

Melissa Mondala, MD

Yes. Studies have shown more neurogenic releases, even in people who are overweight or who have type 2 diabetes or pre-diabetes and heart failure. They have intense feelings of physical and emotional stress, and so if you have those conditions, it’s just compounding a pile of stress that impacts even your view of your day-to-day. Adjusting the stress and peeling it back layer by layer allows us to knock down the layers of why we have hypertension and why stress impacts blood pressure.

Laurie Marbas, MD, MBA

Someone understands that they’re under a lot of stress, and they’re concerned that this might be part of the issue. They wake up, their blood pressure is elevated, and they’re going to bed. The pressure is elevated. Maybe they’re being prescribed one or two, maybe sometimes three or more medications, and they’re struggling to control their medications. Their doctors work them up, and they wait and see. As far as we know, physiologically, there’s no evidence of a secondary cause of hypertension that we need to address. 

Hormones are at play in neurogenesis. the nervous systems at play. How do we begin to address this stress? What is the first step when someone comes into your office and says, Dr. Mondala, I’m on all these medications; I don’t want to be on medications? They have side effects. But I continue to deal with a lot of stuff, such as the medications that are causing me stress, because I don’t want to be on medications. I’m worried about my health. Where do you even start with someone on a psychological level?

Melissa Mondala, MD

Yes, I know. Thank you so much. Because a lot of it has to do with mindset, thoughts, and values, and just meeting them where they’re at and saying, First of all, what are your triggers for stress? Triggers can be someone’s tone and how they speak to you, a memory, or the clutter in your room that you need to clean up. Or it can be that aspect where you feel stuck in your mindset, thinking, Well, I don’t feel I’ll ever get better. I don’t feel that I have the appetite to eat these healthy foods, and I don’t know if I can get to the kitchen and cook meals. 

Meeting them in a way where, if this is a stressful situation, how can we make it, number one, not just feel sick, but how can we not just generalize one thing? Most of the time, we think that if one thing is not okay, everything is not okay. Sometimes we just don’t know that we have it in psychological terms; it’s just disordered thoughts or cognitive dissonance. But in our minds, we just may have these unconscious blind spots that we don’t know that are skewing our way of how we perceive our day-to-day. When we’re able to just either journal it or speak about it openly, we can show ourselves and the provider that there are things that I not only need to work on, but I also need to overcome these hurdles because I want to get to that hope. But I need to minimize that trigger because it’s not ongoing. It’s not a threat every single second of the day.

Laurie Marbas, MD, MBA

It’s an acceptance of understanding that these triggers are setting off a cascade of events that are causing blood pressure to understand a different perspective, maybe, of what is going on in their lives. But are there other types of therapies, such as CBT or ACT therapy, meditation, or mindfulness? What practices do you particularly utilize in your integrative style of treatment?

Melissa Mondala, MD

Yes, CBT behavioral therapy is probably the most common one, and that’s because you’re not just substituting thoughts; you’re also able to find out what misconceptions we have in our minds that are more realistic. CBT is important for those who have experienced trauma. EMDR is great eye movement desensitization in a way that people think it’s not just in person, but studies have shown it can be done. Virtually basic things like eye movement, sleep, and even emotional tapping can be good. I practice this with my patients from head to toe, but you’re tapping on reflexes, primitive reflexes, to relax the nervous system on their face and their body, and that can relax them and get them at the moment. Even in a panic attack, which can be helpful for someone who may be a little bit anxious. 

Some people have OCD, so desensitization. Going into situations that might be very alarming to them, but creating a new scenario, a new narrative, so that it is not as harmful and threatening in their minds. Of course, mindfulness stress reduction therapy is amazing. Mindfulness, it’s hard to grasp without trying it yourself, and mindfulness is taught in a way where can we not only be present with the day-to-day and what we hear and smell, but also be okay with the thoughts that may be intruding our minds and mean they may be negative, but how do we find them? accept it and move on to a pathway of healing?

Laurie Marbas, MD, MBA

Perfect. Then, is there any say in whether acute stress is occurring? Not necessarily to the level that it’s a panic attack where someone might need a higher level of intervention, but someone’s starting to feel stress, to feel the tightness in their test or breathing techniques or thought exercises, writing any writing experiments, anything at all that they can help them calm down, and then maybe other long-term therapies that they can do themselves, or should they be under the guidance of a therapist at all times? What does that look like?

Melissa Mondala, MD

Yes, great question. I love my psychology therapists, colleagues, meditation experts, and coaches. The main thing I teach people is vagus nerve exercises. That’s the opposite of the sympathetic nervous drive and is the parasympathetic. It is the longest nerve in the brain, going down to all the systems, even the gut. That’s where you are. they’re funny. To your favorite song and harpists humming to some jazz song or humming to a song that gives you a sense. I’ve, and it’s amazing because I speak to therapists all the time, even with people with ADHD, as if it’s The Lord of the Rings or it’s it, or if it’s a chant that calms you, you hum that out or you sing it into action, and you get to live it out and experience it within the panic attack. That’s helpful. 

Also gagging. I know this might sound weird, but a gag can activate it quickly. If you get a spoon, just gag. Of course, this is someone who has an eating disorder, but it’s not too bad. You just gag, and then it changes there. There you go. You get the vagus nerve, and then the shock in your chest will slow down. One of my favorite techniques is getting ice packs and putting them on your chest. Some studies show that just putting cold compresses on your chest can leave that sensation during panic attacks that you might have, or putting your hands in cold water. Those are my favorite ones that my patients tend to use rather than taking the medication away if they want, and that can slow that down at least five or 10 points lower than what they usually have in terms of blood pressure. Even their heart rate can go down to 20.

Laurie Marbas, MD, MBA

You’ll see if you’re dropping the intensity of a certain scenario, the panic attacks, and the feelings. You’re shocking your system by physically changing that type of movement. Let’s say they’re in a place where they can’t do something, that they don’t have access to the cold, or what other things can they do? If they’re driving their car, for example, or sitting in a very important meeting or riding on a bus or something? What can they do with that point?

Melissa Mondala, MD

Great. I love that exactly. You may not have an ice pack with you, but you have your breath, and breath is at your fingertips. My favorite is just not only inhaling, exhaling four or five, but also exhaling, but doing so you breathe quickly,  maybe two or three short inhales, and exhale from a long. That’s been shown not only in our event medicine and other ways of meditation, but you’re trying to get here. You’re going to you’re pretty much flushing your you’re in be safe thoughts in your frontal lobe that’s overthinking the moment and you’re just saying let’s start fresh. It’s going to be okay. That’s what the inhale and exhale do. I love doing that, at least for a few minutes, if possible. If you can do it too, do it at least five times. Then do the regular inhale and exhale, and then take a break. Breathe normally after that, and then try again for 5 minutes. It’s important to do that continuously as much as you can, as long as you’re not feeling lightheaded. You might be feeling lightheaded because you’re in a panic. But I would say let’s try to slow down the breathing because most people are hyperventilating during those times, panicking when their blood pressure is also spiking. 

I sympathize with those people who have high blood pressure because I have a mother-in-law whose blood pressure is high throughout the day, night, and day. Sometimes the night hours are when the blood pressure tends to pick up, and that’s either because there are feelings of loneliness for some people or because people are scared of the dark. If you wanted to journal during those times and ask yourself, Why do I feel this way in the evening? What happened during this evening hour now? Because it’s not always the food, You’re right, I did everything. I minimize all my salt, but why is my blood pressure still high at night? That’s where the journaling and exploration will come in. Figuring out when blood feelings are attached to your blood pressure is important because there’s a lot of fear and focus. 

I have one patient who doesn’t even check her blood pressure because she will go to the doctor. She will start crying tremendously because of the whole idea of taking her blood pressure, and her mind jumps to, No, I’m going to get a heart attack, and I need to go to the E.R. That’s where her thoughts go. If there’s anyone out there who has those thoughts, I understand. It’s a hard place to go. That’s why it’s important to have a psychotherapist bring that up with her, and maybe she can walk you through that scenario and see what memories come up so that you can adjust them.

Laurie Marbas, MD, MBA

Yes, I’ve had interesting things happen to me, that physiologic breathing. You’re talking about taking a deep breath in as much as you can and then a little bit more holding your breath and doing a long exhale because of that stimulation of the vagus nerve. Then I’ve done that for seven, eight breaths with someone who’s having elevated blood pressure in my presence and physically—not a telemedicine visit, but in person. I was checking the blood pressure manually, and it dropped 15 points after four, seven, and eight readings. Breathing in over four, holding for seven, and reading over 8 to 4 cycles. It’s a pretty quick response with that breathing technique. then I love the writing, the expression writing. I notice in psychology. I’m in some rabbit holes now just digging into them. I think that’s fabulous. But I also want to speak to your other certifications in your other specialty, which is lifestyle. I think it’s such an important thing here that people understand that they can impact their blood pressure sometimes. There’s this genetic piece, but what are some of the lifestyle interventions people can do to improve their blood pressure?

Melissa Mondala, MD

Yes, thank you, Laura. I love those breathing techniques. It’s the box breathing. There are so many. Whatever is easy for you to remember, everyone who’s listening should do it and do it repetitively. The lifestyle aspect, I would say, is movement walking. Whenever my patients come in, I tell them, Make sure you use the bathroom before you take your blood pressure. Maybe take a little walk, and then we’ll meditate, and then let’s check your blood pressure. Usually, that’s what brings it down—you said, 20 points instantly before diving into other things. 

Then with my patients, it’s taking those slow walks, those strolls, especially if someone’s anxious; if they’re not an anxious person, maybe a faster walk will be okay. I would say a long, slow walk does the job, and I would say at least 30 minutes of walking every day would be a great start if possible. I know that with my mother-in-law too, we went to Japan, and I’m just saying this because it was just so recent. We did 10,000 steps, and that’s what kept her blood pressure rock solid in so doing: walking as much as you can throughout the day and making it a lifestyle. If it’s something you can do once a week, try to do it on weekends and three times a week. What’s going to be key is moving and making it fun and interesting. 

Sometimes they have gyms where you can do a little bit of different styles. Is it Pilates and then yoga and then spin, or is it more of at least your heart rates going up when you’re doing a little bit of weights and working on bone density and other things that you’re working on? That’s a whole bunch of exercise. Then sleep, which can undermine sleep because when you have 3 to 4 hours, it’s going to be hard to have healthy blood pressure readings. Getting deep quality as long as six, seven, eight, or eight is ideal. As much sleep as possible can give you that sense of rest so that you’re not in an alarm state. Then, of course, our favorite warrior is nutrition, as much plant-based as fruits, vegetables, beans, nuts, and seeds. If celery is salt, you can find that flavor; other ways to spice up your meal are to use herbs to make your food interesting; and when it comes to avoiding toxins, people still need to avoid those. Being around smoke or secondhand smoke or vaping more and more, we have people being exposed to that, especially at a young age. That’s the number one way to get your blood pressure up.

Laurie Marbas, MD, MBA

Absolutely. Yes. Of course, eating those dark green leafy veggies is a wonderful thing. Hibiscus tea is one of my favorite ground flaxseed alternatives to salt. Yes. Throughout the summer, everyone’s been told these different things. But I think exercise is such an important piece that people don’t think about. I did some research; I didn’t do research, but I read some things about isometric exercises, which have better benefits than resistance training or aerobic exercise on blood pressure. It was fast. That’s the wall set we did when we were in PE class. Yes, it says something about that extended contraction of muscle that causes that resistance—that heart. When your heart’s pumping, the actual resistance lessens in the arteries. That’s fascinating. 

But with that in mind, I do want to tell everyone to thank you for being here and for joining us today. I hope you found this conversation insightful and engaging. But if you’re a summit purchaser, stay here, because we’re about to dive even deeper into this captivating discussion. If you’re not, click on the button below or to the side, and we’ll continue to have access to this conversation. If you think you’re watching this, thank you for being a valuable member of our community. Let’s continue our discussion with Dr. Mondala. Is there anything else that you need to do? When do you decide that medications are required, for example, while patients are working on all these lifestyle interventions? What are your suggestions for people?

Melissa Mondala, MD

Yes, great question. I know for some people this may be their first time checking their blood pressure, and they’ve seen, Well, my blood pressure’s elevated, and that’s an opportunity to hone in on lifestyle changes because there’s an awareness of not only a high blood pressure, but where we can use lifestyle changes for at least one, three, or six months. I am pretty gracious with patients because it takes time to build new habits, and having a tracker would be great to see. We can see trends over time, and they’ll see that after they exercise, their blood pressure drops, or after they meditate or do yoga, and you can have control. 

I think it’s also being aware of once again triggered is number one what makes you angry, what makes you stressed, what makes you overwhelmed and sad, or what? What are the foods you eat out at that restaurant? Maybe I need to order something healthier, or maybe I need to find a way to walk away from a situation and take a deep breath. Having this understanding of what blood pressure is, listening to the body, and then we talk about medication. If we’ve tried a whole, as you can see, a whole bucket full of possible opportunities and solutions and sometimes, fits in the danger zone where it’s 116 or above. 

I will probably start thinking of medication 140 consistently. Nothing’s working. Maybe I’ll introduce the low dose, but I am going to press hard on the hibiscus tea as we talked about in the flaxseed and all those. I want to see patients know what their blood pressure can do for them because the body can adjust to their lifestyle, and then we can bounce around with different medications if needed. Finding ways—is it more simple, more leafy greens, or simply more nitric oxide smoothies, grapes, and other things that we need in the diet? I think we can personalize it, but, Dr. Laurie Marbas and other healthcare providers are going to walk you through, move through, and see what’s safest for you because that’s what we want to do. Protect your heart and your longevity.

Laurie Marbas, MD, MBA

Yes, because at the end of the day, your kidney health, your brain health, and your heart health—there are so many things that are being impacted by high blood pressure that we want to do everything in our power that we can. But sometimes medications are needed. I know one other thing is, is two things. Inflammation is a big one. As you lose weight and lose that visceral fat, which causes inflammation, the fat around the organs will decrease. I found that people need to hit a BMI under 23 or 22, honestly, to start seeing blood pressure that may have been a little bit stubborn to drop into a more safe and normal zone where we can come off medications. 

Well, this has been great. Dr. Mondala. I want to say, I was trying to say Dr. Melissa and Dr. Mondala, at the same time.

Melissa Mondala, MD

It’s okay.

Laurie Marbas, MD, MBA

It’s been great speaking to you today about all of this, and I’m very excited about people who understand that stress on our mental health is such an important intersection between hypertension and other health disparity issues. Thanks again for being here with us.

Melissa Mondala, MD

Yes, it’s a pleasure. Thanks, everyone. See you soon.