Reverse White Coat Hypertension in a Patient with Anxiety: Treat the Blood Pressure or Treat the Anxiety?

The other day, I saw a woman who was interviewing me in order to decide whether to transfer her care to my practice. That happens now and then. This woman had the diagnoses of hypertension and of general anxiety, as well as a few other things that I didn’t think immediately related to the reason she was considering finding another doctor.

In some office visits with her various specialists and primary care doctor her blood pressure was as low as 118 but most of the time in the mid 120s and occasionally it hit 145. At home, she ranged from 140 to 200.

This is what we call reverse white coat hypertension. This woman had essentially normal readings in the office and almost always ran high at home. It is much less common than white coat hypertension where the medical office environment triggers an adrenaline rush that raises a patient’s blood pressure sometimes.

Her primary care doctor had tried her on many different blood pressure pills without much luck. Her psychiatrist had her on the maximum dose of venlafaxine plus a few other things. In addition to that, she is prescribed 14 tablets of clonazepam with instructions that it has to last her a whole month and not to call for an early refill.

Clonazepam is a benzodiazepine just like Valium or Xanax. The only real difference between the benzodiazepines is how fast they kick in and how long they stay in your system. For people who take them for anxiety in certain situations, Xanax is often used. It is viewed as more addictive because patients feel the relief when it starts to work and experience dread a few hours later when it starts to wear off. Most prescribers think it is good only for rare situations like when flying in an airplane or going to the dentist. Clonazepam on the other hand is slow to kick in and slow to wear off and most of us use it only for chronic anxiety when the usual preventative medication aren’t working. It is dosed once every 12 to 24 hours, so it seemed odd to me that an experienced psychiatrist would dole out 14 tablets a month to be used as needed for somebody with anxiety every single day.

She lives in a housing development where she hears her neighbors through the walls. She sleeps on the living room couch, where she can see the front door, and never uses her bed or even her bedroom for that matter. She worries about people breaking in and sometimes she doesn’t even know exactly what is making her feel anxious. She doesn’t know where she might feel safer or happier, so she feels stuck and paralyzed without even any vision of how or where her life could be better. She completely rejected my suggestion of considering a roommate, maybe even in a different place, living a little bit like in the old sitcom “Golden Girls”.

I know exactly what is going on here. They teach you in medical school that if you try several blood pressure medications without success, it is time to look for what’s driving this. It could be hormonal problem with the thyroid or the adrenal glands. It could be too much alcohol, narrowing of the kidney arteries and many other things. Or it could be stress and anxiety. In this case, it seemed obvious that the anxiety is the driver because this woman, who spends every day and every night alone, has better blood pressures when she is in the presence of another human being.

I know exactly what is going on here in another way. Doctors who work for big hospital systems are often bound by policies and guidelines or simply an unwritten bias within their organizations. Benzodiazepines are like opiates in the sense that they are potentially addictive drugs that may be appropriate for short-term use, but they both have a phenomenon called tachyphylaxis. What that means is that people often develop a tolerance to the medication and over time need more and more for the same effect that they had when they first seemed to benefit from it. For this reason, hospitals, group practices, medical boards and various watchdog are working hard to minimize unnecessary use of these drugs.

This patient’s primary care provider is part of the same big organization so they would also be under pressure to avoid continuous prescribing of benzodiazepines.

So what I did was tell this anxious woman to really talk seriously with her psychiatrist in her upcoming visit about how the venlafaxine is not preventing the anxiety, she feels stuck where she is in an environment where she doesn’t feel safe and the clonazepam gives her good relief on the days she takes it, but if she cannot have it every day, she needs her psychiatrist’s help in getting something else that reduces her anxiety. There are many options for this, but taking a long acting drug only some days and not at all on other days doesn’t sound like a good long-term solution to me.

In some ways, prescribing the long acting clonazepam to be taken when she feels like she needs it the most, essentially, would be like taking a blood pressure pill on days where she thinks her blood pressure might be going extra high. We hardly ever do that, so what’s different in this case?