Labile Hypertension: Lessons to Be Learned From Musical Improvisation

Improvisation is the meaningful expression of musical ideas and a manifestation of musical thought. It is analogous to verbal expression of ideas, thoughts, and feelings through speaking and conversation. In a heightened state of awareness, improvisers listen to and interact spontaneously with music and other musicians. These “in the moment” experiences are the result of understanding music as it is being created. Improvisers listen and play with the material at hand, re‐using it and varying it as they play. Accomplished improvisers predict and anticipate what might occur in the moment of performance because they have a sense of the musical content in a larger context. They are comfortable with familiar musical material and embrace the stimulation of unfamiliar material in the perspective of their improvisational vocabulary.

Improvising requires active focus and internal motivation to take part in musical conversation occurring in the moment. Improvising musicians spontaneously interact with each other as listeners and music makers, sharing musical ideas. ¹ In a functional magnetic resonance imaging (MRI) study of jazz improvisation, Limb and Braun² found that during improvisation, persons demonstrate loss of inhibition and heightened sensory awareness. The medial prefrontal cortex, the area of the brain associated with self‐expression and autobiographical storytelling, lights up when musicians improvise. ²

We are born improvisers. As we grow older, if not encouraged to continue playing in the manner of an improviser, persons may develop anxiety about creating and improvising, fearful of making a “mistake.” Nachmanovitch ³ describes 5 fears Buddhists speak of that stand between ourselves and our freedom: fear of loss of life; fear of loss of livelihood; fear of loss of reputation; fear of actually being a fool; and fear of speaking up. To these fears he adds the fear of ghosts, ie, “being overwhelmed by teachers, authorities, parents, or the great masters.” To create and improvise, musicians move past these fears and concerns about success or failure into a mindset that is relaxed and in the moment. It is our belief that using a similar educational approach, patients can better manage their labile hypertension.

One of the most difficult judgments for a clinician to make is to determine whether a patient’s elevated office blood pressure represents a true “white coat” spike in response to the “noxious stimulus” that only the presence of the physician can provide. Alternatively, is it a worrisome indicator of a physiologically damaging hyperadrenergic response that the patient chronically and frequently displays in response to many life stressors? Efforts to tease this out using home blood pressure monitors or ambulatory blood pressure monitors have had mixed success. ⁴

Efforts to treat labile hypertension presently focus on blunting the response to stress. Relaxation techniques, stress management classes, yoga, deep breathing, and other approaches have had some success. In more severe cases, the precipitating stress is treated as a panic disorder, with appropriate interventions. ⁵ In a great number of cases, however, treatment of labile hypertension succumbs to clinical inertia, importance of treatment is minimized, and an important opportunity to prevent cardiovascular disease may be missed. ⁶

A more effective treatment of labile hypertension may involve an engagement, anticipation, and management of the stress, rather than simply blunting the response to it. Using this approach to the anticipated or unanticipated events, musical improvisers handily synthesize data from their surroundings to spontaneously create and perform music. ⁷ We hypothesize that developing the mindset of the musical improviser can help patients with labile hypertension control their blood pressure spikes more effectively than the presently used stress management techniques.

Information is mixed about the association between anxiety and hypertension. Davies and colleagues ⁸ found no evidence for a link between panic disorder and labile hypertension. The data regarding negative affect and hypertension are also limited but are a bit clearer. Jonas and Lando ⁹ found that negative affect predicted later hypertension. Perhaps even more germane than negative affect is how emotions are expressed. Knox and colleagues ¹⁰ found that normotensive patients expressed sorrow better than hypertensive patients, and hypertensive patients expressed less joy in their lives. Vögele and Steptoe ¹¹ found that inhibited expression of negative emotions predicted future hypertension. Hence, both negative emotions and their inhibition could play some role in labile hypertension.

Positive affect is well known to improve creative problem‐solving, cognitive flexibility, access to alternative cognitive perspectives, and the ability to perceive an interesting task as richer and more varied. There is also a greater likelihood of problem‐solving in ways that benefit all stakeholders and increase activity toward safe and enjoyable outcomes—not risky or dangerous alternatives. Positive affect is known to help people address negative events or information. ¹²

Research into the neural substrates of positive and negative affects as well as musical improvisation contain important clues about how improvisation might be of help in the management of labile hypertension. In a study of pleasurable responses (“chills”) to music, Blood and Zatorre¹³ found increased regional cerebral blood flow in the right amygdala, left hippocampus and amygdala, and ventral medial prefrontal cortex. This is consistent with other studies on the central nervous system areas involved with euphoria or pleasant emotion. Pleasurable emotions are associated with functional MRI activity changes in the nucleus accumbens, ventral tegmental area, basal forebrain, thalamus, insula, anterior cingulate, hippocampus, and amygdala. ¹⁴ The amygdala is associated with fear and evaluative processes linked to socially relevant conditions. ¹⁵ , ¹⁶ , ¹⁷ Increased activity in the amygdala and lateral prefrontal cortical areas appears to serve a self‐monitoring function, which could be critical or judgmental in nature. Decreased neural activity in the amygdala and hippocampus can increase the pleasure response. ¹³ , ¹⁸ Music reduces activity in these limbic structures, which can reduce self‐monitoring of a critical nature, and is part of the pleasure response. In addition, music simultaneously decreases activity in those brain structures associated with negative emotions. ¹³

Labile hypertension may well be linked to the inhibition of the expression of negative emotions. The inhibition of negative emotions is usually done at a conscious or pre‐conscious psychic level in response to learned beliefs and super‐ego constraints. These learned beliefs and super‐ego constraints can be judgmental and self‐critical. Such conscious critical self‐monitoring can decrease task performance ¹⁹ , ²⁰ and perhaps especially creative tasks, including musical performance. The ability of improvisational musicians to suspend the critical and judgmental self‐assessment and “get into” a music conversation with their fellow musicians and with the audience, may well involve neural processes linked to pleasure and negative emotion.

The neural processes linked to music may be particularly suited to helping patients with labile hypertension. It has been suggested that deactivation of the lateral prefrontal regions, found to occur during musical improvisation, may be a primary physiologic change responsible for altered states of consciousness such as hypnosis, meditation, or even daydreaming. ²¹ However, the neural processes involved with musical improvisation appear to be more complex than those of self‐hypnosis or meditation. Music is known to maximize pleasure not only by activating neural substrates of reward, but also simultaneously decreasing activity in brain structures associated with negative emotions. This deactivation also reduces critical or judgmental self‐assessment, something that may be an important issue for patients with labile hypertension.

Improvisation is a skill that can be learned and mastered by most people. To learn to improvise, persons should first listen to music and learn to sing and play by ear many melodies and harmony parts in different tonalities, meters, and styles. Rather than “memorizing” the tunes, the objective is to internalize so many melodies and harmony parts that one begins to comprehend how melodies are made (musical syntax) and generate personal melodic lines. Persons also should learn a vocabulary of rhythmic and harmonic patterns and phrases inspired from the repertoire they know; they can use these patterns and phrases in their personal musical lines in meaningful ways as improvisers. Like conversation in language, interaction with others is essential. As individuals build a repertoire of tunes and a sense of musical style by ear, they develop the aural skills and musical contexts necessary to listen to music with understanding and to interact spontaneously, expressively, and musically with others.

As such, teaching the mental skills involved with musical improvisation to patients with labile hypertension, and helping them master those skills, may help them control their blood pressure spikes. This may well be more successful than interventions like meditation or self‐hypnosis. Learning such skills might induce a pleasure response, which can help these patients better handle negative events or situations, and help them suspend harsh self‐judgment, which may facilitate expression of negative affect and thereby help with their labile hypertension.