Conquering White Coat Syndrome: Relaxation Techniques

Many people experience anxiety when visiting the doctor, and for some, this nervousness can lead to a temporary spike in blood pressure, a condition known as white coat syndrome. Named after the white coats worn by healthcare professionals, this phenomenon occurs when elevated blood pressure readings are noted in medical settings but normal at home, often due to stress or fear of medical procedures. Continue reading to learn more about white coat syndrome and how to prevent it.

What Is White Coat Syndrome?

White coat syndrome, also known as white coat hypertension, is a condition where a person experiences elevated blood pressure specifically in healthcare settings, often due to anxiety or stress during doctor visits. This temporary increase in blood pressure is not typically seen in everyday life, as readings are normal when taken at home. The condition, named after the white coats worn by healthcare providers, may trigger nervousness. Unlike sustained hypertension, where high blood pressure is consistent in medical and non-medical settings, white coat syndrome only occurs in a clinical environment such as hospitals and doctor offices.

Some of the common factors contributing to white coat syndrome include

• Anxiety and stress due to being in a medical setting

• Underlying health problems

• Fear of needles or procedures

• Lifestyle factors – obesity, excessive alcohol consumption, smoking, age (more common in individuals aged 50 years and older).

Is White Coat Syndrome Real?

Yes, white coat syndrome is real. Also called white coat hypertension (high blood pressure), it refers to elevated blood pressure that is present only in healthcare settings, presumably triggered by anxiety, with normal blood pressure readings at home. The syndrome gets its name from doctors who wear white coats that can trigger anxiety and cause a temporary elevation in blood pressure.

How Much Can White Coat Raise BP?

Doctors define white coat syndrome as a blood pressure reading above 130/80 mmHg (but below 160/100 mmHg) in a doctor’s office with normal blood pressure measurement (below 130/80 mmHg) on home monitoring. This is in contrast to sustained hypertension (high blood pressure in the physician’s office as well as on home blood pressure monitoring).

Prevalence and Risk Factors  

Experts estimate that 15 to 30% of hypertensive patients have “white coat hypertension.” Risk factors for white coat syndrome include:

• Age older than 50.

• Female sex.

• Recent diagnosis of hypertension.

• Obesity.

• Non-smokers.

Recognizing Symptoms of White Coat Syndrome 

• Experiencing nervousness or anxiety in a doctor’s office.

• Worsening anxiety when going from the waiting room to the exam room.

• Feeling anxious when getting your blood pressure measured.

• Systolic blood pressure above 130 and diastolic blood pressure above 80 in the doctor’s office but normal readings at home. Learn the difference between systolic and diastolic blood pressure.

Common Causes and Triggers

The main trigger for white coat hypertension is the stress of a healthcare appointment. This temporary anxiety can lead to a high blood pressure reading. Other potential causes and triggers include an underlying anxiety disorder or previous unpleasant experiences in healthcare settings.   

Why Do I Get So Nervous To Take My Blood Pressure?

When the body is under stress, it releases several hormones that make the heart beat faster and cause narrowing of your blood vessels. This causes your blood pressure to spike briefly. 

In addition, chronic stress can lead to behaviors that can cause a long-term elevation in blood pressure. For example, some people deal with stress by drinking too much alcohol or caffeine, overeating, eating unhealthy foods, and/or not getting enough exercise—these are all risk factors for high blood pressure. Untreated high blood pressure puts you at an increased risk of heart disease, heart attack, stroke, and organ damage in many parts of the body.

Diagnosis and Tests  

How White Coat Hypertension Is Diagnosed?  

Your doctor may diagnose white coat hypertension by having you measure your blood pressure outside of healthcare settings. There are two ways to do this—ambulatory blood pressure monitoring and home blood pressure reading.

Ambulatory and Home Blood Pressure Monitoring  

Ambulatory blood pressure monitoring uses a device that automatically records your blood pressure every 15-30 minutes for a 24-hour period. The device consists of a cuff worn around your arm and a small recording device that is attached to a belt or strap. Ambulatory monitoring gives your healthcare provider an accurate picture of your blood pressure numbers while you go about your daily activities and also while you’re asleep. This can help your doctor find out if you only have increased blood pressure only in healthcare settings and whether taking blood pressure medication is necessary.

The other way to diagnose white coat hypertension is to use a home blood pressure monitor and record your blood pressure at different times of the day for 1-2 weeks.

Tips for Accurate Blood Pressure Measurement 

For the most accurate blood pressure measurements at home, the American Heart Association and the Mayo Clinic recommend the following:

• Use a monitor that goes around your upper arm.

• Choose a properly fitting cuff size (your healthcare provider can help).

• Bring your home blood pressure monitor to the doctor’s office for comparison with readings taken with the BP monitors in the medical office.

• Measure your blood pressure in the morning before eating or taking medicine, but not right after you wake up. Measure it again in the evening. 

• Repeat the blood pressure measurement 2-3 times to ensure you are getting the same numbers.

• Avoid alcohol, caffeine, tobacco, or food immediately before measuring your blood pressure.

• Place the blood pressure cuff on bare skin, not on clothing.

• Sit upright and rest your arm on a table at the level of your heart.

• Do not talk or do any activity while checking your blood pressure. Sit with your legs and ankles uncrossed. Try not to think of stressful things.

Managing and Alleviating White Coat Syndrome

How Can I Calm Myself Before a Blood Pressure Test?

You can calm yourself before a blood pressure test with relaxation techniques, such as:

• Focus on something other than the healthcare provider and blood pressure monitor. For example, you could try counting things in the room: three things you can see, two things you can hear, and one thing you can touch.

• Repeat words in your mind that help you relax and feel calmer. For example, “I am safe” or “I am inhaling peace and exhaling worry.”

• Relax your muscles progressively from head to toe. This can help to release muscle tension. 

• Visualize a peaceful and calm place or situation. Use as many of your senses as possible to form this mental picture. For example, if you are imagining yourself on a beach, think of the sound of the waves, the salty smell of the air, the touch of a warm sun and a cool breeze on your skin, and the sight of blue water and white sand. 

How Do You Breathe To Lower Blood Pressure?  

A common breathing technique that can help lower blood pressure is the 4-7-8 method. It involves slowly breathing in through your nose to the count of 4, holding your breath for a count of 7, and breathing out through your mouth to a count of 8.

Relaxation Techniques

Relaxation techniques, such as deep breathing, mindfulness, meditation, yoga, and tai-chi, are skills you get better at with practice. Learning and practicing these relaxation techniques helps you recognize your body’s physical response to stress, for example, a fast heart rate or muscle tension. You can then practice relaxation as soon as you notice yourself getting stressed, such as in a doctor’s office before a blood pressure measurement.

What Is the White Coat Effect?

The white coat effect refers to high blood pressure readings in healthcare settings. It can occur both in normotensive people (people who have normal blood pressure at home) as well as those with a diagnosis of hypertension (where a person has higher blood pressure readings in the doctor’s office than at home). 

Notably, many healthcare professionals now feel that white coat hypertension is not as harmless as previously believed. It may be associated with a higher risk of chronic hypertension (long-term high blood pressure). Studies have also found that untreated white coat hypertension is linked to higher cardiovascular risks compared to people who have normal blood pressure at all times.

What Is Masked Hypertension?

Masked hypertension is the opposite of white coat hypertension. White coat hypertension refers to high blood pressure readings in a medical setting. In contrast, masked hypertension refers to blood pressure readings in the normal range in a medical setting and elevated blood pressure in other settings.

White Coat Syndrome vs Anxiety Disorders

White coat syndrome refers to elevated blood pressure readings that occur only in medical settings. The high blood pressure is attributed to the anxiety experienced during a doctor's visit, which is caused by the environment. 

On the other hand, anxiety disorders are mental health conditions in which a person experiences excessive fear, worry, or dread in the absence of any real danger. 

Therefore, anxiety is a broader term that refers to a general feeling of worry. In contrast, white coat syndrome is a specific type of temporary anxiety triggered by a medical environment that causes a specific physical effect (a spike in blood pressure).

Is White Coat Syndrome an Anxiety Disorder?

White coat syndrome is not technically classified as an anxiety disorder. However, studies have shown that people with white coat syndrome have higher state anxiety scores but normal trait anxiety scores. State anxiety is a temporary condition as opposed to trait anxiety which is a more long-lasting condition.

The other theory is that white coat syndrome (a high blood pressure reading in a doctor’s office) is a conditioned response. The conditioning model suggests that patients with white coat syndrome have a history of unpleasant experiences in healthcare settings, such as undergoing painful medical procedures or receiving frightening medical diagnoses. This leads to transient anxiety and a spike in the patient’s blood pressure on subsequent visits to doctors.

Importance of Accurate Diagnosis  

If the white coat effect is not correctly recognized, it can lead to unnecessary initiation or intensification of antihypertensive treatment. Your doctor may start you on blood pressure medicine or increase the dose of your blood pressure medicine even though it is not needed.

Ruling out white coat hypertension is also important before making a diagnosis of resistant hypertension (high blood pressure that does not respond to concurrent use of three different types of blood pressure medications). 

Failure to diagnose masked hypertension can lead to under-treatment of hypertension. This can increase the risk of heart disease, heart attack, stroke, and target organ damage due to untreated high blood pressure.

How Do You Treat White Coat Syndrome?

If your blood pressure is high in the doctor’s office but at home monitoring always reveals a normal reading, you may be diagnosed with white coat hypertension and may not need treatment. However, lifestyle changes, such as eating a healthy, low-salt diet, getting regular exercise, and losing weight if you’re overweight or obese, are recommended for everyone.

Medication and Lifestyle Changes  

If ambulatory monitoring reveals some high readings, then you may be at risk of cardiovascular disease. Suppose you have other risk factors for cardiovascular events, such as diabetes and high cholesterol. In that case, your internal medicine doctor or cardiologist may recommend starting a blood pressure medicine in addition to lifestyle changes.

Monitoring and Preventative Measures for Heart Health

Here are some tips for American adults to lead a heart-healthy lifestyle:

• Quit smoking if you smoke. Tobacco use can damage your blood vessels and heart muscle and increase your long-term risk of cardiovascular disease.

• Get regular exercise. Aim for 30 to 60 minutes of physical activity daily.

• Eat a heart-healthy diet. Experts recommend the DASH diet or Mediterranean diet.

• Maintain a healthy body weight. The body mass index (BMI) can help determine whether you are overweight or obese.

• Get 7-9 hours of quality sleep each night.

• Manage stress with relaxation techniques (see above).

• Regular health screenings include blood pressure measurements, cholesterol, and blood glucose levels.