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Cynical hostility, anger, and resting blood pressure
Journal of Psychosomatic Research, Vol. 40, No. 4, pp. 359-368, 1996 Copyright © 1996 Elsevier Science Inc. All rights reserved. 0022-3999/96 $15.00 + .00
ELSEVIER
0022-3999(95)00546-3
CYNICAL HOSTILITY, ANGER, AND RESTING BLOOD PRESSURE JOHN SPICER and KERRY CHAMBERLAIN Abstract- Research on associations of anger and hostility with resting blood pressure (BP) has generally ignored their interrelationships. The present study examined the individual and joint relationships of cynical hostility, anger-in, anger-out, and anger frequency with resting BP using the Cook-Medley Hostility Scale and the Spielberger anger scales. Multiple regressions were conducted on data from a community sample of 105 men and women to examine the main and interactive effects of anger and hostility on BP, controlling for established physical covariates. Diastolic BP was inversely related to anger-in scores in men and women. Systolic and diastolic BP were positively associated with Ho (hostility) score only in women. No confounding or interactive effects of hostility and anger on BP were found. It is suggested that the sex-specific link between cynical hostility and BP may reflect a chronic mismatch between the social cognitions of cynically hostile women and some of the cultural norms that govern women's social lives.
Keywords: Hostility; Anger; Blood pressure.
INTRODUCTION T h e effects o f anger a n d h o s t i l i t y o n b l o o d p r e s s u r e have b e e n a focus o f research a t t e n t i o n for m a n y years [1]. A s i d e f r o m the intrinsic p s y c h o p h y s i o l o g i c a l interest o f these effects, this r e s e a r c h is also m o t i v a t e d b y the p o s s i b i l i t y t h a t b l o o d pressure m a y be a key v a r i a b l e in e x p l a i n i n g the c o r r e l a t i o n s o f anger a n d h o s t i l i t y variables with risk o f h y p e r t e n s i o n a n d o t h e r c a r d i o v a s c u l a r diseases [1-3]. These p s y c h o l o g i c a l v a r i a b l e s have been s t u d i e d in r e l a t i o n to b o t h resting b l o o d pressure [3] a n d its reactivity in response to v a r i o u s stressors [4]. In the p r e s e n t article we restrict o u r a t t e n t i o n to their r e l a t i o n s h i p s with resting b l o o d pressure. In c o n t r a s t to the m a n y studies t h a t have e x a m i n e d the i n d e p e n d e n t effects o f a n g e r a n d h o s t i l i t y o n resting b l o o d p r e s s u r e , the p s y c h o l o g i c a l focus o f this article is on their p o t e n t i a l j o i n t effects. T h e r e are a n u m b e r o f reasons w h y it is d e s i r a b l e to include anger a n d hostility v a r i a b l e s in the s a m e research design. I r o n i c a l l y , one r e a s o n these v a r i a b l e s s h o u l d be c o n s i d e r e d t o g e t h e r is so t h a t t h e y can be b e t t e r s e p a r a t e d . E m o t i o n theorists have long d i s t i n g u i s h e d b e t w e e n t h e m , albeit in a v a r i e t y o f ways. But, as reviewers o f the b l o o d p r e s s u r e l i t e r a t u r e have p o i n t e d o u t [e.g., 5], the i n a d e q u a t e c o n c e p t u a l i z a t i o n a n d m e a s u r e m e n t o f a n g e r a n d h o s t i l i t y in this field have c o n t i n u e d to h i n d e r progress. T h u s , even c u r r e n t articles go so f a r as to t r e a t the two c o n s t r u c t s as s y n o n y m o u s
Department of Psychology, Massey University, Palmerston North, New Zealand. Address correspondence to: Dr. J. Spicer, Department of Psychology, Massey University, Private Bag 11-222, Palmerston North, New Zealand. Telephone +64 6 350 4137; Fax +64 6 350 5673; e-mail J .Spicer@ massey.ac.nz. 359
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[e.g., 6]. Recently though, clearer and more discriminating definitions of anger and hostility constructs have begun to emerge in blood pressure research, more through the development or critical evaluation o f particular measures than through the elaboration of theory. Spielberger and his colleagues define anger as "an emotional state that consists of feelings that vary in intensity, from mild irritation or annoyance to fury and rage" [7: 7]. The variation in intensity of these feelings is referred to as State anger, whilst the frequency with which the feelings are experienced is referred to as Trait anger. When anger feelings are experienced, they may be suppressed or expressed. For Spielberger, the former "anger-in" construct simply refers to the frequency with which anger is consciously suppressed rather than to some subtle psychoanalytic processes. Anger expression, or "anger-out," is defined as "the extent that an individual engages in aggressive behaviors when motivated by angry feelings" [7:14]. Thus, as Spielberger highlights, anger suppression and expression, like Trait anger, are regarded as personality traits. In the present study we adopted these definitions of anger constructs, and used the various measures that Spielberger and his associates developed from these definitions [8]. Regarding hostility, Spielberger and his colleagues [7] have suggested that its central feature is a complex set of negative attitudes towards others, such as distrust. These attitudes are intertwined with emotions such as cynicism, resentment, vengeance, and alienation, which tend to have complex cognitive features, thereby differentiating them from emotions such as anger, which are definable more in terms o f affect. This mainly cognitive view of hostility also emerges from recent work on the CookMedley Hostility (Ho) scale [9], research which has accelerated since H o scores were linked prospectively with risk of coronary heart disease [ 10]. The Ho scale's developers saw it as a measure of "dislike for and distrust of others" [9: 418]. From more recent factor analytic research it has been suggested that it is a complex measure of 'cynical hostility' that encompasses negative "beliefs about the trustworthiness of others, negative emotions associated with social relationships, and aggressive behavior towards others" [11: 52]. O f particular interest in the present context is that only 2 of the 50 items make reference to anger or annoyance, thus providing operational differentiation of anger and hostility. In the present research we followed Spielberger's emphasis on hostility as primarily a set of negative attitudes about social relations, and we adopted the operationalization provided by the Ho scale. Given that hostility and various features of anger can be distinguished and measured, empirical study of their joint effects on blood pressure can be advocated on at least two substantive grounds: as one way in which inconsistencies in the available evidence may be resolved, and as a means of testing more sophisticated hypotheses about hostility and anger phenomena. With respect to the first, conflicting results have been reported on the association between Ho score and resting blood pressure in analyses nested within experimental and ambulatory studies of blood pressure reactivity. Thus, Christensen et al. [12] reported higher systolic blood pressure (SBP) in high Ho scorers than in low scorers during the baseline phase of their experiment. Jamner et al. [13] found that high Ho scorers in an ambulatory study of 33 male paramedics exhibited higher mean blood pressures than low scorers, even when they were asleep. Similarly, Linden et al. [14] reported a positive correlation between Ho score and mean diastolic blood pressure (DBP) for male participants in an ambulatory study. In contrast,
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Suarez and Williams [15] and Hardy and Smith [16] found no correlation between Ho score and resting blood pressure in their experimental studies. Similar inconsistencies can be found in the literature on anger expression and resting blood pressure. Exceptions to the trend that blood pressure is higher in individuals who tend to suppress anger [3] have often been explained in terms o f the use of different and inadequate measures. Yet the exceptions have persisted with the adoption of Spielberger's well-developed measures. Thus, whereas Spielberger and his colleagues have reported positive correlations as high as 0.47 between their anger-in measure and resting blood pressure [7], other investigators have found no correlation between these variables [ 17, 18]. Similarly, whilst Spielberger has reported a negative correlation between anger-out scores and resting blood pressure [7], Harburg and his colleagues have found a positive correlation [18]. One possible explanation of these inconsistencies is that the effects of hostility and anger expression are confounded, or that the latter mediates the effects of the former. Clearly, these explanations can only be tested by simultaneous study of both variables in relation to blood pressure. A further possibility requiring joint study is that hostility and anger expression have interactive effects on resting blood pressure. The general proposition here is that blood pressure levels may be associated with particular strategies for dealing with anger, especially- or perhaps only - i n people whose anger is constantly fuelled by a chronically hostile attitude towards others. This type of interaction has recently been proposed and demonstrated using the Ho and Spielberger measures in relation to blood pressure reactivity [19]. To our knowledge, it has not been tested in relation to resting blood pressure, except for a study reported by Gentry [20] where the highest DBP readings in a sample of Black Americans were found in those who had high levels of both interracial hostility and suppressed anger. As Burns and Katkin [19] have argued in the context of blood pressure reactivity, interactions between anger variables themselves may also be a fruitful path of enquiry. For example, they suggest that anger expressors may be best identified as those who simultaneously score high on an anger-out scale and low on an anger-in scale. Such an idea is certainly consistent with Spielberger's report that his anger-in and anger-out scales are independent [7], indicating that anger expression-suppression is not unidimensional. As a further example, it also seems reasonable to suggest that the effects of anger expression or suppression may be moderated by the frequency with which anger occurs: that is, an interaction between anger expression and Trait anger in Spielberger's terms. The main aim of the present study was to test for main and interaction effects of hostility, anger frequency, anger suppression, and anger expression on resting blood pressure, whilst controlling for established determinants such as age and body mass. In studying these psychological variables together we hoped to throw light on some of the inconsistencies in the evidence that links hostility and anger suppression separately with resting blood pressure, and on some of the psychological processes that these variables jointly represent. METHOD Sample Data were gathered from a communitysample of 64 men and 76 women who volunteeredto take part in what was described as a study on how emotions, especiallyanger, relate to blood pressure. These
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participants were recruited by the researchers' attending meetings of a variety of community groups and by advertisements in local community newspapers. Participants who reported that they had been diagnosed as hypertensive were excluded from the following analyses because this knowledge may confound the relationships between psychological variables and blood pressure level [21]. This exclusion and occasional missing data produced a sample of 46 men and 59 women for analysis. Procedure
Participants were assessed individually in a quiet room either at the local Red Cross Centre or in the Psychology Department at the researchers' university. After completing a consent form, participants provided their age and occupation details. Their weight and height were then recorded. After a rest period, blood pressure readings were taken following a standard WHO protocol. Finally participants completed a questionnaire that contained measures of hostility, anger-in, anger-out, anger frequency, and a variety of questions on their own and parental cardiovascular health and on alcohol and cigarette consumption. Measures
Hostility was measured using the 50-item Cook-Medley Hostility Scale [9]. In the present sample, the alpha coefficient for this instrument was 0.83. Anger expression was assessed with the Anger/In and Anger/Out subscales of Spielberger's Anger Expression Scale [7]. The two subscales provide independent assessments of anger management that have displayed satisfactory reliability and validity, both in the United States [8] and in New Zealand [22]. In the present study, the alpha coefficients for the Anger/In and Anger/Out scales were 0.78 and 0.60, respectively. The frequency of anger experience was assessed using the 6-item angry temperament subscale from Spielberger's Trait Anger Scale [23]. These items indicate how often descriptions such as "I have a fiery temper" apply to the respondent. All of the other items in the Trait Anger Scale refer to specific situations that may provoke anger and, therefore, do not provide a pure measure of frequency. The alpha coefficient for the angry temperament subscale was 0.78 in the present sample. Blood pressure for all participants was recorded by the same trained assistant following a standard WHO-approved procedure [24]. After a 5-minute rest in a seated position, blood pressure was recorded from the right arm using a standard mercury sphygmomanometer and a cuff of appropriate size. Two readings of SBP and phase-5 DBP pressure were recorded, with a 30-second interval between the readings. In the following analyses, the average of the two readings was used to index resting SBP and DBP. Participants' weight without shoes was measured, and their self-reported height was recorded. These were combined to form Quetelet's index of body mass (kg/m2). The socioeconomic status (SES) of participants was classified according to the Elley-Irving Scale [25], a standard New Zealand measure. Although this 6-point scale requires only occupational information, the classification system reflects both occupation and education. For the following analyses, the 6 levels were collapsed into 2 (1-3 and 4-6) to produce an approximate white collar/blue collar dichotomy. Information was collected on participants' history, current status, and medication, with respect to hypertension and coronary heart disease. The presence of a family history for either of these diseases was also recorded. Finally, using standardized measures [26], participants were asked whether they were past or present smokers and what the frequency and amount of their alcohol consumption had been in the preceding 3 months. Frequency of consumption was assessed on a 6-point scale ranging from not at all to every day. Amount of alcohol consumed was also assessed on a 6-point scale ranging from 1 to 12 or more drinks on an average day. Statistical A n a l y s i s
To examine the relationships of the psychological variables with SBP and DBP, separate hierarchical moderated regressions were run using the SPSS/PC package [27]. Interaction effects were modelled using product terms [28]. Prior to the regressions, all continuous variables that appeared in product terms were centred around their mean to avoid multicollinearity problems, and all dichotomous variables were dummy coded. At the first step of each regression the psychological variables and covariates were entered: hostility, anger-in, anger-out, anger frequency, age, sex, SES, body mass, frequency and amount of alcohol consumption, and paternal and maternal history of hypertension. Since only 6.7% of the sample were current smokers, this variable was not included. At the second step, all two-way interactions of the psychological variables with each other and with sex were entered. Higher-order interactions were also explored, but since none were statistically significant, they do not appear in the following results. Where two-way interactions were found, their form was explored using subgroup regressions that included all of the psychological variables and covariates other than the moderating variable.
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Table I . - Descriptive statistics for study variables (N = 105) Variable
Mean
Standard Deviation
Hostility Anger-in Anger-out Anger frequency Age (years) Body mass (kg/m 2) Systolic blood pressure (mmHg) Diastolic blood presure (mmHg) Sex Socioeconomic status Paternal hypertension Maternal hypertension Current smoker Alcohol: at least 1-2 times per week Alcohol: at least 2 drinks per day
16.9 16.1 13.5 9.3 44.2 25.7 123.7 82.6
6.4 4.3 2.7 2.0 11.5 4.4 14.6 10.8
°70
43.8 men 87.6 white collar 17.1 35.2 6.7 61.9 52.4
RESULTS T a b l e I c o n t a i n s m e a n s a n d s t a n d a r d d e v i a t i o n s or percentages for the study variables. N o n e o f the c o n t i n u o u s v a r i a b l e d i s t r i b u t i o n s s h o w e d evidence o f skewness o r n o t a b l e outliers. O n l y 3 o f the 105 p a r t i c i p a n t s exhibited b l o o d pressures in the W H O - d e f i n e d h y p e r t e n s i o n range. T h u s , the s a m p l e was a l m o s t entirely c o m p o s e d o f n o r m o t e n s i v e s . O f the r e m a i n i n g v a r i a b l e s , o n l y SES a n d s m o k i n g were n o t e w o r t h y in t h a t the g r e a t m a j o r i t y o f p a r t i c i p a n t s were white collar a n d n o n s m o k e r s . Bivariate c o r r e l a t i o n s a m o n g the p s y c h o l o g i c a l variables, age, sex, SES, a n d b l o o d pressure are s h o w n in T a b l e II. T h e p a t t e r n o f c o r r e l a t i o n s a m o n g the hostility a n d a n g e r v a r i a b l e s suggests t h a t they are distinct, b u t r e l a t e d in a c o h e r e n t p a t t e r n . Thus, i n d i v i d u a l s w h o were cynically hostile b e c a m e a n g r y m o r e f r e q u e n t l y a n d were especially p r o n e to s u p p r e s s i n g their anger. T h o s e w h o expressed their anger also b e c a m e a n g r y m o r e f r e q u e n t l y , b u t were n o t m o r e likely to be cynically hostile. T h e r e were also a g e a n d sex differences, such t h a t m e n were m o r e hostile t h a n w o m e n , a n d o l d e r p e o p l e were less likely to experience anger a n d to express it. T h e r e was a striking absence o f r e l a t i o n s h i p s between t h e p s y c h o l o g i c a l variables a n d b l o o d pressure. A s expected, pressures were higher o n average in t h e o l d e r p a r t i c i p a n t s a n d in men. Table I I . - S i m p l e correlations among hostility, anger, age, sex, socioeconomic status (SES), systolic (SBP) and diastolic (DBP) blood pressure (N = 105)
Hostility Anger-in (AI) Anger-out (AO) Anger frequency (AF) Age Sex SES SBP
AI
AO
AF
Age
Sex
SES
SBP
DBP
41"**
07 - 16
21" 13 47***
02 - 03 -23* -31'**
23* 19 - 14 - 17 29**
10 04 06 06 02 27**
08 09 -03 - 14 38*** 42*** 16
13 - 01 - 10 - 14 27** 43*** 15 78***
Note: Leading decimal point omitted for clarity.
* p < 0.05; ** p < 0.01; *** p < 0.001.
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Table III. --Multiple regressions of systolic (SBP) and diastolic (DBP) blood pressure on psychological variables and covariates (N = 105) SBP Beta Step 1 Hostility Anger-in Anger-out Anger frequency Age Sex White/Blue collar Alcohol frequency Alcohol amount Body mass Paternal hypertension Maternal hypertension
Step 2 Hostility × Sex
DBP t
Beta
t
-0.01 -0.15 0.01 0.02 0.09 0.92 - 0.02 - 0.23 0.25 2.71"* 0.35 3.34** 0.03 0.31 0.11 1.07 -0.18 - 1.77 0.37 4.18"** 0.02 0.21 0.09 1.09 Adjusted R 2 = 0.41 F = 6.68***
0.11 - 0.18 - 0.09 0.03 0.11 0.41 0.02 0.09 -0.19 0.34 0.06 0.19 Adjusted R2 F
1.18 - 2.04* - 0.92 0.27 1.18 3.90*** 0.21 0.93 - 1.89 3.83*** 0.70 2.39* = 0.40 = 6.37***
-0.64 -2.02* Adjusted R2 = 0.43 F = 5.33***
-0.81 -2.58** Adjusted R z = 0.43 F = 6.38***
*p < 0.05; ** p < 0.01; *** p < 0.001. T a b l e III displays the results f r o m regressions of SBP a n d D B P o n the psychological variables a n d covariates. O f all the two-way interactions t h a t were entered at the second step, o n l y the hostility by sex term was statistically significant. T o examine this effect m o r e closely with increased power, the regressions were r e r u n excluding all other interaction terms. It is the result o f this analysis that appears as step 2 in T a b l e III. As n o t e d above, n o three-way or higher order interactions were f o u n d . O n l y one o f the psychological variables, anger-in, was related to b l o o d pressure, b u t the direction was a n o m a l o u s : participants who were m o r e likely to suppress anger had lower D B P o n average. The relationships o f age, b o d y mass, sex, a n d family history with one or b o t h b l o o d pressures, in c o n j u n c t i o n with the SBP a n d D B P distributions, provide some reassurance that b l o o d pressure was m e a s u r e d adequately. As noted earlier, the only i n t e r a c t i o n effect to achieve statistical significance was hostility by sex for b o t h SBP a n d D B P , which a c c o u n t e d for an a d d i t i o n a l 2% to 3 % o f explained variance. T o explore the shape o f this i n t e r a c t i o n , separate regressions were u n d e r t a k e n for m e n a n d w o m e n , whilst c o n t r o l l i n g for all other variables except sex. These analyses showed clearly that, whereas in m e n hostility was u n r e l a t e d to SBP (A = 55.56, B = - 0.64, t = - 1.45) a n d to D B P (A = 53.22, B = - 0.37, t = - 1.14), it was positively related to SBP (A = 9 3 . 2 2 , B = 0 . 6 0 , t = 2 . 3 7 , p < 0 . 0 5 ) a n d to D B P (A = 91.21, B = 0.69, t = 3.59, p < 0 . 0 0 1 ) in w o m e n . E n t e r i n g hostility i n t o the regression after all other variables increased explained variance in female SBP a n d D B P by an a d d i t i o n a l 6.1% a n d 14.2%, respectively. In s u m m a r y , the results suggest that resting b l o o d pressure is higher in m e n a n d w o m e n who are less likely to suppress anger, a n d in w o m e n who are m o r e cynically hostile. These associations are i n d e p e n d e n t o f each other a n d i n d e p e n d e n t o f established physical d e t e r m i n a n t s o f b l o o d pressure.
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DISCUSSION The correlations among the Ho scale and the Spielberger anger scale scores provide further evidence that these variables are related but distinct. The finding that high Ho scorers experience anger more frequently replicates the results reported by Williams et al. [29] and by Hardy and Smith [16]. Even more striking is the correlation of 0.41 between Ho and anger-in. This is consistent with Johnson's [1: 12] proposal that hostility and resentment are a consequence of chronically suppressed anger, though a reciprocal relationship is perhaps more likely. The pattern of relationships among the Spielberger anger scales follows that reported by his research group [7], namely the independence of anger-in and anger-out scores, and the tendency for those who experience anger frequently to express rather than to suppress it. This pattern of associations among hostility and anger variables has theoretical and empirical implications. It suggests the need to theorize the structure and dynamics of anger and hostility, so that their health effects may be interpreted and integrated in a coherent fashion. There are relevant emotion theories, but they do not seem to be guiding blood pressure-related research in any explicit way. Spielberger has suggested a syndrome approach to conceptualizing anger, hostility, and aggression (the AHA syndrome) [7], but this seems more aimed at guiding measurement strategies than at providing a basis for integrative theory. From a more empirical perspective, the correlations between anger and hostility variables raise the possibility that their relationships with blood pressure (or any other health outcome) may be confounded. The present findings provide some limited reassurance on this front. It is true that the negative association between anger-in and DBP only appeared when other covariates were controlled. However, exploratory analyses showed that this contrast between the simple and partialled association was due to the control of sex and body mass, not of the other psychological variables. Similarly, the positive association between hostility and blood pressure in women remained even when all other variables were controlled. These data are limited, but they do suggest that the relationships of anger and hostility variables with resting blood pressure are relatively independent of each other, despite their intercorrelations. The finding that DBP is higher in men and women who tend not to suppress anger runs counter to the trend in the literature. However, as noted above, there have been other exceptions to this trend in studies using the Spielberger anger scales. A positive association between anger expression and blood pressure has also been reported by users of other measures. Thus, in the Framingham study, Haynes et al. [30] found that women who discussed their anger exhibited higher DBP. The inconsistency of relationships between anger suppression/expression and health variables has also been noted for variables other than blood pressure [31]. A much more radical approach to the problem of inconsistent findings is implied by recent social constructionist approaches to the conceptualization of emotions [32, 33]. In this view, phenomena such as anger and hostility are not objectively defined intrapsychic states that can be assessed with a standard measuring procedure, analogous to the measurement of blood pressure. Instead they are viewed as primarily social in constitution and function, and as manifest in discourses that are governed by local social and moral rules. This implies that, even within the same language community, the definition, or at least the import, of anger and hostility experiences may vary. Thus, it may not be coincidental that previous attempts to detect a positive
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relationship between suppressed anger or hostility and blood pressure in New Zealand, using measures developed in the United States, have also been unsuccessful [17, 3435]. With increased understanding of the cultural context of emotional life, the utility of standardized emotion measures may well be an issue worth exploring. If the preceding comments carry any force, our failure to detect any interaction effects among the anger and hostility v a r i a b l e s - the intended focus of the s t u d y - i s also understandable. But their absence may be explicable in more statistical terms [36], such as low power, only moderate test reliabilities, or nonlinear relationships, though our exploratory analyses o f the last of these possibilities revealed nothing. As reviewers have pointed out [e.g., 5], large-scale prospective designs that involve repeated measurement of psychological and physical, mediating and moderating, variables are clearly required if these issues are to be definitively settled. The only interaction effect in the present study was that between cynical hostility and sex on both SBP and DBP. This finding is striking in that it is specific to women, surprisingly strong, and independent of anger experience and of physical correlates of blood pressure. It is also noteworthy that the relationship occurred despite the fact that men in the present sample scored on average about 3 points higher than women on the Ho scale. Why should the attributes assessed by the Ho scale be associated with higher blood pressures in women but not in men? The scale items depict someone who construes her social relationships very negatively in terms of avoidance, alienation, resentment, vengeance, and distrust. The psychological and physiological cost of maintaining such a perspective may be much greater for women than for men, since from an early age women appear to invest relatively more in social relations than in task-oriented activity [37]. Compared with a man, a cynically hostile woman is therefore likely to be statistically more unusual, as the Ho mean scores suggest, and more at odds with the prevailing gender stereotype. In terms of Totman's psychosomatic theory of social rules [38] and of the general constructionist perspective outlined earlier, her health would be endangered because of a chronic mismatch between her cognitions and the rules that govern social activity in her culture. This interpretation is also reasonably consistent with more specific findings from studies of resting and reactive blood pressure. In the Michigan Blood Pressure Survey, Cottington et al. [39] reported that women, but not men, with poor social relations exhibited higher SBP. Ewart et al. [40] found that female, but not male, hypertensives reacted to hostile exchanges in a problem-solving task with increased blood pressure. Finally, Harburg et al. [41] reported that women were less likely than men to react resentfully to an angry confrontation, and that a resentful reaction was generally associated with higher blood pressures. The relationship between cynical hostility and resting blood pressure in women would bear further examination in more extensive samples. Apart from the specific association suggested by our data, there are more general reasons to study women in this context. The underrepresentation of women participants in health studies [42] is readily apparent in psychological investigations of blood pressure. Many studies, including the few prospective ones, exclude women altogether. Those who do include men and women either pool the data or tend to rely on subgroup analyses without formally testing for sex differences. Despite the existence o f strong stereotypes about male-female differences in anger experience and expression, there is surprisingly little
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d a t a t o s u p p o r t o r r e f u t e t h e m [1]. I t t h e r e f o r e s e e m s p r u d e n t t o p u r s u e f u r t h e r i n v e s t i g a t i o n o f t h e h e a l t h effects o f a n g e r a n d h o s t i l i t y i n w a y s t h a t a l l o w sex differences to emerge.
Acknowledgments-We gratefully acknowledge support from the Massey University Research Fund, technical assistance from Nicola Marriott-Lloyd, and the helpful comments of two anonymous reviewers.
REFERENCES 1. JOHNSON EH. The Deadly Emotions: The Role of Anger, Hostility and Aggression in Health and Emotional Well-Being. New York: Praeger, 1990. 2. SMITH TW. Hostility and health: current status of a psychosomatic hypothesis. Health Psycho11992; 11: 139-150. 3. GOLD AE, JOHNSTON DW. Anger, hypertension and heart disease. In: Current Developments in Health Psychology (Edited by Bennett P, Weinman J, Spurgeon P) pp. 105-128. Chur, Switzerland: Harwood, 1990. 4. SULS J, WAN CK. The relationship between trait hostility and cardiovascular reactivity: a quantitative review and analysis. Psychophysiol 1993; 30:615-626. 5. KRANTZ DS, DEQUATTRO V, BLACKBURN HW, EAKER E, HAYNES S, JAMES SA, MANUCK SB, MYERS H, SHEKELLE RB, SYME SL, TYROLER HA, WOLF S. Task Force 1: psychosocial factors in hypertension. Circulation 1987; 76 (Suppl. 1): 84-88. 6. VITALIANO PP, RUSSO J, BAILEY SL, YOUNG HM, McCANN BS. Psychosocial factors associated with cardiovascular reactivity in older adults. Psychosom Med 1993; 55: 164-177. 7. SPIELBERGER CD, JOHNSON EH, RUSSELL SF, CRANE RJ, JACOBS GA, WORDEN TJ. The experience and expression of anger: construction and validation of an anger expression scale. In: Anger and Hostility in Cardiovascular and Behavioral Disorders (Edited by Chesney MA, Rosenman RH) pp. 5-30. Washington, DC: Hemisphere, 1985. 8. SPIELBERGER CD. State-Trait Anger Expression Inventory Manual. Odessa, FL: Psychological Assessment Resources, 1988. 9. COOK WW, MEDLEY DM. Proposed hostility and pharisaic-virtue scales for the MMPI. J Appl Psychol 1954; 38: 414-418. 10. BAREFOOT JC, DAHLSTROM G, WILLIAMS RB. Hostility CHD incidence, and total mortality: a 25-year follow-up of 255 physicians. Psychosom Med 1983; 45: 59-63. 11. BAREFOOT JC, DODGE KA, PETERSON BL, DAHLSTROM WG, WILLIAMS RB. The CookMedley hostility scale: item content and ability to predict survival. Psychosom Med 1989; 51: 46-57. 12. CHRISTENSEN A J, SMITH TW. Cynical hostility and cardiovascular reactivity during selfdisclosure. Psychosom Med 1993; 55: 193-202. 13. JAMNER LD, SHAPIRO D, GOLDSTEIN IB, HUG R. Ambulatory blood pressure and heart rate in paramedics: effects of cynical hostility and defensiveness. Psychosom Med 1991; 53: 393-406. 14. LINDEN W, CHAMBERS L, MAURICE J, LENZ JW. Sex differences in social support, selfdeception, hostility, and ambulatory cardiovascular activity. Health Psychol 1993; 12: 376-380. 15. SUAREZ EC, WILLIAMS RB. Situational determinants of cardiovascular and emotional reactivity in high and low hostile men. Psychosom Med 1989; 51: 404-418. 16. HARDY JD, SMITH TW. Cynical hostility and vulnerability to disease: social support, life stress, and physiological response to conflict. Health Psychol 1988; 7: 447-459. 17. KNIGHT RG, CHISHOLM BJ, PAULIN JM, WAAL-MANNING HJ. The Spielberger anger expression scale: factor structure and correlations with blood pressure. In: Stress andAnxiety, Vol 13 (Edited by Spielberger CD, Sarason IG, Strelau J, Brebner JMT) pp. 167-173. New York: Hemisphere, 1991. 18. HARBURG E, GLIEBERMAN L, RUSSELL M, COOPER ML. Anger-coping styles and blood pressure in black and white males: Buffalo, New York. Psychosom Med 1991; 53: 153-164. 19. BURNS JW, KATKIN ES. Psychological, situational, and gender predictors of cardiovascular reactivity to stress: a multivariate approach. J Behav Med 1993; 16: 445-465. 20. GENTRY WD. Relationship of anger-coping styles and blood pressure among black Americans. In: Anger and Hostility in Cardiovascular and Behavioral Disorders (Edited by Chesney MA, Rosenman RH) pp. 139-147. Washington, DC: Hemisphere, 1985. 21. IRVINE M J, GARNER DM, OLMSTED MP, LOGAN AG. Personality differences between hypertensive and normotensive individuals: influence of knowledge of hypertension status. Psychosom Med 1989; 51: 537-549. 22. KNIGHT RG, CHISHOLM BJ, PAULIN JM, WAAL-MANN1NG HJ. The Spielberger anger expression scale: some psychometric data. Br J Clin Psychol 1988; 27: 279-281.
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23. SPIELBERGER CD, JACOBS G, RUSSELL S, CRANE RJ. Assessment of anger: the State-Trait Anger Scale. In: Advances in Personality Assessment, Vol 2 (Edited by Butcher JN, Spielberger CD) pp. 159-187. Hillsdale, N J: Erlbaum, 1983. 24. WHO MONICA PROJECT PRINCIPAL INVESTIGATORS. The World Health Organization MONICA project: a major international collaboration. J Clin Epidemiol 1988; 41:105-114. 25. ELLEY WB, IRVING JC. Revised socio-economic index for New Zealand. N Z Ed Stud 1976; 11: 25-36. 26. WANG MQ, EDDY JM, FITZHUGH EC. Towards standard measures in health assessments. Health Values 1992; 16: 52-56. 27. NORUSIS MJ. SPSS/PC+ Advanced Statistics II5.0. Chicago: SPSS Inc., 1992. 28. JACCARD J, TURRISI R, WAN CK. Interaction Effects in Multiple Regression. Newbury Park, CA: Sage, 1990. 29. WILLIAMS RB, BAREFOOT JC, SHEKELLE RB. The health consequences of hostility. In: Anger and Hostility in Cardiovascular and Behavioral Disorders (Edited by Chesney MA, Rosenman RH) pp. 173-185. Washington, DC: Hemisphere, 1985. 30. HAYNES SG, LEVINE S, SCOTCH N, FEINLEIB M, KANNEL WB. The relationship of psychosocial factors to coronary heart disease in the Framingham study: I. Methods and risk factors. A m J Epidemiol 1978; 107: 362-383. 31. KIENAN G, BEN-ZUR H, ZILKA M, CAREL RS. Anger in or out, which is healthier? An attempt to reconcile inconsistent findings. Psychol Health 1992; 7: 83-98. 32. SABINI J, SILVER M. Moralities o f Everyday Life. New York: Oxford University Press, 1982. 33. HARRI~ R. (Ed.) The Social Construction o f Emotions. Oxford: Blackwell, 1986. 34. WAAL-MANNING H, KNIGHT RG, SPEARS GF, PAULIN JM. The relationship between blood pressure and personality in a large unselected adult sample. JPsychosom Res 1986; 30: 361-368. 35. SPICER J, JACKSON R, SCRAGG R. Social network, anger suppression and blood pressure. (Submitted for publication). 36. McCLELLAND GH, JUDD CM. Statistical difficulties o f detecting interactions and moderator effects. Psychol Bull 1993; 114: 376-390. 37. MACCOBY EE. Gender and relationships: a developmental account. A m Psycho/1990; 45: 513-520. 38. TOTMAN R. Social Causes o f Illness. London: Souvenir Press, 1979. 39. COTTINGTON EM, BROCK BM, HOUSE JS, HAWTHORNE VM. Psychosocial factors and blood pressure in the Michigan statewide blood pressure survey. A m JEpidemiol 1985; 121: 515-529. 40. EWART CK, BARR TAYLOR C, KRAEMER HC, AGRAS WS. High blood pressure and marital discord: not being nasty matters more than being nice. Health Psychol 1991; 10: 155-163. 41. HARBURG E, BLAKELOCK EH, ROEPER PJ. Resentful and reflective coping with arbitrary authority and blood pressure: Detroit. Psychosom Ailed 1979; 41: 189-202. 42. RODIN J, ICKOVICS JR. Women's health: review and research agenda as we approach the 21st century. A m Psychol 1990; 45: 1018-1034.
ELSEVIER
0022-3999(95)00546-3
CYNICAL HOSTILITY, ANGER, AND RESTING BLOOD PRESSURE JOHN SPICER and KERRY CHAMBERLAIN Abstract- Research on associations of anger and hostility with resting blood pressure (BP) has generally ignored their interrelationships. The present study examined the individual and joint relationships of cynical hostility, anger-in, anger-out, and anger frequency with resting BP using the Cook-Medley Hostility Scale and the Spielberger anger scales. Multiple regressions were conducted on data from a community sample of 105 men and women to examine the main and interactive effects of anger and hostility on BP, controlling for established physical covariates. Diastolic BP was inversely related to anger-in scores in men and women. Systolic and diastolic BP were positively associated with Ho (hostility) score only in women. No confounding or interactive effects of hostility and anger on BP were found. It is suggested that the sex-specific link between cynical hostility and BP may reflect a chronic mismatch between the social cognitions of cynically hostile women and some of the cultural norms that govern women's social lives.
Keywords: Hostility; Anger; Blood pressure.
INTRODUCTION T h e effects o f anger a n d h o s t i l i t y o n b l o o d p r e s s u r e have b e e n a focus o f research a t t e n t i o n for m a n y years [1]. A s i d e f r o m the intrinsic p s y c h o p h y s i o l o g i c a l interest o f these effects, this r e s e a r c h is also m o t i v a t e d b y the p o s s i b i l i t y t h a t b l o o d pressure m a y be a key v a r i a b l e in e x p l a i n i n g the c o r r e l a t i o n s o f anger a n d h o s t i l i t y variables with risk o f h y p e r t e n s i o n a n d o t h e r c a r d i o v a s c u l a r diseases [1-3]. These p s y c h o l o g i c a l v a r i a b l e s have been s t u d i e d in r e l a t i o n to b o t h resting b l o o d pressure [3] a n d its reactivity in response to v a r i o u s stressors [4]. In the p r e s e n t article we restrict o u r a t t e n t i o n to their r e l a t i o n s h i p s with resting b l o o d pressure. In c o n t r a s t to the m a n y studies t h a t have e x a m i n e d the i n d e p e n d e n t effects o f a n g e r a n d h o s t i l i t y o n resting b l o o d p r e s s u r e , the p s y c h o l o g i c a l focus o f this article is on their p o t e n t i a l j o i n t effects. T h e r e are a n u m b e r o f reasons w h y it is d e s i r a b l e to include anger a n d hostility v a r i a b l e s in the s a m e research design. I r o n i c a l l y , one r e a s o n these v a r i a b l e s s h o u l d be c o n s i d e r e d t o g e t h e r is so t h a t t h e y can be b e t t e r s e p a r a t e d . E m o t i o n theorists have long d i s t i n g u i s h e d b e t w e e n t h e m , albeit in a v a r i e t y o f ways. But, as reviewers o f the b l o o d p r e s s u r e l i t e r a t u r e have p o i n t e d o u t [e.g., 5], the i n a d e q u a t e c o n c e p t u a l i z a t i o n a n d m e a s u r e m e n t o f a n g e r a n d h o s t i l i t y in this field have c o n t i n u e d to h i n d e r progress. T h u s , even c u r r e n t articles go so f a r as to t r e a t the two c o n s t r u c t s as s y n o n y m o u s
Department of Psychology, Massey University, Palmerston North, New Zealand. Address correspondence to: Dr. J. Spicer, Department of Psychology, Massey University, Private Bag 11-222, Palmerston North, New Zealand. Telephone +64 6 350 4137; Fax +64 6 350 5673; e-mail J .Spicer@ massey.ac.nz. 359
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[e.g., 6]. Recently though, clearer and more discriminating definitions of anger and hostility constructs have begun to emerge in blood pressure research, more through the development or critical evaluation o f particular measures than through the elaboration of theory. Spielberger and his colleagues define anger as "an emotional state that consists of feelings that vary in intensity, from mild irritation or annoyance to fury and rage" [7: 7]. The variation in intensity of these feelings is referred to as State anger, whilst the frequency with which the feelings are experienced is referred to as Trait anger. When anger feelings are experienced, they may be suppressed or expressed. For Spielberger, the former "anger-in" construct simply refers to the frequency with which anger is consciously suppressed rather than to some subtle psychoanalytic processes. Anger expression, or "anger-out," is defined as "the extent that an individual engages in aggressive behaviors when motivated by angry feelings" [7:14]. Thus, as Spielberger highlights, anger suppression and expression, like Trait anger, are regarded as personality traits. In the present study we adopted these definitions of anger constructs, and used the various measures that Spielberger and his associates developed from these definitions [8]. Regarding hostility, Spielberger and his colleagues [7] have suggested that its central feature is a complex set of negative attitudes towards others, such as distrust. These attitudes are intertwined with emotions such as cynicism, resentment, vengeance, and alienation, which tend to have complex cognitive features, thereby differentiating them from emotions such as anger, which are definable more in terms o f affect. This mainly cognitive view of hostility also emerges from recent work on the CookMedley Hostility (Ho) scale [9], research which has accelerated since H o scores were linked prospectively with risk of coronary heart disease [ 10]. The Ho scale's developers saw it as a measure of "dislike for and distrust of others" [9: 418]. From more recent factor analytic research it has been suggested that it is a complex measure of 'cynical hostility' that encompasses negative "beliefs about the trustworthiness of others, negative emotions associated with social relationships, and aggressive behavior towards others" [11: 52]. O f particular interest in the present context is that only 2 of the 50 items make reference to anger or annoyance, thus providing operational differentiation of anger and hostility. In the present research we followed Spielberger's emphasis on hostility as primarily a set of negative attitudes about social relations, and we adopted the operationalization provided by the Ho scale. Given that hostility and various features of anger can be distinguished and measured, empirical study of their joint effects on blood pressure can be advocated on at least two substantive grounds: as one way in which inconsistencies in the available evidence may be resolved, and as a means of testing more sophisticated hypotheses about hostility and anger phenomena. With respect to the first, conflicting results have been reported on the association between Ho score and resting blood pressure in analyses nested within experimental and ambulatory studies of blood pressure reactivity. Thus, Christensen et al. [12] reported higher systolic blood pressure (SBP) in high Ho scorers than in low scorers during the baseline phase of their experiment. Jamner et al. [13] found that high Ho scorers in an ambulatory study of 33 male paramedics exhibited higher mean blood pressures than low scorers, even when they were asleep. Similarly, Linden et al. [14] reported a positive correlation between Ho score and mean diastolic blood pressure (DBP) for male participants in an ambulatory study. In contrast,
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Suarez and Williams [15] and Hardy and Smith [16] found no correlation between Ho score and resting blood pressure in their experimental studies. Similar inconsistencies can be found in the literature on anger expression and resting blood pressure. Exceptions to the trend that blood pressure is higher in individuals who tend to suppress anger [3] have often been explained in terms o f the use of different and inadequate measures. Yet the exceptions have persisted with the adoption of Spielberger's well-developed measures. Thus, whereas Spielberger and his colleagues have reported positive correlations as high as 0.47 between their anger-in measure and resting blood pressure [7], other investigators have found no correlation between these variables [ 17, 18]. Similarly, whilst Spielberger has reported a negative correlation between anger-out scores and resting blood pressure [7], Harburg and his colleagues have found a positive correlation [18]. One possible explanation of these inconsistencies is that the effects of hostility and anger expression are confounded, or that the latter mediates the effects of the former. Clearly, these explanations can only be tested by simultaneous study of both variables in relation to blood pressure. A further possibility requiring joint study is that hostility and anger expression have interactive effects on resting blood pressure. The general proposition here is that blood pressure levels may be associated with particular strategies for dealing with anger, especially- or perhaps only - i n people whose anger is constantly fuelled by a chronically hostile attitude towards others. This type of interaction has recently been proposed and demonstrated using the Ho and Spielberger measures in relation to blood pressure reactivity [19]. To our knowledge, it has not been tested in relation to resting blood pressure, except for a study reported by Gentry [20] where the highest DBP readings in a sample of Black Americans were found in those who had high levels of both interracial hostility and suppressed anger. As Burns and Katkin [19] have argued in the context of blood pressure reactivity, interactions between anger variables themselves may also be a fruitful path of enquiry. For example, they suggest that anger expressors may be best identified as those who simultaneously score high on an anger-out scale and low on an anger-in scale. Such an idea is certainly consistent with Spielberger's report that his anger-in and anger-out scales are independent [7], indicating that anger expression-suppression is not unidimensional. As a further example, it also seems reasonable to suggest that the effects of anger expression or suppression may be moderated by the frequency with which anger occurs: that is, an interaction between anger expression and Trait anger in Spielberger's terms. The main aim of the present study was to test for main and interaction effects of hostility, anger frequency, anger suppression, and anger expression on resting blood pressure, whilst controlling for established determinants such as age and body mass. In studying these psychological variables together we hoped to throw light on some of the inconsistencies in the evidence that links hostility and anger suppression separately with resting blood pressure, and on some of the psychological processes that these variables jointly represent. METHOD Sample Data were gathered from a communitysample of 64 men and 76 women who volunteeredto take part in what was described as a study on how emotions, especiallyanger, relate to blood pressure. These
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participants were recruited by the researchers' attending meetings of a variety of community groups and by advertisements in local community newspapers. Participants who reported that they had been diagnosed as hypertensive were excluded from the following analyses because this knowledge may confound the relationships between psychological variables and blood pressure level [21]. This exclusion and occasional missing data produced a sample of 46 men and 59 women for analysis. Procedure
Participants were assessed individually in a quiet room either at the local Red Cross Centre or in the Psychology Department at the researchers' university. After completing a consent form, participants provided their age and occupation details. Their weight and height were then recorded. After a rest period, blood pressure readings were taken following a standard WHO protocol. Finally participants completed a questionnaire that contained measures of hostility, anger-in, anger-out, anger frequency, and a variety of questions on their own and parental cardiovascular health and on alcohol and cigarette consumption. Measures
Hostility was measured using the 50-item Cook-Medley Hostility Scale [9]. In the present sample, the alpha coefficient for this instrument was 0.83. Anger expression was assessed with the Anger/In and Anger/Out subscales of Spielberger's Anger Expression Scale [7]. The two subscales provide independent assessments of anger management that have displayed satisfactory reliability and validity, both in the United States [8] and in New Zealand [22]. In the present study, the alpha coefficients for the Anger/In and Anger/Out scales were 0.78 and 0.60, respectively. The frequency of anger experience was assessed using the 6-item angry temperament subscale from Spielberger's Trait Anger Scale [23]. These items indicate how often descriptions such as "I have a fiery temper" apply to the respondent. All of the other items in the Trait Anger Scale refer to specific situations that may provoke anger and, therefore, do not provide a pure measure of frequency. The alpha coefficient for the angry temperament subscale was 0.78 in the present sample. Blood pressure for all participants was recorded by the same trained assistant following a standard WHO-approved procedure [24]. After a 5-minute rest in a seated position, blood pressure was recorded from the right arm using a standard mercury sphygmomanometer and a cuff of appropriate size. Two readings of SBP and phase-5 DBP pressure were recorded, with a 30-second interval between the readings. In the following analyses, the average of the two readings was used to index resting SBP and DBP. Participants' weight without shoes was measured, and their self-reported height was recorded. These were combined to form Quetelet's index of body mass (kg/m2). The socioeconomic status (SES) of participants was classified according to the Elley-Irving Scale [25], a standard New Zealand measure. Although this 6-point scale requires only occupational information, the classification system reflects both occupation and education. For the following analyses, the 6 levels were collapsed into 2 (1-3 and 4-6) to produce an approximate white collar/blue collar dichotomy. Information was collected on participants' history, current status, and medication, with respect to hypertension and coronary heart disease. The presence of a family history for either of these diseases was also recorded. Finally, using standardized measures [26], participants were asked whether they were past or present smokers and what the frequency and amount of their alcohol consumption had been in the preceding 3 months. Frequency of consumption was assessed on a 6-point scale ranging from not at all to every day. Amount of alcohol consumed was also assessed on a 6-point scale ranging from 1 to 12 or more drinks on an average day. Statistical A n a l y s i s
To examine the relationships of the psychological variables with SBP and DBP, separate hierarchical moderated regressions were run using the SPSS/PC package [27]. Interaction effects were modelled using product terms [28]. Prior to the regressions, all continuous variables that appeared in product terms were centred around their mean to avoid multicollinearity problems, and all dichotomous variables were dummy coded. At the first step of each regression the psychological variables and covariates were entered: hostility, anger-in, anger-out, anger frequency, age, sex, SES, body mass, frequency and amount of alcohol consumption, and paternal and maternal history of hypertension. Since only 6.7% of the sample were current smokers, this variable was not included. At the second step, all two-way interactions of the psychological variables with each other and with sex were entered. Higher-order interactions were also explored, but since none were statistically significant, they do not appear in the following results. Where two-way interactions were found, their form was explored using subgroup regressions that included all of the psychological variables and covariates other than the moderating variable.
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Table I . - Descriptive statistics for study variables (N = 105) Variable
Mean
Standard Deviation
Hostility Anger-in Anger-out Anger frequency Age (years) Body mass (kg/m 2) Systolic blood pressure (mmHg) Diastolic blood presure (mmHg) Sex Socioeconomic status Paternal hypertension Maternal hypertension Current smoker Alcohol: at least 1-2 times per week Alcohol: at least 2 drinks per day
16.9 16.1 13.5 9.3 44.2 25.7 123.7 82.6
6.4 4.3 2.7 2.0 11.5 4.4 14.6 10.8
°70
43.8 men 87.6 white collar 17.1 35.2 6.7 61.9 52.4
RESULTS T a b l e I c o n t a i n s m e a n s a n d s t a n d a r d d e v i a t i o n s or percentages for the study variables. N o n e o f the c o n t i n u o u s v a r i a b l e d i s t r i b u t i o n s s h o w e d evidence o f skewness o r n o t a b l e outliers. O n l y 3 o f the 105 p a r t i c i p a n t s exhibited b l o o d pressures in the W H O - d e f i n e d h y p e r t e n s i o n range. T h u s , the s a m p l e was a l m o s t entirely c o m p o s e d o f n o r m o t e n s i v e s . O f the r e m a i n i n g v a r i a b l e s , o n l y SES a n d s m o k i n g were n o t e w o r t h y in t h a t the g r e a t m a j o r i t y o f p a r t i c i p a n t s were white collar a n d n o n s m o k e r s . Bivariate c o r r e l a t i o n s a m o n g the p s y c h o l o g i c a l variables, age, sex, SES, a n d b l o o d pressure are s h o w n in T a b l e II. T h e p a t t e r n o f c o r r e l a t i o n s a m o n g the hostility a n d a n g e r v a r i a b l e s suggests t h a t they are distinct, b u t r e l a t e d in a c o h e r e n t p a t t e r n . Thus, i n d i v i d u a l s w h o were cynically hostile b e c a m e a n g r y m o r e f r e q u e n t l y a n d were especially p r o n e to s u p p r e s s i n g their anger. T h o s e w h o expressed their anger also b e c a m e a n g r y m o r e f r e q u e n t l y , b u t were n o t m o r e likely to be cynically hostile. T h e r e were also a g e a n d sex differences, such t h a t m e n were m o r e hostile t h a n w o m e n , a n d o l d e r p e o p l e were less likely to experience anger a n d to express it. T h e r e was a striking absence o f r e l a t i o n s h i p s between t h e p s y c h o l o g i c a l variables a n d b l o o d pressure. A s expected, pressures were higher o n average in t h e o l d e r p a r t i c i p a n t s a n d in men. Table I I . - S i m p l e correlations among hostility, anger, age, sex, socioeconomic status (SES), systolic (SBP) and diastolic (DBP) blood pressure (N = 105)
Hostility Anger-in (AI) Anger-out (AO) Anger frequency (AF) Age Sex SES SBP
AI
AO
AF
Age
Sex
SES
SBP
DBP
41"**
07 - 16
21" 13 47***
02 - 03 -23* -31'**
23* 19 - 14 - 17 29**
10 04 06 06 02 27**
08 09 -03 - 14 38*** 42*** 16
13 - 01 - 10 - 14 27** 43*** 15 78***
Note: Leading decimal point omitted for clarity.
* p < 0.05; ** p < 0.01; *** p < 0.001.
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Table III. --Multiple regressions of systolic (SBP) and diastolic (DBP) blood pressure on psychological variables and covariates (N = 105) SBP Beta Step 1 Hostility Anger-in Anger-out Anger frequency Age Sex White/Blue collar Alcohol frequency Alcohol amount Body mass Paternal hypertension Maternal hypertension
Step 2 Hostility × Sex
DBP t
Beta
t
-0.01 -0.15 0.01 0.02 0.09 0.92 - 0.02 - 0.23 0.25 2.71"* 0.35 3.34** 0.03 0.31 0.11 1.07 -0.18 - 1.77 0.37 4.18"** 0.02 0.21 0.09 1.09 Adjusted R 2 = 0.41 F = 6.68***
0.11 - 0.18 - 0.09 0.03 0.11 0.41 0.02 0.09 -0.19 0.34 0.06 0.19 Adjusted R2 F
1.18 - 2.04* - 0.92 0.27 1.18 3.90*** 0.21 0.93 - 1.89 3.83*** 0.70 2.39* = 0.40 = 6.37***
-0.64 -2.02* Adjusted R2 = 0.43 F = 5.33***
-0.81 -2.58** Adjusted R z = 0.43 F = 6.38***
*p < 0.05; ** p < 0.01; *** p < 0.001. T a b l e III displays the results f r o m regressions of SBP a n d D B P o n the psychological variables a n d covariates. O f all the two-way interactions t h a t were entered at the second step, o n l y the hostility by sex term was statistically significant. T o examine this effect m o r e closely with increased power, the regressions were r e r u n excluding all other interaction terms. It is the result o f this analysis that appears as step 2 in T a b l e III. As n o t e d above, n o three-way or higher order interactions were f o u n d . O n l y one o f the psychological variables, anger-in, was related to b l o o d pressure, b u t the direction was a n o m a l o u s : participants who were m o r e likely to suppress anger had lower D B P o n average. The relationships o f age, b o d y mass, sex, a n d family history with one or b o t h b l o o d pressures, in c o n j u n c t i o n with the SBP a n d D B P distributions, provide some reassurance that b l o o d pressure was m e a s u r e d adequately. As noted earlier, the only i n t e r a c t i o n effect to achieve statistical significance was hostility by sex for b o t h SBP a n d D B P , which a c c o u n t e d for an a d d i t i o n a l 2% to 3 % o f explained variance. T o explore the shape o f this i n t e r a c t i o n , separate regressions were u n d e r t a k e n for m e n a n d w o m e n , whilst c o n t r o l l i n g for all other variables except sex. These analyses showed clearly that, whereas in m e n hostility was u n r e l a t e d to SBP (A = 55.56, B = - 0.64, t = - 1.45) a n d to D B P (A = 53.22, B = - 0.37, t = - 1.14), it was positively related to SBP (A = 9 3 . 2 2 , B = 0 . 6 0 , t = 2 . 3 7 , p < 0 . 0 5 ) a n d to D B P (A = 91.21, B = 0.69, t = 3.59, p < 0 . 0 0 1 ) in w o m e n . E n t e r i n g hostility i n t o the regression after all other variables increased explained variance in female SBP a n d D B P by an a d d i t i o n a l 6.1% a n d 14.2%, respectively. In s u m m a r y , the results suggest that resting b l o o d pressure is higher in m e n a n d w o m e n who are less likely to suppress anger, a n d in w o m e n who are m o r e cynically hostile. These associations are i n d e p e n d e n t o f each other a n d i n d e p e n d e n t o f established physical d e t e r m i n a n t s o f b l o o d pressure.
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DISCUSSION The correlations among the Ho scale and the Spielberger anger scale scores provide further evidence that these variables are related but distinct. The finding that high Ho scorers experience anger more frequently replicates the results reported by Williams et al. [29] and by Hardy and Smith [16]. Even more striking is the correlation of 0.41 between Ho and anger-in. This is consistent with Johnson's [1: 12] proposal that hostility and resentment are a consequence of chronically suppressed anger, though a reciprocal relationship is perhaps more likely. The pattern of relationships among the Spielberger anger scales follows that reported by his research group [7], namely the independence of anger-in and anger-out scores, and the tendency for those who experience anger frequently to express rather than to suppress it. This pattern of associations among hostility and anger variables has theoretical and empirical implications. It suggests the need to theorize the structure and dynamics of anger and hostility, so that their health effects may be interpreted and integrated in a coherent fashion. There are relevant emotion theories, but they do not seem to be guiding blood pressure-related research in any explicit way. Spielberger has suggested a syndrome approach to conceptualizing anger, hostility, and aggression (the AHA syndrome) [7], but this seems more aimed at guiding measurement strategies than at providing a basis for integrative theory. From a more empirical perspective, the correlations between anger and hostility variables raise the possibility that their relationships with blood pressure (or any other health outcome) may be confounded. The present findings provide some limited reassurance on this front. It is true that the negative association between anger-in and DBP only appeared when other covariates were controlled. However, exploratory analyses showed that this contrast between the simple and partialled association was due to the control of sex and body mass, not of the other psychological variables. Similarly, the positive association between hostility and blood pressure in women remained even when all other variables were controlled. These data are limited, but they do suggest that the relationships of anger and hostility variables with resting blood pressure are relatively independent of each other, despite their intercorrelations. The finding that DBP is higher in men and women who tend not to suppress anger runs counter to the trend in the literature. However, as noted above, there have been other exceptions to this trend in studies using the Spielberger anger scales. A positive association between anger expression and blood pressure has also been reported by users of other measures. Thus, in the Framingham study, Haynes et al. [30] found that women who discussed their anger exhibited higher DBP. The inconsistency of relationships between anger suppression/expression and health variables has also been noted for variables other than blood pressure [31]. A much more radical approach to the problem of inconsistent findings is implied by recent social constructionist approaches to the conceptualization of emotions [32, 33]. In this view, phenomena such as anger and hostility are not objectively defined intrapsychic states that can be assessed with a standard measuring procedure, analogous to the measurement of blood pressure. Instead they are viewed as primarily social in constitution and function, and as manifest in discourses that are governed by local social and moral rules. This implies that, even within the same language community, the definition, or at least the import, of anger and hostility experiences may vary. Thus, it may not be coincidental that previous attempts to detect a positive
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relationship between suppressed anger or hostility and blood pressure in New Zealand, using measures developed in the United States, have also been unsuccessful [17, 3435]. With increased understanding of the cultural context of emotional life, the utility of standardized emotion measures may well be an issue worth exploring. If the preceding comments carry any force, our failure to detect any interaction effects among the anger and hostility v a r i a b l e s - the intended focus of the s t u d y - i s also understandable. But their absence may be explicable in more statistical terms [36], such as low power, only moderate test reliabilities, or nonlinear relationships, though our exploratory analyses o f the last of these possibilities revealed nothing. As reviewers have pointed out [e.g., 5], large-scale prospective designs that involve repeated measurement of psychological and physical, mediating and moderating, variables are clearly required if these issues are to be definitively settled. The only interaction effect in the present study was that between cynical hostility and sex on both SBP and DBP. This finding is striking in that it is specific to women, surprisingly strong, and independent of anger experience and of physical correlates of blood pressure. It is also noteworthy that the relationship occurred despite the fact that men in the present sample scored on average about 3 points higher than women on the Ho scale. Why should the attributes assessed by the Ho scale be associated with higher blood pressures in women but not in men? The scale items depict someone who construes her social relationships very negatively in terms of avoidance, alienation, resentment, vengeance, and distrust. The psychological and physiological cost of maintaining such a perspective may be much greater for women than for men, since from an early age women appear to invest relatively more in social relations than in task-oriented activity [37]. Compared with a man, a cynically hostile woman is therefore likely to be statistically more unusual, as the Ho mean scores suggest, and more at odds with the prevailing gender stereotype. In terms of Totman's psychosomatic theory of social rules [38] and of the general constructionist perspective outlined earlier, her health would be endangered because of a chronic mismatch between her cognitions and the rules that govern social activity in her culture. This interpretation is also reasonably consistent with more specific findings from studies of resting and reactive blood pressure. In the Michigan Blood Pressure Survey, Cottington et al. [39] reported that women, but not men, with poor social relations exhibited higher SBP. Ewart et al. [40] found that female, but not male, hypertensives reacted to hostile exchanges in a problem-solving task with increased blood pressure. Finally, Harburg et al. [41] reported that women were less likely than men to react resentfully to an angry confrontation, and that a resentful reaction was generally associated with higher blood pressures. The relationship between cynical hostility and resting blood pressure in women would bear further examination in more extensive samples. Apart from the specific association suggested by our data, there are more general reasons to study women in this context. The underrepresentation of women participants in health studies [42] is readily apparent in psychological investigations of blood pressure. Many studies, including the few prospective ones, exclude women altogether. Those who do include men and women either pool the data or tend to rely on subgroup analyses without formally testing for sex differences. Despite the existence o f strong stereotypes about male-female differences in anger experience and expression, there is surprisingly little
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d a t a t o s u p p o r t o r r e f u t e t h e m [1]. I t t h e r e f o r e s e e m s p r u d e n t t o p u r s u e f u r t h e r i n v e s t i g a t i o n o f t h e h e a l t h effects o f a n g e r a n d h o s t i l i t y i n w a y s t h a t a l l o w sex differences to emerge.
Acknowledgments-We gratefully acknowledge support from the Massey University Research Fund, technical assistance from Nicola Marriott-Lloyd, and the helpful comments of two anonymous reviewers.
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