Assessment of hostility in patients with coronary heart disease

One of the problems in efforts to more clearly conceptualize hostility is the amount of method variance, which ranges from self-report techniques to interview-based methods and mirrors the multidimensional nature of hostility and related constructs. In addition, rather few studies concerned with the assessment of hostility have specifically used samples of coronary heart disease (CHD) patients. The purpose of this study was, therefore, to examine the multidimensionality of the construct of hostility in a sample of male coronary patients with some frequently used instruments. Factor analysis was used to detect the relevant underlying constructs, which were assessed using a variety of hostility measures in a sample of cardiac patients undergoing baseline assessment in an ongoing health-education intervention study. Measurement included both questionnaires and interviews. Participants (N = 235) were divided into 3 diagnostic groups: patients who had recently undergone (a) a myocardial infarction, (b) coronary artery bypass grafting, or (c) percutaneous transluminal coronary angioplasty. A 4-factor solution appeared to provide the best fit, and the following factors were isolated: Anger-Out, Negative Affect, Coping, and Anger-In. All intercorrelations were less than .50. Medical diagnosis did not differ with regard to the 4 factors found. The total hostility construct as measured by the structured interview (SI) did not fit into the 4-factor model. This study was the first to show that dimensions of anger and hostility constitute valid and relevant aspects of the general construct of hostility for a representative group of CHD patients. The 4 aspects of hostility isolated using some well-known hostility questionnaires and the SI explained most of the observed variance. Although the SI appeared to tap more general state anger, the 4 aspects of hostility may be differentially related to health in those who are coronary prone. Future studies on the role of hostile or negative emotions in CHD patients should, therefore, pay greater attention to the multidimensional nature of hostility and may clearly benefit from the use of the 4-factor model described in this article.     

Hostility, anger, aggressiveness, and coronary heart disease: an interpersonal perspective on personality, emotion, and health

The related traits of hostility, anger, and aggressiveness have long been suggested as risk factors for coronary heart disease (CHD). Our prior review of this literature (Smith, 1992) found both considerable evidence in support of this hypothesis and important limitations that precluded firm conclusions. In the present review, we discuss recent research on the assessment of these traits, their association with CHD and longevity, and mechanisms possibly underlying the association. In doing so, we illustrate the value of the interpersonal tradition in personality psychology (Sullivan, 1953; Leary, 1957; Carson, 1969; Kiesler, 1996) for not only research on the health consequences of hostility, anger, and aggressiveness, but also for the general study of the effects of emotion, personality and other psychosocial characteristics on physical health.     

Cognitive-behavioral modification of coronary-prone behaviors: Proposal for a treatment model and review of the evidence

The Type A behavior pattern (TABP) has been proposed as a causal risk factor in coronary heart disease (CHD), and Cognitive-Behavioral treatment procedures have been proposed as a means of altering TABP. However, recent research suggests that only one component of TABP, hostility and anger, is the primary pathogenic factor in CHD. We review the research literature addressing the relationship of cognitive dysfunction and TABP and the relationship between cognitive dysfunction and anger expression. We then review the cognitive-behavioral therapy research literature regarding the modification of cognitive dysfunction, TABP and anger expression. While sparse, the research suggests that cognitive-behavioral treatments for anger and hostility hold promise for the treatment of individuals at risk for CHD.Jeffrey M. Lohr, Ph.D., is an Associate Professor of Psychology at the University of Arkansas-Fayetteville. His research interests are in the assessment of irrational beliefs and their association with dsyphoric motivational statesL. Kevin Hamberger, Ph.D., is an Associate Professor in the Department of Family Medicine of the Medical College of Wisconsin. His clinical and research interests are in the cognitive-behavioral treatment of male spouse abusers     

Dimensions of driver anger, aggressive and highway code violations and their mediation by safety orientation in UK drivers

Aggressive behaviour on the roads is reported to be on the increase. This study administered Driving Anger Scale (Deffenbacher et al. (1994). Development of a driving anger scale. Psychological Reports, 74, 83–91.), the Driver Behaviour Questionnaire, and the Driving Skill Inventory to a sample of 270 British drivers. Factor analysis of the Driving Anger Scale items yielded three factors measuring anger generated by the reckless driving, direct hostility and impeded progress by others—contrary to the six subscales found with the original US sample. Younger drivers and low mileage drivers were more likely to exhibit all three types of driving anger, but no differences between male and female drivers were found. In addition, a driver’s safety orientation predicted (negatively) anger evoked by impeded progress and direct hostility whereas self-assessed perceptual-motor skills were positively related to anger generated by impeded progress. Both Highway Code and aggressive violations were significantly related to the anger factors, and, using the procedure by Baron and Kenny (Baron & Kenny (1986). The moderator–mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173–1182.), the prediction of violating behaviour (Driver Behaviour Questionnaire) by reported anger was shown to be mediated by the self-assessed safety skill scale but not the perceptual-motor skill scale (Driver Skill Inventory), and moderated by neither. Implications for driver education countermeasures are noted.     

Personality as a risk factor in coronary heart disease

The pioneering work of the authors of the Type A personality concept has now been shown to be seriously flawed, with only the traits of anger, aggression, and hostility remaining as risk factors for coronary heart disease (CHD). There is now evidence for a much stronger relationship between CHD and personality involving a rather different set of concepts and theories. The evidence for such a relationship is summarized, and a causal link suggested. It is also shown that the CHD-prone type of behaviour can be changed by behaviour therapy, decreasing considerably the risk of dying from CHD.     

Familial environment associated with type A behaviors and psychophysiological responses to stress in children

This study tested two major hypotheses regarding the characteristics of family environments associated with children's Type A behaviors, anger frequency and expression, hostile outlook, hostility displayed during an interview, and cardiovascular responses to laboratory stressors. Two measures of family environment, Positive Affiliation and Authoritarianism, were derived by a factor analysis of the Family Environment Scale completed by parents. The sample consisted of 66 girls and 48 boys enrolled in Grades 2 through 12 from 114 families residing in a predominantly White, upper-middle-class suburb of Pittsburgh. Analyses largely supported the first hypothesis--that a less supportive and positively involved family climate would be associated with attributes of potential coronary heart disease (CHD) risk in children. Families scoring low on Positive Affiliation had children who were assessed as more angry and hostile on the basis of questionnaires and interview. Boys from these families had a more pronounced heart rate response to all laboratory stressors. The second hypothesis--that authoritarianism, in the absence of positive involvement and supportiveness in the family, would be associated with attributes of potential CHD risk in children--received support in regard to boys' heart rate responses to the serial-subtraction and mirror-image-tracing tasks. High Authoritarianism scores in combination with low Positive Affiliation scores in families predicted a heightened heart rate response in boys. Sex differences in the pattern of associations among family and child characteristics were also found. Results suggest that factors in the family environment may be important influences in children's development of characteristics that may, in adulthood, place them at risk for CHD.     

Are All Hostility Scales Alike? Factor Structure and Covariation Among Measures of Hostility1

Few studies have examined the correlational and structural relationships between measures of hostility that may predict coronary heart disease. Using data from a population-based study (N= 2,682), we examined the factor structure among the five subscales from Siegel's (1986) Multi-dimensional Anger Inventory, the three subscales from Spielberger et al.'s (1985) anger expression scales, a Cook-Medley (Cook & Madley, 1954) hostility subscale that measures cynicism, and items measuring hostility from four scales that assess Type A behavior. Eight separate factors were identified: hostile anger expression, perceived control over the expression of one's anger, frequency of anger, ease of anger provocation, brooding, hostile outlook, cynicism, and sullenness. These results suggest that the structure of hostility measures is more complex than previous factor analyses have suggested. Our findings point to the dangers in assuming that a factor structure can be generalized beyond the data on which it is based to provide theoretical statements about psychological structure. The new scales appear to be valid because they correlate with demographic variables and indicators of social support in the expected directions.     

Hostility, the metabolic syndrome, and incident coronary heart disease.

This invesgation examined the impact of hostility and the metabolic syndrome on coronary heart disease (CHD) using prospective data from the Normative Aging Study. Seven hundred seventy-four older, unmedicated men free of cardiovascular disease were included in the study. The total Cook-Medley Hostility (Ho) Scale score, anthropometric data, serum lipids, fasting insulin concentrations, blood pressure, cigarette smoking, alcohol consumption, and total dietary calories were used to predict incident CHD during a 3-year follow-up interval. Multivariate analysis indicated that only Ho positively predicted and high-density lipoprotein cholesterol level negatively predicted incident CHD. Ho's effects on CHD may be mediated though mechanisms other than factors that constitute the metabolic syndrome.     

The Psychosocial Vulnerability Model of Hostility as a Predictor of Coronary Heart Disease in Low-income African Americans

The current study examined social support and stress as mediators of the hostility—coronary heart disease (CHD) relationship as suggested by the psychosocial vulnerability model in a sample of low-income African Americans. Among 95 CHD patients and 30 healthy controls, hostility was negatively correlated with social support, but was not related to minor stress. CHD patients endorsed higher levels of hostility; however, the relationship between hostility and CHD status was diminished once stress and social support were included in the model. This study lends partial support for the psychosocial vulnerability model of hostility in African Americans, but suggests that the relationship between hostility and stress may be impacted by socioeconomic status.     

Stability and level of self-esteem as predictors of anger arousal and hostility

We examined stability of self-esteem and level of self-esteem as predictors of dispositional tendencies to experience anger and hostility. We reasoned that individuals with unstable high self-esteem would report especially high tendencies to experience anger and hostility, and that individuals with stable high self-esteem would report particularly low tendencies. We expected individuals with stable and unstable low self-esteem to fall between these two extremes. These predictions were derived from an analysis of anger and hostility that emphasized the instigating role of threats to self-esteem. Stability of self-esteem was assessed through multiple assessments of global self-esteem in naturalistic settings. Results revealed the predicted pattern for the tendency to experience anger and a "motor" component of hostility. The importance of considering both stability and level of self-esteem in analyses of anger and hostility is discussed.     

Associations among behavior, personality, and traditional risk factors for coronary heart disease: a study at a primary health care center in mid-Norway

The continuing presence of different negative emotions has been suggested as an important factor in the development of coronary heart disease (CHD). The present study was carried out at a medical center to investigate the presence of negative emotions and Type A behavior in a group of 40-yr.-old men and women. The National Institute of Public Health in Norway carried out the data-collection as a part of their CHD risk factor screenings. The correlation between hostility and total cholesterol is negative as is that between systolic blood pressures and the feeling of guilt for women. There was no further support for earlier findings of relationships between either Type A behavior pattern and negative emotions or Type A and elevated cholesterol values. A number of possible explanations are offered. In the study, assessment of hostility was questioned; there was possible support for poor assessment of hostility on the Karolinska Scales of Personality employed in the study.     

The assessment of anger and hostility: a critical review

While the emotion of anger has become an increasingly important part of clinical assessment, the theoretical and psychometric adequacy of the instruments used to assess anger and hostility have long been questioned. In the present review, we first provide definitions of anger and hostility in order to provide a theoretical context from which to evaluate the scope of current measures of these constructs. Second, we review the major self-report scales used to assess anger and hostility in light of these definitions and provide a detailed evaluation of psychometric evidence concerning their reliability and validity. Finally, we offer specific recommendations concerning how anger and hostility assessment instruments can be improved and expanded. In particular, we note the need for (a) an expansion of anger assessment methods beyond traditional endorsement approaches, (b) scales to assess specific domains of anger experience, (c) scales that assess unique content domains of anger experience and expressions, such as spouse-specific or driving-related anger scales, and (d) scales that assess the clinical aspects of the anger construct.     

Type a behavior,irritability, and cardiovascular response

Previous research suggests that high levels of hostility may augment the cardiovascular reactivity and risk of coronary heart disease (CHD) associated with Type A behavior. In contrast, other research indicates that the tendency to deny or suppress anger is associated with enhanced cardiovascular reactivity and risk of CHD. To delineate further the combined role of anger processes and Type A behavior in CHD risk, this study examined the interactive effects of Type A behavior and self-reported irritability on cardiovascular response to a challenging mental task. Type A and Type B college students were further classified as either high or low in self-reported irritability. Type A subjects who were low in self-reported irritability evidenced greater cardiovascular reactivity (i.e., systolic blood pressure and pulse rate) than did Type B subjects low in irritability. However, Type A subjects who were high in irritability tended to demonstrate less cardiovascular response than Type B subjects high in irritability. Further, Type A's low in self-reported irritability evidenced greater cardiovascular response than high-irritability Type A's. It is suggested that reduced reporting of irritability by Type A's may reflect suppression or denial, and further that this reduced reporting is associated with enhanced cardiovascular responsivity.     

A principal components analysis of Rorschach aggression and hostility variables

We examined the structure of 9 Rorschach variables related to hostility and aggression (Aggressive Movement, Morbid, Primary Process Aggression, Secondary Process Aggression, Aggressive Content, Aggressive Past, Strong Hostility, Lesser Hostility) in a sample of medical students (N= 225) from the Johns Hopkins Precursors Study (The Johns Hopkins University, 1999). Principal components analysis revealed 2 dimensions accounting for 58% of the total variance. These dimensions extended previous findings for a 2-component model of Rorschach aggressive imagery that had been identified using just 5 or 6 marker variables (Baity & Hilsenroth, 1999; Liebman, Porcerelli, & Abell, 2005). In light of this evidence, we draw an empirical link between the historical research literature and current studies of Rorschach aggression and hostility that helps organize their findings. We also offer suggestions for condensing the array of aggression-related measures to simplify Rorschach aggression scoring.     

Socioeconomic Differences in Psychosocial Factors Contributing to Coronary Heart Disease: A Review

Psychosocial factors have been shown to play an important role in the aetiology of coronary heart disease (CHD). A strong association between CHD and socioeconomic status (lower-level education, poor financial situation) has also been well established. Socioeconomic differences may thus also have an effect on psychosocial risk factors associated with CHD, and socioeconomic disadvantage may negatively affect the later prognosis and quality of life of cardiac patients. The aim of this study was to review the available evidence on socioeconomic differences in psychosocial factors which specifically contribute to CHD. A computer-aided search of the Medline and PsycINFO databases resulted in 301 articles in English published between 1994 and 2007. A comprehensive screening process identified 12 empirical studies which described the socioeconomic differences in CHD risk factors. A review of these studies showed that socioeconomic status (educational grade, occupation or income) was adversely associated with psychosocial factors linked to CHD. This association was evident in the case of hostility and depression. Available studies also showed a similar trend with respect to social support, perception of health and lack of optimism. Less consistent were the results related to anger and perceived stress levels. Socioeconomic disadvantage seems to be an important element influencing the psychosocial factors related to CHD, thus, a more comprehensive clarification of associations between these factors might be useful. More studies are needed, focused not only on well-known risk factors such as depression and hostility, but also on some lesser known psychosocial factors such as Type D and vital exhaustion and their role in CHD.     

Assessing the relationship of Type A beliefs to cardiovascular disease risk and psychosocial distress

Investigators have begun to take a multimodal approach to the assessment and treatment of psychosocial risk factors for cardiovascular disease (CVD). For instance, cognitive responses have become the focus of contemporary research along with continued examination of overt Type A behaviors. Price (1982) has outlined a set of beliefs purportedly associated with Type A behavior and subsequent CVD risk. The current study examines the validity of this belief set as represented by a newly developed measure, the Type A Cognitive Questionnaire (TACQ). Subjects were 221 employed adults participating in a worksite CVD risk reduction program. They completed the TACQ as part of a pretreatment CVD risk screening protocol. As hypothesized, TACQ scores were significantly associated with Type A behavior, hostility, physiological mediators of CVD, and psychosocial distress. Discussion addresses continued refinement of the Type A belief construct.     

The Intrapersonal and Interpersonal Effects of Anger on Negotiation Strategies: A Cross‐Cultural Investigation

This study assessed the effects of negotiators’ anger on their own and their counterparts’ use of negotiation strategies and whether such effects were moderated by national culture. Participants (N= 130) were 66 sojourning Chinese and 64 Americans who performed an intracultural negotiation simulation. Findings indicated that (a) anger caused negotiators to use more positional statements and propose fewer integrative offers, (b) anger caused the counterparts to use fewer positional statements but also exchange less information about priorities, (c) Chinese negotiators used more persuasive arguments as their counterparts’ anger increased, whereas Americans did not, and (d) Chinese negotiators used more distributive and fewer integrative tactics than American negotiators. Theoretical and practical implications of these findings are discussed in this article.     

The short-term effects of a hostility-reduction intervention on male coronary heart disease patients.

This preliminary study examined the effects of a hostility-reduction intervention on patients with coronary heart disease (CHD). Twenty-two high-hostile CHD men were matched on age and hostility and then randomly assigned to a hostility intervention (N = 10) or an information-control group (N = 12). Patients were reassessed immediately and 2 months posttreatment on hostility (with self-report and structured interview) and resting blood pressure. The intervention's overall effect size was moderately strong (d' = .62). Intervention patients reported at both reassessments and were observed at follow-up to be less hostile than controls. At follow-up, intervention patients had significantly lower diastolic blood pressure (DBP) than controls. Finally, reductions in hostility were significantly and positively correlated with reductions in DBP. Replication with a larger sample and CHD outcomes is recommended.     

Infant Distress During Immunization: A Multimethod Assessment

The purpose of this study was to comprehensively describe infant procedural distress and pain across assessment modalities, and to compare similarities and differences across measures. A multimethod assessment of distress was conducted to investigate infants (N = 37) undergoing routine immunizations. Measures of infant distress included Parent report, nurse report, infant heart rate, and an observational measure of infant distress. Parents rated their infant's distress and pain significantly higher than did nurses. Observational and physiological ratings of infant distress were found to vary significantly by phase, and there were no correlations between adult ratings of pain and distress and physiological ratings. Findings suggest that infant procedural distress can be assessed in a number of manners. The discordance between these measures emphasizes the need for multimethod assessment of pediatric procedural distress in both research and clinical settings. Given the differences between parent and nurse ratings, clinicians should be aware that different assessment methods might lead to different conclusions about infant procedural distress.     

Anger as driving factor of moral courage in comparison with guilt and global mood: A multimethod approach

Although moral courage is a highly desirable behavior whose determinants need to be understood, research has largely neglected the emotions involved in moral courage. Does anger about the norm violation or (anticipated) guilt enhance such interventions even if general mood does not? As previous studies have often failed to overcome the limitations of self‐reported emotions and the use of behavior intention measures, we used a multimethod emotion measurement while observing real behavior. By realizing a real theft scenario in the laboratory (N = 68), we found that anger but neither guilt nor general mood predicted intervention behavior. Our findings complement and expand previous studies by showing that people who experience and express anger more strongly are able to overcome the psychological barrier of potential negative (social) consequences in a situation in which a fast and immediate intervention is needed, whereas others stand and watch. Copyright © 2014 John Wiley & Sons, Ltd.