Neuroendocrine and Behavioral Mechanisms Mediating the Relationship between Anger Expression and Cardiovascular Risk: Assessment Considerations and Improvements

When Anger Remains Unspoken: Anger and Accelerated Epigenetic Aging Among Stress-Exposed Black Americans

OBJECTIVE

Race-related lifetime stress exposure (LSE) including racial discrimination, trauma, and stressful life events have been shown to contribute to racial health disparities. However, little is known about associations between race-related stressors and premature biological aging that confer the risk of adverse health outcomes. Even less is known about the mechanisms through which race-related stressors may be associated with accelerated aging. Early evidence suggests psychological processes such as anger, and particularly the internalization of anger, may play a role.

METHODS

In a community sample of predominantly low-income Black adults (n = 219; age = 45.91 [12.33] years; 64% female), the present study examined the association of race-related LSE (as defined by exposure to racial discrimination, trauma, and stressful life events) and epigenetic age acceleration through anger expression.

RESULTS

Internalized and externalized anger expression were each significantly associated with LSE and age acceleration. Although LSE was not directly associated with age acceleration (ΔR2 = 0.001, p = .64), we found that greater LSE was indirectly associated with age acceleration through increases in internalized, but not externalized, anger (indirect effect: β = 0.03, standard error = 0.02, 95% confidence interval = 0.003 to 0.08; total effect: β = 0.02, 95% confidence interval = -0.25 to 0.31).

CONCLUSIONS

These results suggest race-related LSE may elicit the internalization of anger, which, along with the externalization of anger, may initiate detrimental epigenetic alterations that confer the risk of adverse health outcomes. These findings lay the groundwork for longitudinal studies of the association between race-related stress and racial health disparities.

Neurobiological mechanisms of early life adversity, blunted stress reactivity and risk for addiction

Blunted stress reactivity resulting from early exposure to stress during childhood and adolescence may increase vulnerability to addiction. Early life adversity (ELA) affects brain structure and function and results in blunted stress axis reactivity. In this review, we focus on the underlying neurobiological mechanisms associated with a blunted response to stress, ELA, and risk for addictive disorders. ELA and blunted reactivity are accompanied by unstable mood regulation, impulsive behaviors, and reduced cognitive function. Neuroimaging studies reveal cortical and subcortical changes in persons exposed to ELA and those who have a genetic disposition for addiction. We propose a model in which blunted stress reactivity may be a marker of risk for addiction through an altered motivational and behavioral reactivity to stress that contribute to disinhibited behavioral reactivity and impulsivity leading in turn to increased vulnerability for substance use. Evidence supporting this hypothesis in the context of substance use initiation, maintenance, and risk for relapse is presented. The effects of ELA on persons at risk for addiction may lead to early experimentation with drugs of abuse. Early adoption of drug intake may alter neuroregulation in such vulnerable persons leading to a permanent dysregulation of motivational responses consistent with dependence. This article is part of the special issue on 'Vulnerabilities to Substance Abuse'.

Stress and Addiction: When a Robust Stress Response Indicates Resiliency

OBJECTIVE

Stress reactivity research has traditionally focused on the idea that exaggerated responses to stress may have adverse effects on health. Accumulating evidence suggests that attenuated responses to stress and delayed recovery may also be problematic.

METHODS

This review focuses on the role of the stress response of the hypothalamic-pituitary-adrenocortical axis, the endogenous opioid system, and the cardiovascular system in hypertension, pain perception, and addictive behaviors. Results from multiple methods of assessment and stress paradigms conducted in our laboratory over the past two decades are integrated with research from other investigators and with existing theories.

RESULTS

Research indicates that exaggerated biological and physiological responses to stress and attenuated pain perception are associated with hypertension and risk for cardiovascular diseases. This research complements work linking reduced stress responses with enhanced pain sensitivity and discomfort. Multiple studies have also demonstrated that an attenuated stress response is linked to exacerbation of withdrawal symptoms and relapse in nicotine addiction. Evidence indicates important moderators (i.e., sex, personality traits, and early life adversity) and hypothalamic-pituitary-adrenocortical- and endogenous opioid system-related mechanisms in the altered response to stress. I integrate these findings in a conceptual model emphasizing that robust stress responses in the context of addiction and relapse should be considered as a marker of resiliency.

CONCLUSIONS

A blunted stress response may indicate long-term physiological dysregulation that could usher harmful consequences for cardiovascular disease, pain perception, and addictive disorders. The impact of dysregulation is influenced by multiple individual and situational factors that should be considered in evaluating the clinical significance of stress response dysregulation.

Change in urinary cortisol excretion mediates the effect of angry/hostile mood on 9 month diastolic blood pressure in HIV+ adults

Cardiovascular disease is a growing concern in HIV disease management and nearly 1 out of 3 persons living with the virus is hypertensive. Biobehavioral factors such as anger, hostility, and HPA axis reactivity are emperically linked to blood pressure regulation. Whether HPA axis or mood disturbance increases risk for hypertension remains unclear in HIV disease. The aim of this study was to determine whether 9-month change in angry/hostile mood predicts alterations in systolic (SBP) or diastolic blood pressure (DBP), and whether this change is mediated by 24-h urinary cortisol (CORT) output. Sixty-one HIV positive adults, aged 41.1 ± 8.6 years, assigned to the control condition of a stress management intervention provided blood samples, 24-h urine specimens, blood pressure in-office, and self-reported mood at baseline and a 9-month follow-up. CORT was tested as a mediator in two separate models controlling for baseline BP, CD4 count, HIV-1 viral load, protease inhibitor use, body mass index, smoking status, and family history of cardiometabolic disease. Increase in angry/hostile mood was associated with greater SBP (β = 0.33, CI 0.09, 0.56, p = 0.01) and DBP (β = 0.39, CI 0.16, 0.62, p < 0.001) at follow-up. CORT partially mediated the effect of angry/hostile mood on DBP (β = 0.28, CI 0.03, 0.54, p = 0.03). Change in CORT was not related to SBP (β = 0.12, CI -0.20, 0.44, p = 0.46). The final mediation model accounted for 41.2% of the variance in 9-month DBP. Angry or hostile mood may contribute to increased risk for hypertension in persons treated for HIV via disturbance of the HPA-axis.

Anger Expression Style Predicts the Domain of the First Smoking Relapse After a Quit Attempt

BACKGROUND

Risk for smoking relapse may be associated with context-dependent social and behavioral cues. However, lack of research examining the role of trait negative mood such as anger in this relationship and assessment of objective indices related to smoking status (e.g., biochemical measures) may limit existing findings. We examined the roles of trait anger, habitual anger expression behavior, and the situation in which the first incident of smoking lapse following a quit attempt occurs.

METHODS

One-hundred and five smokers interested in cessation (mean age, SD: 34.7 ± 11.8) set a quit day and attended multiple post-quit assessments where they were asked to provide biochemical measures including exhaled carbon monoxide (CO) and self-report measurements, including smoking status.

RESULTS

Eighty-eight participants (40 women) returned to smoking over the 12-month study period. Self-reported smoking status was verified by exhaled CO measurements. Thirty-one percent of participants who relapsed reported the first lapse occurring at home, 15% at work, 14% at a restaurant or a bar, and 8% in a car. Multinomial logistic regression models found that high levels of anger-out were associated with smoking relapse in situations other than work or home (p <.05).

CONCLUSIONS

These results expand prior work suggesting habitual anger expression style may moderate associations between situational factors and risk for smoking relapse, highlighting the need to incorporate findings in treatment methods. Absence of gender differences suggests the situational factors explored here affect relapse independent of gender.

Psychometric Examination of an Arabic Version of the State-Trait Anger Expression Inventory

OBJECTIVES

This study aimed to examine the psychometric properties of an Arabic version of the trait anger and anger expression scales of the State-Trait Anger Expression Inventory (STAXI).

METHODS

This study took place between April 2005 and August 2014. Adults in Yemen (n = 334) and Tunisia (n = 200) were recruited from university campuses and a smoking cessation clinic, respectively. The STAXI was translated into Arabic using back-translation methods. An explanatory principal component analysis was conducted to explore the factor structure of the anger expression scale, utilising parallel analyses to determine the number of retained factors.

RESULTS

Good internal consistency of the trait anger scale was observed among the Yemeni (Cronbach's alpha = 0.76) and Tunisian (Cronbach's alpha = 0.86) samples. The parallel analysis suggested a three-factor solution for the anger expression scale (anger in, anger out and anger control), in accordance with the original STAXI. The internal consistency of anger in, anger out and anger control factors ranged between 0.51-0.79 in the Yemeni sample and 0.66-0.81 in the Tunisian sample. Overall, items loaded on the anger control factor included all items proposed by the original authors and this factor had higher reliability than the other two factors in both samples.

CONCLUSION

The results of the current study provide initial support for the use of the trait anger and anger expression scales of the STAXI in Arabic-speaking countries.

Hostility and quality of life among Hispanics/Latinos in the HCHS/SOL Sociocultural Ancillary Study

OBJECTIVE

The purpose of this study was to determine if hostility is associated with physical and mental health-related quality of life (QoL) in US. Hispanics/Latinos after accounting for depression and anxiety.

METHODS

Analyses included 5313 adults (62% women, 18-75 years) who completed the ancillary sociocultural assessment of the Hispanic Community Health Study/Study of Latinos. Participants completed the Center for Epidemiological Studies Depression Scale, Spielberger Trait Anxiety Scale, Spielberger Trait Anger Scale, Cook-Medley Hostility cynicism subscale and Short Form Health Survey. In a structural regression model, associations of hostility with mental and physical QoL were examined.

RESULTS

In a model adjusting for age, sex, disease burden, income, education and years in the US., hostility was related to worse mental QoL, and was marginally associated with worse physical QoL. However, when adjusting for the influence of depression and anxiety, greater hostility was associated with better mental QoL, and was not associated with physical QoL.

CONCLUSIONS

Results indicate observed associations between hostility and QoL are confounded by symptoms of anxiety and depression, and suggest hostility is independently associated with better mental QoL in this population. Findings also highlight the importance of differentiating shared and unique associations of specific emotions with health outcomes.

Prenatal stress, development, health and disease risk: A psychobiological perspective-2015 Curt Richter Award Paper

The long-term consequences of exposure to excess stress, particularly during sensitive developmental windows, on the initiation and progression of many complex, common physical and mental disorders that confer a major global burden of disease are well established. The period of intrauterine life represents among the most sensitive of these windows, at which time the effects of stress may be transmitted inter-generationally from a mother to her as-yet-unborn child. As explicated by the concept of fetal or developmental programming of health and disease susceptibility, a growing body of evidence supports the notion that health and disease susceptibility is determined by the dynamic interplay between genetic makeup and environment, particularly during intrauterine and early postnatal life. Except in extreme cases, an adverse intrauterine exposure may not, per se, 'cause' disease, but, instead, may determine propensity for disease(s) in later life (by shaping phenotypic responsivity to endogenous and exogenous disease-related risk conditions). Accumulating evidence suggests that maternal psychological and social stress during pregnancy represents one such condition that may adversely affect the developing child, with important implications for a diverse range of physical and mental health outcomes. In this paper we review primarily our own contributions to the field of maternal stress during pregnancy and child mental and physical health-related outcomes. We present findings on stress-related maternal-placental-fetal endocrine and immune/inflammatory processes that may mediate the effects of various adverse conditions during pregnancy on the developing human embryo and fetus. We enunciate conceptual and methodological issues related to the assessment of stress during pregnancy and discuss potential mechanisms of intergenerational transmission of the effects of stress. Lastly, we describe on-going research and some future directions of our program.

Stress psychobiology in the context of addiction medicine: from drugs of abuse to behavioral addictions

In this chapter, we briefly review the basic biology of psychological stress and the stress response. We propose that psychological stress and the neurobiology of the stress response play in substance use initiation, maintenance, and relapse. The proposed mechanisms for this include, on the one hand, the complex interactions between biological mediators of the stress response and the dopaminergic reward system and, on the other hand, mediators of the stress response and other systems crucial in moderating key addiction-related behaviors such as endogenous opioids, the sympathetic-adrenal-medullary system, and endocannabinoids. Exciting new avenues of study including genomics, sex as a moderator of the stress response, and behavioral addictions (gambling, hypersexuality, dysfunctional internet use, and food as an addictive substance) are also briefly presented within the context of stress as a moderator of the addictive process.

Association between anger and mental stress-induced myocardial ischemia

BACKGROUND

Mental stress-induced myocardial ischemia is associated with adverse prognosis in coronary artery disease patients. Anger is thought to be a trigger of acute coronary syndromes and is associated with increased cardiovascular risk; however, little direct evidence exists for a link between anger and myocardial ischemia.

METHODS

[(99m)Tc]-sestamibi single-photon emission tomography was performed at rest, after mental stress (a social stressor with a speech task) and after exercise/pharmacologic stress. Summed scores of perfusion abnormalities were obtained by observer-independent software. A summed-difference score, the difference between stress and rest scores, was used to quantify myocardial ischemia under both stress conditions. The Spielberger's State-Trait Anger Expression Inventory was used to assess different anger dimensions.

RESULTS

The mean age was 50 years, 50% were female, and 60% were non-white. After adjusting for demographic factors, smoking, coronary artery disease severity, depressive, and anxiety symptoms, each IQR increment in state-anger score was associated with 0.36 U-adjusted increase in ischemia as measured by the summed-difference score (95% CI 0.14-0.59); the corresponding association for trait anger was 0.95 (95% CI 0.21-1.69). Anger expression scales were not associated with ischemia. None of the anger dimensions was related to ischemia during exercise/pharmacologic stress.

CONCLUSION

Anger, both as an emotional state and as a personality trait, is significantly associated with propensity to develop myocardial ischemia during mental stress but not during exercise/pharmacologic stress. Patients with this psychologic profile may be at increased risk for silent ischemia induced by emotional stress, and this may translate into worse prognosis.

Anger proneness, gender, and the risk of heart failure

BACKGROUND

Evidence regarding the association of anger proneness with incidence of heart failure is lacking.

METHODS AND RESULTS

Anger proneness was ascertained among 13,171 black and white participants of the Atherosclerosis Risk in Communities (ARIC) study cohort with the use of the Spielberger Trait Anger Scale. Incident heart failure events, defined as occurrence of ICD-9-CM code 428.x, were ascertained from participants' medical records during follow-up in the years 1990-2010. Relative hazard of heart failure across categories of trait anger was estimated with the use of Cox proportional hazard models. Study participants (mean age 56.9 [SD 5.7] years) experienced 1,985 incident HF events during 18.5 (SD 4.9) years of follow-up. Incidence of HF was greater among those with high, as compared to those with low or moderate trait anger, with higher incidence observed for men than for women. The relative hazard of incident HF was modestly high among those with high trait anger, compared with those with low or moderate trait anger (age-adjusted hazard ratio for men: 1.44 (95% confidence interval [CI] 1.23-1.69). Adjustment for comorbidities and depressive symptoms attenuated the estimated age-adjusted relative hazard in men to 1.26 (95% CI 1.00-1.60).

CONCLUSIONS

Assessment of anger proneness may be necessary in successful prevention and clinical management of heart failure, especially in men.

Anger, adiposity, and glucose control in nondiabetic adults: findings from MIDUS II

Anger has been linked to cardiovascular disease, but few studies have examined the relationship between anger and type 2 diabetes. The aim was to investigate associations among different indicators of anger expression, adiposity, and nondiabetic glucose metabolism in a national survey of adults. Participants were 939 adults without diabetes in the Midlife in the US study (MIDUS II). Glucose metabolism was characterized by fasting glucose, insulin, insulin resistance, and glycosylated hemoglobin (HbA1c). Spielberger's Anger Expression inventory was used to measure suppressed anger (anger-in), expressed anger (anger-out), and controlled anger (anger-control). We investigated the relationship between anger and glucose metabolism, and whether anger amplified the adverse relationship between body weight distribution (body mass index = BMI and waist-to-hip ratio = WHR) and glucose metabolism. Multivariate-adjusted analyses revealed an association between anger-out and both insulin and insulin resistance. As predicted, anger-in amplified the relationships between BMI and insulin and insulin resistance, while anger-out amplified the association between WHR and insulin and insulin resistance. Low anger-control was associated with higher glucose. None of the three anger measures was significantly associated with HbA1c. Our findings extend previous research on anger as a potential risk factor for type 2 diabetes by demonstrating that anger expression is associated with clinical indicators of glycemic control, especially among those with pre-existing risk due to obesity and high central adiposity.

Current understanding of the bi-directional relationship of major depression with inflammation

Consistent evidence links major depression and its affective components to negative health outcomes. Although the pathways of these effects are likely complex and multifactorial, recent evidence suggests that innate inflammatory processes may play a role. An overview of current literature suggests that pathways between negative moods and inflammation are bi-directional. Indeed, negative moods activate peripheral physiologic mechanisms that result in an up regulation of systemic levels of inflammation. Conversely, peripheral inflammatory mediators signal the brain to affect behavioral, affective and cognitive changes that are consistent with symptoms of major depressive disorder. It is likely that these pathways are part of a complex feedback loop that involves the nervous, endocrine, and immune systems and plays a role in the modulation of peripheral inflammatory responses to central and peripheral stimuli, in central responses to peripheral immune activation and in the maintenance of homeostatic balance. Further research is warranted to fully understand the role of central processes in this feedback loop, which likely contributes to the pathophysiology of mental and physical health.

The contribution of maternal stress to preterm birth: issues and considerations

Preterm birth represents the most significant problem in maternal-child health, with maternal stress identified as a variable of interest. The effects of maternal stress on risk of preterm birth may vary as a function of context. This article focuses on select key issues and questions highlighting the need to develop a better understanding of which particular subgroups of pregnant women may be especially vulnerable to the potentially detrimental effects of maternal stress, and under what circumstances and at which stages of gestation. Issues related to the characterization and assessment of maternal stress and candidate biologic mechanisms are addressed.

Evaluation of a domain-specific anger expression assessment strategy

Previous studies have shown that self-reports of an individual's anger expression vary between the home and the work domain. The aim of this study was to investigate the validity of such self-reports by comparing them with reports of intimate partners and work colleagues in the respective domain. Participants (N= 86) rated their anger expression on the general and on domain-specific versions of the State-Trait-Anger Expression Inventory (Spielberger, 1988). The self-rated anger-out-home scores correlated highly with partner ratings of anger-out-home scores (r = .61) and colleague ratings of anger-out-work scores correlated substantially with self-rated anger-out-work scores (r = .54). A similar but weaker correlation pattern emerged for anger control but not for anger-in. Self-other correspondence was higher for the domain-specific anger expression assessment than for the general anger expression assessment. These results demonstrate that the domain-specific strategy for the assessment of self-reported anger expression can validly measure differences in anger expression in different domains.

Antagonistic characteristics are positively associated with inflammatory markers independently of trait negative emotionality

Recent evidence suggests that individuals with certain personality traits are at elevated risk for chronic systemic inflammation. To date, this literature has focused on the related traits of hostility and negative affect (NA). In this study, we examine the covariation of trait measures of hostility and NA with the inflammatory mediators interleukin-6 and C-reactive protein. We also explore whether observed associations reflect independent contributions of cognitive, affective and behavioral components of hostile dispositions or shared trait variance with global negative affectivity. Subjects were a diverse sample of 855 relatively healthy middle-aged community volunteers (50% male) from the Adult Health and Behavior Project. The Buss and Perry Aggression Questionnaire (BPAQ) and an Abbreviated Cook-Medley Hostility Scale (ACM) were used to measure dimensions of hostility, and the Multidimensional Personality Questionnaire was used to measure trait NA. Regression analyses accounting for demographic characteristics and medical covariates showed a positive relationship of all components of hostility and trait NA with both IL-6 and CRP. After controlling for trait NA, only the behavioral component of hostility was independently associated with the inflammatory markers. The relationships of cognitive and affective components of hostility with inflammatory markers were largely explained by lifestyle factors, particularly body mass index and smoking. In contrast, lifestyle factors did not explain the covariation of hostile behavioral tendencies and inflammation. These findings suggest that unique attributes of aggressive behavioral tendencies account for much of the variability in inflammation associated with hostility and negative emotions, raising the possibility that individuals high in aggression are at increased risk of inflammatory disease.

Emotional irritation before mental stress is associated with enhanced peripheral norepinephrine

Research suggests equivocal findings on associations of catecholamines and mood. Our study investigated the associations of emotional state, blood pressure and catecholamines in 55 healthy males undergoing mental stress. We especially checked the reported link between norepinephrine (NE) and emotional irritation. Blood pressure (SBP, DBP) and heart rate (HR) were continuously monitored. NE and epinephrine (EPI) were measured before, after, and 20 minutes after stress. Participants were divided into irritated versus non-irritated and anxious versus non-anxious subjects by median split on their baseline questionnaires. The task elicited significant cardiovascular, hormonal, and psychological stress responses. NE levels were significantly correlated with irritation before stress. Irritated subjects showed significantly higher DBP and NE than non-irritated subjects. The higher NE and DBP levels in the irritated participants suggest detrimental psycho-physiological interrelations promoting the development of stress-mediated cardiovascular diseases. Heightened emotional irritation before stress may be regarded as a psychological risk factor.

Differential Effects of Incongruent Anger Expression on Memory Performance

Abstract. There is growing evidence that certain strategies of emotion regulation may lead to impaired cognitive performance. The present study investigated the impact of manipulated discrepancy between felt and displayed anger on cognitive performance and how it is modulated by extraversion. Fifty-six female participants were asked to solve two blocks of anagrams. Additionally, half of the subjects were instructed to show an angry emotional expression while solving the second block of anagrams, the remaining half were asked to keep their expression neutral. Before the second anagram trial, half of the participants were provoked, half of them were not. The subsequent unexpected memory test revealed a detrimental effect of the incongruent anger expression on the recall of the anagram solutions seen in the second trial. Compared to participants low on extraversion, high extraverts appeared to profit from showing an emotional display that was congruent with their feelings.

Anger Management Style and Endogenous Opioid Function: Is Gender a Moderator?

This study explored possible gender moderation of previously reported associations between elevated trait anger-out and reduced endogenous opioid analgesia. One hundred forty-five healthy participants underwent acute electrocutaneous pain stimulation after placebo and oral opioid blockade in separate sessions. Blockade effects were derived reflecting changes in pain responses induced by opioid blockade. Hierarchical regressions revealed that elevated anger-out was associated with smaller pain threshold blockade effects (less opioid analgesia) in females, with opposite findings in males (interaction p < .001). Similar marginally significant interactions were noted for blockade effects derived for nociceptive flexion reflex threshold, pain tolerance, and pain ratings (p < .10). Anger-in was also associated negatively with pain threshold blockade effects in females but not males (interaction p < .05). Across genders, elevated anger-in was related to smaller pain tolerance blockade effects (p < .01). Overlap with negative affect did not account for these opioid effects. The anger-in/opioid association was partially due to overlap with anger-out, but the converse was not true. These findings provide additional evidence of an association between trait anger-out and endogenous opioid analgesia, but further suggest that gender may moderate these effects. In contrast to past work, anger-in was related to reduced opioid analgesia, although overlap with anger-out may contribute to this finding.