Defensive hostility: relationship to multiple markers of cardiac ischemia in patients with coronary disease

Hostility, Anger, Psycho-emotional Factors and Cardiovascular Disease

The review presents the main aspects of the relationship between psychoemotional factors, hostility, anger and cardiovascular diseases. The first chapter describes the main historical stages in the study of this problem, starting from the Middle Ages and ending with fundamental research of the 19-20 centuries. In the second part, the authors demonstrated that hostility/anger are a risk factor for the CVD development and affect the prognosis and course of CVD (hypertension, ischemic heart disease, various cardiac arrhythmias, etc.). In the third chapter, there were studies that found that high rates of hostility/ anger reduced the effectiveness of cardiovascular therapy. In the fourth part, there are the main correlation mechanisms of negative emotions, hostility/anger and the cardiovascular system, carried out through the relationships with the activation of the hypothalamic-pituitary-adrenal, autonomic nervous system, platelet activation, with the changes in the risk factors characteristics etc. In the final chapter, the authors suggested prospects for further study of the problem, probably associated with the assessment of behavioral interventions, pharmacological or complex effects on the severity of hostility/anger to reduce CVD mortality in individuals with high rates of hostility / anger.

A systematic review comparing two popular methods to assess a Type D personality effect

INTRODUCTION

Type D personality, operationalized as high scores on negative affectivity (NA) and social inhibition (SI), has been associated with various medical and psychosocial outcomes. The recent failure to replicate several earlier findings could result from the various methods used to assess the Type D effect. Despite recommendations to analyze the continuous NA and SI scores, a popular approach groups people as having Type D personality or not. This method does not adequately detect a Type D effect as it is also sensitive to main effects of NA or SI only, suggesting the literature contains false positive Type D effects. Here, we systematically assess the extent of this problem.

METHOD

We conducted a systematic review including 44 published studies assessing a Type D effect with both a continuous and dichotomous operationalization.

RESULTS

The dichotomous method showed poor agreement with the continuous Type D effect. Of the 89 significant dichotomous method effects, 37 (41.6%) were Type D effects according to the continuous method. The remaining 52 (58.4%) are therefore likely not Type D effects based on the continuous method, as 42 (47.2%) were main effects of NA or SI only.

CONCLUSION

Half of the published Type D effect according to the dichotomous method may be false positives, with only NA or SI driving the outcome.

Blood pressure responses of defensive hostile women when facing a real stress task

OBJECTIVE

This study investigated the importance of the combination of the hostility and defensiveness variables as psychosocial factors that predict the risk of cardiovascular dysfunction. We examined the impact of a stressful situation on blood pressure responses, using a continuous psychophysiological assessment approach.

DESIGN

We measured the evolution of these responses over three experimental phases (adaptation, task and recovery), also considering a minute-by-minute analysis within each phase.

MAIN OUTCOME MEASURES

We used the Cook-Medley Hostility Scale and the Social Desirability Questionnaire to form four groups (high hostility and high defensiveness, high hostility and low defensiveness, low hostility and high defensiveness, and low hostility and low defensiveness).

RESULTS

We expected the group of hostile defensive women to record higher activation (task phase: an academic exam) and slower habituation (recovery phase) compared to the other groups. The results confirmed our hypothesis, as the profile of the hostile defensive individuals was one of constant or sensitization during the task phase, while during the recovery phase those individuals underwent a slow recovery.

CONCLUSION

Therefore, it can be indicated that the low hostility and low defensive group is the most adaptive, as recorded very little activation in response, and rapid recovery.

Psychological Profiles in the Prediction of Leukocyte Telomere Length in Healthy Individuals

BACKGROUND

Shorter telomere length (TL) may signal premature cellular aging and increased risk for disease. While depression and psychosocial stress have been associated with shorter telomeres, other psychological risk factors for cardiovascular disease have received less attention.

PURPOSE

To evaluate the association between TL and psychological risk factors (symptoms of anxiety and depression, hostility and defensiveness traits) for heart disease, and to examine whether chronological age and sex moderate the associations observed.

METHODS

132 healthy men and women (Mage = 45.34 years) completed the Marlowe-Crowne Social Desirability Scale, the Beck Depression Inventory II, The Beck Anxiety Inventory and the Cook-Medley Hostility Scale. Relative TL was measured by quantitative polymerase chain reaction (PCR) of total genomic DNA samples. A series of hierarchical linear regressions were performed controlling for pertinent covariates.

RESULTS

Shorter TL was observed among individuals high in defensiveness (β = -.221) and depressive symptoms (β = -.213), as well as in those with less hostility (β =.256) and anxiety (β =.220)(all Ps<.05). Psychological variables explained 19% of the variance over and above that explained by covariates (age, sex, exercise, alcohol consumption, systemic inflammation, and 24-hr mean arterial pressure). Age moderated the relation between TL and defensiveness (β =.179, p =.03). Sex did not influence any of the relations.

CONCLUSIONS

Telomere length is associated with psychological burden though the direction of effect differs depending on the psychological variables under study. Further research is needed to determine the reasons for and implications of these seemingly contradictory findings.

Denial of Depression as an Independent Correlate of Coronary Artery Disease

A number of psychosocial measures were tested as correlates of coronary artery disease (CAD) in 122 males with positive coronary angiograms and 56 males with no manifest history of atherosclerotic disease who were selected to approximate the patients' age and socio economic status. Only denial of depression as indexed by spouse/friend-minus-self scores on the Ketterer Stress Symptom Frequency Checklist and number of unprovoked nocturnal awakenings were independently and positively related to CAD severity in multivariate regression analyses which controlled for jointly associated cardiac risk factors and commonly used cardiovascular medications. Denial of depression and unprovoked nocturnal awakening appear to be independent correlates of coronary artery disease.

Psychological Correlates of Mental Stress-induced Ischemia in the Laboratory: The Psychophysiological Investigation of Myocardial Ischemia (PIMI) Study

Participants consisted of 184 patients (160 males, 24 females) with positive angiograms or prior myocardial infarctions who displayed at least 1 mm of ST segment depression on a standardized treadmill test. Mean scores on the Reward Dependence subscale of the Tridimensional Personality Questionnaire were higher in patients displaying ischemia during mental stress. Patients who reported higher levels of irritability/anger in response to the Speech stressor were also more likely to display ischemia. However, this result was primarily a result of the females in the sample whose ratings of interest and irritability were associated with ischemia during the Speech task. Psychometric measures previously found in prospective studies to predict acute cardiac events were unrelated to mental stress-induced ischemia in the laboratory.

Dipping status and hostility in newly diagnosed essential hypertension

AIM

Personality traits, including hostility, play an important role in the development of cardiovascular disease. Moreover, abnormalities in blood pressure circadian pattern, such as a lack of nocturnal BP fall, are related with target organ damage and increased cardiovascular risk. The aim of this study was to investigate the impact of hostility and its dimensions on dipping status, in newly diagnosed hypertensive patients.

METHODS

The study population consisted of 114 newly diagnosed untreated essential hypertensives. All participants underwent 24-hour ambulatory blood pressure monitoring (ABPM) in order to assess dipping status. Hostility was assessed by Hostility and Direction of Hostility Questionnaire (HDHQ). The study population was divided in terms of dipping status in two groups, "dippers" and "non-dippers."

RESULTS

The statistical analysis revealed that dippers presented significantly higher score of extrapunitiveness (13.2 +/- 4.9 vs 11.4 +/- 3.9, p = 0.032), as well as significantly higher score of the dimension "urge to act out hostility (AH)" (4 +/- 3 vs 3 +/- 2, p = 0.025) compared to non-dippers. Multivariate regression analysis revealed extrapunitiveness as the only independent predictor of dipping status. The odds ratio (OR) for dipping status associated with each point increase in extrapunitiveness was 0.912 (95% CI: 0.832-0.992; p = 0.048).

CONCLUSION

The present findings may suggest that hostility and its features affect the circadian variation of blood pressure in hypertensive patients, providing a promising objective for future investigations linking psychological factors and dipping status in essential hypertension.

Social desirability does not confound reports of wellbeing or of socio-demographic attributes by older women

This study assesses the relationship of social desirability response bias with self-reported physical, mental and cognitive health, successful ageing, and socio-demographic attributes among 1,860 older women at the University of California, San Diego's Clinical Center for the Women's Health Initiative and the Sam and Rose Stein Institute for Research on Aging. The women were aged between 57 and 91 years and lived in the San Diego community. Measures included a ten-item Marlowe–Crowne Social Desirability Scale, and self-report scales of physical, mental and cognitive health, successful ageing and wellbeing, as well as standard socio-demographic attributes. Bivariate correlation and multiple regression models indicated that social desirability scores negatively associated with self-reported levels of hostility, anxiety, perceived stress and self-reported cognitive failures, and that they predicted additional variance in multiple regression analyses above models containing socio-demographic predictors alone. On the other hand, even the strongest associations were what are generally considered ‘small effects’ (r<0.30). Overall, while the findings support the general validity of most of the self-report measures in studies of normal and successful ageing, consideration of social desirability response bias in the interpretation of self-reports of low levels of some key constructs (anxiety, hostility, stress, self-perceived cognitive deficits) is warranted.

Impact of defensive hostility in cardiovascular disease

Among the psychosocial factors that may influence the development, maintenance, and progression of cardiovascular disease, defensive hostility as a possible risk factor has received substantial empirical support in recent years. The aim of our study was to analyze the relationship between defensive hostility and cardiovascular response to stress situations, as a better predictor of cardiovascular functioning than hostility alone. The sample was composed of 130 female university students. The Cook-Medley Hostility Inventory (Ho) and the Spanish version (CRP) of the Marlowe-Crowne Social Desirability Scale (MC) were used to measure defensive hostility. We used the registration system MP150 (Biopac) to measure the physiological variables throughout the 3 experimental phases (adaptation, task, and recovery). The stress task was a real exam. We expected cardiovascular responses, heart rate, and systolic and diastolic blood pressure to be higher in subjects with high hostility and high defensiveness in all 3 phases. The results reflect that individuals with high hostility and high defensiveness present the highest values in the physiological variables, thus supporting the hypothesis that defensive hostility shows the greatest predictive power in relation to cardiovascular functioning in stressful situations.

Physiological stress responses in defensive individuals: age and sex matter

The association between defensiveness and physiological responses to stress were evaluated in 81 healthy working men and 118 women, aged 20 to 64 years (M=41; SD=11.45). Participants underwent laboratory testing during which they were exposed to interpersonal stressors. Heart rate (HR), heart rate variability (HRV), blood pressure (BP), and salivary cortisol were measured. Defensiveness was evaluated using the Marlowe-Crowne Social Desirability Scale. In women, higher defensiveness was associated with greater BP and HR reactivity to stress (p<.05). In older men, lower defensiveness was associated with increased systolic BP reactivity to stress (p<.02), delayed HRV recovery (p<.02), and greater salivary cortisol levels (p<.02). In conclusion, greater defensiveness was associated with increased reactivity to stress in women whereas in older men, lower defensiveness was associated with elevated cardiovascular, autonomic, and endocrine responses to stress.

Defensiveness and metabolic syndrome: impact of sex and age

The association between defensiveness and metabolic burden, as well as the moderating effects of sex and age were evaluated in 199 healthy working men (N=81) and women (N=118), aged 20-64 years (M=41; S.D.=11.45). Defensiveness (Marlowe-Crowne Social Desirability Scale) and parameters of metabolic syndrome (MS; waist circumference, HDL, triglycerides, glucose, 24h ambulatory blood pressure) were obtained. In men, defensiveness was inversely related to MS burden (Beta=-.288; p=.001), as well as to individual measures of SBP, DBP, glucose and waist circumference (p<.05). In older women, high defensiveness was associated with a greater MS burden (p=.050) and glucose level (p=.005) while the reverse was true in younger women (p=.012). In conclusion, defensiveness was associated with a worse metabolic profile in older women but may be protective for men and younger women. Understanding the pathophysiological processes underlying these associations could elucidate sex and age differences and inform prevention efforts.

Psychometric evaluation of a Coping Strategies Inventory Short-Form (CSI-SF) in the Jackson Heart Study cohort

This study sought to establish the psychometric properties of a Coping Strategies Inventory Short Form (CSISF) by examining coping skills in the Jackson Heart Study cohort. We used exploratory and confirmatory factor analysis, Pearson's correlation, and Cronbach Alpha to examine reliability and validity in the CSI-SF that solicited responses from 5302 African American men and women between the ages of 35 and 84. One item was dropped from the 16-item CSI-SF, making it a 15-item survey. No significant effects were found for age and gender, strengthening the generalizability of the CSI-SF. The internal consistency reliability analysis revealed reliability between alpha = 0.58-0.72 for all of the scales, and all of the fit indices used to examine the CSI-SF provided support for its use as an adequate measure of coping. This study provides empirical support for utilizing this instrument in future efforts to understand the role of coping in moderating health outcomes.

Autonomic characteristics of defensive hostility: reactivity and recovery to active and passive stressors

The autonomic characteristics of hostility and defensiveness were assessed in 55 male undergraduates based on composite Cook Medley Hostility (Chost) and Marlowe Crowne Social Desirability (MC) scores to create 4 groups: Defensive Hostile (DH; high MC, high Chost), High Hostile (HH; low MC, high Chost), Defensive (Def; high MC, low Chost) and Low Hostile (LH; low MC, low Chost). All subjects engaged in a video game (VG) and hand cold pressor (CP) task. Cardiovascular responses in DH subjects were predicted to show enhanced sympathetic alpha and beta-adrenergic activity and the least vagal control compared to others across tasks. DH and LH men showed significant heart rate reactivity to the CP task compared to HH men. LH men showed significant reductions in high frequency power (vagal assessment) to the tasks compared to HH men. Future studies may employ harassment techniques and include the factors of gender and ethnicity in their assessments.

Association between hostility and plasma total homocysteine concentrations in a general population sample

OBJECTIVE

The present study focuses on testing the association of hostility with plasma homocysteine levels in a general population sample.

METHOD

Four hundred and ten healthy adults (200 men and 210 women), participating in a health survey in Greece, had blood samples taken for homocysteine concentrations and also completed a multidimensional hostility questionnaire, assessing direction of hostility ('extra- and intropunitive') as well as total hostility and its ingredients, i.e. urge to act out hostility, criticism of others, delusional hostility, self-criticism and delusional guilt. Multivariate relationship was tested between hostility components and homocysteine, after statistically controlling for potential confounders such as age, gender, educational status, smoking and body mass index.

RESULTS

Total hostility, delusional guilt as well as extrapunitive direction of hostility were positively related to homocysteine levels. Self-criticism was negatively related to homocysteine.

CONCLUSION

The study provides further evidence that particular dimensions of hostility are associated with increased plasma homocysteine levels, thus deserving a place within the spectrum of the coronary heart disease risk factors.

The influence of hostility and family history of cardiovascular disease on autonomic activation in response to controllable versus noncontrollable stress, anger imagery induction, and relaxation imagery

Autonomic activation in response to controllable versus noncontrollable stress, anger imagery induction, and relaxation imagery was studied among 80 participants between the ages of 18 and 34 years. Participants differed in level of trait hostility and family history of cardiovascular disease. Results were obtained through power spectral analyses of electrocardiograph R-R intervals, which produced an index of autonomic nervous system activation. For both male and female populations, parasympathetic regulation was diminished during anger induction for individuals with high levels of trait hostility and having a family history of cardiovascular disease. Similar results were obtained for women during the uncontrolled stress condition. Based on family history of cardiovascular disease and trait hostility, men responded differentially to relaxation imagery induction, whereas no differences were found among females.

Suppressed hostility predicted hypertension incidence among middle-aged men: the normative aging study

This study tested whether suppressed hostility predicted incident hypertension (HTN) in initially nonhypertensive men, using prospective data from the Normative Aging Study. Six hundred twenty-seven men who completed the MMPI and participated in a subsequent laboratory assessment were included in the study. The Cook-Medley Hostility scale (Ho), a suppression factor, and other risk factors were used to predict incident HTN over a 3-year period. Logistic regression showed a significant three-way interaction among Ho, suppression, and age in predicting incident HTN. Among middle-aged men (<or=60 years) with higher suppression, a 1-point decrease in the Ho score was associated with an 18% increase in HTN risk. This relationship remained significant after controlling for relevant risk factors. Among older participants, the HoxSuppression interaction was not predictive of HTN incidence. These results provide support for the Suppressed Hostility hypothesis in middle-aged men.

Hostility scores are associated with increased risk of cardiovascular events in women undergoing coronary angiography: a report from the NHLBI-Sponsored WISE Study

OBJECTIVE

To evaluate hostility-related personality traits assessed by the Cook Medley Hostility Inventory and to relate these to the occurrence of adverse cardiac events in women with suspected myocardial ischemia.

METHODS

The cohort included 506 women with suspected coronary artery disease from the National Heart, Lung, and Blood Institute-sponsored Women's Ischemia Syndrome Evaluation (WISE) study. We examined individual components of the Cook Medley Hostility Score (CMHS) measuring cynicism, hostile affect, and aggressive responding, and a total CMHS (sum of these three) and associations with adverse events (defined as hospitalization for angina, nonfatal myocardial infarction, stroke, congestive heart failure (CHF) other vascular events and death) during 3 to 6 years follow-up using Cox proportional hazard modeling.

RESULTS

Women with adverse events had higher total CMHS (10.6 +/- 5.5) than women without any of these events (9.2 +/- 5.1) p = .02. They also had poorer survival by Kaplan-Meier analysis (log-rank p < .05). Unadjusted Cox models showed that the individual scores of cynicism and aggressive responding and the total CMHS were associated with more adverse events (all p < .05). Women with total CMHS above the median had a 35% increase risk of an adverse event in comparison to women with lower scores. In a risk-adjusted Cox model, the hazard ratio for an adverse event was 1.5 (p = .03) for women with total CMHS above the median.

CONCLUSION

In this cohort of women with suspected myocardial ischemia, higher Cook Medley scores reflecting cynicism, hostile affect, and aggressive responding were associated with poorer 3 to 6 year event-free survival and a higher risk of adverse events. After adjusting for risk factors and CAD, the association with risk for adverse events increased.

Psychobiological mechanisms of socioeconomic differences in health

The association between low socioeconomic status and poor health is well established. Empirical studies suggest that psychosocial factors are important mediators for these effects, and that the effects are mediated by psychobiological mechanisms related to stress physiology. The objective of this paper is to explore these psychobiological mechanisms. Psychobiological responses to environmental challenges depend on acquired expectancies (learning) of the relations between responses and stimuli. The stress response occurs whenever an individual is faced with a challenge. It is an essential element in the total adaptive system of the body, and necessary for adaptation, performance and survival. However, a period of recovery is necessary to rebalance and to manage new demands. Individuals with low social status report more environmental challenges and less psychosocial resources. This may lead to vicious circles of learning to expect negative outcomes, loss of coping ability, strain, hopelessness and chronic stress. This type of learning may interfere with the recovery processes, leading to sustained psychobiological activation and loss of dynamic capacity to respond to new challenges. Psychobiological responses and health effects in humans and animals depend on combinations of demands and expected outcomes (coping, control). In studies of humans with chronic psychosocial stress, and low SES, cortisol baseline levels were raised, and the cortisol response to acute stress attenuated. Low job control was associated with insufficient recovery of catecholamines and cortisol, and a range of negative health effects. Biological effects of choice of lifestyle, which also depends on the acquired outcome expectancies, reinforce these direct psychobiological effects on health. The paper concludes that sustained activation and loss of capacity to respond to a novel stressor could be a cause of the higher risk of illness and disease found among people with lower SES.

What's “Unstable” in Unstable Angina?

The role of emotional distress (e.g., anger, depression, and anxiety) in anginal chest discomfort (ACD) may have been underestimated. The authors review the empirical studies in this area, which are inconsistent with the standard theory on the ischemia-angina relationship; summarize the substantial evidence indicating a strong and consistent cross-sectional/prospective epidemiological association of emotional distress and ischemia/ACD; review the distress-targeted, interventional evidence confirming a causal relationship (i.e., reduced chest discomfort and health system utilization), thus confirming clinical utility of such interventions; and explore the possible mechanisms that might account for the relationship between emotional distress and chest discomfort. Substantial clinical benefit may be achieved by aggressively detecting and treating emotional distress in ACD patients.

Effects of mental stress on flow-mediated brachial arterial dilation and influence of behavioral factors and hypercholesterolemia in subjects without cardiovascular disease

Mental and emotional arousal are known to trigger coronary events. The relation between hypercholesterolemia, behavioral factors, and mental stress-induced alterations in endothelial function are not well defined. Flow-mediated brachial arterial vasodilation has been established as a measure of arterial endothelial function. High-resolution ultrasound was used to measure mental stress-mediated, flow-mediated, and the combination of mental stress- and flow-mediated brachial artery dilation in 38 subjects, 20 of whom had total cholesterol levels > or =200 mg/dl. Mental stress was provoked by anger recall and mental arithmetic and trait hostility were assessed using the Cook-Medley scale. Under mental stress, participants with hypercholesterolemia showed less vasodilation than participants without hypercholesterolemia, even after adjustment for age and the magnitude of blood pressure response to mental stress. Mental stress attenuated flow-mediated brachial arterial vasodilation. There was an inverse relation between hostile affect and percent change in brachial artery diameter after mental stress combined with hyperemia (r = -0.57, p <0.001). Thus, hypercholesterolemia is associated with impaired vasodilation in response to mental stress. Mental stress inhibits flow-mediated vasodilation in normal subjects and those with hypercholesterolemia. The magnitude of this inhibition is associated with hostility.

Defensiveness and 3-year blood pressure levels among young adults: the mediating effect of stress-reactivity

Stress-reactivity has long been proposed to act as a possible mechanism linking psychological factors and increases in blood pressure (BP). This study used results from an intensive cardiovascular investigation to examine the mediating role of reactivity in the relationship between defensiveness and 3-year ambulatory BP levels. A total of 125 male and female participants (M = 29.1 years) completed a protocol including laboratory reactivity testing, 8- to 12-hr ambulatory BP monitoring, and standardized response style instruments. Further, participants returned 3 years later for an identical second test protocol. Results indicated that high- and low-defensiveness participants did not differ on Year 1 BP, but the high-defensiveness group showed higher BP during the reactivity tasks and on Year 3 ambulatory measures. Statistical mediation testing supported reactivity levels as an intervening mechanism between defensiveness and 3-year BP levels.

Marlowe-Crowne Social Desirability Scale and short Form C: forensic norms

Marlowe-Crowne Social Desirability Scale (MC) (Crowne & Marlowe, 1960) scores were collected on 1096 individuals involved in forensic evaluations. No prior publication of forensic norms was found for this instrument, which provides a measure of biased self-presentation (dissimulation). MC mean score was 19.42 for the sample. Also calculated was the score on Form C (MC-C) (Reynolds, 1982), and the mean for this 13-item scale was 7.61. The scores for the current sample generally are higher than those published for non-forensic groups, and statistical analysis indicated the difference was significant for both the MC and MC-C (d =.75 and.70, respectively, p <.001). Neither gender nor educational level proved to be significant factors in accounting for variance, and age did not appear to be correlated with scores. Group membership of subjects based on referral reason (family violence, abuse, neglect, competency, disability) was significant for both the MC and MC-C scores. Results suggest the MC or MC-C can be useful as part of a forensic-assessment battery to measure biased self-presentation.

Defensiveness and individual response stereotypy in asthma

OBJECTIVE

Previous literature has shown that the psychological trait of defensiveness is related to elevated sympathetic reactivity to stress and to several cardiac risk factors. The aim of this study was to examine whether these previous findings on defensiveness extend to an asthmatic population.

METHODS

Defensiveness was measured by the Marlowe-Crowne Social Desirability Scale using a quartile split: high (upper 25%) and low (bottom 75%). Twenty-two defensive and 66 nondefensive participants with asthma were exposed to laboratory tasks (initial baseline rest period, reaction time task, and a shop accident film).

RESULTS

During the tasks there was evidence of lower skin conductance levels and greater respiratory sinus arrhythmia amplitudes among defensive patients with asthma. After exposure to the tasks, defensive patients with asthma showed a decline on spirometry test measures compared with nondefensive asthmatic patients, who displayed an increase.

CONCLUSIONS

These data confirm individual response stereotypy and suggest that defensiveness may be characterized by sympathetic hypoarousal and parasympathetic hyperarousal among patients with asthma. Future studies are needed to determine whether defensiveness is a risk factor for stress-induced bronchoconstriction.

Psychosocial stress and cardiovascular disease: pathophysiological links

The remarkable decline in cardiovascular disease (CVD) experienced in developed countries over the last 40 years appears to have abated. Currently, many CVD patients continue to show cardiac events despite optimal treatment of traditional risk factors. This evidence suggests that additional interventions, particularly those aimed at nontraditional factors, might be useful for continuing the decline. Psychosocial stress is a newly recognized (nontraditional) risk factor that appears to contribute to all recognized mechanisms underlying cardiac events, specifically, (a) clustering of traditional cardiovascular risk factors, (b) endothelial dysfunction, (c) myocardial ischemia, (d) plaque rupture, (e) thrombosis, and (f) malignant arrhythmias. A better understanding of the behavioral and physiologic associations between psychosocial stress and CVD will assist researchers in identifying effective approaches for reducing or reversing the damaging effects of stress and may lead to further reductions of CVD morbidity and mortality.

Psychological status and the role of coping style after coronary artery bypass graft surgery. Results of a prospective study

The results of a prospective study in patients who underwent a first coronary artery bypass graft operation are presented. The goals of this project consisted in assessing the psychological changes during the first year after surgery. For that purpose, 330 consecutive patients were recruited. They were assessed by means of several psychological scales before and on three occasions after surgery. These scales were: the Heart Patients' Psychological Questionnaire (HPPQ), the State-Trait Anxiety Scale (STAI), the Symptom Check List (SCL-90), the Maastricht Questionnaire (MQ) and the Marlowe Crowne Desirability Scale. Furthermore, the study focused on the differential influence of three coping styles. The data demonstrate a clear overall improvement in psychological status over the first year, more specifically during the first 6 months after CABG. Patients were less anxious, less depressed, less exhausted and experienced more subjective well-being. However, almost 30% of all patients did not experience that average favourable evolution. The final psychological end-state was predicted by psychological variables, measured pre-operatively (somatic complaints, hostility and dysphoria) and short-term post-operatively (anxiety). No single medical variable could predict patients' psychological end-state. Finally, the most favourable change was made by patients who display the sensitising coping style, resulting in lower anxiety and depression. Health care providers, physicians as well as nursing staff and psychologists, should therefore use psychodiagnostic tools in order to identify patients at risk for negative psychological outcome. Appropriate therapeutic interventions may consequently be developed and evaluated in future research.

Interpersonal behavior and resting blood pressure in college women: a daily monitoring study

Psychological factors have long been implicated in the development of hypertension. Most studies exploring this relationship employed questionnaires administered on only one occasion.

OBJECTIVE

to evaluate the relation between blood pressure and social behavior in the natural environment over an extended period of time.

METHOD

40 healthy young adult women at varying risk for hypertension were asked to record their behavior and affect following social interactions, three times a day for 32 days. Behaviors were representative of the interpersonal circumplex: dominance, submissiveness, agreeableness, and quarrelsomeness.

RESULTS

Casual blood pressure was significantly correlated with submissive behavior (r=.45, P<.05) and inversely correlated with agreeable behavior (r=-.35, P<.05). ANOVAs confirmed these findings and further revealed that offspring of hypertensives with relatively elevated blood pressure were most quarrelsome.

CONCLUSION

These results concur with the literature on the relationship between hostility and blood pressure but also suggest the importance of submissiveness in college women.

Defensive hostility and coronary heart disease: a preliminary investigation of male veterans

OBJECTIVE

Research and theory link an interpersonal conflict model to cardiovascular disease. Specifically, persons scoring high on cynical hostility and social defensiveness are thought to manifest a defensive need for approval while harboring basic distrust and hostility toward those who could provide such approval. The objective of this study was to assess whether angiographically determined coronary artery disease (CAD) was associated with this combination of high cynical hostility and high social defensiveness.

METHODS

Fifty-nine male patients of a Veterans Administration Medical Center (86% white, mean age = 59.9 years) participated in the study on the day before their angiographic procedure; these men filled out the Cook-Medley Hostility Scale and the Marlowe-Crowne Social Desirability Scale (social defensiveness). They subsequently were categorized as having defensive hostility (DH), high hostility (HH), high social defensiveness (SD), or low psychosocial risk (LRisk; low on both scales).

RESULTS

The four groups did not differ significantly on risk factor status or health status. As predicted, a preplanned contrast showed that the DH group's mean number of arteries with at least 50% blockage (mean = 2.5) differed significantly from the combined means of the other groups. The HH and SD groups did not differ from the LRisk group.

CONCLUSIONS

When combined with other reports, the approach-avoidance interpersonal conflict model holds the promise of providing additional information about the psychosocial factors contributing to CAD development among men with high cynical hostility.

Heart period and QT variability, hostility, and type-A behavior in normal controls and patients with panic disorder

OBJECTIVES

Excess cardiovascular morbidity has been reported in association with phobic anxiety as well as in association with hostility and type-A behavior. The aim of this study was to investigate the relationship between the measures of hostility and type-A behavior, and heart period (HP) and QT variability in normal controls and patients with panic disorder.

METHODS

Data were obtained from Holter ECG records for HP and heart rate (HR) and QT variability measures were obtained from 5 min laboratory ECG records in normal controls (n=21) and patients with panic disorder (n=27).

RESULTS

Patients with panic disorder were significantly more hostile, and had significantly higher scores on Jenkins Activity Survey (JAS) speed and impatience subscale (S scale). Hostility did not correlate with either HP variability or QT variability. Higher type-A scores were associated with higher low frequency (LF) and high frequency (HF) powers of HP variability and standing QT variability was associated inversely with type-A and S scores of the JAS in patients with panic disorder.

CONCLUSIONS

Our results do not support the hypothesis that higher hostility and higher type-A scores are associated with decreased cardiac vagal function.

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.

Defensiveness status predicts 3-year incidence of hypertension

OBJECTIVE

A growing body of research indicates that defensive personality styles (in particular, self-deception) may be related to higher resting blood pressure and stress reactivity levels. This study is the first, however, to examine the value of defensiveness as a prognostic indicator for the development of clinical hypertension.

METHODS

Participants were 127 initially normotensive male and female adults who completed a comprehensive protocol including psychological testing, assessment of smoking, physical activity and body fat levels, and 8-12 h ambulatory blood pressure monitoring. Participants returned 3-years later for an identical follow-up protocol. Defensiveness was assessed using the Balanced Inventory of Desirable Responding.

RESULTS

At 3-year testing, 15 of 127 participants (12%) met criteria for hypertension (i.e. ambulatory mean blood pressure > 140/90). Comparisons between defensiveness groups showed that 12 of 60 (20%) high defensiveness participants met hypertension criteria, whereas only three of 67 (4.5%) low defensiveness participants were hypertensive. Logistic regression equations adjusted for age, alcohol usage, bodyfat, self-reported exercise levels, smoking, and year-1 ambulatory blood pressure, revealed that membership in the high defensiveness group was associated with more than a sevenfold risk of 3-year hypertension (adjusted risk ratio, 7.5; 95% confidence interval, 1.5-39.2).

CONCLUSIONS

These findings link defensive characteristics to an increased prospective risk of hypertension using state of the art ambulatory monitoring techniques, and were robust after controlling for established risk factors. We conclude that the current results add to the hypertension literature by demonstrating associations between personality and clinically relevant blood pressure criteria.

Influence of psychosocial factors and biopsychosocial interventions on outcomes after myocardial infarction

Management of the myocardial infarction patient may extend beyond the physiologic to include psychosocial factors that may adversely affect cardiac health. Psychosocial factors such as depression, coronary-prone behavior, hostility, social isolation, anxiety, anger, and stress are related to increased cardiac death and illness. Various interventions including cognitive-behavioral therapies, techniques that elicit the relaxation response, meditation, exercise, and increasing social networks, may play a role in improving health outcomes. This article explores the relationship of these psychosocial factors to cardiac health and proposes a biopsychosocial model of care.

Feindseligkeit als koronarer Risikofaktor

Zusammenfassung. Das Persönlichkeitsmerkmal “Feindseligkeit” ist in den letzten Jahren insbesondere in US-Forschungsarbeiten zu den Risikofaktoren der koronaren Herzerkrankung stark beachtet worden. Dabei wurde zumeist die Cook-Medley Hostility Scale (Ho-Skala) zur Messung von Feindseligkeit verwandt, die im wesentlichen Zynismus erfaßt. Vorliegende empirische Studien legen nahe, daß Feindseligkeit mit einer erhöhten koronaren Morbidität bzw. Mortalität sowie der Schwere der Erkrankung verbunden ist. Hinsichtlich der zugrundeliegenden Mechanismen liegen Befunde zur kardiovaskulären Reaktivität sowie zum Zusammenhang zwischen Hostilität und dem gesundheitsbezogenen Lebensstil bzw. dem Risikofaktorenprofil (z.B. fehlende soziale Unterstützung) vor. Die Konsequenzen für weitere Forschung werden diskutiert.

Psychosocial variables, age, and angiographically-determined coronary artery disease in women

The present study explored the relationship between psychosocial measures and the degree of coronary stenosis in a sample of 59 women between the ages of 39 and 84. Coronary occlusion was correlated with elevated cholesterol and marginally correlated with age and was inversely associated with years of education. Based on hierarchical multiple regression, an interview-based measure of hostility was associated with coronary stenosis after controlling for traditional risk factors, and age moderated the hostility-stenosis relationship. Further, a second regression model suggested that trait anxiety was inversely correlated with degree of occlusion, perhaps because low-anxious women are referred for catheterization later in the course of the disease. Contrary to hypotheses, there was no evidence that repression of interview-based hostility or anxiety predicted coronary occlusion. Given the small sample size, results should be considered preliminary. Future studies should explore the degree to which anxiety and hostility are associated with coronary heart disease (CHD) in larger samples of women and the degree to which age moderates the hostility-occlusion association.

Five-year follow-up for adverse outcomes in males with at least minimally positive angiograms: importance of "denial" in assessing psychosocial risk factors

The purpose of this study was to test the role of "denial" (spouse/friend minus self-ratings on parallel versions of the same questionnaire) in diluting the predictive value of emotional distress for cardiac events (deaths, new MIs, and/or revascularizations). One hundred forty-four men with no history of prior revascularization who had at least minimally positive diagnostic coronary angiograms, and someone they selected as "someone who knows you well," completed parallel versions of the Ketterer Stress Symptom Frequency Checklist (KSSFC). They were followed up by phone an average of 59.7 months after recruitment. Length of follow-up, baseline cardiac risk factors, and a number of baseline-obtained psychosocial risk factors were tested as prospective predictors of combined events (death by any cause, new MIs, and/or revascularizations) and current anginal frequency. Only spouse/friend observed anxiety on the KSSFC predicted current anginal frequency (p = 0.001). On the self-report version of the KSSFC, patients with one or more events reported less anger (p = 0.031), depression (p = 0.008), and anxiety (p = 0.003). These results may be attributable to "denial" because there were no differences in spouse/friend ratings, and difference scores (spouse/friend minus patient) on the KSSFC scales, particularly anger, were also related to events: AIAI (p = 0.002); depression (p = 0.063); and anxiety (p = 0.010). Denial may be a major limiting factor in accurately assessing emotional distress in cardiac populations, and may help account for a number of the previous findings.

Blood pressure responses to mental stress in emotionally defensive patients with stable coronary artery disease

Emotional defensiveness, defined by concealment of both negative emotions and personal vulnerability, was substantially and consistently correlated with the magnitude of blood pressure reactions to 2 types of mental stress among coronary patients, independently of clinical status. Given recent studies denoting stress-related blood pressure surges as triggers of dangerous cardiovascular events, exaggerated vasomotor reactions among defensive patients may be of clinical significance.

Acute and chronic psychological risk factors for coronary syndromes: moderating effects of coronary artery disease severity

This article provides a selective review of the effects of psychosocial factors and responses to acute mental stress on the onset of acute coronary syndromes. The literature suggests that the relationship between the anatomical severity of coronary artery disease (CAD) and likelihood of subsequent cardiac events, such as myocardial infarction, is not linear. Furthermore, evidence will be provided that the age-dependent associations between psychosocial factors and risk of cardiac events is at least in part mediated through the severity of underlying CAD. Finally, research will be summarized that supports the importance of both chronic psychosocial factors (e.g., low socioeconomic status and/or high hostility) and episodic psychological distress syndromes, such as vital exhaustion and depression. In reviewing this literature, two perspectives will be focused on: (1) the relationship between psychosocial factors and progressive CAD; and (2) the evidence concerning underlying pathophysiological mechanisms.

Defensive hostility and anger expression: relationship to additional heart rate reactivity during active coping

The main purpose of the present study was twofold: (a) to assess the relationship between defensive hostility (high hostility/high defensiveness) and additional heart rate reactivity during active coping and (b) to determine if the construct of anger-out might lend additional sensitivity to the predictive power of the defensive hostility model. Forty individuals were randomly assigned to complete a mental arithmetic task with or without the threat of shock. Participants also completed the Cook-Medley Hostility Inventory (Ho), the Marlowe-Crowne Social Desirability Scale (MC), and the Spielberger Anger Expression Scale. Defensive hostile subjects (high Ho/high MC) were significantly more reactive than any other subgroup. In addition, the combination of low Ho/high anger-out scores yielded a subgroup significantly less reactive than any other subgroup. These findings clarify the complex relationship of hostility and cardiovascular reactivity.

Effects of cynical hostility, anger out, anxiety, and defensiveness on ambulatory blood pressure in black and white college students

This study asked whether individual differences in four personality traits (cynical hostility, anger out, anxiety, and defensiveness) would predict waking and sleeping ambulatory blood pressure and heart rate and whether information about these traits would provide a source of racial and gender differences in these measures. Ambulatory blood pressure and heart rate were recorded over a 24-hour period in 58 black and 86 white college students equally divided by gender. Waking and sleeping values were examined as a function of gender, race, and personality factors. Independent of personality factors, women had lower ambulatory blood pressure and higher heart rate than men, and black subjects had higher blood pressure levels and less of a decrease in heart rate from waking to sleeping than white subjects. The above differences were associated with personality factors. Black subjects scoring high on cynical hostility had elevated daytime and nighttime systolic pressure. Black subjects scoring high on both anxiety and defensiveness had higher waking diastolic blood pressure. Additional effects were shown for heart rate as a function of anger out, anxiety, and defensiveness. Given the special significance of ambulatory blood pressure for cardiovascular disease, these findings underscore the importance of personality factors for cardiovascular risk and their relevance for race and gender differences in this risk.

Triggers of myocardial ischemia during daily life in patients with coronary artery disease: physical and mental activities, anger and smoking

OBJECTIVES

This study assessed the potency of physical and mental activities and emotions (anger and anxiety) and smoking and other substance use as proximate triggers of ischemia in patients with coronary artery disease during daily life.

BACKGROUND

Myocardial ischemia occurs during a wide variety of activities in patients with coronary artery disease, but frequency and relative potency of physical and mental activities, smoking and use of caffeine and alcohol as triggers of ischemia during daily life have not been established.

METHODS

Patients (n = 63) with coronary artery disease and evidence of out-of-hospital ischemia kept a validated structured diary of physical and mental activities and psychologic states while undergoing ambulatory electrocardiographic monitoring for 24 to 48 h.

RESULTS

Ischemia occurred most frequently during moderately intense physical and mental activities. Patients spent the largest proportion of time engaged in low intensity physical and mental activities (p < 0.05), but the likelihood of ischemia was greatest during intense physical (p < 0.0001) and stressful mental activities (p < 0.03). The percentage of time in ischemia was elevated and approximately equivalent for high intensity physical and high intensity mental activities (5%) compared with 0.2% when patients were engaged in low intensity activities. Strenuous physical activity (e.g., effortful walking, p < 0.05) and the experience of intense anger were potent ischemic triggers, and heart rates at onset of ischemia increased with the intensity of physical and mental activity and with anger. Among smokers, ischemia was more than five times as likely when patients smoked than when they did not (during 24% vs. 5% of diary entries, p < 0.0001). Coffee and alcohol consumption were also related to ischemia (p < 0.05), but this association disappeared after controlling for concurrent cigarette smoking.

CONCLUSIONS

Triggers of ischemia in patients with coronary artery disease during daily life include not only strenuous exercise, but also activities involving low levels of exertion, such as anger and smoking. Mental activities appear to be as potent as physical activities in triggering daily life ischemia. Coffee and alcohol consumption are related to ischemia only by virtue of their associations with smoking.