Cover Story

Research findings indicate a clear pattern--being an angry or hostile person is bad for your heart. For example:

  • People most prone to anger were almost three times more likely to have a heart attack than those with low anger in a recent study of 12,986 participants in Circulation (Vol. 101, No. 17).

  • Medical students who became angry quickly when under stress were three times more likely to develop premature heart disease and five times more likely to have an early heart attack than their calmer colleagues in a 2002 study in the Archives of Internal Medicine (Vol. 162, No. 8). Hot tempers, pointed out the authors, predicted heart disease even before such traditional risk factors as diabetes and hypertension.

Other studies--but not all--have found that high anger and hostility are associated with an increased risk of coronary heart disease incidence and mortality, hypertension, blood pressure and other heart-related problems. However, researchers are still exploring exactly how hostility--an inclination to be suspicious of others and see their actions as hostile even when they're not--and anger--the tendency to inappropriately fly into a rage--cause cardiovascular problems, as well as how other social factors might exacerbate those problems.

"For all that we know about hostility and health, we need much more information about the exact mechanisms that make hostility so toxic," explains Ohio State University psychologist Catherine Stoney, PhD.

Teasing out the nuances of its complicated relationship with social and cognitive influences, Stoney conjectures, will help explain why some methodologically sound studies have found no anger-health associations while many others have.

Social influences

Indeed, social situations and support appear to be a crucial mediating factor in anger and cardiovascular health. In a 1998 Psychosomatic Medicine (Vol. 60, No. 1) article, Duke University psychologist Edward C. Suarez, PhD, and colleagues report that highly hostile men who were harassed by a laboratory technician while unscrambling five-letter words had greater physiological reactions than participants with low hostility. The harassed hostile men had higher blood pressures, heart rate, norepinephrine, testosterone and cortisol responses--and that was also true when the researchers compared them with hostile men who were not harassed while completing the task. Moreover, hostile participants who reported being angry with the experimenter for harassing them had poorer systolic blood pressure recovery and had greater norepinephrine increases during recovery.

"The evidence at hand confirms once again the importance of social situations and anger arousal in moderating the relationship between hostility and physiological activity," write the authors, who reported similar results for women in a 1993 Health Psychology (Vol. 12, No. 6) article. In that study, harassed hostile women had greater increases in systolic blood pressure during the task and recovery periods than the harassed low-hostile and nonharassed women. And hostile women who reported experiencing tension, frustration, anxiety and irritation during the task had even higher blood-pressure and heart-rate levels. Interestingly, anger was not associated with cardiovascular response--possibly because women may be less likely to express their anger, the researchers suggest.

Other research has shown that isolation, low perceived social support and social conflict can put people at a greater risk for coronary heart disease--and that people who are angry tend to have low social support and high levels of conflict in close relationships. That's why psychologist Timothy W. Smith, PhD, and colleagues at the University of Utah are taking a closer look at marriage and cardiovascular health.

In a 1999 Psychosomatic Medicine (Vol. 61, No. 4) study of young married couples, he and psychologist Linda C. Gallo, PhD, found that husbands who scored higher on pencil-and-paper tests of hostile and suspicious attitudes showed larger increases in blood pressure during discussions of a stressful marital issue than those who had lower scores--and so did their wives.

"So it wasn't just being a hostile husband," says Smith, "It was interacting with a hostile husband that [also] seemed to increase the stressfulness of those interactions."

In a follow-up study to be presented at the American Psychosomatic Society conference this spring, the researchers replicated these findings and also examined angry temperament. They found that wives with short tempers, and their husbands, had greater changes in heart rate and blood pressure than did non-angry wives and their husbands.

Angry and hostile spouses, then, face a double whammy, says Smith: Being angry and hostile (or being married to someone who is) not only raises their physiological reactivity--putting them at greater cardiovascular risk--but also exposes them to more marital stress, which could increase their risk even more.

Other research by Smith backs this up. In research under review and presented at a Society for Psychophysiological Research annual meeting, he's found that hostile people often fail to benefit from the social support of friends. When participants with high and low hostility completed stressful tasks in the laboratory, Smith found that the less hostile individuals benefited from friends' support--having less of a rise in blood pressure than those whose friends just acted neutrally. However, hostile participants didn't benefit from their friends' support.

"By over-responding to conflict and not trusting others, hostile people might also be at risk because they don't benefit physiologically from their social relationships," Smith explains.

Coping skills

Other psychologists are examining whether coping skills affect cardiovascular health. For example, psychologist Karina Davidson, PhD, of Mount Sinai Medical Center in New York City and her colleagues report in the International Journal of Behavioral Medicine (Vol. 6, No. 3) that people who cope with their anger constructively--such as by working to solve the problem that made them angry--have lower resting blood pressure than people with fewer coping skills.

In research presented at an International Society of Behavioral Medicine meeting in 1998, they measured undergraduates' physiological responses after an experimenter asked questions meant to spark irritation, such as "What do you find most annoying?" People who scored high on a measure of constructive anger returned to their baseline blood pressure levels fairly quickly, often within five minutes, while those with low constructive-anger scores took up to 90 minutes to reduce their blood pressure.

Based on similar findings, some researchers now theorize that it's not just getting angry, but the physical stress of being angry for longer periods of time that takes its toll on cardiovascular health. Davidson is developing a program to teach hostile men how to shorten the time they are angry in order to reduce their health risks (see page 44).

Catherine Stoney and her colleagues at Ohio State University are examining a similar coping construct to get at the root of some confounding research findings: While some studies have found that it's a person's tendency to suppress their anger (often called "anger-in") that has an effect on cardiovascular health, others have found that it's a tendency to vent anger ("anger-out") that's bad. Stoney's work is indicating that anger's effects may be more complex.

Her team is examining people's anger expression on a continuum that ranges from people who always express their anger to those who always suppress their anger. Those in the middle of the scale have flexible coping skills. They, for example, might tone down their anger when having a conversation with their supervisors, but express their feelings more fully with their spouse.

Compared with flexible copers, people who always vent or suppress their anger have significantly greater rises in blood pressure during a stressful event, as well as higher cholesterol and higher levels of homocysteine, an amino acid that's a risk factor for heart disease, finds Stoney. In general, the findings are consistent for both African-American and white men, report Montenique L. Finney, Stoney and Tilmer O. Engebretson, PhD, in Psychophysiology (Vol. 39, No. 3).

"We think that people with this more rigid style are physiologically a little bit different," explains Stoney. "They seem to have large autonomic nervous system responses that have health-damaging consequences....The real question is, what is it that's driving that?"

Further reading

  • Davidson, K., MacGregor, M.W., Stuhr, J., Dixon, K., & MacLean, D. (2000). Constructive anger verbal behavior predicts blood pressure in a population-based sample. Health Psychology, 19, 55-64.

  • Finney, M.L., Stoney, C.M., & Engebretson, T.O. (2002). Hostility and anger expression in African-American and European American men is associated with cardiovascular and lipid reactivity. Psychophysiology, 39, 340-349.

  • Friedman, H.S. (Ed.)(1992). Hostility, coping, and health. Washington, DC: American Psychological Association.

  • Smith, T.W., & Gallo, L.C. (1999). Hostility and cardiovascular reactivity during marital interaction. Psychosomatic Medicine, 61, 436-445.

  • Stoney, C.M., & Engebretson, T.O. (2000). Plasma homocysteine concentrations are positively associated with hostility and anger. Life Sciences, 66, 2267-2275.

  • Suarez, E.C., Harlan, E., Peoples, M.C., & Williams, R.B., Jr. (1993). Cardiovascular and emotional responses in women: The role of hostility and harassment. Health Psychology, 12, 459-468.

  • Suarez, E.C., Kuhn, C.M., Schanberg, S.M., Williams, R.B., Jr., Zimmermann, E.A. (1998). Neuroendocrine, cardiovascular, and emotional responses of hostile men: The role of interpersonal challenge. Psychosomatic Medicine, 60, 78-88.