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Anger: Measurement
A linkage of emotional factors to psychological and physical health was posited in the pre-Cartesian writings of philosophers and physicians. With theoretical and methodological advances in physiology, psychology, medicine, and sociology, prescientific speculations evolved to a rigorous examination of the scientific basis of the role of the experience, management, and expression of emotion in the etiology and pathophysiology of disease. Although inconsistent findings are reported, a body of evidence is consistent with the notion that the connection between stressors and disease can be mediated by such psychosocial factors as hostility, and the experience and expression of anger.
Because of the major impact of cardiovascular disorders on morbidity and mortality and the fact that traditional risk factors (e.g., cholesterol, smoking, obesity) cannot account for all incidences of these diseases, a large body of empirical evidence has accumulated across decades attempting to link anger and hostility to the development of heart disease and high blood pressure. Moreover, empirical analyses (viz., meta-analyses) of this literature have shed light on issues pertaining to the study of anger, hostility, and health status. Thus, as a means of elucidating measurement and conceptual issues related to investigating linkages of health status with anger and hostility, this entry focuses on an examination of the empirical literature correlating diseases of the cardiovascular system with hostility and anger experience and expression.
Dimensions of Anger and Hostility
Typically, hostility is defined as a cognitive set characterized by a cynical mistrust and suspiciousness of others. Within the interpersonal context, this cognitive set is thought to increase the likelihood of the experience of angry affect, including resentment, disgust, irritability, and contempt, and the subsequent behavioral expression of aggression (e.g., verbal attack, physical assault, and indirect actions such as gossip and character assassination). Anger expression has been further divided into (a) anger-out (use of overt behavior that can be viewed by others), (b) anger-in (the suppression of the overt expression of anger), and (c) constructive anger expression (an assertive and mature discussion of the interpersonal triggers of the anger). Jorgensen and colleagues created another set of distinctions; namely, anger assessments were divided into (a) interpersonal analogue assessment for measures associated with an interpersonal context (e.g., role-playing, projective tests administered by another person, use of interpersonal vignettes, and interviews), (b) reported overt reactions (e.g., self-report of anger-out, assertion, or dominance strivings), (c) covert anger reactions (e.g., anger-in and trait anger), and (d) ambiguous (a combination of reported overt reactions and covert reactions). These distinctions have proven useful in understanding the nature of anger/hostility measurement in the study of disease outcomes.
Nature of the Association
Meta-analytic work on research correlating anger and hostility measures with heart disease outcomes shows, in general, weak associations and substantial variation between studies. Moreover, associations have been shown to vary as a function of demographics (e.g., ethnicity, age, socioeconomic status [SES]), health status (e.g., awareness vs. unawareness of high blood pressure or studying individuals with coronary heart disease [CHD] or at high risk for CHD), and type of assessment procedure.
Categories of Covert Anger Reactions and Ambiguous
Measures of covert anger and hostility and the ambiguous category show very weak, positive associations with CHD and high blood pressure (a risk factor for CHD). A number of reasons may contribute to these results. First, these measures (e.g., the Cook-Medley Hostility Scale [Ho]; Anger-In and Trait Anger Scales of Spielberger and colleagues) do not provide a unitary, summed score centering on a specific context. Given the importance of the interpersonal context in hostility and anger, it is possible that overall scores for covert anger and hostility do not adequately tap salient interpersonal dimensions when items basically capture a generalized affective experience. Second, respondents are asked to report on socially undesirable attributes. Thus, people may either knowingly (impression management) or unknowingly (defensive, self-deception) underreport the experience of covert anger and hostile cognition. These measures typically correlate positively with measures of social defensiveness (e.g., Marlowe-Crowne Social Desirability Scale).
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