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Anger as a Psychological Risk Factor of Hypertension

  • Higher Education Department Lahore, Pakistan

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The present research was conducted to explore the relationship of anger and its components like state-anger, trait-anger, anger-in, anger-out, anger-control, and anger-expression with hypertension. Further, to explore the role of anger as psychological risk factor in predicting hypertension. A sample of 237 participants (hypertensive patients = 137; non-hypertensive age matched healthy controls = 100) with age range 30 to 65 years (M = 45; SD = 8.37) was taken from outdoor departments of public hospitals. State Trait Anger Expression Inventory (Spielberger, 1988) translated into the Urdu language by Mushtaq (2012) was used to assess anger and its dimensions. The analyses revealed a significant positive relationship between dimensions of anger and hypertension. State-anger, trait-anger, anger-in, anger-control, and anger turned out to be psychological predictors of hypertension in binary logistic regression analysis. Significant differences were found on anger and its dimensions between hypertensive men and women.
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Pakistan Journal of Psychological Research, 2014, Vol. 29, No. 1, 21-37
Anger as a Psychological Risk Factor of
Mamoona Mushtaq and Najma Najam
University of the Punjab1
The present research was conducted to explore the relationship
of anger and its components like state-anger, trait-anger, anger-
in, anger-out, anger-control, and anger-expression with
hypertension. Further, to explore the role of anger as
psychological risk factor in predicting hypertension. A sample
of 237 participants (hypertensive patients = 137; non-
hypertensive age matched healthy controls = 100) with age
range 30 to 65 years (M = 45; SD = 8.37) was taken from
outdoor departments of public hospitals. State Trait Anger
Expression Inventory (Spielberger, 1988) translated in to Urdu
language by Mushtaq (2012) was used to assess anger and its
dimensions. The analyses revealed significant positive
relationship between dimensions of anger and hypertension.
State-anger, trait-anger, anger-in, anger-control, and anger
turned out to be psychological predictors of hypertension in
binary logistic regression analysis. Significant differences were
found on anger and its dimensions between hypertensive men
and women.
Keywords: Hypertension, State-anger, Trait-anger, Anger-in, Anger-
Out, Anger-control
Hypertension is rapidly pervasive among different nations of the
world. It brings about multiple chronic conditions in human body
(Grimsrud, Stein, Seedat, Williams, & Myer, 2009) without
apparently noticeable symptoms and is often called a silent killer
(Barcelo, 2000). Hypertension affects the overall body functioning
and human life in many ways. Untreated patient with hypertension has
an average life expectancy between 50-60 years, compared with 71
Mamoona Mushtaq and Najma Najam, Institute of Applied Psychology,
University of the Punjab, Lahore, Pakistan.
Mamoona Mushtaq is currently in Department of Applied Psychology, Govt. M.
A. O. College, Lahore; and Najma Najam is currently in Karakoram International
University, Gilgit Biltistan, Pakistan.
Correspondence concerning this article should be addressed to Mamoona
Mushtaq, Department of Applied Psychology, Govt. M. A. O. College, Lahore.
years for the population at large. Prevalence of hypertension among
Pakistani men is 34% and among women is 24% (Safdar, Omair,
Faisal, & Hasan, 2004). It is frequently prevalent in men after the age
of 35 years than women of that age and 58% of the patients are
unaware that they are suffering from hypertension. Research data
support that women also suffer from high rate of hypertension (Steele
& McGarvey, 1997). Additionally, there are an estimated 12 million
patients with hypertension in Pakistan (Nishter, 2001). Shah, Luby,
Rahbar, Khan, and McCormick (2001) have reported that in
Rawalpindi Division, more than 24.3% of the population over the age
of 18 years, and 36% over the age of 45 years suffers from high blood
pressure. Shah et al. also reported that there are 23% men with
hypertension in Karachi. Thus, it may be concluded that hypertension
is wide spread in different areas of Pakistan; is rapidly increasing;
scantily treated and controlled; and is a great health hazard.
Psychological condition of an individual greatly affects his
physical condition. Anger is a normal emotion, but if increases, can
cause devastating effects upon body and most conspicuously upon
heart (Williams, Nieto, Sanford, Couper, & Tyroler, 2002). It has been
observed that occasionally healthy persons may also have conspicuous
boost in their blood pressure if they are angery (Spielberger, Jacobs,
Russell, & Crane, 1983). Borteyrou, Bruchon-Schweitzer, and
Spielberger (2008) explain that anger is an arousing state which
consists of feelings that vary in intensity from mild irritation to intense
fury or rage. It is reported that anger arousing situation also becomes a
great reason of increase in blood pressure (Gerin et al., 2006).
Historically, it roots back to 1939, when Alexander identified the
suppression of anger as a major cause of hypertension and further
investigated its lethal outcomes upon human body. Reactivity
hypothesis describes that individual prone to hypertension reacts to
environmental stress with intense anger (Light, 2001). In an earlier
study on people with hypertension, Landesbergis, Schnoall, Warren,
Pickering, and Schwartz (1994) explored that blood pressure rises
remarkably during anger states. Association of anger with
hypertension has been confirmed by many researchers (Player, King,
Mainous, & Geesey, 2007; Rutelage, & Hogan, 2002; Webb &
Beckstead, 2001), which is a well-established risk factor for coronary
heart disease (Player et al., 2007). Borde-Perry, Campbell, Murtaugh,
Gidding, and Falkner (2002) further append that there is an
association between hypertension and cardiovascular diseases.
Anger has many facets which affect the body equally, but are
different in nature and expression as described by Spielberger (1988).
State-anger is explained as a psycho-physiological condition
comprising of subjective feelings that is different in emotion from
mild resentment to intense anger and is related to the activation of
autonomic nervous system. Trait-anger is defined in terms of variation
from person to person in the frequency of occurrence with which
state-anger is experienced over time. So trait-anger may rightly be
called intense fury with greater frequency of occurrence. Next
dimension of anger is anger-in or anger suppression. This is the
attribute of a person how often he/she experiences, but held in or
suppresses anger. It refers to the frequency with which angry feelings
of an individual are suppressed. Individual in front of an authority
cannot express anger and has to hold in the angry feelings which have
lethal affects upon body. Anger-out is the frequency with which a
person expresses angry feelings toward other people or objects in the
environment in the forms of verbal or aggressive behavior. Anger-
control measures the frequency of attempting to control the expression
of anger by an individual. It is the tendency of an individual to prevent
anger experience even passing through angry situation. Finally, anger-
expression is an index of anger-in, anger-out, and Anger-control, in
which a person expresses and controls anger. It reflects either the
intensity of feeling or the frequency with which it is expressed
(Sinclair, Czech, Joyner, & Munkasy, 2006).
According to Schlomann and Schmitke (2007), high blood
pressure is the most common cause of hospital visits, which means
throwing away one’s precious capital and time. Pakistan is a
developing country where sources to earn livelihood are meager and
prevalence of hypertension is 26% (Safdar et al., 2004). Grimsrud et
al. (2009) examined that about 79% hypertensive patients also
experience one chronic disease co-morbid with hypertension.
Literature provides sufficient evidence that hypertension is a vital risk
factor for many lethal diseases like heart problems, renal disease, loss
of vision, diabetes, rheumatism, etc. (Kannel, 2000).
There is research evidence that hypertensive men and women are
different in the expression of anger. It is important to observe that
gender differences in the expression of anger have been reported, but
these differences are related to the expression of anger and not with
the frequency of anger expression (Spielberger, Krasner, & Solomon,
1988). It is observed that men score high on anger-out, whereas,
women attain more scores on anger-suppression and anger-control,
which suggests that female role characteristics are related with anger-
suppression and male role characteristics are related with outwardly
expressing anger (Kopper & Epperson, 1996). It is reported that anger
expression is strongly related to increase in blood pressure reactivity
in men, whereas, controlling anger is related to higher blood pressure
reactivity in women (Shapiro, Jamner, & Goldstein, 1993). In
another investigation on gender-related differences in cardiovascular
reactivity and the role of anger inhibition as a risk of future
hypertension, it was concluded that there is more cardiovascular
reactivity in men than in women during the state of anger (Vogele,
Jarvis, & Cheeseman, 1997). Within the male group, a combination of
hypertension risk and anger-in led to the highest reactivity, whereas,
in female participants anger-in had no effect on reactivity. High anger
level among hypertensive women have been reported by Steele and
McGarvey (1997). The researchers also report that women less than or
equal to 40 years of age have a high tendency of anger expression and
the children of parents with hypertension, who were suffering from
high rate on two measures of blood pressure. They also had high
scores on trait-anger, anger out, and submissiveness. Thus, it may be
concluded that anger is equally prevalent not only in men, but also in
women and children of parents with hypertension. In a recent study,
anger-in was found to be more prevalent in men than in women
(Doster, Purdum, Martin, Goven, & Moorefield, 2009).
Burgeoning literature on the subject reports that control of
hypertension disease in Pakistan has partial success (Jafar, Chaturvedi,
& Pappas, 2006). Inadequate data is on hands regarding anger as a risk
factor of hypertension within the indigenous population. Information
obtained from some researches carried out on indigenous population is
restricted to stress, anxiety, depression, and hostility as risk factors of
hypertension (Mushtaq & Najam, 2014) or biological factors only
(Vaillant & Gerber, 1996). Additionally, it is a matter of concern for
researchers that established risk factors in many cases do not
completely determine hypertension. Notwithstanding, the reality that
hypertension was diagnosed many years earlier in South Asia, no
study was conducted to identify the risk factors associated with
hypertension. In Pakistan, studies have hardly thrown light on the
early onset of hypertension. Furthermore, the awareness of threatening
factors of hypertension has been greatly derived from data provided
by developed countries; nevertheless, the expression or suppression of
anger may vary from country to country due to cultural factors.
Investigators are doubtful about the findings obtained from European
societies and their application in rest of the world is questionable. In
Pakistan, especially, this phenomenon has rarely been studied and
researches conducted in this area are based upon the data drawn from
lower masses only (Jafar et al., 2006).
Regardless of its significance, psychological aspects of
hypertension have been ignored by researchers. Hereditary and
biological factors of hypertension have always been over-emphasized
by physicians and medical specialists, but the role of anger as a
psychological risk factor have been ignored in Pakistan. Therefore, the
current research would be the first and unique one to investigate the
relationship between components of anger and hypertension among
Pakistani men and women belonging to middle class. Studying the
prevalence of anger among hypertensive men and women and its
predictive role in hypertension are the main objectives of present
Previous research data related to the subject provides the
evidence of researches using only correlational design by employing
participants with hypertensive only. However, case control research
design was employed in the present research to compare both groups
on all dimensions of anger, which is considered a standardized method
for studies (Sparrenberger et al., 2009). The following hypotheses
were formulated keeping in view the objectives of the study.
1. There is positive relationship between components of anger
and hypertension.
2. Key components of anger are the positive predictors of
3. Men with hypertension experience more anger on all
components of anger than women with hypertension.
The data (N = 237) were collected outdoor departments of public
hospitals from the two major public hospitals by using purposive
sampling technique.
Inclusion criteria for hypertensive patients was (a) participants
who had the confirmed diagnosis of hypertension; (b) who had been
currently taking medicines for hypertension; (c) who were able to read
and write Urdu language; and (d) patients who were not suffering
from any terminal illness or chronic disease including, renal disease,
cancer, coronary heart disease, liver disease and history of any
psychiatric diagnosis or psychiatric medication and pregnant women
with high blood pressure complaints.
Non-hypertensive group was matched to every case of
hypertension for age (up to 3 years older and younger), gender,
monthly income and working hours. Non-hypertensive group was
taken from the hospitals. (a) They were not the siblings, children or
parents of the cases diagnosed with hypertension; (b) they were not
diagnosed with hypertension; and (c) with no past or current family
history of hypertension were included in the non-hypertensive group.
Sample characteristics of hypertensive patients. Age range of
hypertensive patients was from 30 to 65 years (M = 45; SD = 8.37).
Their monthly income was ranged from Rs. 15000 to 85000,
(M = 28219; SD = 14440.91). Their monthly expenditures ranged
from Rs. 15000 to 85000 (M = 40212, SD = 16523).The weight of the
hypertensive patients ranged from 56 to 100 kg (M = 83; SD = 9.83),
and their height ranged from 4.08 to 6.08 feet, (M = 5.39; SD = .29).
The working hours of the respondents were ranged from 1 to 20 hours
(M = 10.77; SD = 4.08).
Sample characteristics of non-hypertensive control group.
The age range of cases controls (non-hypertensive group) was from 30
to 65 years (M = 46; SD = 8.86). The monthly expenditures of the
participants were ranged from Rs. 17000 to 83000, (M = 29190; SD
= 14821.87). Their monthly expenditures ranged from Rs. 15055 to
87500 (M = 30415, SD = 15527). The weight of the case controls was
ranged from 56 to 100 kg (M = 74; SD = 8.13), and their height
ranged from 5.03 to 6.10 feet, (M = 5.65; SD = .35). The working
hours of the cases controls were ranged from 4 to 17 hours (M = 7.89;
SD = 3.12).
Table 1
Demographic Characteristics of the Sample (N=237)
Demographic Variables Hypertensive
(n = 137)
(n = 100)
f % f %
Males 77 56 50 50
Females 60 44 50 50
Up to matric 70 51 53 53
Up to M.A/M Sc. 55 40 40 40
Up to Ph.D 12 9 7 7
No Job 48 35 42 42
Demographic Variables Hypertensive
(n = 137)
(n = 100)
f % f %
Job 64 47 36 36
Business 12 09 15 15
Job and business 13 09 8 8
New in city
No 50 36 83 83
Yes 87 64 17 17
Family history of hypertension
No 16 12 90 90
Yes 121 88 10 10
Family system
Joint 119 87 15 15
Nuclear 18 13 85 85
Demographic Information Form. We developed a
demographic information form to gather information about age,
education, occupation, number of children, number of dependents,
monthly income, monthly expenditures, height and weight, family
history of hypertension, spouse job, family system, hospital visits, and
working hours of the research participants.
State Trait-anger Expression Inventory. It was originally
developed by Spielberger (1988) consisting of 44 items. The
respondents can obtain scores from 44 to76. Higher scores show
higher level of anger in all cases. The items are divided into six
subscales and overall anger which are State-anger, Trait-anger, Anger-
in, Anger-Out, Anger-control and Anger Expression. State-anger and
Trait-anger subscales contain 10 items each. Anger-in, Anger-Out,
and Anger-control contain 8 items each. Anger-expression is an
overall index of anger-in, anger-out and anger-control. Each item has
four response categories representing 4-point Likert scale, ranging
from 1 (never) to 4 (very often). Spielberger reported that State Trait-
anger Expression Inventory (STAXI) has high internal consistency
with Cronbach’s α = .95. Urdu version was prepared by the researcher
and used in the present research (Mushtaq, 2012).
Permission was obtained from administration of two public
hospitals for data collection and from author of the scale. Consent
from the participants suffering from hypertension and healthy controls
was sought to participate in present study. Initially, rapport was
established by assuring them about the discretion of their personal
information and that it would be used for research purpose only.
Before administration of Urdu version of STAXI (1988), participants
were briefed about the nature and purpose of the study. A
demographic information form and STAXI were individually
administered to all research participants.
Total 300 individuals were approached and 237 gave their
consent to take part in the research. Participants were not given
monetary compensation for their participation. They were only
verbally told the likely benefits the research would impart to the
society and may be the future generations could be saved from
becoming hypertensive. Many patients who initially refused to
participate in the research after this brief description got ready to take
part. Many participants were eager to know their scores on
components of anger which was provided to them by making
individual telephone calls. The sample was drawn from outdoors of
Descriptive statistics was used to calculate the preliminary profile
of the sample characteristics. Mentel Haenzel Test of Linear
Association (MHTLA) was run to explore the relationship between
components of anger and hypertension. Binary Logistic Regression
Models were used to identify subscales of anger as predictors of
hypertension. Independent sample t-test was employed to examine
differences on anger subscales between hypertensive men and women.
Relationship between Anger and Hypertension
MHTLA was applied for exploring the relationship between
different measures of STAXI and hypertension. If the exposure
variable is ordinal, the ordinary chi-square test does not take into
account the inherent order among the categories. It hardly checks the
overall departure of observed from expected across the cells of the
table. A test of linear association (Pearson Chi-square) between
columns and rows will be statistically insufficient, because it fails to
distinguish between one and two category differences (Hanif, Ahmed,
& Ahmed, 2006). MHTLA is considered statistically more powerful
test which gives smaller p-value if the relationship is significant as
compared to Chi-Square test. In case of categorical outcome variable,
it has been observed that MHTLA provides better results than Chi-
square Test of Association.
Table 2
Relationship between Subscales of Anger and Hypertension (N = 237)
Variables No of items α M SD χ2
State-anger 10 .94 15.19 6.31 81.79**
Trait-anger 10 .74 20.17 8.46 75.05**
Anger-in 8 .87 16.77 7.84 101.36**
Anger-out 8 .71 14.58 5.29 -24.83
Anger-control 8 .81 19.63 8.41 67.44**
Anger expression - - 15.19 8.32 .77
Total anger 44 .80 104.50 38.30 147.35**
**p < .01. df = 1; χ2 MH = Mantle Haenzel Chi-square; α = reliability coefficient
The chi-square values of Mantle Haenzel Linear Association
given in Table 2 indicate that State-anger, trait-anger, Anger-in,
Anger-control and total Anger are significantly positively correlated
with hypertension, whereas, Anger-Out is negatively correlated with
hypertension but relationship is statistically non-significant.
Predictors of Hypertension
A logistic regression analysis was carried out to find the
subscales of anger as predictors of hypertension, which included
State-anger, Trait-anger, Anger-in, Anger-control, and Anger.
Hypertension was taken as dependent variable and dichotomized into
two groups based upon their being hypertensive or not hypertensive
and were coded as: Non-hypertensive = 0, and hypertensive = 1.
Anger and its subscales were taken as independent and ordinal
Table 3
Logistic Regression Analysis to Examine Components of Anger as
Risk Factors (predictors) of Hypertension (N = 237)
Variable B S.E Wald p 95% CI
Constant -3.38 .97
State-anger .24** .07 10.35 .001 1.09 1.47
Trait-anger .15* .06 5.69 .017 1.02 1.32
Anger-in .17** .05 9.54 .002 1.06 1.33
Anger-control .14* .04 8.46 .035 1.00 1.21
Anger .61** .19 10.55 .001 1.27 2.69
Note. B = standardized coefficient; CI = Confidence Interval; LL = Lower Limit;
UL = Upper Limit.
= 55.23; Hosmer & Lemeshow = 10.74; Cox & Snell = .4; Negelkerke = .67;
Model χ2 (21) = 51.60.
*p < .05. **p < .01.
The prediction value of R2 = 55.23 in Table 3 shows that model is
adequately fit and anger and its subscales are contributing 55.23 % in
the hypertension disease. The odds ratio for State-anger is 1.27 and
coefficient is positive. Therefore, as the State-anger increases by one
scale unit, chances of hypertension in a person increased 1.27 times.
The odds ratio for Trait-anger is 1.16 and coefficient is positive, so
each unit increase in the scores of Trait-anger is associated with the
odds of hypertension increase by a factor of 1.16. The odds ratio for
Anger-in is 1.19 and coefficient is positive, consequently, as the
Anger-in increases by one scale unit, chances of hypertension in a
person is increased 1.19 times. The odds ratio for Anger-control is
1.10 and coefficient in positive. So, each unit increase in the scores of
Anger-control is associated with the odds of hypertension increase by
a factor of 1.10. The odds ratio for Anger is 1.85 and the coefficient is
positive, therefore as the Anger increases by one scale unit, chances of
hypertension in an individual is increased 1.85 times. Thus, State-
anger, Trait-anger, Anger-in, Anger-control, and Anger are
significantly predicting hypertension progression.
Gender Differences on Anger
To measure gender differences in anger among hypertensive
group, Independent sample t-test was computed.
Table 4
Mean Scores and Standard Deviations for STAXI between
Hypertensive Men and Women (N=137)
(n = 77) Women
(n = 60)
95% CI
Variables M(SD) M(SD) t(135) Cohen’s d LL UL
State-anger 21.90(5.45) 13.76(4.82) 9.11*** 1.56 6.37 9.91
Trait-anger 17.70(5.84) 29.33(5.91) 11.47*** 1.97 9.63 13.64
Anger in 25.77(5.76) 15.21(3.18) 12.75*** 2.19 8.92 12.20
Anger out 14.51(5.02) 10.98(3.15) 3.98*** .68 1.61 4.79
A/CON 17.98(4.02) 27.75(5.06) 12.58*** 2.16 8.23 11.30
A/X 28.54(7.02) 24.55(5.87) 3.54** .60 1.76 6.22
Anger 147.84(17.57) 100.53(20.30) 14.60*** 2.51 40.90 53.71
Note. CI = confidence interval; LL = Lower Limit; UL = Upper Limit; A/CON = Anger-control;
A/X = Anger-Expression.
**p < .01. ***p < .001.
As shown in the Table 4, gender differences in mean scores for
State-anger, Trait-anger, Anger-in, Anger-Out, Anger-Expression and
Anger are statistically significant. Men express more State-anger,
Anger-in, Anger-Out, Anger-Expression and Anger as compared to
women. Women exhibit higher levels of Trait-anger and Anger-
control than men. The values of Cohen’s d indicate that Anger-in, and
Anger have larger affect on hypertensive men as compared to
hypertensive women, whereas Anger-control has greater affect on
hypertensive women than hypertensive men.
The present study has sought the relationship of anger with
hypertension. The results indicate the relationship of hypertension
with State-anger, Trait-anger, Anger-in, Anger-control, and Anger is
statistically significant.
Further, present research showed that state-anger is significantly
correlated and predicts hypertension. Gupta Joshi, Mohan, Reddy, and
Yusuf (2008) elaborate the factors which lead angry individual
towards developing hypertension. Those factors are irrational
perceptions of reality and four types of thinking styles which are
emotional reasoning (emotional misinterpreting normal events and
tend to become irritated), low frustration tolerance, unreasonable
expectations, and evaluations of other people. The external factors of
anger include verbal abuses, attack one’s ideas, threat to one’s needs,
and frustrations. Other causes of anger are frustration, disappointment,
and feelings of powerlessness, unfulfilled expectations, annoyance,
harassment, and rejection. Thus, it can be concluded that low
frustration tolerance and external factors leads them immediately to
enrage or become furious in present situation, experiencing state-
anger. This finding is corroborated with other researches conducted in
Europe which conclude that hypertensive patients experience more
state-anger than normal individuals (Everson, Goldberg, Kaplan,
Julkunen, & Salonen, 1997; Porter, Stone, & Schwartz, 1999). It is
also observed that individuals with state-anger experience intense
anger which may be expressed as a wish to yell at others or to break
things. According to Spielberger (1988), during this state of anger
there is moderate to severe activation in the sympathetic nervous
system of the individuals. We may conclude that due to this activation
of autonomous nervous system they immediately get enraged. These
individuals are impulsive in reaction to anger provoking situations.
The finding further supported the hypothesis that trait-anger is
statistically significant in hypertensive patients and predicts
hypertension. Trait-anger is defined in terms of variation from person
to person in the frequency of occurrence that state-anger is
experienced occasionally. Trait-anger can rightly be called intense
fury with greater frequency of occurrence and the individuals with this
trait might easily become victims of hypertension (Spielberger, 1988).
This result coincides with previous researches which have stated that
trait-anger in adults was associated with increased risk of developing
hypertension. By and large, trait-anger assesses an individual’s
general personality predisposition to become furious easily. It is
manifested among individuals who have overall confrontational or
argumentative personality makeup. According to Spielberger (1988),
if individual thinks that he/she is mistreated by others or criticized by
others, he/she is experiencing trait-anger. Hypertension predicted by
trait-anger is also reported by earlier finding (Williams et al., 2002).
Furthermore, the results reveal that anger-in or anger suppression
is statistically significant in hypertensive patients and anger-in also
predicts hypertension. If the individual holds in or suppress anger
when passing through resentful situation, it is called anger-in.
Hypertensive patients cannot express their anger related impulses in a
healthy way, rather they try to suppress these impulses. There is
sufficient empirical evidence which suggest that anger suppression is
significantly related with hypertension (Cottington, Matthews,
Talbott, & Kuller 1986; Ghosh & Sharma, 1998; Pickering, 2007;
Schneider Egan, Johnson, Dronby, & Julius., 1986; Vogele et al.,
1997; Webb & Beckstead, 2001). Moreover, strong association of
anger suppression with hypertension has been found by previous
researches (Alexander, 1939; Pickering, 2007; Rutelage & Hogan,
2002). There is widespread uniformity in the results drawn by
researches all over the world that psychological anger is responsible
for developing hypertension (Everson et al., 1997; Player et al., 2007).
The findings from an earlier study argued that the hypertension is
an emotional disease and many psychological variables especially
anger control is a major factor in developing hypertension (Rosen &
Gregory, 1965). This explanation is in accordance with state and trait
theory presented by Spielberger (2005) which states that hypertensive
individuals possess trait-anger and wants to express it, however, due
to some reasons they could not express their anger, and are forced to
control it. This suppressing of anger or anger control leads reactivity
in their nervous system which ultimately causes different diseases, one
of them is hypertension. Earlier in 1939, Alexander explains that
controlling anger would result in increase in blood pressure and cause
hypertension to develop.
The current results further suggest statistically significant
differences on different components of state-anger, trait-anger, anger-
in, anger-out, anger-control, anger- expression and anger as reported
by hypertensive men and women. It has been noticed that the
hypertensive men reported more anger than hypertensive women in
the current research project. This research finding is corroborative
with the Matthews et al. (2004) that delineated the incidence of
significantly more anger in men. Therefore, the difference on
psychological anger between men and women was statistically
significant. It is worldwide established that anger is a strong risk
factor of hypertension in men than in women (Chida & Steptoe,
2009). In a research, anger-in was significantly found in men as
compared to women (Harburg, Julius, Kaciroti, Gleiberman, & Schork
2003). Trait-anger was found to be more prevalent among women in
the present research. It is also globally established that women express
more trait-anger as compared to men (Raikkonen, Matthews, Flory, &
Owens, 1999). Furthermore, men in the present research obtained high
scores on state-anger and anger-out that corroborates with previous
researches (Spielberger et al., 1988). In fact, a close relationship exists
between trait-anger and anger. Trait-anger and anger-control are found
more significantly associated with women as compared to men
coincides with early findings (Spielberger, Reheiser, & Sydeman,
Limitations and Suggestions
The main limitation of the current research was that the present
study was carried out with a small sample which may not be
considered exact representative of entire hypertensive population. It
may be a threat to the external validity of this research. Another main
limitation was that BMI was not calculated in the present research.
BMI could have given more comprehensive results regarding the role
of physical conditions in developing hypertension. Another limitation
of the current research was the use of self-report scales which might
have resulted in under reporting or over reporting due to the nature of
the disease they were suffering from. Therefore, it is recommended
that in future researches focus group and interview techniques must
also be conducted in addition to self-report questionnaires to gather
more wide-ranging information about the degree and nature of anger
assessment among men and women hypertensive patients. Moderating
role of gender in the relationship between anger and hypertension is
also strongly recommended to examine in future researches.
The investigation regarding role of anger in developing
hypertension is an important area of the present research. The early
identification of anger and its suppression in developing hypertension
in America has yielded some promising results in treating it. The
results can be highlighted through media and public health awareness
programs. Understanding the psychological causes of hypertension
could open up lines of scientific inquiry and to investigate the
heterogeneity of outcome, when measured across multiple dimensions
of anger.
The findings of this research have implications for promoting our
understanding regarding role of anger as a major predictor of
hypertension in Pakistani population in order to introduce effective
preventive measures and to reduce the prevalence of hypertension.
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Received March 25, 2013
Revision received April 23, 2014
... All the studies were observational in nature; 7 (18.9%) were case-control [30][31][32][33][34][35][36] and 30 (81.1%) were cross-sectional. They were conducted in various regions across Pakistan and were published between 1980 and 2019. ...
... Another study [46] used a cutoff value of BP � 160/90 mm Hg for children aged 5-10 years and BP � 165/90 mm Hg for adults aged 20-60 years. Four studies enrolled previously diagnosed cases of hypertension without specifying the standard methods used for diagnoses [32][33][34][35] (S1 Table). ...
... Of 37 studies, 13 (35.1%; 7 cross-sectional: [40,41,45,52,57,61,66] and 7 case-control: [30,31,[33][34][35][36]46]) scored at least 7 points out of 9 on NOQAS [25] and were considered high-quality. The median score was 6 (range: 4-8). ...
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Background High blood pressure is an important public health concern and the leading risk factor for global mortality and morbidity. To assess the implications of this condition, we aimed to review the existing literature and study the factors that are significantly associated with hypertension in the Pakistani population. Methods We conducted several electronic searches in PubMed, ISI Web of Science, PsycINFO, EMBASE, Scopus, Elsevier, and manually searched the citations of published articles on hypertension from May 2019 to August 2019. We included all studies that examined factors associated with hypertension regardless of the study design. To assess the quality of the research, we used the Newcastle-Ottawa Quality Assessment Scale. We also conducted meta-analyses using the DerSimonian & Laird random-effects model to collate results from at least three studies. Results We included 30 cross-sectional and 7 case-control studies (99,391 participants country-wide) in this review and found 13 (35.1%) to be high-quality studies. We identified 5 socio-demographic, 3 lifestyle, 3 health-related, and 4 psychological variables that were significantly associated with hypertension. Adults aged between 30–60 years who were married, living in urban areas with high incomes, used tobacco, had a family history of hypertension, and had comorbidities (overweight, obesity, diabetes, anxiety, stress, and anger management issues) were positively associated with hypertension. On the other hand, individuals having high education levels, normal physical activity, and unrestricted salt in their diet were negatively associated with hypertension. Conclusion We found several socio-demographic, lifestyle, health-related, and psychological factors that were significantly (positively and negatively) associated with hypertension. Our findings may help physicians and public health workers to identify high-risk groups and recommend appropriate prevention strategies. Further research is warranted to investigate these factors rigorously and collate global evidence on the same.
... Sometimes the person also experiences anger. 15 If the situation comes again and again the persistent increase would cause them to suffer from hypertension. ...
ABSTRACT… The literature review portrays a reasonable picture of the role of certain coping strategies in developing hypertension. Objectives: Present research based on self-regulation theory explored correlation of coping strategies of stress with hypertension. Design: Cross sectional research design. Setting: Shaikh Zayed Hospital, Services Hospital, Ganga Ram Hospital, Lahore. Period: June 2010 to June 2011. Method & material: Sample (N = 400) outdoor hypertensive males (N = 100) and hypertensive females (N = 100) between ages 30-60, and their age matched healthy controls (N= 200, 100 males, 100 females) were taken from 3 hospitals. Measures: Brief COPE scale was used to measure coping strategies. Analysis: Chi-square and logistic regression analysis were carried out. Results: Significant positive correlation of hypertension with active coping, substance use, instrumental support, positive reframing, acceptance, and self-blame was found and active coping, acceptance, instrumental social support and self-blame coping strategies appeared as significant predictors of hypertension.
... Findings demonstrated that participants understood the medical importance of treating and controlling hypertension and were aware of long-term physical and mental risks associated with the condition. Similar to participants in other studies, interviewees demonstrated a colloquial understanding of biological, lifestyle, and psychological predictors of hypertension, including heredity [22], diet and exercise [23], anger or "bad blood" [24], and occupational stress [25]. In addition to confirming findings in previous research, this study adds new findings to the literature regarding hypertension-related health beliefs and practices of Dominicans from a low resource community. ...
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Understanding health beliefs is important to facilitate health promotion and disease prevention as they influence health behaviors, outcomes, and disease management. Given the rise of hypertension-related diseases in the Dominican Republic, the purpose of our study was to identify hypertension-related health beliefs of Dominicans in order to inform the development of culturally appropriate interventions for hypertension prevention, care, and treatment. Semi-structured interviews were conducted with 20 Dominicans, 15 of whom were receiving treatment for hypertension. Operating within the interpretative paradigmatic framework, we conducted thematic analyses of interview data to identify hypertension-related health beliefs and practices. Iterative data analysis revealed the following themes: 1) Negative emotions are a primary cause of hypertension, 2) Medication is the best treatment but adherence is challenging, 3) Systemic barriers impede treatment access, 4) Hypertension negatively impacts mental and physical well-being, and 5) Lifestyle changes, relaxation, and social support help manage hypertension. Data gathered from member checking validated these findings. This study enhances understanding of the beliefs and experiences of Dominicans and emphasize the importance of implementing culturally competent health programming and care.
... Case study-I The 1st study data has been taken from [13]. We are interested to estimate the population mean for the study variable (Expenditure) by incorporating auxiliary information. ...
In this paper, single-phase mixture regression cum ratio estimators are presented by utilizing auxiliary variables and auxiliary attributes simultaneously under stratified random sampling. Special cases of these estimators are discussed and further mean square errors are extracted mathematically. Also, to observe the properties of proposed estimators, simulation technique is used which shows that the distribution of the proposed estimators is approximately normal. To differentiate the performance of the proposed estimators, an empirical study has been conducted by incorporating quantitative and qualitative characteristics in the form of auxiliary attributes and variables simultaneously. Comparisons are made with single-phase mixture regression cum ratio estimators under simple random sampling. It has been found that the mixture regression cum ratio estimators employing multiple auxiliary variables and attributes, simultaneously, under stratified random sampling are more efficient than mixture regression cum ratio estimator under simple random sampling.
... In the case of anxiety on the other hand, there are more data in support of (Bajkó et al., 2012;Uceda et al., 2013;Yu et al., 2015) than against (Yan et al. 2004) such association. The findings on anger have been more in favor of (Mushtaq & Najam, 2014;Sahraian et al., 2015;Yan et al., 2004) than opposed (Uceda, et al. 2013) such association between this particular negative affect and HTN. ...
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Research on the relationship between hypertension and variables linked to negative affectivity has given rise to divergent findings and differing interpretations. The main objective of this paper was therefore to shed light on the issue by analyzing measures of depression, anxiety and anger in adults suffering from hypertension (HTN). Based on a case-control design, a group of individuals suffering from HTN (n=50) was compared with a control group of the same number of cases, age and sex. In general, the HTN Group showed higher levels of depression in its somatic dimension and of trait anger in its temperament dimension. Individuals with HTN presented symptoms of irritability and loss of energy (depressive-somatic symptoms) and propensity to anger easily (temperament anger symptoms). It has been demonstrated in preceding researches that addressing these comorbid psychological factors is of importance in increase adherence to medical treatment in patients who have been diagnosed with hypertension or similar pathologies.
... No obstante, si bien en una serie de estudios se ha encontrado evidencia a favor de dicha hipótesis (véase, por ejemplo, la revisión de Kaplan & Nunes, 2003, o el metaanálisis de Rutledge & Hogan, 2002), los resultados no son consistentes. En algunas investigaciones más actuales se ha encontrado, por ejemplo, para la depresión, más evidencia en contra (Bajkó et al., 2012;Uceda, Sanz-Fernández, Espinosa-López & García-Vera, 2013;Yan et al., 2004) que a favor (Meyer, Armenian, Eaton & Ford, 2004) de dicha hipótesis; mientras que para la ansiedad hay más datos favorables (Bajkó et al., 2012;Uceda et al., 2013;Yu et al., 2015) que desfavorables (Yan et al., 2004) respecto a ella; al igual que en el estudio de la ira, donde han sido más los resultados en favor (Mushtaq & Najam, 2014;Sahraian et al., 2015;Yan et al., 2004) que en contra (Uceda et al., 2013). ...
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En la literatura científica se encuentra un gran número de controversias y resultados dispares a la hora de explicar la relación entre la hipertensión arterial y algunas variables vinculadas a la afectividad negativa, como la depresión, la ansiedad y la ira. Teniendo esto en cuenta, en la presente investigación se planteó como objetivo principal analizar medidas de ansiedad, depresión e ira en personas adultas que padecen de hipertensión arterial (HTA). A partir de un diseño de caso-control, se contrastaron dos grupos, uno conformado por personas con HTA (n = 50) y otro de control equiparado en número de casos, edad y sexo. A nivel general, el grupo de HTA mostró mayores niveles de depresión (en su dimensión somática) y de ira-rasgo (en su dimensión de temperamento). Asimismo, las personas con HTA presentaron síntomas de irritabilidad y pérdida de energía (síntomas depresivo-somáticos), además de que tendían a enojarse con facilidad o rápidamente (síntomas de temperamento de ira). El abordaje de estos factores psicológicos comórbidos resulta de relevancia dado que en estudios precedentes ha demostrado aumentar la adherencia al tratamiento médico en pacientes que han sido diagnosticados con hipertensión o patologías similares.
... Although suppression of emotion can be adaptive under some circumstances, when used consistently and inflexibly it becomes maladaptive (Gillath, Bunge, Shaver, Wendelken, & Mikulincer, 2005). Furthermore, emotion suppression has been linked to a variety of aversive health outcomes such as hypertension (Mushtaq & Najam, 2014), higher pain experience (Quartana & Burns, 2007), and reduced responsivity to pain management (Burns et al., 1998). As suppression takes place toward the end of the emotion-generative process, it also fails to alleviate the full experience of negative emotion (John & Gross, 2004). ...
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Attachment insecurity has been associated with dysfunctional strategies for emotion regulation, leading to inflexible or maladaptive responding. Currently, application of the attachment framework to anger is underspecified. This study presents a preliminary investigation of attachment-related differences in the dispositional regulation of anger and aggressive outcomes. 270 participants completed measures of adult attachment (attachment anxiety and attachment avoidance), anger regulation processes (anger suppression, unregulated anger and anger control) and aggressive outcomes (physical aggression, verbal aggression and hostility). While those high in attachment anxiety have been found to under-regulate other negative emotions, our results postulate that these individuals may implement a suppression strategy when faced with the experience of anger. Mediation models indicate that anger suppression is implicated in the relationship between attachment dimensions and hostility, but not physical aggression. This supports the notion that suppression may be useful in reducing the external expression of anger, but cannot alleviate the associated internal cognitions. These findings suggest that levels of attachment anxiety and avoidance should be considered when identifying techniques to target specific anger regulatory difficulties that contribute to increased aggression. Further, consideration and exploration of the role of security priming is encouraged as a possible mechanism by which to reduce dispositional hostility in those with high levels of attachment insecurity.
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Unlabelled: Emotional dampening (blunted responses to affective stimuli or experiences) has been reported in individuals with clinical and subclinical levels of elevated blood pressure (BP). Our aim in the present study was to explore how the basic motivational systems of approach and avoidance to positively- and negatively-valenced stimuli are affected in elevated BP. High BP (n = 27) and Low BP (n = 29) participants completed an approach-avoidance task. In this task, participants pulled the joystick towards them when viewing a happy face (approach) and pushing it away when viewing an angry face (avoid) in the congruent condition, and reversed these action-to-emotion pairings in the incongruent condition. A mixed-design ANOVA revealed a significant main effect of condition, such that overall participants were faster across trials in the congruent than trials of the incongruent condition. There was also an emotion x BP interaction. Among the Low BP group, there were no RT differences to happy and angry expressions (across congruent and incongruent conditions) but those with High BP were quicker to respond to actions paired with angry than happy facial expressions (across conditions). Findings suggest that valence-specific motivational reactions are not dampened with an increase in BP, and are rather sensitized for the negative emotion of anger. Supplementary information: The online version contains supplementary material available at 10.1007/s12144-023-04337-2.
Background Higher trait anger has inconsistently been associated with hypertension and hypertension development, but social context in terms of recognition of other persons’ anger has been neglected in this context. Purpose Here, we investigated anger recognition of facial affect and trait anger in essential hypertensive and normotensive men in addition to prospective associations with blood pressure (BP) increases. Methods Baseline assessment comprised a total of 145 participants including 57 essential hypertensive and 65 normotensive men who were otherwise healthy and medication-free. Seventy-two eligible participants additionally completed follow-up assessment 3.1 (±0.08 SEM) years later to analyze BP changes over time. We assessed emotion recognition of facial affect with a paradigm displaying mixed facial affect of two morphed basic emotions including anger, fear, sadness, and happiness. Trait anger was assessed with the Spielberger trait anger scale. Results Cross-sectionally, we found that with increasing BP, hypertensive men overrated anger displayed in facial expressions of mixed emotions as compared to normotensive men (ps ≤ .019) while there were no differences in trait anger (p = .16). Prospectively, the interaction between mean anger recognition and trait anger independently predicted BP increases from baseline to follow-up (ps ≤ .043), in that overrating displayed anger predicted future BP increases only if trait anger was high. Conclusions Our findings indicate an anger recognition bias in men with essential hypertension and that overrating displayed anger in combination with higher trait anger seems to predict future BP increases. This might be of clinical relevance for the development and progression of hypertension and cardiovascular disease.
Objectives The study aims to test novel proposed biocultural pathways linking the stressful lived experience of water insecurity to elevated blood pressure, a risk factor for chronic disease. Using the case of Nepal, where women have primary responsibility for managing household water, allows testing for potentially gendered mechanisms that exacerbate negative physiological consequences of water insecurity for women relative to men. Methods Data are from the nationally representative 2016 Nepal Demographic and Health Survey (DHS), N = 8633 women and 6209 men. Multiple regression models tested effects of low household water access on systolic and diastolic blood pressure, as stress biomarkers, comparing women to men. Key covariates included HFIAS food insecurity scores, household wealth class (high, medium, low), and body mass index. Results In this cross‐sectional study, low water access was consistently associated with higher women's systolic and diastolic blood pressure across all wealth levels. The strongest results were for the lowest wealth households, where low water access is concentrated. Higher food insecurity was also associated with higher systolic blood pressure values in women in these households. Men showed no such effects. Conclusions This is the first study, to our knowledge, to demonstrate a consistent and direct association between living with water insecurity and elevated blood pressure measures. Findings support the proposition that the stress of living with water insecurity could manifest as chronic disease risk. In the Nepali case, the proposed mechanism appears highly gendered, reflecting the culturally prescribed responsibilities women particularly face for managing household water. Living with food insecurity compounds further the apparent effects.
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Psychological distress is the combined effect of depression, anxiety, and stress. The present study explored the variables like psychological distress (depression, anxiety, stress) and components of anger as predictors of hypertension development. Total sample of 360 participants, outdoor hypertensive patients N = 216 between ages 30-60, and their age-matched healthy control group N= 144, was taken from outdoor departments of three public hospitals by using a purposive sampling technique. Protocols used in the study were; DASS (Lovibond & Lovibond, 1995); Urdu version (Potangaroa, 2006); and STAXI (Spielberger, 1988). Mantle Haenzel test of linear association, logistic regression, and independent samples t-test was carried out for data analysis. The results indicate a significant correlation between psychological distress and hypertension (χ2MH =79.95, p<. 001). Depression, anxiety, stress, state anger, trait anger, anger-in, anger-control, anger expression, and anger turned out to be the strongest predictors of hypertension. The result also shows significant differences in depression, anxiety stress, and anger between hypertensive and non-hypertensive groups.
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Growing evidence suggests high levels of comorbidity between hypertension and mental illness but there are few data from low- and middle-income countries. We examined the association between hypertension and depression and anxiety in South Africa. Data come from a nationally-representative survey of adults (n = 4351). The Composite International Diagnostic Interview was used to measure DSM-IV mental disorders during the previous 12-months. The relationships between self-reported hypertension and anxiety disorders, depressive disorders and comorbid anxiety-depression were assessed after adjustment for participant characteristics including experience of trauma and other chronic physical conditions. Overall 16.7% reported a previous medical diagnosis of hypertension, and 8.1% and 4.9% were found to have a 12-month anxiety or depressive disorder, respectively. In adjusted analyses, hypertension diagnosis was associated with 12-month anxiety disorders [Odds ratio (OR) = 1.55, 95% Confidence interval (CI) = 1.10-2.18] but not 12-month depressive disorders or 12-month comorbid anxiety-depression. Hypertension in the absence of other chronic physical conditions was not associated with any of the 12-month mental health outcomes (p-values all <0.05), while being diagnosed with both hypertension and another chronic physical condition were associated with 12-month anxiety disorders (OR = 2.25, 95% CI = 1.46-3.45), but not 12-month depressive disorders or comorbid anxiety-depression. These are the first population-based estimates to demonstrate an association between hypertension and mental disorders in sub-Saharan Africa. Further investigation is needed into role of traumatic life events in the aetiology of hypertension as well as the temporality of the association between hypertension and mental disorders.
In this chapter, Spielberger, Krasner, and Solomon concentrate upon the sensation that is called anger, hostility, or aggression. They liken anger to a state emotion and hostility to a trait, whereas the label aggression is reserved for the behavioral expression of the first two. They refer to the structure of these three concepts as the AHA! Syndrome. The chapter begins with a thorough review of the history of the relationship between anger and psychosomatics. Also featured is a discussion of the role of anger in the Type A behavior pattern and on the nature of anger itself. Following a brief review of the history of attempts to measure hostility and anger, we are introduced to the State-Trait Anger Scale (STAS) developed by Spielberger and his colleagues. The authors then provide an in-depth review of research and thinking on the nature of the expression of anger; that is, whether it is directed inward (suppressed) or outward (expressed). The nature and meaning of the control of anger is also reviewed. We are presented with the principal psychometric data related to the development of the Anger Expression Scale (AX), which measures anger-in, anger-out, and anger-control. In concluding, the authors explain the need for scales such as the STAS and AX and describe their usefulness in individual difference and health research.
Hypertension represents a critical health problem for African American women in the United States. The purpose of this study was to evaluate the influence of anger suppression on blood pressure, perceptions of strain, abdominal adiposity, and physical activity levels of 90 employed African American women. Measures for the study included (1) the State-Trait Anger Expression Inventory, (2) abdominal adiposity (waist, waist/hip ratio), (3) Paffenberger Physical Activity Questionnaire, (4) Personal Strain Inventory, and (5) blood pressure. Correlation coefficients were used to evaluate the relationships among the study variables; ANOVAS were used to test for significant differences between women classified as hypertensive (defined as a SBP ≥ 140 mmHg, or a DBP ≥ 90 mmHG, or use of hypertensive medications) or normotensive. Forty-three women were classified as hypertensive; 47 were normotensive. Anger suppression was significantly related to DBP, abdominal adiposity, physical activity level, and feelings of physical and psychological strain. The hypertensive women had significantly higher levels of SBP, DBP, anger suppression, abdominal adiposity, and lower levels of physical activity. The findings suggest that African American women may benefit by further education regarding the influence of anger on blood pressure elevation. Efficacy of interventions to assist in therapeutic methods of anger diffusion should be evaluated.
Using a sample of 445 female and 260 male college students, we investigated relationships between the experience and expression of anger and gender, gender role characteristics, and several mental health variables. Factor analyses of 17 measures of anger, aggressiveness, and hostility revealed a 3-factor pattern of aggressive acting-out, high anger proneness and poorly controlled verbally expressed anger, and anger suppression. Correlational and hierarchical regression analyses indicated that the anger composites were strong predictors of the mental health variables. Masculinity, but not femininity or androgyny, also made fairly consistent unique contributions to the prediction of the mental health variables. Gender did not uniquely contribute to the prediction of any of the mental health variables, nor did it moderate the relationships of these variables with other predictors. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Research has established the influence of serum cholesterol and anger management style as cardiovascular risk factors. However, mixed and sometimes contradictory results have created uncertainty with respect to contributions of anger. Some incongruities may be accounted for on the basis of gender differences since a number of studies have employed male samples rather than female samples or mixed samples. The present study examined both gender and anger management style in relation to cardiovascular risk. One hundred three (72 men and 31 women) midlevel executives completed questionnaires and a blood draw during a week long, succession training program within a large international organization. Gender, anger expression, and anger expressed outward were significant predictors for levels of high-density lipids, low-density lipids/very low-density lipids, and triglycerides, and cardiovascular risk ratios. Results replicate and extend previous research. Anger held inward and anger control were significant for men but not women, contrary to earlier gender-specific findings.