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Anger expression and suppression among patients with essential hypertension

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Anger expression and suppression among patients with essential hypertension

Abstract

Hypertension (HTN) is among the seven psychosomatic diseases for which mental etiologies were proposed in 1950s. The objective of this study was to evaluate the rate of anger suppression and expression in individuals with hypertension referred to the heart clinic of "Fatemeh Zahra" Hospital, Sari, Iran. 200 patients with primary hypertension were categorized as the case group. One hundred healthy individuals older than 30 years without previous history of arterial hypertension and severe mental disorders were considered as the control group. Both groups were matched in terms of age, gender and level of education. The Spielberger questionnaire was used to assess the trait anger, anger in and anger out. The data were analyzed using SPSS software with statistical tests such as t-test, chi-square and regression. The trait anger and anger suppression in patients with hypertension were significantly higher than the control group (P < 0.001); however, anger out was not significantly different between the two groups (P = 0.984). Considering the fact that trait anger and anger suppression is more prevalent among people with hypertension than healthy individuals, it seems suitable to provide education concerning anger management and emotional expression for these patients with regard to the anger issue which is a psychosomatic aspect of the disease.
Correspondence: Seyed Hamzeh Hosseini, PO Box 13185-1678, Tehran, Iran. Tel: 9821 66439463. Fax: 9821 66919206. E-mail: shhosseini@mzums.
ac.ir and hosseinish20@gmail.com
(Received 4 August 20 09 ; accepted 11 February 2011 )
ORIGINAL ARTICLE
Anger expression and suppression among patients
with essential hypertension
SEYED HAMZEH HOSSEINI
1 , VAHID MOKHBERI
2 , REZA ALI MOHAMMADPOUR
3 ,
MAHSA MEHRABIANFARD
4 & NASRIN BALI LASHAK
4
1 Psychiatry and Behavioral Sciences Research Center and Department Psychiatry of Mazandaran Medical University,
Sari, Iran,
2 Department of Cardiology, Mazandaran University of Medical Sciences, Sari, Iran,
3 Department of Biostatistics,
Mazandaran University of Medical Sciences, Sari, Iran, and
4 Psychiatry and Behavioral Sciences Reasearch Center,
Mazandaran University of Medical Sciences,Sari, Iran
Abstract
Objective. Hypertension (HTN) is among the seven psychosomatic diseases for which mental etiologies were proposed in
1950s. The objective of this study was to evaluate the rate of anger suppression and expression in individuals with hyper-
tension referred to the heart clinic of Fatemeh Zahra Hospital, Sari, Iran. Methods. 200 patients with primary hyperten-
sion were categorized as the case group. One hundred healthy individuals older than 30 years without previous history of
arterial hypertension and severe mental disorders were considered as the control group. Both groups were matched in terms
of age, gender and level of education. The Spielberger questionnaire was used to assess the trait anger, anger in and anger
out. The data were analyzed using SPSS software with statistical tests such as t -test, chi-square and regression. Results. The
trait anger and anger suppression in patients with hypertension were signifi cantly higher than the control group ( P 0.001);
however, anger out was not signifi cantly different between the two groups ( P 0.984). Conclusion. Considering the fact
that trait anger and anger suppression is more prevalent among people with hypertension than healthy individuals, it seems
suitable to provide education concerning anger management and emotional expression for these patients with regard to
the anger issue which is a psychosomatic aspect of the disease.
Key Words: Hypertension , anger expression , anger suppression
Objective
Hypertension (HTN) is probably the most impor-
tant society-related health issue. It is a common dis-
ease with limited symptoms (occasional symptoms
like headache and vertigo) which is easily identifi -
able; however, failure to treat HTN usually results in
lethal complications [1]. With one quarter of adult
population involved (60 million in the US and 1 bil-
lion worldwide), HTN is the main cause of death in
the world, the most common reason for referral to
physicians and the most readily diagnosed and treated
risk factor for stroke, myocardial infarction, periph-
eral vascular disease, aortic dissection, and end-stage
renal disease [2].
By the year 2010, HTN prevention will be one
of the major public health requirements of all
societies [3].
Hypertension is among the seven psychosomatic
diseases for which mental etiologies were proposed in
the 1950s [4]. Studies conducted during the last
decade have reported clear relationships between HTN
and psychological factors such as anger and anxiety.
Approximately 60 years ago, Alexander proposed
the hydraulic model of anger impact on human health
and stated that anger suppression may lead to HTN
[5]. Since then, numerous studies have been organized
to evaluate the relationship between anger and pri-
mary HTN, yielding various results. Web and Beck-
stand reported that African women with HTN were
more likely to suppress anger and anger suppression
resulted in rise of blood pressure among them [6].
Larkin and Zayfert [7] observed no signifi cant dif-
ference between healthy individuals and those with
HTN in terms of anger expression and suppression.
International Journal of Psychiatry in Clinical Practice, 2011; 15: 214–218
ISSN 1365 -1501 print/ISSN 1471-1788 online © 2011 Informa Healthcare
DOI : 10.3109 /13 6515 01.2 011.572168
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Anger expression and hypertension 215
However, when results are assessed together in
meta-analysis, overt anger affect expression is weakly
related to lower blood pressure [8].
Considering the controversial fi ndings, and also
the high prevalence of primary HTN in our country
along with the fact that no such study has been con-
ducted in our region, particularly with regard to the
fact that some consider cultural differences in anger
expression to be relevant, we decided to evaluate the
rate of anger expression and suppression in people
with primary HTN in Iran.
Materials and methods
This case control study was conducted on 200
patients with primary HTN referring to the heart
clinic of Fatemeh Zahra Hospital, Sari, Iran, and 100
healthy controls. All participants were aged above 30
years and had no previous history of severe mental
disorder.
The case group included patients with diagnosis
of primary HTN confi rmed by cardiologist following
diagnostic procedures. They were already receiving
pharmaceutical therapy. The control group consisted
of individuals referring to hospital without history of
arterial hypertension and severe mental disease. Both
groups were matched in terms of age, gender, and
level of education.
Demographic data including age, gender, resi-
dence, level of education, duration of HTN, type of
anti-hypertensive agent used, simultaneous hyper-
lipidemia and diabetes, cigarette smoking, sport
activities, family history of HTN, previous referral to
psychologist, psychological agent used and its type
were collected using checklists. Our study used the
Spielberger questionnaire (version 2, STAXI-2) to
assess trait anger, anger in and anger out. This ques-
tionnaire was devised by Spielberger et al. in 1983
and standardized for Iran by Farahani and Mokhtari
in 2001 [9]. The α coeffi cient (Cronbach’s α ) was
84% for trait anger, 90% for anger in, and 74% for
anger out.
There were 10 Likert scale questions in the trait
anger section. The “anger in” (suppressed anger) and
“anger out” (expressed anger, verbally or physically)
sections each included eight Likert scale questions
grading from Almost Never (1) to Most of the Time
(4) [9].
The study protocol was approved in ethics com-
mittee of Mazandaran University of Medical Sci-
ences and each patient gave informed consent before
enrollment.
Table I. Demographics variable case and control group.
Group Variable Case n 200 Control n 100 P value
Sex n (%)
NS ( χ
2 1.61, df 1, P 0.17)
Male 79 (39.5%) 32 (32%)
Female 121 (60.5%) 68 (68%)
Age (mean SD) 52.17 7.5 51.11 7.5 NS (t 1.19, df 298, P 0.15)
Residential Place, n (%)
Town 121 (60.5%) 72 (72%) ( χ
2 3.47, df 1,
Village 79 (39.5%) 28 (28%) P 0.05)
Occupation, n (%)
Unemployed 36 (18%) 14 (14%)
Retired
Worker 11 (5.5%) 9 (9%) ( χ
2 12.46, df 5, P 0.02)
Farmer 40 (20%) 4 (4%)
House wife 72 (36%) 38 (38%)
Employer 32 (16%) 20 (20%)
Employer 9 (4.5%) 15 (15%)
Education level, n (%)
NS ( χ
2 4.75, df 3, P 0.20)
Reading writing 36 (18%) 14 (14%)
Below Diploma 51 (25.5%) 17 (17%)
Diploma 54 (3%) 34 (34%)
University 35 (17.5%) 23 (23%)
Duration of hypertension, n (%) Less than 5 years 72 (36%)
5 10 years 94 (47%)
10 15 years 26 (13%)
More than 10 years 8 (4%)
Anti-hypertensive drug, n (%)
Beta blockers 117 (58.5%)
ACEIs 64 (32%)
Diuretics 24 (12%)
Calcium channel blockers 16 (8%)
NS, not signifi cant; ACEI, angiotensin converting enzyme inhibitors.
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216 S. H. Hosseini et al.
Eventually, data were analyzed using SPSS soft-
ware version 15.00 for Windows. Independent sam-
ple t -test was used for comparison of numerical data
with normal distribution between the two groups.
Chi-square was applied for analysis of categorical
data and ratios between the two groups. Also, linear
regression model was used to adjust the fi ndings for
confounding variables (occupation. education, sport
activity, cigarette smoking, and psychoactive drugs).
The results were considered signifi cant at the level
of P 0.05.
Results
Demographic characteristics of the two groups (case
and control) are presented in Table I.
Duration of HTN was divided into four catego-
ries according to the year and the frequency of each
category is shown in Table I.
The types of anti-hypertensive drugs used by the
patients are shown in Table I. The related variables
to HTN are presented in Table II.
Twenty-two percent of patients in the case group
and 16% in the control group used psychoactive
drugs, indicating no signifi cant difference between
the two groups ( χ
2 3.54, df 1, P 0.224).
In the case group, 12% used benzodiazepines, 8%
used TCAs (tricyclic antidepressants) and 5% used
SSRIs (selective serotonin reuptake inhibitors) as well
as 10, 60 and 4%, respectively, in the control group.
Multiple linear regression was used to adjust
ndings for confounding variables (occupation, edu-
cation, sport activity, cigarette smoking, psychoactive
drugs). A statistically signifi cant difference was
observed between the two groups in terms of trait
anger and anger in ( P 0.001). The individuals with
HTN were more likely to experience anger and they
were more likely to suppress it. However, no signifi -
cant difference was observed regarding anger out.
The results of trait anger, anger out and anger in for
two groups are presented in Table III.
Furthermore, analyzing the effect of the vari-
ables of the study on trait anger, anger in and anger
out among individuals with HTN the following
results were found. There was a signifi cant relation-
ship between trait anger and level of education
( χ
2 10.4, df 4, P 0.001), most commonly
occurring in the illiterate to reading and writing
group, followed by below high school , high
school diploma and university degree groups.
There was a signifi cant relationship between trait
anger and consumption of psychoactive drugs
( P 0.002).
People consuming psychoactive drugs were more
likely to experience anger. Also, a signifi cant relation-
ship was observed between anger in and family his-
tory of hypertension ( χ
2 53.5, df 2, P 0.001);
people with family history of HTN were more likely
to suppress their anger.
Discussion
The fi ndings of this study indicate that trait anger
and anger in are signifi cantly more common in peo-
ple suffering from HTN, while the two groups were
not different signifi cantly in terms of anger out.
Table II. Frequency of each risk factor related to hypertension in the two groups.
Group Variable Case n (%) Control n (%) P value
Sport activity, n (%)
NS ( χ
2 3.99, df 2, P 0.15)
Never 110 (55%) 37 (47%)
Occasionally 65 (32.5%) 37 (37%)
At least 3 times per week 25 (12.5%) 16 (16%)
Cigarette smoking, n (%)
NS ( χ
2 3.39, df 2, P 0.20)
Smoker 29 (14.5%) 14 (14%)
Non-smoker 137 (68.5%) 75 (75%)
Former smoker 34 (17%) 9 (9%)
Hyperlipidemia, n (%)
NS ( χ
2 0.74, df 1, P 0.1)
Yes 56 (28%) 23 (23%)
No 144 (72%) 77 (77%)
Diabetes, n (%)
NS ( χ
2 0.949, df 1, P 0.45)
Yes 20 (10%) 14 (14%)
No 180 (90%) 86 (86%)
Family history of hypertension, n (%)
( χ
2 4.98, df 1, P 0.02)
Yes 67 (33.5%) 21 (21%)
No 133 (66.5%) 79 (79%)
Previous referral to psychiatrist, n (%)
NS ( χ
2 1.71, df 1, P 0.15)
Yes 27 (13.5%) 8 (8%)
No 173 (86.5%) 92 (92%)
NS, not signifi cant.
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Anger expression and hypertension 217
In a study conducted by Web and Beckstand [6]
on African females with HTN, the patients were
observed to suppress their anger clearly and this
anger suppression accompanied higher degrees of
rise in blood pressure [10], a fi nding in line of our
study. A study conducted by Hogan et al. [5] indi-
cated that expressing angry emotions resulted in
lower blood pressure in females [5], which is in
line of our study. Moreover, in a study conducted
by Helmers et al. [10] on 128 men and 66 women
with primary HTN having received no therapy
previously, it was indicated that anger suppression
leads to rise in systolic blood pressure [10], which
is corroborated by our fi ndings. This nding that
hypertensives show greater anger-related parame-
ters may be attributed to the illness itself. The
hypertensives receive medication, thus they know
they are ill. This aspect may be additionally respon-
sible for changes in the experience and expression
of anger. It is still unclear how and if anger traits
are causally related to hypertension or if hyperten-
sion and its effects on the central nervous activity,
e.g., is itself responsible for anger reactivity and
anger styles.
Furthermore, another study conducted by
Javadi and Ansarifar [11] on 135 female nurses
indicated that participants who expressed their
anger at home and in workplace had lower systolic
and diastolic blood pressures. Moreover, people
with family history of HTN were more likely to
suppress their anger [11]. This observation was
confi rmed by our study.
A study conducted by Vandervort et al. on 1407 bus
drivers in San Francisco indicated that there is no sta-
tistically signifi cant difference in HTN between those
who expressed their anger and those who suppressed
it; this fi nding is not in line of our fi ndings [12].
In the Larkin and Zayfert study conducted on 26
patients with primary HTN and 16 healthy individu-
als using the Spielberger questionnaire (similar to
our study), no statistically signifi cant difference was
found between the two groups in terms of anger sup-
pression and expression. This observation may be
due to the small number of participants [7].
The controversial fi ndings of the previous studies
may be accounted for by cultural variations in differ-
ent societies with different raising patterns and social
supports. Many cultures consider anger to be a
negative emotion and suggest against it. Moreover,
gender differences are considered to infl uence the
manner of anger expression. In this study anger in
was more in females than males.
In many cultures, the parents tend to encour-
age their male children to express their anger with
angry behaviors, whereas the daughters are warned
against anger expression. In older ages, they learn
to express their anger only to children and weaker
individuals. Anger is a natural emotion, the oldest
type of emotion, representing the natural response
of body to dangers and events. Therefore, sup-
pressing anger brings about harmful impacts on
the body, rendering it prone to medical conditions
such as HTN [13].
Some studies have reported higher plasma level
of epinephrine, rennin, and sympathetic tone in indi-
viduals who suppressed their anger the most. This
observation may account for higher blood pressure
in these individuals [14].
Furthermore, it has been observed that patients
with HTN tend to express their negative emotions
less than healthy people while being visited by their
physicians, thus the physician patient rapport
may be damaged leading to delay in diagnosis and
therapy [15].
In other hand, as it has been shown recently,
changes in blood pressure infl uence cognitive func-
tions profoundly that can be confounding variable
and must evaluate the relationship between cogni-
tion, aggression and hypertension in case control
studies in future [16].
Considering the above, we must emphasize the
importance and necessity of educating patients with
HTN about the appropriate methods of expressing
emotions and anger management. These precautions
will contribute to better prevention and control of
the disease, alongside other factors.
Key points
This study is case- control (hypertntion and
healthy
Relationship between trait anger and level of
education in individual with hypertention
The individuals with HTN were more likely to
experience anger and they were more likely to
suppress it
Table III. Mean and standard deviation of grades of case and control groups for trait anger, anger in and anger out sections.
Case
(Mean SD)
Control
(Mean SD) P value
Trait anger 24.21 4.97 20.79 4.79 t 5.62, df 298, P 0.005
Anger out 14.1 49.35 14.90 3.22 t 1.47, df 298, P 0.984
Anger in 20.80 3.85 17.20 2.49 t 8.49, df 298, P 0.005
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218 S. H. Hosseini et al.
Acknowledgement
We would like to thank Research Dupty of Mazandaran
University of Medical Sciences for fi nancial support
of this project and also Farzan Institute for Research
and Technology for technical assistance.
Statement of Interest
There is no confl ict of interest to declare.
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... Although a considerable amount of research evidence showed that anger experience is associated to elevated BP (e.g., Hosseini et al., 2011;Sahraian et al., 2015), the nature of this relationship remains unclear (Hogan & Linden, 2004). Individuals who are prone to anger arousal and provocation may in their lifetime not develop high BP, which probably may have led to the conflicting research findings on anger-BP relationships. ...
... This implies that the higher the anger experience, the higher the elevated BP. This finding is consistent with previous studies (e.g., Hosseini et al., 2011;Schum et al., 2003) that support the idea that anger experience could lead to heightened cardiovascular reactivity which leads to elevated BP. This shows that the link between anger and elevated BP found in other Western cultures is relevant in understanding such phenomena in Nigeria. ...
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... In particular, the most frequently reported diagnostic rubrics were irritable mood, illness denial and alexithymia. Anger and hostility have been shown to be associated with increased risk of hypertension, even though the cognitive, affective and behavioral dimensions of anger may affect blood pressure differently (Hosseini et al., 2011;Trudel-Fitzgerald et al., 2015;Tilov et al., 2016). Illness denial represents a manifestation of abnormal illness behavior and may hinder the prevention and treatment of medical disorders (Fava et al., 2017). ...
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