International Journal of Psychiatry in Clinical Practice, 2011; 15: 214218

ORIGINAL ARTICLE

Anger expression and suppression among patients with essential hypertension

SEYED HAMZEH HOSSEINI1, VAHID MOKHBERI2, REZA ALI MOHAMMADPOUR3, MAHSA MEHRABIANFARD4 & NASRIN BALI LASHAK4
and Behavioral Sciences Research Center and Department Psychiatry of Mazandaran Medical University, Sari, Iran, 2Department of Cardiology, Mazandaran University of Medical Sciences, Sari, Iran, 3Department of Biostatistics, Mazandaran University of Medical Sciences, Sari, Iran, and 4Psychiatry and Behavioral Sciences Reasearch Center, Mazandaran University of Medical Sciences,Sari, Iran
1Psychiatry

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 hypertension referred to the heart clinic of Fatemeh Zahra Hospital, Sari, Iran. Methods. 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. Results. The trait anger and anger suppression in patients with hypertension were signicantly higher than the control group (P 0.001); however, anger out was not signicantly 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 important society-related health issue. It is a common disease with limited symptoms (occasional symptoms like headache and vertigo) which is easily identiable; 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 billion 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, peripheral 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 primary HTN, yielding various results. Web and Beckstand 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 signicant difference between healthy individuals and those with HTN in terms of anger expression and suppression.

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 2009 ; accepted 11 February 2011)

ISSN 1365-1501 print/ISSN 1471-1788 online 2011 Informa Healthcare DOI: 10.3109/13651501.2011.572168

Anger expression and hypertension However, when results are assessed together in meta-analysis, overt anger affect expression is weakly related to lower blood pressure [8]. Considering the controversial ndings, and also the high prevalence of primary HTN in our country along with the fact that no such study has been conducted 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 casecontrol 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 conrmed 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
Table I. Demographics variable case and control group. Group Variable Sex n (%) Male Female Age (mean SD) Residential Place, n (%) Town Village Occupation, n (%) Unemployed Retired Worker Farmer House wife Employer Employer Education level, n (%) Reading writing Below Diploma Diploma University Duration of hypertension, n (%) Less than 5 years 510 years 1015 years More than 10 years Anti-hypertensive drug, n (%) Beta blockers ACEIs Diuretics Calcium channel blockers Case n 200 79 (39.5%) 121 (60.5%) 52.17 7.5 121 (60.5%) 79 (39.5%) 36 (18%) 11 40 72 32 9 36 51 54 35 72 94 26 8 117 64 24 16 (5.5%) (20%) (36%) (16%) (4.5%) (18%) (25.5%) (3%) (17.5%) (36%) (47%) (13%) (4%) (58.5%) (32%) (12%) (8%) Control n 100 32 (32%) 68 (68%) 51.11 7.5 72 (72%) 28 (28%) 14 (14%) 9 4 38 20 15 14 17 34 23 (9%) (4%) (38%) (20%) (15%) (14%) (17%) (34%) (23%) P value

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groups were matched in terms of age, gender, and level of education. Demographic data including age, gender, residence, level of education, duration of HTN, type of anti-hypertensive agent used, simultaneous hyperlipidemia 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 questionnaire was devised by Spielberger et al. in 1983 and standardized for Iran by Farahani and Mokhtari in 2001 [9]. The coefcient (Cronbachs ) 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 committee of Mazandaran University of Medical Sciences and each patient gave informed consent before enrollment.

NS (2 1.61, df 1, P 0.17) NS (t 1.19, df 298, P 0.15) (2 3.47, df 1, P 0.05)

(2 12.46, df 5, P 0.02)

NS (2 4.75, df 3, P 0.20)

NS, not signicant; ACEI, angiotensin converting enzyme inhibitors.

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Table II. Frequency of each risk factor related to hypertension in the two groups. Group Variable Sport activity, n (%) Never Occasionally At least 3 times per week Cigarette smoking, n (%) Smoker Non-smoker Former smoker Hyperlipidemia, n (%) Yes No Diabetes, n (%) Yes No Family history of hypertension, n (%) Yes No Previous referral to psychiatrist, n (%) Yes No NS, not signicant. Case n (%) Control n (%) P value

110 (55%) 65 (32.5%) 25 (12.5%) 29 (14.5%) 137 (68.5%) 34 (17%) 56 (28%) 144 (72%) 20 (10%) 180 (90%) 67 (33.5%) 133 (66.5%) 27 (13.5%) 173 (86.5%)

37 (47%) 37 (37%) 16 (16%) 14 (14%) 75 (75%) 9 (9%) 23 (23%) 77 (77%) 14 (14%) 86 (86%) 21 (21%) 79 (79%) 8 (8%) 92 (92%)

NS (2 3.99, df 2, P 0.15)

NS (2 3.39, df 2, P 0.20)

NS (2 0.74, df 1, P 0.1) NS (2 0.949, df 1, P 0.45) (2 4.98, df 1, P 0.02)

NS (2 1.71, df 1, P 0.15)

Eventually, data were analyzed using SPSS software version 15.00 for Windows. Independent sample 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 ndings for confounding variables (occupation. education, sport activity, cigarette smoking, and psychoactive drugs). The results were considered signicant 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 categories 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 signicant difference between the two groups (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, education, sport activity, cigarette smoking, psychoactive

drugs). A statistically signicant 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 signicant 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 variables of the study on trait anger, anger in and anger out among individuals with HTN the following results were found. There was a signicant relationship between trait anger and level of education (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 signicant relationship between trait anger and consumption of psychoactive drugs (P 0.002). People consuming psychoactive drugs were more likely to experience anger. Also, a signicant relationship was observed between anger in and family history of hypertension (2 53.5, df 2, P 0.001); people with family history of HTN were more likely to suppress their anger. Discussion The ndings of this study indicate that trait anger and anger in are signicantly more common in people suffering from HTN, while the two groups were not different signicantly in terms of anger out.

Anger expression and hypertension

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) Trait anger Anger out Anger in 24.21 4.97 14.1 49.35 20.80 3.85 Control (Mean SD) 20.79 4.79 14.90 3.22 17.20 2.49

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P value t 5.62, df 298, P 0.005 t 1.47, df 298, P 0.984 t 8.49, df 298, P 0.005

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 nding in line of our study. A study conducted by Hogan et al. [5] indicated 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 ndings. This nding that hypertensives show greater anger-related parameters may be attributed to the illness itself. The hypertensives receive medication, thus they know they are ill. This aspect may be additionally responsible 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 hypertension 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 conrmed by our study. A study conducted by Vandervort et al. on 1407 bus drivers in San Francisco indicated that there is no statistically signicant difference in HTN between those who expressed their anger and those who suppressed it; this nding is not in line of our ndings [12]. In the Larkin and Zayfert study conducted on 26 patients with primary HTN and 16 healthy individuals using the Spielberger questionnaire (similar to our study), no statistically signicant difference was found between the two groups in terms of anger suppression and expression. This observation may be due to the small number of participants [7]. The controversial ndings of the previous studies may be accounted for by cultural variations in different 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 inuence the manner of anger expression. In this study anger in was more in females than males. In many cultures, the parents tend to encourage 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, suppressing 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 individuals 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 physicianpatient 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 inuence cognitive functions profoundly that can be confounding variable and must evaluate the relationship between cognition, aggression and hypertension in casecontrol 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

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[7] Larkin KT, Zayfert C. Anger management training with mild essential hypertension patients. J Behav Med 2004;19: 33415. [8] Jorgensen RS, Johnson BT, Kolodziej ME, Schreer GE. Elevated blood pressure and personality: a meta-analytic review. Psychol Bull 1996;120:293330. [9] Farahani MT, Mokhtari F. Normalization of trait anger, anger expression questionnaire spielberger 2 (Staxi 2) on students of Isphahan University, Dissertation for Masters Degree, University of Tarbiat Modarres, 2001. [10] Helmers KF, Baker B, OKelly B, Tobe S. Anger expression gender and ambulatory blood Pressure in mild unmedicated adults with hypertension. Ann Behav Med 2000;22: 604 [11] Javadi F, Ansarifar A. Evaluating the relationship between blood Pressure and frequency, Intensity and style of anger expression in home and workplace of female nurses working in hospitals afliated with Iran University of Medical Sciences, Dissertation for Masters Degree, Iran University of Medical Sciences, Faculty of Nursing and Midwifery, 1998 [in Persian]. [12] VanderVoort DJ, Ragland DR, Syme SL. Anger expression and hypertension in transit workers. Ethn Dis 2001;11: 809. [13] Feindler EL. Anger related disorder. 2nd ed. New York: Springer; 2006. p 7195. [14] Schneider R, Egan BM, Johnson EH, Drobny H, Jullius S. Anger and anxiety in borderline hypertension. J Am Bord Fam Med 2003;16:13147. [15] Nyklicek J, Temoshok T. Emotional expression and health. 2nd ed New York: Brunner; 2000. p 6072. [16] Del Paso GA, Gonzlez MI, Hernndez JA, Duschek S, Gutirrez N. Tonic blood pressure modulates the relationship between baroreceptor cardiac reex sensitivity and cognitive performance. Psychophysiology 2009;46:9328.

Acknowledgement We would like to thank Research Dupty of Mazandaran University of Medical Sciences for nancial support of this project and also Farzan Institute for Research and Technology for technical assistance. Statement of Interest There is no conict of interest to declare.

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