Anger, Hostility, and the Heart

Aron Wolfe Siegman, Timothy W. Smith, Aron Wolfe Siegman, Timothy W. Smith

• Publisher: Psychology Press
• Year: 2013
• eBook ISBN: 9781134772735
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Research on the roles played by hostility and anger in the etiology and course of coronary heart disease (CHD) has mushroomed. Moreover, there has been considerable progress in the knowledge of neurohormonal correlates of anger and hostility that could conceivably play a role in the pathogenesis of CHD. The editors of this volume believe that this is the appropriate time in the history of coronary-prone behavior research to take stock -- to identify the basic questions that need further elucidation, and to provide future direction. Although there is a surprising consensus among the contributors about the nature of the critical issues, they each offer a somewhat different perspective. This book will provide a variety of perspectives on what is known and what still needs to be known -- a useful source for promising research hypotheses.

Chapter

1

FROM TYPE A TO HOSTILITY TO ANGER: REFLECTIONS ON THE HISTORY OF CORONARY-PRONE BEHAVIOR

Aron Wolfe Siegman

University of Maryland Baltimore County

Research on the contribution of psychological factors to coronary heart disease (CHD) has changed from a preoccupation with the role of the Type A behavior pattern (TABP) to that of hostility, and more recently to that of anger. This chapter will trace the origin and rationale for these shifts, and will place these developments within the broader framework of behavioral medicine. Although terms like behavioral medicine, psychosomatic medicine, and holistic medicine each have their own unique connotations, they share the assumption that the mind influences the body,¹ that expectations and cognitions, emotions, and personality traits play a significant role in the development, maintenance, and treatment of physical diseases. This point of view represents a major paradigm shift from that which dominated the thinking of the biomedical community until very recently. Nevertheless, this brief and admittedly selective review intends to demonstrate that this new psychosomatic, holistic perspective has its roots in antiquity, and existed throughout history, alongside other paradigms and models. Conflicting models existed side by side, and the tension that was generated by such conflicting models frequently led to the emergence of new models. At times, progress was slow and incremental, at other times it occurred in quantum leaps, and sometimes it was preceded by serious regressions. Progress in this regard, like progress in science in general, is probably best represented by an ellipse rather than by a straight line. Perhaps there is validity to Hegelian dialectics, at least insofar as scientific progress is concerned.

Body and Mind in Antiquity

The concept that strong negative emotions and the aggravations that are encountered in the course of everyday life (stress, in contemporary parlance) can adversely affect one’s health, indeed one’s very survival, was well understood as far back as Biblical times. When Jacob’s sons wanted to take their youngest sibling, Benjamin, with them to Egypt, Jacob refused to let Benjamin go because if anything were to happen to Benjamin on the way, he, Jacob, would die from grief² (Genesis 42:38). A dictum of Talmudic origin maintains that a hurried walking style is damaging to one’s eyesight³—shades of Type A. The rabbis of the Talmud were aware not only of the damaging health consequences of strong negative emotions and stress but also of the benefits of positive emotions and experiences.⁴ They were also aware of beneficial consequences of strong social support. A Talmudic dictum maintains that visiting and spending time with the sick relieves them of one sixtieth of their illness (Tractate Nedarim 39b). In discussing the ability of a certain medication to reverse an eye disease common in animals, the Talmud suggests that its effectiveness is contingent on the animal being treated in a tranquil, pastoral environment and on it being in the company of other animals (Tractate Behorot 39a). In general, the rabbis of the Talmud had a profound appreciation of the importance of social support. This is reflected in the Talmudic laws that make it incumbent on the members of the community to entertain a newly married bride and groom and to comfort the bereaved.

To the best of my knowledge, there is no reference in the Talmud specifically linking anger to heart disease, but there are numerous references regarding the devastating effects of anger on a person’s physical and spiritual well-being. The rabbis base their warnings about the undesirable consequences of anger on a verse in Ecclesiasties (11:10): “Remove anger from your heart and evil from your body …” that the rabbis interpret in terms of a cause-effect relationship, If you will remove anger from your heart, then your body will be spared evil (illness, pain). A similar thought is expressed by the Psalmist when he exclaims (6:7): “My eye is dimmed by anger,” although in Biblical Hebrew the same word that connotes anger also connotes mental torment and anguish. Moreover, the Psalmist’s earlier plea (6:2): “God heal me,” can be, and has been, interpreted to refer to that which ails the Psalmist’s spirit. The very fact that Biblical Hebrew allows, nay, demands such dual interpretations bears witness to the thoroughly holistic world view of biblical man. Even a cursory reading of this particular psalm as well as other psalms reveals how the author moves freely from the physical to the mental-spiritual and vice versa. The aforementioned verse (Psalms 6:7) is undoubtedly the source of the later Rabbinic dictum that anger is damaging to one’s eyesight (Midrash Aggadah, Toledot 27a). When Rabbi Zeira, a Talmudic scholar who lived about 300 C.E., was asked by his students to what he attributed his longevity, he replied: “I have never lost my temper in dealing with the members of my family” (Tractate Taanit 20a). Similarly, Rabbi Joshua ben Hananya, a first and second century (C.E.) scholar, maintained that hostility and hatred of one’s fellow man were among the factors that shorten one’s lifespan (Tractate Avot 2:15).

I have dwelt on these ancient Biblical and Rabbinic texts primarily because of my first-hand acquaintance with this literature, and not because the holistic approach to health and illness that is reflected in these texts was unique to ancient Israel. Quite to the contrary, it was the dominant view of the ancient world in general. For example, suggestion and other behavioral interventions were widely practiced in the temples of ancient Greece that were dedicated to Aesculapius, the god of healing (see Ullman & Krasner, 1969, pp. 109–110). Until recently, it was assumed that the patients who visited these temples suffered from mental illness. However, given the fact that the stadium in the temple in Epidaurus had a 12,000 seating capacity—and there were numerous such shrines throughout ancient Greece—it is more reasonable to assume that these shrines ministered to the physically ill as well. True, with the ascendancy of a more empirical scientific approach in ancient Greece, increasingly less attention was being paid to the role of psychological factors in physical diseases. But even so, there were those who lamented the loss of the holistic approach. As noted in Charmides by Plato, Socrates stated, “Let no one persuade you to cure his headache until he has first given you his soul to be cured, for this is the great error of our day in the treatment of the human body, that physicians separate the soul from the body.” Clearly, then, the holistic approach to explaining and treating disease is not a modern discovery.

With the rise of modern scientific medicine during the Renaissance, however, the holistic paradigm—which readily acknowledges the role of emotional factors in health and illness—was replaced by another paradigm. According to this new paradigm, only physical factors initiate physical disease processes, which in turn are to be treated by physical means such as surgery and drugs. The spectacular success of modern scientific medicine, especially in controlling infectious diseases, reinforced this point of view. Even during the new scientific era, however, there were those who, for a variety of reasons, acknowledged the role of psychological factors in physical disease. Thus, in 1628, William Harvey, the father of cardiovascular physiology, wrote: “A mental disturbance provoking pain, excessive joy, hope or anxiety extends to the heart, where it affects its temper, and rate, impairing general nutrition and vigor” (1628/1928, p. 106). Dr. J. Archer, the noted 17th-century physician, wrote: “The observations I have made in the practice of physicks these several years have confirmed me in this opinion, that the origin or cause of most men and women’s sickness, disease and death, is first some great discontent which brings a habit of sadness of mind” (Archer, 1673). Heber-den (1772), who was one of the first to clearly describe the symptoms of angina pectoris, implicated strong emotions, especially anger, in CHD. Similar views were held by Fothergill (1781) and Wardrop (1851), and Trousseau (1882) went as far as to propose that outbursts of anger could precipitate sudden death in CHD patients. John Hunter, the 18th-century pioneer in cardiovascular surgery and pathology, who suffered from emotion-related bouts of angina, used to say: “My life is in the hands of any rascal who chooses to put me in passion” (cited in DeBakey & Gotto, 1977). In fact, he died from a heart attack soon after a heated exchange at a faculty meeting at the Royal College of Physicians in Glascow, Scotland. It is of interest to note that these early writers emphasized the role of anger in the pathogenesis of CHD, while in more recent times anger has taken a back seat to such constructs as the TABP and hostility.

Twentieth-Century Precursors of Behavioral Medicine

The clinical work of Sigmund Freud and his followers, especially that of Alexander, French, and associates (Alexander, 1950; Alexander, French, & Pollack, 1968), and the physiological research of Cannon (1932), contributed to the re-emergence of the holistic paradigm. Based on their clinical experience, psychoanalysts like French and Alexander claimed that psychological conflicts can trigger or at least contribute to disease processes. In this psychoanalytic version of psychosomatic medicine, specific conflicts were linked to specific diseases. Thus, conflicts about expressing anger were linked to heart disease, conflicts about dependency needs to ulcers, and repressed depression to dermatological disorders (Alexander et al., 1968). These various somatic manifestations were said to represent symbolic expressions of underlying repressed psychological conflicts. Unfortunately, empirical tests of these psychoanalytically inspired hypotheses were inconsistent at best.

The psychoanalytic explanations of psychosomatic disorders (or psychophysiological disorders, as they are now referred to) were lacking a physiologically credible rationale of how psychological events become translated into physical disease processes. This was provided by Cannon’s (1932) research on the fight-flight response. His investigations showed that the fight-flight phenomenon involves a number of adaptive physiological responses, such as increased blood pressure, the release of epinephrine, and corticosteroids. Although adaptive in the short term, in that these physiological changes prepare the body to engage in the intense motor activity that is required for the fight-flight response, their chronic activation can cause tissue damage and disease. Furthermore, the threats faced by modern man, such as loss of job, divorce, and chronic disease, are not resolved by intense physical activity, increasing the potential tissue damage of the fight-flight response. Of course, we now know that fight and flight are the behavioral (action) manifestations of anger and fear. The emotions, then, play a key role in the transformation of psychological events into disease processes. Of the three major negative emotions, namely, fear, depression, and anger, it is the latter that is most uniquely associated with dangerously high blood pressure elevations (Siegman, 1992). Anger, then, is a logical candidate for being a behavioral risk factor for coronary heart disease—but this gets us ahead of our story.

The Type a Behavior Pattern and Coronary Heart Disease

The search for “psychological” risk factors in coronary heart disease (CHD) was driven primarily by the fact that the traditional risk factors, such as habitual cigarette smoking, high blood pressure, hyperlipidemia, obesity, parental history of CHD, account for less than 50% of CHD cases (Jenkins, 1978; Keys, 1970; Rosenman, 1983). During the 1950s, two cardiologists, Friedman and Rosenman, identified a complex of behaviors that they considered to be risk factors for CHD. These behaviors include extreme ambition and competitiveness, impatience, aggressive and hostile behavior, and a sense of time pressure. These behaviors were labeled as the Type A coronary-prone behavior pattern (TABP). By way of summary, the Type A individual was described by Friedman and Rosenman as “a person who is aggressively involved in a chronic, incessant struggle to achieve more and more in less and less time, and, if required to do so, against the opposing efforts of other things or other persons” (Friedman & Rosenman, 1974; Rosenman & Friedman, 1974). Most often, the Type B behavior pattern is defined negatively, that is, the absence of Type A characteristics. Occasionally, investigators (e.g., Siegman & Dembroski, 1989) suggested a somewhat more positive definition of the Type B behavior pattern, for example, when they refer to this behavior pattern in terms of a “relaxed” lifestyle, but, so far, there is no precise conceptualization and definition of the Type B behavior pattern similar to that of the Type A behavior pattern. It is important to point out that from the very beginning, anger, hostility, and aggressive behavior were considered to be part of the TABP, although by no means its only or even its most prominent constituents. The idea that Type A like behaviors may be related to CHD did not originate with Friedman and Rosenman. The contribution of these investigators consists of their efforts to operationalize and measure the Type A behavior pattern, so that its hypothesized role in CHD could be investigated in a scientifically convincing manner.

Rosenman and Friedman developed a structured interview (SI) designed to assess the TABP. (Over the years, Rosenman and Friedman took somewhat divergent approaches to the administration and scoring of the SI, but more about this later.) Having developed the SI, the two investigators were now ready to launch a major prospective epidemiological study—the Western Collaborative Group Study (WCGS)—to test the hypothesized TABP-CHD link. The study included 3,154 men, ages 39–59, who were administered the SI and who were followed for 8.5 years. The results of this study disclosed that, relative to the Type Bs, the Type As were slightly more than twice as likely to show clinical manifestations of CHD (Rosenman, et al., 1975). This increased risk for CHD in Type A men remained significant after multivariate statistical adjustment for the traditional risk factors. Moreover, the amount of risk associated with the TABP was about the same as that conferred by the traditional risk factors.

Other research revealed that the TABP was related to the severity of coronary artery disease (CAD) documented by autopsy in the WCGS (Friedman, Rosenman, Straus, Wurm, & Kositchek, 1968), and through cardiac catheterization by independent investigative groups (Blumenthal, Williams, Kong, Schanberg, & Thompson, 1978; Frank, Heller, Kornfeld, Sporn, & Weiss, 1978; Zyzanski, Jenkins, Ryan, Flessas, & Everist, 1976).

By the late 1970s, the evidence in support of the hypothesized TABP-CHD link was sufficiently persuasive to convince an NIH sponsored review panel that the TABP was associated with increased risk for CHD “over and above that imposed by age, systolic blood pressure, serum cholesterol, and smoking and [that increased risk due to TABP] appears to be of the same order of magnitude as the relative risk associated with any of these factors” (Review Panel on Coronary-Prone Behavior and Coronary Heart Disease, 1981, p. 1199).

Early results of the Recurrent Coronary Prevention Project (Friedman et al., 1986) also provided support for the hypothesized Type A-CHD relationship. In this project, MI survivors were randomly assigned to a behavioral intervention procedure designed to modify Type A behavior or to one of two control groups. Initial results showed that the behavioral intervention produced marked reduction in Type A behavior and that recurrence of MI in the treatment group was only about 13%, compared to 21% and 28% in the two control groups. These findings provided a strong boost to the hypothesized Type A-CHD relationship.

The Emergence of Negative Findings

It is somewhat ironic that just about the time when general textbooks in abnormal and social psychology began to cite the link between the TABP and CHD as evidence of a causal relationship between psychosocial variables and disease, and just as the biomedical community appeared ready for the first time to accept a psychosocial variable as an independent risk factor for CHD (Cooper, Detre, & Weiss, 1981), evidence began to appear that challenged the validity of the presumed relationship between the TABP and C...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Contents
• Introduction
• 1. From Type A to Hostility to Anger: Reflections on the History of Coronary-Prone Behavior
• 2. Concepts and Methods in the Study of Anger, Hostility, and Health
• 3. The Assessment of Anger and Hostility
• 4. Associations of Hostility and Coronary Artery Disease: A Review of Studies
• 5. Anger, Hostility, and Psychophysiological Reactivity
• 6. Basic Biological Mechanisms
• 7. Animal Models of Aggression and Cardiovascular Disease
• 8. Personality and Anger in Cardiovascular Disease: Toward a Psychological Model
• 9. Cardiovascular Consequences of Expressing and Repressing Anger
• 10. Hostility and Risk: Demographic and Lifestyle Variables
• 11. Anger and Hostility: Potential Mediators of the Gender Difference in Coronary Heart Disease
• 12. Anger Reduction: Issues, Assessment, and Intervention Strategies
• Author Index
• Subject Index