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Anger expression in men with elevated blood pressure: Relationships to assertiveness

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Anger expression in men with elevated blood pressure: Relationships to assertiveness

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ANGER EXPRESSION IN MEN WITH ELEVATED BLOOD PRESSURE:
RELATIONSHIPS TO ASSERTIVENESS
Copyright 2002
by
Krista Arlington Barbour
A Dissertation Presented to the
FACULTY OF THE GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
in Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PHILOSOPHY
(PSYCHOLOGY)
August 2002
Krista Arlington Barbour
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UM I Number: 3180768
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ACKNOWLEDGMENTS
This effort would not have been possible without the support and encouragement
of many individuals. First, I would like to thank my dissertation committee: Beth
Meyerowitz, Ph.D., Kathleen Chambers, Ph.D., and Rodney Goodyear, Ph.D. I am
grateful for their time and guidance throughout this endeavor. In addition, I would like to
recognize Beth Meyerowitz for sharing her expertise in clinical health psychology. It was
Beth who introduced me to the field and never hesitated to offer career advice and general
professional guidance. It is with great pride that I acknowledge my advisor and mentor,
Jerry Davison, Ph.D. It has been an honor to learn from a pioneer in the field of cognitive-
behavioral therapy and research. Jerry has dedicated much ofhis time to ensure the high
quality training ofhis students. He has provided unwavering support and fostered my
growth as an empirically-minded clinical psychologist. I am grateful for his warmth and
sincerity. Jerry, you have served as a source of great inspiration for me, both
professionally and personally. I look forward to sharing many more lunches together in the
future! My training has also benefitted from the support of the students in the ATSS lab.
Their thoughtful feedback has strengthened my work. My coders, Emily Hart and April
Malitz, put in hours of often tedious work to complete this project. I am thankful for their
dedication. I would also like to thank my dear friend Kecia Watari for her companionship,
encouragement, and humor. Finally, I wish to recognize my family, who celebrated my
achievements every step of the way. I am grateful for their unending love and support.
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H i
TABLE OF CONTENTS
Acknowledgments ii
List of Tables v
Abstract vi
Introduction 1
Anger and Hostility in EH 1
Assertiveness and EH 4
Hypotheses 10
Design of the Present Study 1 1
Alternatives to Questionnaire Assessment 12
Relevance of the Present Study 14
Method 15
Participants 15
Measures 16
AX 17
HAX 18
PEQ 18
Procedure 19
ATSS 20
VI 21
Variable Coding 22
Results 24
Hypothesis 1 24
Hypothesis 2 28
Hypothesis 3 29
Hypothesis 4 30
Hypothesis 5 31
Hypothesis 6 31
Nonhypothesized Findings 32
Discussion 37
Anger Suppression 38
BP Recovery 42
Constructive Anger Expression and Resting BP 45
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iv
Prediction of BP Levels 47
Limitations o f Present Study 49
Comparisons with Published Data from the Larger Study 55
Methodological Considerations 56
BP Recovery 56
Laboratory Stimuli 58
Coding Schemes 59
General Conclusions 59
References 61
Appendices
A. Anger Expression Scale (AX) 68
B. Harburg Anger Expression Scale (HAX) 70
C. Post Experimental Questionnaire (PEQ) 73
D. Transcripts of ATSS Stimulus Tapes 74
E. Transcripts ofVideotaped Interaction 77
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¥
TABLE
1
2
3
4
5
6
7
8
LIST OF TABLES
Means and Standard Deviations for Demographic
Variables and Blood Pressure Levels.
Estimated Power and Effect Sizes for Assertiveness
Difficulties in PEQ High and Low Anger Suppressors.
Means and Standard Deviations o f Assertiveness
Variables for PEQ Low and High Anger Suppressors.
High and Low PEQ Anger Suppressors by BP
Recovery Status.
Estimated Power and Effect Sizes for Assertiveness
Difficulties in Recovered and Non-Recovered Participants.
Correlations Between SBP and Assertiveness During
Anger Induction.
Correlations Between DBP and Assertiveness During
Anger Induction.
Correlations Among Anger Questionnaires,
ATSS and VI Anger Expression, and BP.
PAGE
80
81
82
83
84
85
86
87
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vi
Abstract
Anger expression and suppression have been assessed repeatedly for decades in the
study o f essential hypertension. However, assertiveness, a construct closely related to the
expression of emotion, has been relatively neglected in the literature. In addition,
researchers have yet to examine the nature of the relationship between these variables. The
present study assessed anger expression style and assertiveness in a sample of men with
mildly elevated blood pressure levels. Because both the expression of anger and
assertiveness occur in an interpersonal context, these variables were measured using
ecologically valid assessment methods (versus the traditional questionnaire method).
Participants were asked to engage in two procedures, Articulated Thoughts in Simulated
Situations (ATSS) and Videotaped Interaction (VI), which were designed in the present
study to tap into the cognitions and emotions experienced during anger arousal
It was found that mean office blood pressure levels were significantly and directly related
to self-reported anger suppression following a laboratory anger induction procedure.
Contrary to predictions, participants who reported a tendency to inhibit expression of their
angry feelings did not display more difficulties with assertiveness (during ATSS or the VI
procedures), or exhibit longer blood pressure recovery times following the VI procedure
relative to those participants who reported less anger suppression. Finally, limited support
was obtained for the hypothesis that assertive anger expression would be negatively
correlated to blood pressure recovery times. Implications of these findings are discussed in
terms o f fixture research in the area, as well as possible interventions for those with mild to
moderately elevated blood pressure.
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INTRODUCTION
Hypertension (HTN), or elevated blood pressure, affects approximately 50 million
adults in the United States (Kaplan, 1998). Of this number, roughly 90-95% of the cases
are characterized as essential (or primary) hypertension (EH). In contrast to secondary
HTN, which is due to an identifiable etiology (e.g., renal disease), EH cannot be traced to
an identifiable medical cause.
Hypertension is a major health issue in the United States, representing the most
significant risk factor for the development of cardiovascular disease (CVD), including both
coronary heart disease (CHD) and stroke (MacMahon et al., 1990). In fact, the primary
importance of HTN is in its contribution to increased risk of cardiovascular (CV)
conditions that result in considerable disability and mortality. Because most hypertensive
patients’ blood pressure (BP) levels are elevated for unknown reasons and are not
consistently controlled with antihypertensive medication (most likely due to poor
compliance with medications, see Mancia, Sega, Milesi, Cesana, & Zanchetti, 1997 for
discussion of this issue), decades of research have been devoted to the search for the
psychological factors involved in EH. The variables that have received the bulk of this
attention are anger and hostility.
Anger and Hostility in EH
Before data regarding the link between anger/hostility and EH can be adequately
evaluated, it is necessary to examine the way in which the constructs are defined.
Unfortunately, the constructs of anger and hostility are frequently confused in the EH
literature. For example, researchers often utilize measures of hostility while purporting to
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assess anger, and vice versa. However, these variables must be assessed separately in
order to establish construct validity.
Whereas hostility is most often regarded as an attitude involving the dislike and
negative evaluation (e.g., mistrust) of others (Buss, 1961), anger is best conceptualized as
a multidimensional construct consisting of phenomenological (i.e., subjective experience
labeled as anger), cognitive (e.g., encoding and information processing styles,
attributions), behavioral (e.g., sulking), and physiological (e.g., autonomic nervous system
arousal) components (Kassinove & Sukhodolsky, 1995). Although anger and hostility are
undeniably related, such that individuals who are high in hostility (and therefore tend to
view others in a negative, suspicious way) may experience angry feelings more intensely
and frequently, the difference between them must be recognized in order to demonstrate
construct validity (Eckhardt, Barbour, & Stuart, 1997).
Consistent with the idea that anger and hostility should be considered separate constructs,
Durel and colleagues (1989) found that, whereas measures of anger and hostility were
positively correlated, the association was not strong enough as to warrant treatment of
them as the same construct.
In addition, researchers have used hostility, anger, and aggression synonymously.
However, hostility and anger should be considered distinct from aggression, which is
considered to be destructive behavior directed toward another individual. Although anger
and hostility may make it more likely that one will behave aggressively in a given situation,
the vast majority of the time during which anger is present, aggression is not a outcome
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(Averill, 1983). Clearly, it is also possible for one to aggress in the absence of angry
feelings.
Despite the definitions used, the notion that there exists a meaningful link between
anger (and hostility) and elevated BP has great intuitive appeal. Indeed, both
normotensives and hypertensives believe that the experience of anger/annoyance leads to
increases in BP levels (Baumann & LeventhaL, 1985; Pennebaker & Watson, 1988). In
addition, experimental evidence indicates that the transitory experience of anger is
accompanied by an elevation in BP (Jacob et al., 1999; James et a!., 1986), as well as
other physiologic changes (e.g., increased catecholamine release; Verrier & Mittleman,
1996), and it has been hypothesized that chronic levels of anger lead to the development
of EH via structural changes in the CV system. This hypothesis seems particularly relevant
for individuals characterized by an anger suppression style, who may experience a
prolongation of angry feelings (e.g., via rumination) and thus increased exposure to the
associated physiological effects (Goldstein et al., 1988).
Although relatively serious conceptual problems plague the literature, data have
generally supported a meaningful relationship between anger/hostility and EH. More
specifically, research has more often focused on the expression (rather than the
experience) of anger. It has been demonstrated that those with EH are significantly more
likely to suppress their angry feelings than those with normal BP levels (for a review, see
Barbour & Davison, 2000).
Although this finding has been replicated in numerous investigations using a
variety of participants and measures, researchers have failed to move beyond this
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description to investigate why hypertensives might inhibit their anger. For example,
perhaps those with elevated BP choose not to express their angry feelings due to a fear of
criticism from others. Alternatively, it may be that those with EH are unable to articulate
their negative emotions to others. Consistent with this notion, it has been hypothesized
that hypertensive individuals lack the ability to appropriately express their emotions
(particularly negative emotions) to others. To test this hypothesis, assertiveness has been
assessed in hypertensives.
Assertiveness has been described as the direct communication of thoughts,
feelings, and beliefs which are expressed in such a way that allows one to stand up for her
or his own rights without violating the rights of others. One behaves assertively when she
or he expresses needs, wants, opinions, and emotions without punishing, threatening, or
putting down the other person (Alberti & Emmons, 1986). Therefore, emotional
expression can be a form of assertiveness, such that individuals who are self-expressive
(i.e., those who articulate their feelings and wishes) while respectful of the rights of others
are considered to be behaving assertively (Lange & Jakubowski, 1976).
Assertiveness and EH
Keane and colleagues (1982) examined assertiveness in hypertensive outpatients,
medical outpatients (with no known history of HTN), and normotensive veterans, all of
whom were exposed to an interpersonal stressor. These participants were observed
during several role-played interactions (work, marriage, and general) with confederates.
Although the hypertensive group displayed significantly less assertion relative to the
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noraiotensive group, there were no differences found between the hypertensive and
medical groups.
However, no data were reported for a variable labeled as “inappropriate
verbalization” (which appeared to include both hostile and aggressive statements). Thus, it
is unclear whether or not the groups differed on this dimension. This category is a crucial
one in the assessment of assertiveness in EH because unassertiveness may sometimes
manifest itself as verbal aggression, especially in situations where expression of negative
emotion is necessary (i.e., when angry, an individual with an inability to respond
assertively may resort to verbal, and even physical, aggression as a way to express angry
feelings; see Barbour et al., 1998).
Morrison, Bellack, and Manuck (1985) addressed the issue of aggression in an
examination of assertiveness in a sample o f men who were either hypertensive or
nonnotensive. Like the Keane et al. (1982) study, participants were asked to engage in a
behavioral role play (involving both work and general scenarios) during which their
assertive behavior was assessed.
During the role play exercise, hypertensive participants were significantly more likely to
verbalize aggressive and hostile responses than the nonnotensive group. In addition, based
on the reports of significant others, the hypertensive group was rated as less socially
competent relative to the normotensive men.
Morrison and colleagues (1985) then divided the hypertensive group into two
subgroups based on their level of cardiovascular reactivity during the role play.
Hypertensives included in Group One (high reactors) displayed significantly more
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aggression during the role play than the Group Two (low reactors) hypertensives. On the
other hand, the Group Two hypertensives were rated being the least assertive (i.e.,
passive) o f the participants. Thus, it appears that EH may be related to both a lack of
assertiveness and the use of verbal aggression. The existence of apparent subtypes of
hypertensives may partially explain the lack of consistent findings obtained in previous
studies.
In sum, these data (see also Schalling & Svensson, 1984) suggest that
hypertensives possess difficulties with assertiveness when faced with potentially negative
interpersonal interactions, relative to normotensive comparison groups. In addition,
variations in assertion difficulties may exist (i.e., aggressiveness versus the inhibition of
emotion), suggesting subtypes of EH. Although this knowledge of assertiveness problems
in hypertensives is useful, previous studies have not assessed whether or not these
problems with assertion coincide with the anger suppression that has also been shown to
be characteristic of those with EH. That is, although assertiveness and anger expression
are undoubtedly linked (i.e., assertiveness involves the appropriate expression of emotion,
including anger) and researchers have recognized the importance of the link between the
two variables (Manuck et al., 1985), they have not yet been examined within the same
sample of hypertensives. Thus, it has not been possible to demonstrate empirically whether
or not these two constructs are significantly related in EH.
In sum, a frequent finding in the study o f EH is that individuals with elevated BP
are significantly more likely to suppress angry feelings relative to those with normal BP
levels (Jorgensen et al., 1996; Sommers-Flanagan, 1989). However, data regarding the
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relationship between anger suppression and EH are far from equivocal As indicated by a
recent review of this literature (Barbour & Davison, 2000), whether or not a significant
relationship between these variables is demonstrated depends on the way in which anger
suppression is assessed. When conceptually clear measures of anger are utilized, the
results generally support a meaningful link between suppression of angry feelings and BP.
Despite promising findings, the majority of this research has failed to go beyond
this description of anger expression in EH. That is, there have been no studies to date that
have investigated the reasons those with EH may inhibit emotional expression. This
neglect is surprising given the considerable literature suggesting a link between the
expression of negative emotions and health outcomes in general (Berry & Pennebaker,
1993). Examination of why elevated BP is associated with the suppression of anger is one
focus of the present study, in an effort to further basic knowledge regarding the
psychological processes involved in the development and maintenance of EH.
A second finding in the EH literature related to emotional expressiveness is that
hypertensives exhibit difficulties in assertiveness compared with nonnotensives (Schalling
& Svensson, 1984). As with anger expression, previous literature has “ended” with the
description of assertiveness difficulties in EH. However, this information must be seen as
merely the stepping stone to further understanding of the psychological variables related to
EH (either etiologically or as a maintaining factor). In addition, anger expression and
assertiveness, two closely related variables, have not been studied within the same
participants in previous EH studies. Examination of the relationship between these
constructs is necessary to demonstrate their co-occurrence in individuals with elevated BP.
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Thus, a goal of the present investigation was to assess both anger expression and
assertiveness in a single sample of participants with elevated BP levels. More specifically,
the present investigation sought to demonstrate meaningful relationships among anger
suppression, assertiveness, and BP, and to move beyond description of these phenomena
toward greater understanding of the underlying mechanism(s) involved.
Constructive Anger Expression. In addition, the traditional focus in EH has been
on maladaptive anger expression styles. However, as suggested by Davidson and
colleagues (2000), there exists a third alternative to the “anger-out” (e.g., verbal
aggression) and “anger-in” (e.g., holding a grudge) styles. That is, it is possible to
verbally express angry feelings with both the goals of conflict resolution and maintaining
respect for the target of one’s anger. These researchers have referred to this form of anger
expression as “constructive”. They suggest that persons utilizing a constructive anger
expression style “...deal directly with the person with whom they are angry, discuss why
they feel upset, and resolve the anger situation, in part, by understanding the other
person’s point of view (p.57).” Lower blood pressure levels have been exhibited in
individuals characterized by this constructive (I.e., assertive) anger expression style
relative to those with a verbally aggressive style (Davidson et al., 2000). In other words,
anger expression may serve a protective function for some individuals if it involves
assertive, conflict-reducing behavior.
In order to examine this possibility, one goal of the present study was to examine
those participants who express their anger “constructively” (i.e., assertively; see Davidson
et al., 2000). Those who express their anger in a constructive manner have demonstrated
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9
lower BP levels than those who suppress angry feelings or those who express anger
aggressively (Davidson et al., 2000).
Assertive anger expression often includes the use of anger controlling strategies.
“Anger control” represents the extent to which an individual attempts to reduce angry
feelings (e.g., stating a desire to calmly discuss an issue, taking time to “cool oft” when
angry, changing one’s thoughts regarding a difficult situation), and has been found (via
questionnaire assessment) to be negatively related to elevated blood pressure (e.g.,
Everson et al., 1998). Anger control is important to assess due to its relation to the
assertive expression of emotion. Interestingly, this more adaptive style of anger expression
has been relatively ignored in the EH literature (Thomas & Williams, 1991). Perhaps the
utilization of a more assertive anger expression style would result in improved
interpersonal relations, as opposed to the increase in stress that may accompany
expression of anger in an aggressive manner. Given this possibility, it is surprising that
assertive expression of anger has not yet been examined.
In addition, such assertive anger expression, including the use of anger-controlling
strategies, may result in a quicker return to baseline BP levels (i.e., quicker BP recovery)
following stressM or emotion-eliciting stimuli (this notion has also been hypothesized by
Davidson et al., 2000). Researchers have recently called for a reconceptualization o f the
association between cardiovascular disease (CVD) and anger. Brosschot and Thayer
(1998) argue for a shift from the focus on anger expression and cardiovascular reactivity,
to anger inhibition and cardiovascular recovery (i.e., length of time necessary for post
stimulus BP levels to return to baseline). These authors argue that anger inhibition, which
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10
has been underestimated by researchers, has received more empirical support than the
outward expression of anger in playing a role in CVD risk. Further, anger inhibition has
been linked to longer cardiovascular recovery time (Hokanson & Burgess, 1962). It is
posited that this combination of anger inhibition and its accompanying prolonged recovery
time leads to disease.
Hypotheses
In order to address the goals discussed above, the following hypotheses were
examined:
1. It was predicted that anger suppression (i.e, the tendency to withhold the
expression of angry feelings) would be positively related to both systolic blood pressure
(SBP) and diastolic blood pressure (DBF) levels.
2. It was hypothesized that those participants who demonstrated a tendency to
suppress their anger would exhibit significantly more assertiveness difficulties (i.e,
aggressiveness and passivity) during two laboratory anger induction procedures relative to
participants who reported less anger suppression.
3. It was predicted that those participants who score higher in anger suppression
would exhibit significantly slower BP recovery time (Le., the return to baseline levels of
BP) than those participants who score lower in anger suppression during anger induction.
4. It was hypothesized that those participants who display a constructive (i.e.,
displays of assertion, anger control strategies) anger expression style would exhibit a
significantly faster blood pressure recovery time following anger induction than those with
a more “destructive” (Le, aggressive) anger expression style.
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5. It was hypothesized that there would exist a negative relationship between
constructive anger expression behaviors (i.e., assertion, anger control strategies) during
two anger induction procedures and resting SBP and DBF.
6. It was predicted that an inverse relationship would exist between constructive
anger and more aggressive expressions of anger during two anger induction procedures
(evidence of such a relationship would replicate a similar finding by Davidson et al, 2000).
Design of the Present Study
The present study sought to address problems of previous research through the
following improvements in design. First, anger and assertiveness were assessed within the
same participants. As previously discussed, these two constructs, despite their obvious
connection, have been traditionally examined in isolation. Indeed, researchers have
frequently focused on anger expression, in the absence of consideration of assertiveness.
Second, in the present study, multiple measures of both anger and assertiveness were
utilized (Le., interpersonal stimuli, as well as conceptually clear and psychometrically
sound questionnaires). Thus, it was possible to examine evidence o f construct validity.
Finally, ecologically valid assessment techniques were utilized, entailing participant
behavior in more realistic, interpersonal situations. Numerous researchers have argued for
the importance of assessment of anger (Jorgensen et al., 1996) and assertiveness (Manuck
et al., 1985) within the context of an interpersonal situation. In feet, a contextual approach
is likely the only way these constructs can be adequately assessed, and may lend more
credence to the data obtained with them relative to information gleaned from
questionnaire measures.
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Although the most widely used method to assess anger and assertiveness has been
the questionnaire, there are several difficulties associated with such paper-and-pencil
measurement (Davison, Robins, & Johnson, 1983). Questionnaire assessment allows only
for participants’ retrospective, and therefore often censored and distorted accounts of
behavior, thoughts, or emotions. Secondly, the validity of questionnaire measures may be
lowered by participants’ attempts to present themselves in a positive manner. Because of
their desire to make a good impression, participants will give answers they believe will be
socially approved. This biased responding may be more likely to occur for emotions or
behaviors that may be socially undesirable, such as anger. Another limitation of
questionnaire assessment is the structured response format in which participants are forced
to choose from experimenter-selected options, which may not be representative of their
behavior, thoughts, or emotions. For these reasons, an alternate methodology which
allows for open-ended, verbal responding from participants may be a useful adjunct in the
assessment of anger expression.
Alternatives to Questionnaire Assessment
Such a paradigm, the Articulated Thoughts in Simulated Situations (ATSS), was
developed by Davison, Robins, and Johnson (1983) as an alternative to questionnaire
assessment. This "think aloud" cognitive assessment procedure allows for the open-ended,
verbal reports of the thoughts which occur during emotional arousal (for a review of
studies utilizing the ATSS paradigm, see Davison, Vogel, & Coffman, 1997). In the ATSS
procedure, participants listen to emotion-eliciting audiotaped scenarios and are asked to
imagine that the situations are actually occurring. Each scenario introduced to participants
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13
is divided into brief segments. At the end of each segment, a tone sounds and participants
are asked to articulate their thoughts and feelings during a 30-second pause. Although the
possibility remains that participants will censor any socially undesirable responses, it is
believed that this tendency may be minimized somewhat due to the requirements of the
task (Le., the participant is instructed to respond immediately upon hearing the scenario).
The taped articulations of the participants are later transcribed and coded along a number
of dimensions by trained coders. The validity of the ATSS procedure has been
demonstrated in numerous investigations (e.g., Bates, Campbell, & Burgess, 1990;
Davison, Feldman, & Osborn, 1984).
As a second measure of anger expression and assertiveness, participants in the
present study engaged in a Videotaped Interaction (VI) procedure. This procedure, based
on Novaco’s (1975) behavioral assessment of anger, allowed for the observation of
participants’ social skills during difficult interpersonal interactions. It has been argued that
such observation is superior to participant self-report of assertive behaviors (Manuck et
al., 1985). The VI consists of interpersonal interactions that the participant is asked to
imagine are actually happening. During these interactions, which are divided into
segments, a videotaped character becomes argumentative and insults the participant, who
is then instructed to “ talk back” to the character during a 30-second period. The situations
presented require the participant to deal with conflict with another person, allowing for
both style of anger expression and assertiveness to be examined via subsequent coding o f
both verbal and nonverbal behavior (the importance o f consideration o f both forms of
behavior has been noted by Berry & Pennebaker, 1993).
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In sum, in an effort to assess their anger expression style and assertiveness,
participants in the present study were asked to complete anger-related questionnaires and
engage in two anger-inducing laboratory procedures. More specifically, participants
underwent anger induction via the ATSS and VI procedures in order to examine the
expression of affect as it occurs during anger arousal. According to the mood-state
hypothesis (Persons & Miranda, 1992), mood induction results in increased accessibility of
mood-relevant information. Thus, it was expected that during anger induction, participants
would be better able to report their angry feelings because they are in an angry state.
Relevance of the Present Study
The goal of the present investigation was to further basic knowledge of the
psychological processes involved in EH. More specifically, an effort was made to
simultaneously assess two constructs previously found to characterize individuals with
EH: anger expression and assertiveness. It was expected that examination of these
variables within the same participants would allow for tests of interrelationships among
several aspects of interpersonal communication and elevated blood pressure. Although not
the focus of the present investigation, the results may provide relevant information to
guide treatment interventions. That is, if lack of assertion is found to be related to anger
suppression and EH, appropriate skills might be taught (i.e., assertiveness training).
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METHOD
Participants
The sample consisted of 89 Caucasian males with mildly elevated blood pressure
levels who were recruited for participation in a non-pharmacological treatment study of
EH (ie., an investigation of the effects of psychoeducation and relaxation on elevated BP
and Type A Behavior Pattern (TABP; refer to Davison et al., 1991 and Haaga et al., 1994
for detailed descriptions of the sample and study design). The majority of participants
possessed DBP readings at or above 90 mm Hg, and SBP readings at or above 140 mm
Hg, and thus were considered hypertensive by the current standards. Eighteen participants
(20%) in the present investigation exhibited BP levels below the conventional cut-offs
described earlier, but above the threshold to be classified as normotensive (Le., 120/80 mm
Hg; Joint National Committee on Detection, Evaluation, and Treatment of High Blood
Pressure, 1993). Thus, all participants had BP readings that were in the elevated range.
Range in BP levels was from 120-158 mmHg and 85-100 mmHg for SBP and DBP
respectively.
The data utilized in the present study were obtained during this larger investigation
(supported by Grant number ROl HL31090 from the National Heart, Lung, and Blood
Institute awarded to Vincent L. DeQuattro, M.D. and Gerald C. Davison, Ph.D.). More
specifically, the data used in the present investigation consisted o f those gathered prior to
the introduction o f the intervention phase of the larger study (i.e, the present study
includes only “ pre-treatment” information obtained from participants).
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16
Inclusionary criteria for participation in the study included: males between the ages
of 30 and 60 years of age who are Caucasian, with no known major medical or psychiatric
disorders. Any participant included in the study was withdrawn from any antihypertensive
medication for the duration of the study. Careful monitoring by medical personnel ensured
the safety of all participants. In addition, those participants with a history of drug and/or
alcohol abuse or who were overweight were excluded. Finally, cases o f secondary
hypertension (i.e., elevated blood pressure with an identifiable medical etiology) were not
included in the present investigation.
The demographic characteristics of the participants are shown in Table 1.
Although it was not the goal of the present investigation to assess change in the relevant
variables over time (ie., the larger study, from which the data reported herein come, was
an intervention study and as such was concerned with both pre and post treatment data),
attrition in the larger study was tracked in an effort to determine its effect on the data
utilized in the present study. More specifically, those participants who dropped out of the
study (n= 45) were compared to those who completed the intervention study (n=44) on
demographic variables and BP levels. No significant differences were found between the
groups in age, marital status, level of education, SBP or DBP.
Measures
In addition to demographic data, records of dietary habits, medical history, and
frequency of physical exercise, a complete medical work-up was performed on each
participant. These extensive data were collected over several visits to the laboratory.
Because BP is quite variable across time, it is unlikely that a single measurement will result
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17
in a reliable estimate of an individual’s true BP. Thus, numerous office blood pressure
levels were obtained (both standing and sitting). Each participants’s average BP levels
were calculated by taking the mean of three measurements taken during three separate
occasions. Repeated blood pressure measurement has been demonstrated to be the most
valid and accepted method of assessment (Garcia-Vera & Sanz, 1999; Gerardi, Blanchard,
& Andrasik, 1985).
Although many questionnaires were administered in the larger study to assess a
variety of psychological variables, only those relevant to the present investigation will be
described. The following anger questionnaires were utilized in the present study in the
assessment of anger expression (i.e., including outwardly expressed anger, suppressed
anger and anger control):
Anger Expression scale (AX). A component of the State-Trait Anger Expression
Inventory (STAXI) was utilized. The STAXI, a 44-item self-report measure developed by
Spielberger (1988), consists of six scales and two subscales, one of which is most relevant
to the present study: the Anger Expression Scale (AX; see Appendix A). The AX includes
the 8-item Anger-In scale (which assesses the tendency to withhold expression of angry
feelings), the 8-item Anger-Out scale (which measures the degree to which anger is
expressed aggressively), and the 8-item Anger Control scale (which assesses the degree to
which angry feelings are controlled and reduced).
In addition to the AX scale, several other STAXI scales were utilized in the
present study due to their relevance to study hypotheses. For example, the State Anger
Scale assesses the intensity of angry feelings at the time of administration and was utilized
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18
in the present study to measure anger both pre and post-anger induction. The Trait Anger
scale was also included as a measure of the frequency and intensity of angry feelings
experienced in general. Thus, it was possible to examine the relationship between anger
experience and expression. The adequate psychometric properties of the STAXI, such as
high internal consistency for each of the scales and convergent validity with other widely
used anger measures, have been demonstrated in numerous investigations (Fuqua et al.,
1991; Smith, Foffick, & Korr, 1984).
Harburg Anger In/Out Scale (HAX). This scale includes provocative items
(i.e., confrontational, interpersonal situations) tapping into the conscious inhibition of
anger, the denial of anger when the majority o f people would respond in anger, and guilt
related to the expression of anger (see Appendix B). Although widely used, the measure
has been found to have low internal consistency in one investigation (Durel et al, 1989).
Although the scale also contains items assessing guilt, this emotion has not been found to
be a valid component of anger (Siegal, 1985), and thus was not considered in the present
examination. Instead, responses indicating the inhibition of angry feelings were summed to
form an “anger suppression” score.
Post Experimental Questionnaire (PEQ). The PEQ was administered subsequent
to the VI anger induction procedure as an additional measure of anger expression (see
Appendix C). This brief questionnaire allowed for participants’ subjective report of their
anger expression style, as well as a validity check of the procedure, while they were in an
angry state. More specifically, participants were asked to report the anger expression style
they would likely utilize if the VI scenarios they imagined were actually happening to
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19
them. Participants endorsed one of three anger expression styles for both the Neighbor
and Salesperson scenarios: the outward expression of anger directed toward the
videotaped character, the experience of anger without outward expression toward the
videotaped character, or the absence of angry feelings.
A PEQ anger suppression score was formed by summing responses across the two
items (i.e., corresponding to Neighbor and Salesperson scenarios). That is, a participant
could obtain a score of zero (no endorsement of anger suppression on either item), one
(endorsement of anger suppression in response to only one of the scenarios), or two
(endorsement of an anger suppression style in response to both VI scenarios) in PEQ
anger suppression.
Procedure
Upon completion of the medical examination (and informed consent), participants
were invited to the laboratory for data collection of the psychological variables.
Participants completed an assessment packet which included the STAXI (including the AX
scale) and the HAX. After completion of the assessment packet, the participants were
introduced to the ATSS procedure via tape-recorded instructions and a practice scenario.
The VI was conducted during a separate session. During both of the anger induction
procedures, BP was recorded at two minute intervals via a Dinamap recorder (an
automated instrument that uses an electrical pump and possesses a digital BP display). BP
readings were available at all three phases of the procedures (i.e., baseline, during the
anger induction per se, and recovery). The STAXI State Anger Scale was administered
both before and after the two anger induction procedures.
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20
ATSS
In the ATSS instructions, it was emphasized that the researchers were interested in
what people think, and that they would be asked to listen to audiotaped scenarios and to
imagine that they were actually involved in the taped situations that they will hear.
Participants were asked to "tune into what is running through their minds" while listening
to the stimulus situations. At the end of each segment, a tone sounded, after which
participants were asked to "say these thoughts out loud" into a tape recorder, which
recorded each participant's articulations. Following the instructions, the participants were
asked to listen and respond to a brief practice scenario, after which any questions were
addressed. When the participant indicated that he understood the procedure, the
experimenter began the ATSS procedure and BP monitoring.
The ATSS procedure consisted of two, anger-inducing stimulus tapes and one
control tape (see Appendix D for scripts). The order of presentation o f the stimulus tapes
was counterbalanced. The situations depicted on the stimulus tapes included the following:
In the Garage scenario, the participant was asked to imagine that he is
overhearing conversations taking place among employees of an auto repair shop
regarding the participant’s car. The taped characters are commenting about the extensive
repair work that is required in a rude and unprofessional manner.
In the Social Evaluation scenario, the participant was asked to imagine that he is
overhearing a conversation of which he is the topic. During this conversation, the taped
characters are making insulting and demeaning comments about the participant (e.g.,
about his political views and style of dress).
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21
Videotaped Interaction (VI)
A second anger induction procedure, the VI, was utilized in the present study to
measure anger expression and assertiveness in this sample of men with elevated BP.
During the VI, participants were asked to respond to videotaped, argumentative
characters while their BP levels were monitored and blood samples were drawn (both
from the left arm). The VI included two interpersonal, conflictual scenarios. The order of
presentation of the stimulus tapes was counterbalanced. The first scenario involved a
confrontation with a neighbor who accuses the participant of being inconsiderate and
careless. The second interaction included a salesperson who refuses to refund the
participant’s money for defective merchandise that was previously sold to him, and even
blames the participant for buying it.
It was believed that the VI procedure allowed for a more externally valid
assessment (versus questionnaires) of the manner in which each participant handles
interpersonal conflict. In an effort to maximize the possibility that the interactions indeed
mimic real-life confrontational interpersonal situations, the participants were provided with
standardized, verbal replies (delivered via prompts on the television screen) to the taped
characters during the first several segments of the interactions (see Appendix E for scripts
and the specific prompts utilized). These prompts were designed to drive the participant
into a confrontation with the taped character (Novaco, 1975). Subsequent segments
required the participants to supply their own replies to the taped characters.
In addition, BP levels were assessed throughout the VI procedure (at two-minute
intervals), including a 15-minute adaptation period prior to presentation of the stimulus
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22
tapes as well as a 10-minute recovery period following the tapes. This post-VI monitoring
allowed for the assessment of BP recovery time (i.e., latency to return to baseline)
following interpersonal conflict.
It has been demonstrated that the level of cardiovascular reactivity obtained is
dependent on type of stimulus (Drummond, 1983). For example, “active” stimuli have
been shown to be more effective than “passive” stimuli (e.g., cold pressor) and lead to
more consistent results (Fredrickson & Matthews, 1990). Thus, the VI procedure was
believed to be an effective way to assess BP levels during anger induction.
Variable Coding
The taped articulations (as well as nonverbal behavior, in the case of the VI
procedure) of each participant were transcribed and coded by two female undergraduate
research assistants blind to the study's hypotheses and BP levels of the participants. These
research assistants received training by the author and coded practice tapes until they
reached 70% agreement on all codes. Once adequate agreement was reached, each
research assistant then coded both ATSS and VI data for all participants. The assistants
counted the frequency of occurrence of each variable. Intraclass correlation coefficients
were calculated to determine the degree of interrater reliability on the ATSS and VI
variables.
For ATSS anger expression, the raters recorded the frequency of such statements
as Angry Verbalizations (articulations of anger-related emotion words), Aggressive
Verbalizations (articulations in which a participant expresses the desire to inflict harm on a
character depicted on the tape, either verbally or physically), and Anger Control
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23
statements (articulations in which a participant attempts to control and reduce angry
feelings). Expression of negative emotion by the participants that could not be classified as
Anger were coded as Other Negative Emotions (e.g., anxiety).
Anger expression was also coded during the VI task. Both maladaptive (i.e.,
Aggressive Expression of Anger) and more appropriate forms of anger expression (i.e.,
Assertive Anger Expression and Constructive Anger) were assessed. The items comprising
the Constructive Expression of Anger were taken from the Constructive Anger Behavior-
Verbal Style Scale (CAB-V) developed by Davidson and colleagues (2000) to assess a
more adaptive form of anger expression. This measure includes the coding of statements
of compromise, apologies, and empathy, and recognition by a participant of his or her own
role in the interpersonal problem as Constructive. Negative nonverbal behavior was also
observed and recorded (including voice tone, grimacing, eye rolling, and sighing).
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24
RESULTS
Hypothesis 1
STAXI Anger Expression Scale (AX). There was no significant relationship found
between SBP and AX Anger-In scores, r (84)= .12, p>.05, or DBF and Anger-In scores, r
(84)= .11, p>.05. Although not hypothesized, no relationship was obtained between SBP
and Trait Anger scores, r (89)= .06, p>.05, or DBF and Trait Anger scores, r (89)= .11,
I>>.05. In addition, several significant correlations were demonstrated between STAXI
anger experience (Trait Anger) and expression (Anger-In, Anger-Out, and Anger-
Control). For example, there were positive relationships found between Trait Anger and
Anger-Out, r (85)=.58, p=.01, as well as Trait Anger and Anger-In, r (85)=.43, p=.01.
There was a negative correlation obtained between Trait Anger and Anger-Control, r
(85)=-51, p=.01.
Because there was a significant relationship between Trait Anger and Anger-In,
Trait Anger scores were entered as a covariate when assessing the relationship between
BP and the anger suppression measures (AX, HAX, PEQ). Controlling for Trait Anger
scores did not alter the significance of any of the relationships.
Harburg Anger Expression Scale (HAX). As with the STAXI Anger-In, there was
no significant relationship found between HAX scores and SBP, r (85)= .12, jj>.05, or
HAX scores and DBF, r (85)= .13, p >.05.
Post Experimental Questionnaire (PEQ). There was no significant relationship
demonstrated between PEQ scores and SBP, r (78)= .15, p>.05. However, there was a
significant, positive correlation found between PEQ scores and DBF, r (78)= .29, j»=.01.
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Articulated Thoughts in Simulated Situations (ATSS)
In order to determine the effectiveness of the ATSS scenarios in arousing anger, a
repeated-subjects t-test was performed on STAXI State Anger scores. Results indicated
that participants reported significantly more anger after the ATSS procedure (M=l 7.67,
SD=4.13) relative to their baseline level of anger (MM6.08, SD-2.67I t (83)= 3.98,
g=.001. For each of the ATSS variables, intraclass correlation coefficients (ICC) were
calculated to assess interrater reliability (and are reported parenthetically below with each
corresponding variable).
The following ATSS variables were coded:
Angrv Verbalizations ( ICC=.95). This code included statements made by the
participants that referred to angry feelings directed toward characters on the audiotape.
Anger Statements could range in intensity from mild irritation to rage (e.g., “You two are
really pissing me off right now!”). There was a significant difference between the two
ATSS scenarios in number of Anger Statements articulated by participants, t (83)= 2.11,
2= 04, such that participants verbalized significantly more Anger Statements during the
Garage (MM. 12, SD=.50) relative to the Social Criticism tape (M=70, SDM.10). Thus,
this variable was analyzed separately by scenario.
Aggressive Verbalizations (ICC=.94). This variable involved name-calling, threats,
or sarcasm directed toward a taped character (e.g., “You’re such an idiot!”), or
verbalizations indicating an intent to physically aggress against a taped character (e.g., “I
feel like punching this guy’s lights out!”). There was no significant difference between the
Garage (M =l.13, SDM.55) and Social Criticism (MM.39, SD=2.45) tapes in the number
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of Aggression statements expressed by participants, t (83) = -.97, p>.05. Thus, data were
collapsed across the two scenarios for this variable to form a single ATSS Aggression
score for each participant.
Anger Control (ICO.75). Anger Control statements included any attempts by the
participant to reduce his angry feelings in response to the ATSS scenarios (e.g., ‘ 1 guess
it’s pretty normal to have to wait this long to get your car fixed.”). There was a significant
difference between the scenarios in the number of Anger Control statements verbalized by
participants during the Garage (Mr-18, SD=.50) and the Social Criticism (M=.57,
SD-1.07) scenarios, t (83)= -2.91 g=.01. Therefore, articulations in response to the two
scenarios were analyzed separately.
Other Negative Emotions ( ICC=95). This variable comprised articulations of
affect that did not fall under the category of Anger Statements. Thus, statements indicative
of sadness and anxiety were considered Other Negative Emotions (e.g., “I’m worried that
they think I’m stupid.”). There was a significant difference between the two ATSS
scenarios in expression of Other Negative Emotion by participants, t (83)= -3.34, g=.01,
such that participants verbalized these statements significantly more during the Social
Criticism (M =l.25, SD=2.03) relative to the Garage tape (M=.48, SD=1.13).
Videotaped Interaction (VI)
Results o f a repeated-measures t-test demonstrated that the VI procedure was
anger-inducing. That is, participants reported significantly more state anger (via the
STAXI State Anger scale) following the VI procedure (M= 19.61, SD=7.40) than before
it began (M=16.43, SD= 3.15), t (76)=4.56, j)= 01.
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Several of the ¥1 variables coded occurred so infrequently as to warrant excluding
them from further statistical analyses (these variables are identified below). Those
variables observed in less than five percent of the sample (i.e., four or fewer participants)
were dropped from further analyses.
The VI data included the assessment of anger expression (constructive and
aggressive), coding for both verbal and nonverbal behaviors. The following codes were
utilized (ICC’s for each variable are reported parenthetically with each corresponding
variable):
Assertive Expression of Anger (ICC=.89). This code, corresponding to the ATSS
Anger Statements variable, included verbalizations by the participants that referred to
anger directed toward characters on the audiotape. Assertive Expressions of Anger could
range in intensity from mild irritation to rage (e.g., “I am so pissed off with this guy!”).
The Assertive Expression of Anger was observed by coders in only four participants
across the two scenarios. Thus, the Assertive Expression of Anger (M= .03, SD= .17) was
not considered in subsequent data analyses.
Aggressive Expression of Anger (ICC=.83-.89). As with ATSS, this variable
included participant articulations of verbal (e.g., name-calling, insults) or physical (i.e., a
desire to inflict physical harm against a taped character) aggression. Because there was a
significant difference between the Neighbor (M=.99, SD=1.28 ) and Salesperson (M= .51,
SD= .84) scenarios in the number of Aggressive Expression statements, t (73)= 4.05,
jK.Ol, these variables were analyzed separately by scenario.
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Nonverbal Expression of Anger (ICC=.71-.92). This code included behaviors by
the participants that indicated anger that was not expressed verbally (e.g., eye-rolling,
hand gestures, grimacing). Nonverbal behavior by participants during the YI was coded
infrequently. All verbal codes met the low frequency criterion described above, and thus
were excluded from statistical analyses.
Constructive Anger (ICC= 8S-.94). This variable comprised the sum of six items
taken from the Constructive Anger Behavior scale (Davidson et al, 2000), assessing anger
expressed with the goal of solving an interpersonal difficulty with respect for the other
person. Because there was no significant difference in responses on the scale between the
Neighbor (M=2.41, SD=2.24) and Salesperson (M=2.56, SD=1.18) scenarios, t (73)= .48,
g>.05, scores on the measure were collapsed across scenarios.
Hypothesis 2
Relationship between Anger Suppression and Assertiveness Difficulties. Upon
inspection of the data, it was found that the only anger suppression questionnaire
significantly associated with measures of the assertive expression of anger (i.e., ATSS and
VI codes) was the PEQ. Thus, AX and HAX scores were not considered in subsequent
analyses examining these relationships. A median split was performed on PEQ scores to
create groups of Low and High anger suppressors. A Multivariate Analysis of Variance
(MANOVA) was conducted to assess differences between the Low and High anger
suppressors in the assertive expression of anger (i.e., ATSS Aggressive Statements,
aggressive statements verbalized during the VI Salesperson scenario, aggressive
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statements verbalized during the VI Neighbor scenario, and VI Constructive Anger
Expression).
The multivariate F test revealed a significant difference between the groups among
the; see Table 2 for power and effect sizes) assertiveness measures, F (1,69)= 4.79, p=.01.
Follow-up univariate tests (using Bonferroni correction, such that p values must equal or
be less than .01 to achieve statistical significance in this analysis) indicated significant
differences between the PEQ Low and High anger suppressors in ATSS Aggressive
Statements, F (1,69)= 9.19, p=.01, as well as aggression expressed in response to the
Salesperson VI scenario, F (1,69)= 8.13, jp.Ol. There was a trend toward a significant
difference between the groups in aggression expressed during the Neighbor scenario, F
(1,69)= 5.14, p=.03 (see Table 3 for means and standard deviations for each of the
assertivheness variables). For each of these, the High anger suppressors behaved less
aggressively relative to the Low suppressors. In addition, there was trend toward
significance obtained between the groups in VI Constructive Anger Expression, such that
those scoring High in anger suppression displayed more constructive anger expression
than Low suppressors, F (1,69)= 6.57, p=.02.
Hypothesis 3 (Blood Pressure Recovery during VI procedure)
Association between Anger Suppression and BP Recovery. Two Chi Square
analyses (for both SBP and DBP) were conducted to test for an association between the
Low and High scorers in PEQ anger suppression and BP recovery (i.e., a return to
baseline level of SBP or DBP, coded dichotomously as Yes or No) following the VI
procedure at 10 minutes post stimulus completion (the five minute measurement was not
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30
utilized as 66% of the sample had not recovered by this time point). Following the
recommendation of Linden and colleagues (1997), baseline levels of SBP and DBP were
not covaried out due to a lack of a strong relationship (i.e., r>.6Q) between the baseline
measures and the change scores (i.e., baseline BP levels subtracted from BP levels during
anger induction which serves as a measure of BP reactivity).
It was found that SBP recovery was independent of scores on the PEQ, x2 (fr
N=74)=.67, p>.05. That is, there was no significant association between level of anger
suppression and whether or not participants recovered from the VI procedure within 10
minutes (see Table 4 for number of participants reporting either High or Low anger
suppression by recovery status). Similar results were obtained for DBP, such that recovery
was independent of PEQ scores, x2 (1, N=74)=. 01, p>.05. Again, the degree of anger
inhibition was not significantly related to probability o f recovering within 10 minutes post
stimulus.
Hypothesis 4
Anger Differences between BP Recoverers and Non-Recoverers. A MANOVA
was conducted to assess differences between those participants who did and did not
recover by the end of the 10 minute assessment period in style of anger expressed during
the anger induction procedures (see Table 5 for power and effect sizes). More specifically,
Constructive Anger Expression, as well as aggressive verbalizations were examined in
these two groups.
Results o f the MANOVA indicated a nonsignificant omnibus F statistic, F (1,69)=
2.27, j3=.07. Indeed, there was no significant difference between those participants who
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31
recovered and those who did not in VI Constractive Anger Expression, ATSS Aggression,
ATSS Anger Control, and Aggression expressed during the VI Neighbor scenario (all F’s
less than 2.00; all p’s >.05). However, one follow-up univariate ANOVA indicated a
significant difference in the level of Aggression expressed by the recovered (M=.22,
SD=95) and non-recovered (M=. 74, SD=.60) participants during the VI Salesperson
scenario, F (1,69)=5.56, p=.01. Due to the nonsignificant multivariate test, a correction
for Type I error was applied (i.e., Bonferroni) in order to assess the significance of this
univariate result. Even after adjusting for the fact that multiple comparisons
were made, the significant difference between the recovery groups in VI Salesperson
Aggression remained.
Hypothesis 5
Resting BP and Assertive Anger Expression during Anger Induction. There were
no significant negative relationships found between assertive expression o f anger during
the anger induction procedures (i.e., VI Constructive Anger Expression, ATSS Anger
Control, and ATSS and VI Anger Statements) and either resting SBP or resting DBP.
There was one significant correlation obtained in the opposite direction than predicted.
SBP and Anger Statements expressed during the VI procedure were significantly and
positively associated (see Tables 6 and 7 for correlations among the variables).
Hypothesis 6
Relationships Among Anger Measures (Construct Validity). There were no
significant correlations found among the three anger suppression measures (see Table 8
for Pearson correlation coefficients obtained among AX, HAX, PEQ, ATSS, and VI
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32
scores). There was a significant indirect relationship obtained between AX scores and
aggression expressed during the VI procedure. A significant, negative relationship was
demonstrated between the PEQ and Aggressive verbalizations during ATSS, as well as
PEQ scores and aggression expressed during the VI procedure. In addition, there was a
trend found (2= 06) between STAXI AX scores and ATSS Anger Statements, such that as
anger suppression (AX) increased, the frequency of the outward expression toward others
(ATSS) decreased.
There was a significant correlation obtained between the two laboratory anger
induction procedures (ATSS and VI). That is, verbalized Aggression on ATSS was
' positively and significantly related to Aggression expressed during the VI procedure.
Lastly, there were several significant relationships found within each anger induction
procedure. For example, for the ATSS procedure, the number of Anger Control
Statements articulated was positively related to the expression o f Anger Statements, as
well as Aggressive Statements. Within the VI codes, the Assertive Expression of Anger
was directly and significantly correlated with Aggression. Also, there was a significant,
negative relationship demonstrated between Constructive Anger Expression and
Aggression.
Nonhvpothesized Findings
Predicting BP Levels: Regression Analyses. Although not specified in the research
hypotheses of the present study, multiple regression analyses were utilized in an attempt to
predict both SBP and DBP levels from the questionnaire and anger induction variables.
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33
The first set of regression analyses was conducted to examine the relationship between the
anger suppression measures (i.e., AX, PEQ, and HAX) and BP levels.
The following control variables were also entered to determine their predictive
value: Age, Trait Anger, and Trait Anxiety. For SBP, the full model was significant, F
(6,73)= 2.60, g=.03, with the combined variables accounting for 19% of the variance in
SBP level. Examination of the beta weights indicated that only participant Age
independently predicted SBP level, J 3 = .55, p=.01. In addition, 10% of the variance was
explained by the combination of control variables (Age, Trait Anger, and Trait Anxiety).
Thus, the anger suppression variables did not predict SBP over and above the control
variables, Fc h a n g e (3, 67)=1.99, p>.05.
For DBP, the full model was also significant, F (6,73)= 2.68, j>=.02, with the
combined variables accounting for 20% of the variance in DBP. Inspection of the beta
weights indicated that both the PEQ and HAX scores were independently predictive of
DBP level, §= .36, g=.01, J 3 = .62, j>=.03 respectively. The control variables accounted for
4.3% of the variance in DBP. The R2 change increased by .15, indicating that the anger
suppression variables significantly added to the variance accounted for in DBP, F ^ e (3,
67)=4.02, p=.01.
A second set of regression analyses was conducted to assess the relationship
between an assertive anger expression style (i.e., ATSS Anger Control, ATSS Anger
Statements, and VI Constructive Anger Expression) and BP levels. Again, the three
control variables were entered to investigate their value in predicting BP. For SBP, the full
model was nonsignificant, F (6,67)= 2.10, p.>.05, with the combined variables accounting
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34
for 17% of the variance in SBP level. As with anger suppression, participant Age was the
only independent predictor of SBP, J 3 = .50, j)= 02. After accounting for the control
variables, the assertive expression of anger explained 7% of the variance in SBP level.
This change in R2 value was nonsignificant, demonstrating that the assertive anger
expression variables did not add to the variance accounted for in SBP,
Eotage(3, 64)=1.56, E>.05.
For DBP, the full model was nonsignificant, F (6,67)= .94, j>.>.05, with the
combined variables accounting for 9% of the variance. No variables independently
predicted DBP. After accounting for the control variables, the assertive expression of
anger explained 4.7% of the variance in DBP level, which did not predict independently of
the control variables, 3 E c h a iige(3, 64)=.84, j>>.05.
The third set of regression analyses investigated the relationship between an
aggressive style of anger expression (i.e., ATSS Aggression, VI Aggression during the
Neighbor scenario, and VI Aggression during the Salesperson scenario) and BP levels
(accounting for the control variables). The full model for SBP was nonsignificant, F
(6,67)= 1.41, p.>.05, with the combined variables accounting for 12% of the variance in
SBP level. As with the other two regression analyses ran with SBP as the outcome
variable, only Age independently predicted SBP level, J 3 = .51, g= 02. Aggressive style of
anger expression accounted for 2% o f the variance in SBP independently of the control
variables. Thus, the change in R2 was nonsignificant, £ ^ ^ (3 , 64)=.33, p>.05. For DBP,
the full model was nonsignificant, F (6,67)= .49, j).>.05, with the combined variables
accounting for 5% of the variance. No variables independently predicted DBP. Because
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35
the control variables explained 4.3% of the variance in DBP level, aggressive expression
of anger during anger arousal predicted virtually nothing above these variables, (3,
64)=.06, £>.05.
Test for Moderating Effects. Because it was believed that Age, Trait Anxiety
scores, and Trait Anger scores may act as moderators of the link between the anger
suppression measures and BP levels, regression analyses were conducted in order to
assess the possible moderating roles of these variables. To test for the moderating role of
Age, separate regression analyses were conducted for each of the three anger suppression
variables (PEQ, HAX, AX). In each analysis, BP (both SBP and DBP) were predicted
from the main effects of the anger suppression variables and Age, and the interaction
between them. Significant interaction effects between the predictors and Age would be
considered indicative of moderation (Baron & Kenny, 1986). However, no significant
interactions were obtained. Similar results were demonstrated for the moderating effect of
Trait Anxiety. That is, no significant interactions were found between any of the anger
suppression variables and Trait Anxiety.
For STAXI Trait Anger, however, a significant interaction was obtained between
this variable and AX scores when predicting DBP only. To explore this interaction, a
median split was performed on the Trait Anger scores and correlations between the DBP
and AX scores were computed. It was found that at lower levels of Trait Anger, AX
scores were predictive of DBP, r (42)=.39, £=.01. However, at higher levels of Trait
Anger, AX scores were not predictive of DBP, r (42)= -.10, £>.05. That is, for those
participants who reported higher levels o f angry feelings, anger suppression did not seem
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3 6
to be significantly related to DBP level But, for those who endorsed less frequent anger,
anger suppression did appear to play a role in predicting level ofDBP.
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37
DISCUSSION
The present study was conducted to assess the role of anger expression in a
community sample of men with mildly elevated blood pressure. More specifically, the
inhibition of, as well as assertive (i.e., constructive) expression of anger was examined.
Although previous researchers have investigated these constructs separately in relation to
elevated blood pressure, none have investigated the relationship between them within the
same sample of participants. Thus, this was a primary goal of the present study.
In addition, an effort was made to measure anger expression using more externally
valid techniques (i.e., those which involved “active” stimuli and assessed anger expression
as angry feelings were being experienced by participants). The results of the present study
were intended to Anther the understanding of the role of anger expression in elevated BP
through investigation of anger expression style (assertive or aggressive) exhibited during
anger induction and self-reported inhibition of anger via questionnaire measures. An
additional goal was to link participant style of anger expression to BP recovery following
anger arousal.
In general, the results of the present investigation indicated that individuals who
reported a greater tendency to suppress their angry feelings had higher resting levels of
DBP than those who endorse less inhibition of anger. This finding is consistent with
numerous previous investigations (for a review of this literature, see Barbour & Davison,
2000). However, this relationship held only for suppression of anger in response to
laboratory anger induction. Contrary to expectation, those participants who scored High
in anger suppression did not display difficulties in assertiveness relative to Low
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38
suppressors. In fact, those self-reporting less anger suppression actually exhibited a
significantly more aggressive style of anger expression than the High scorers. In addition,
neither anger suppression nor Constructive Anger was significantly correlated with BP
recovery following anger induction, although there was limited support demonstrated for a
relationship between an aggressive style of expressing angry feelings and whether or not
BP returned to baseline levels following anger induction. The hypothesis that Constructive
Anger Expression would be negatively correlated with resting SBP and DBP was not
supported. There was little evidence found to support the hypothesis that assertive anger
expression would be negatively correlated with more “destructive” means of expressing
angry feelings. Finally, anger suppression, as well as style of anger expression
(i.e., assertive versus aggressive) as measured in the present study were found to be
weak predictors of resting SBP level. However, resting DBP was predicted by scores on
two of the anger suppression measures.
Anger Suppression
The hypothesis that anger suppression would be directly correlated with BP was
generally not supported. The exception was the significant correlation obtained between
the Post Experimental Questionnnaire (PEQ) anger suppression and DBP. It is possible
that significant results were obtained with the PEQ and not the other anger suppression
measures (AX, HAX) because the PEQ was tied to anger expression related to a specific
situation soon after it actually took place (versus a measure of anger expression in general,
across situations). That is, the PEQ may provide a more valid measure of the link between
anger suppression and BP, as it was assessed during (or immediately following) the
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39
experience of angry feelings elicited in the laboratory. It is also possible that a restricted
range in blood pressures, particularly DBP, may have contributed to the low correlations
obtained between BP levels and the anger suppression measures. However, the fact that
significant findings were demonstrated between DBP and the variables of interest argues
against this possibility.
In addition to DBP level, there appeared to be a narrow range in AX scores. That
is, participants in the present study obtained a mean AX Anger-In score that was eight
points higher than the normative sample described in the STAXI manual (Spielberger,
1988; this sample was comprised of adult males with a mean age of 40 years old). Because
few participants in the present study scored low (i.e., less anger suppression) on the AX
Anger-In scale, it appeared that, as a group, these individuals were self-reporting a
relatively high level o f inhibited anger expression. Although this would support the notion
of those with elevated BP levels reporting higher levels of anger suppression, it may have
made it more difficult to detect relationships with other variables due to the lack of
variability in AX scores.
It was surprising that there were no significant correlations obtained among the
anger suppression measures utilized in the present study (AX, HAX, and PEQ). Although
each questionnaire taps into different aspects o f anger suppression (i.e., the AX assesses
anger suppression in general, the HAX inquires about anger suppression in response to
vignettes, and the PEQ was specific to anger suppressed during the actual experience of
state anger in the laboratory), it was expected that they would be at least moderately
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40
correlated. Thus, construct validity among the three anger suppression measures was not
demonstrated in the present study.
In addition, there were no significant correlations obtained between questionnaire
measures of anger suppression and anger expressed during the ATSS and VI laboratory
procedures (with the exception of a trend in the expected direction between AX scores
and ATSS Anger Statements). Although not directly hypothesized in the present study,
one might expect these variables to be negatively correlated. That is, as anger suppression
increases, it becomes less likely that anger will be outwardly expressed. However, it is
possible that this lack of correspondence between the questionnaire and the anger
induction procedures is due to differences in methodology, as opposed to a lack of
convergence between the constructs. Indeed, it is not uncommon for researchers to obtain
disparate results regarding a given construct between questionnaire measures and ATSS
(for discussion of this issue, see Chamberlain & Haaga, 1999).
It was predicted that a significant and positive relationship would exist between
anger suppression and assertiveness difficulties during laboratory anger induction.
However, this hypothesis was not supported. In fact, those scoring higher on a measure o f
anger suppression demonstrated significantly fewer problems with assertiveness. That is,
those who reported higher PEQ anger suppression articulated significantly less verbal and
physical aggression during the two anger induction procedures than those who obtained
lower anger suppression scores. Although it was expected that those who suppress anger
would lack the ability to directly express their angry feelings (e.g., “I am so mad at you!”),
and would instead verbalize their anger aggressively (“What a jerk.”), it may be that those
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41
who suppress their angry feelings are less likely to articulate them in any manner. This
notion is consistent with data showing that those with hypertension are less likely to
express anger specifically, as well as other emotions more generally (Cumes-Rayner &
Price, 1989; Pilowsky et al., 1973; Rotter & Ewart, 1992).
Previous research has found support for subtypes of hypertensives in assertiveness,
such that while some individuals become aggressive when faced with difficult interpersonal
situations (as was predicted in the present study), others have been found to respond with
passivity (Morrison, Bellack, & Manuck, 1985). This differential pattern o f responding
among participants in the present study may account for the lack of assertiveness
difficulties found in those who endorsed higher levels of anger suppression. That is,
perhaps those individuals who are more likely to suppress their angry feelings also respond
to interpersonal conflict with passivity, instead of aggression, and thus no relationship
between anger suppression and style of anger expression during anger induction was
detected in the present investigation.
Despite no significant difference between those participants who scored High and
Low in PEQ anger suppression, an interesting pattern emerged in the data. Upon visual
inspection, it was found that High suppressors rarely expressed anger aggressively during
the laboratory procedures. However, those scoring Low in anger suppression displayed a
less consistent pattern, with many expressing aggression and many expressing no
aggression. In other words, there was not as much predictive value in knowing a
participant scored Low in anger suppression with regards to their expression o f anger. In
contrast, High suppressors reliably verbalized no aggression. Perhaps individuals without a
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tendency to suppress anger have more options at their disposal for managing interpersonal
conflict (e.g., expressing anger aggressively, assertively, or not at all, depending on the
context) relative to those who inhibit expression of angry feelings.
BP Recovery
It is believed that the acute BP increases that occur with anger arousal eventually,
over time, lead to structural changes in the vasculature (i.e., increased peripheral
resistance) that may result in hypertension. Thus, the prolongation of this increase in BP
(i.e., longer recovery time) is relevant due to its possible role in the development and/or
progression of the disease. Cognitively, it has been hypothesized that those with slower
blood pressure recovery times following anger arousal may be continuing to ruminate
about actual or perceived wrongdoings committed against them (Goldstein, 1988).
Engaging in rumination has been shown to exacerbate angry feelings (Rusting &
Nolen-Hoeksema, 1998). It is interesting that more attention has not been paid to angry
rumination relative to that which occurs with other emotions (e.g., depressed mood), as
angry rumination likely affects cardiovascular ftmctioning and may be more difficult to
regulate via the strategies that have been shown to be effective with other emotions, such
as distraction. That is, control of the ruminative process in anger may be more problematic
because an individual who is angry engages in other-blame and often feels justified in her
or his anger (Rusting & Nolen-Hoeksema, 1998).
It was hypothesized that there would exist a significant positive correlation
between anger suppression and BP recovery time following VI anger induction. It was
believed that those participants who are able to more quickly “resolve” their angry feelings
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43
through outward expression would exhibit a quicker return to baseline BP levels following
a stressor (Hokanson & Burgess, 1962). However, this notion was not supported by the
data in the present investigation.
In addition, it was predicted that those participants utilizing an assertive anger
expression style during the anger induction procedures would exhibit a significantly faster
BP recovery than those characterized by a more aggressive manner of expressing angry
feelings. This hypothesis was only partially supported by a significant difference between
those who had and had not recovered by the 10 minute time period in Aggression
expressed during the VI Salesperson scenario. Those participants who had recovered to
baseline levels of BP expressed significantly less Aggression in response to this scenario
relative to those who had not recovered. This finding may lend support to the notion that
the use of aggression is not an effective way to resolve angry feelings.
Aside from the possibility that there truly exists no significant relationship between
anger suppression or the assertive expression of anger and BP recovery, there are also
several difficulties in the measurement of BP recovery that may contribute to the lack of
findings (Rutledge, Linden, & Paul, 2000). Some of these are relevant to the present study
and are outlined below.
Difficulties in the Assessment of BP Recovery. Perhaps partly due to the novelty of
the study of BP recovery, here is considerable confusion in the literature regarding the
optimal manner in which to quantify this variable (Christenfeld, Glynn, & Gerin, 2000;
Schuler & O’Brien, 1997; Warner & Strowman, 1995). For example, although some
researchers favor the use of change scores (i.e., subtracting baseline blood pressure levels
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44
from reactivity blood pressure levels), others advocate covarying out the effect of baseline
measures (for a review of this dilemma, see Linden et aL , 1997). A decision was made in
the present study not to control for baseline BP levels (following the convention outlined
by Linden et al., 1997). This issue continues to be debated in the cardiovascular recovery
literature.
A second complication involves the length of time necessary for adequate
assessment of BP recovery. There exists a wide range reported in the literature in the
period o f time utilized by researchers (Linden et al., 1997). Perhaps the recovery data in
the present examination would have been different if BP had continued to be assessed until
a return to baseline was reached (in contrast to the 10 minute assessment period used in
the present study for all participants). However, researchers have cautioned against
allowing BP levels to be monitored for excessive periods of time, as the further away
temporally these measures are from the task, the less certain one may be that these BP
levels are indeed due to the effects of the stimulus. In feet, it is possible to create further
BP reactivity secondary to participant frustration at being forced to sit for an extended
period of time following the completion of a task. As a result, Schuler and
O’Brien (1997) have suggested the use of a recovery time of less than 10 minutes. Thus,
this complex issue remains unresolved in the literature and awaits further empirical
examination.
Nonverbal behavior (e.g., eye-rolling, angry hand gestures, sighing) during the VI
procedure occurred so infrequently in the present sample as to necessitate the exclusion o f
these data from statistical analyses. Although not directly hypothesized, it was expected
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that a negative relationship would exist between participant use of nonverbal behavior
during the VI procedure and BP reactivity. Such an association has been demonstrated in
previous research and suggests that inhibition of nonverbal responses in times of stress
leads to covert “expression” via increases in autonomic arousal (for a review of this
literature, see Berry & Pennebaker, 1993).
Constructive Anger Expression and Resting BP
Next, it was hypothesized that a significant negative relationship would be
uncovered between a Constructive Anger expression style and both resting SBP and DBP.
However, this hypothesis was not supported in the present investigation. Thus, the finding
of an inverse relationship between the variables reported by Davidson and colleagues
(2000) was not replicated here. Several methodological differences between the studies
that may help account for this discrepancy are described below.
First, Davidson and colleagues (2000) utilized a considerably larger sample size
(N=1,862) than was employed in the present study. With the higher level of power
afforded by this sample size, it is possible that the present study would have obtained
similar results. In addition, the range in BP was larger in the Davidson et al. study
(comprising both hypertensive and normotensive participants) relative to the present
study. The inclusion of those individuals with BP levels in the normotensive range may be
necessary to detect a significant relationship between constructive anger expression and
BP.
Lastly, a difference between the studies lies in the context in which the
Constructive Anger Expression items were coded. That is, Davidson and colleagues
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assessed this anger expression style while participants were engaged in a stressful
interview (based on the Structured Interview, an interview widely used to assess the Type
A, so-called coronary-prone Behavior Pattern; Rosenman, 1978) with a nurse, whereas
the present study assessed Constructive Anger Expression while participants were
engaged in a conflictual interaction with videotaped characters. Although there exist no
data to suggest differences in anger expression style between the two procedures, perhaps
they pull for unique participant behaviors (e.g., it is possible that the Constructive Anger
expression items are more relevant in an interview situation). Therefore, examination of
assertive anger expression in those with elevated BP requires further study across a variety
oflaboratoiy procedures.
Finally, it was hypothesized that a significant inverse correlation would exist
between constructive and aggressive forms of anger expression during the laboratory
procedures. In general, this hypothesis was not supported. Although there was a
significant negative relationship demonstrated between Constructive Anger Expression
and Aggression expressed during the VI procedure (Neighbor scenario), the majority of
correlations between the more “healthy” mode of anger expression and an aggressive style
were nonsignificant.
In addition, correlations were obtained that were in the direction opposite o f that
predicted in the hypothesis. For example, ATSS Aggression was positively correlated to
ATSS Anger Control. Thus, the more participants expressed aggression against a taped
character, the more likely they were to also attempt to reduce their angry feelings. Perhaps
those who did not try to control their anger had no need to do so as they were not
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47
expressing (aggressively) any anger toward the taped characters. This might suggest that
those who did not express anger, despite the fact that they experienced it (as demonstrated
by the significant increase in State Anger from Pre-Post ATSS), may not have engaged in
efforts to reduce these feelings when aroused. However, this scenario is less likely given
the fact that self-reported State Anger post-ATSS was positively and significantly related
to number of Aggressive Statements articulated during the procedure.
Although the degree to which participants experienced anger during ATSS is
unknown, it seems probable (due to the post-ATSS State Anger scores) that those who
experienced more anger also expressed more aggression. Interestingly, however, the
degree to which participants used Anger Control strategies during ATSS was not
significantly related to the intensity of the anger they experienced post-ATSS. The
relationship between the assertive and more aggressive expressions of anger in individuals
with elevated BP is unclear and appears to be complex given the data obtained in the
present study. Because these phenomena have just recently begun to be examined
systematically by researchers (e.g., Davidson et al., 2000; Ghosh & Sharma, 1998;
Hauber et al., 1998), much more data are needed before firm conclusions can be drawn
regarding their role in elevated BP.
Prediction of BP Levels
Although no specific predictions were made, regression analyses were conducted
to examine the value of the anger suppression, Constructive Anger Expression, and
Aggressive Anger Expression variables in predicting both SBP and DBF. In addition,
three control variables were entered to assess their predictive power: Age, Trait Anger
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48
scores, and Trait Anxiety scores. It was shown that none of the anger variables was
predictive of SBP level. Age did have predictive value above that of the anger variables.
This finding is logical and consistent with literature showing that SBP level rises with
increasing age, at least in Western cultures (Stamler, Stamler, & Neaton, 1993).
For DBP, the pattern was much like that obtained with SBP with the exception of
the anger suppression measures. That is, both the PEQ and HAX scores predicted DBP
above and beyond the control variables. In addition, Age was not predictive of DBP. This
finding is consistent with the literature showing that DBP does not appear to rise with
increasing age. It is unclear why anger suppression might be predictive of DBP only.
Because DBP value represents the force of blood while the heart muscle is at rest, it may
be that inhibition of anger affects that particular phase of the cardiovascular cycle.
However, the way in which DBP alters the structure of the cardiovascular system is less
clear than with SBP. That is, SBP is indicative of rigid, atherosclerotic arteries and
represents the high pressure placed on the cardiovascular system (Kaplan, 1998). In some
studies, SBP has been found to be more strongly predictive of CHD, as well as stroke,
than DBP (e.g., Stamler et al., 1993). However, other researchers have found that the
predictive powers of SBP and DBP for stroke and CHD are similar (Isles, 1995).
Finally, neither Age nor Trait Anxiety was found to moderate the relationship
between anger suppression (AX scores) and either SBP or DBP. However, there was a
significant interaction obtained between anger suppression and STAXI Trait Anger for
DBP. It was found that at lower levels o f Trait Anger, anger suppression was predictive of
higher DBP. However, at higher levels o f Trait Anger, anger suppression was not
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49
predictive of higher levels of DBP. This finding may suggest that, for those who report the
experience of less anger, suppressing these feelings may lead to higher DBP levels. It may
also be the case, however, that those who suppress their angry feelings are also less likely
than those who do not suppress angry feelings to endorse items found on the Trait Anger
scale (e.g., “ I have a fiery temper,” ‘T am a hotheaded person”).
In addition, this interaction is difficult to interpret given that AX scores were
highly correlated with the moderator. Thus, it is not possible to make a distinction
between anger experience and anger expression (suppression) on this measure. Finally, the
problems associated with the measurement of anger suppression (see discussion of this
issue below) further complicate interpretation.
In sum, the present study was conducted in an effort to further basic knowledge of
the role of anger expression in elevated blood pressure. More specifically, anger
suppression, anger expression, and assertiveness were assessed within the same sample of
men. These variables were also examined in relation to BP recovery. It was found that
self-reported anger suppression during anger induction was positively related to DBP
only. Those who suppressed their anger reported significantly less assertiveness
difficulties. In addition, aggression was found to predict BP recovery. Finally, construct
validity among the variables generally was not demonstrated in the present study.
Limitations of the Present Study
The results of the present investigation must be viewed in light o f several
limitations. First, the present study was designed to detect the existence of a linear
relationship between BP and the dependent variables. However, the possibility remains
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50
that the relative lack of results demonstrated here is due to failure to uncover potential
relationships between the variables (e.g., a curvilinear relationship or threshold model).
Future research studies should be designed with these hypotheses in mind.
Next, because of the nature of the sample, the results obtained may not generalize
to other populations. More specifically, the present study included participants who were
well-educated, with many possessing a graduate degree. This high level of education is not
typical of participants in BP studies. For example, many investigations include factory
workers or those in similar occupations. It may be that the relationships among the
variables is not the same across groups with differing levels of education (and the possible
differences in job stress that may result). The possibility exists that the data may have been
different had they been gathered from a sample similar to those used in previous studies.
In addition, the inclusion of other ethnic groups may have altered the findings. Of
particular importance would be the inclusion of African Americans. The prevalence of EH
is much higher in the African American than the Caucasian population. Not only is EH
more common among African Americans, it is also more severe and less well-controlled.
Thus, the disease is associated with more morbidity and mortality in this group.
Although socioeconomic status and stressful living conditions may play a role in
the higher prevalence rates (Harburg et al, 1973), African Americans have higher levels of
BP even when compared to Caucasians at the same income level (Sorlie et al., 1992).
Also, several psychological variables have been found to be more strongly related to BP
levels in African Americans than in European Americans as early as the adolescent
years (Johnson et al., 1987). Thus, the examination of psychological factors in EH remains
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a relevant and important goal to pursue in this population. In fact, stronger relationships
have been obtained between anger/hostility and BP in black relative to white participants
(e.g., for suppressed anger, Dimsdale et al 1986). Therefore, it has been suggested that
the role o f anger in BP may be different for blacks than whites. Consistent with this
hypothesis, suppressed anger has been found to be an independent predictor of subsequent
HTN for blacks, but not for whites (Somova, Connolly, & Diara, 1995).
In the present examination, it is possible that the role of anger suppression in
elevated BP may have varied across ethnic groups. In addition, the BP recovery results
may have differed had African Americans been included. For example, African Americans
have been consistently found to exhibit slower DBP recovery times following laboratory
stressors relative to European Americans (e.g., Fredrickson et al, 2000; Schuler &
O’Brien, 1997).
In addition, numerous investigations have suggested that the role of anger in BP
(as well as CVD) may vary according to gender (e.g., Dimsdale et al.,1986; Harburg,
Blakelock, & Roeper, 1979; Steele & McGarvey, 1997). However, it is difficult to know
if these differences are reliable or not due to a lack of female participants in earlier studies.
That is, women have only relatively recently been routinely included in studies of BP. In
sum, future studies should examine anger expression style and assertiveness in ethnic
minorities, as well as in women.
A second difficulty of the present study included a relative lack o f variability in
blood pressures, especially in DBP. Although not unexpected given the nature of the
sample (i.e., participants who had been identified as having mildly elevated BP), this
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52
restricted range may have resulted in a decreased ability to detect significant relationships
among the variables had they existed. As noted previously, many studies in the literature
either employed samples with both hypertensive and normotensive participants or assessed
the role o f anger in hypertensives, but included a wider range of BP.
Difficulties in Assessing Anger Suppression. It has been established that there is
much conceptual confusion regarding the assessment of anger and hostility in general. In
addition, there is difficulty in the assessment of the specific components of each construct.
This is particularly relevant in the case of suppressed anger/hostility. Jorgensen et al.
(1996) underscored this conceptual confusion in their discussion of the heterogeneity of
items that are considered “anger suppression” (e.g., harboring grudges, guilt, resentment).
Some researchers highlight the role of repressed anger (and emotions in general)
as the important risk factor for development of EH. In fact, in his recent book directed
toward a nonprofessional audience, Mann (1999) suggested that HTN is more related to
“emotions we harbor but do not feel and often do not even know exist within us (p. 16).”
Thus, the focus is on the role of emotions that are not experienced by those with
hypertension. That is, the development of EH arises from “hidden” emotions of which the
hypertensive individual is completely unaware. However, this view of emotional
suppression differs from the way in which the construct was conceptualized in the present
study. Anger suppression in the present examination was defined as angry feelings that are
experienced, yet not expressed. That is, the individual with elevated BP is likely to be
aware of her or his anger, but either chooses not to or is unable to express the emotion.
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Assuming individuals with elevated BP experience anger that they do not
outwardly express, how might such anger suppression be detected? A primary difficulty
with the assessment of suppressed anger involves the possible ambiguity that results when
a high score (i.e., high level of suppression) is observed. That is, a high score could
represent one or more of several different possibilities (Goldstein et al, 1988): the
respondent really is not experiencing anger (thus, there would be nothing to suppress), the
respondent is not aware of feelings of anger (repression), or social desirability factors are
at play (perhaps it is more desirable to endorse suppression versus the overt expression of
anger). Thus, the existence of a high score in anger suppression results in considerable
interpretational difficulties.
In the present investigation, this issue arises when attempting to interpret the
results obtained. For example, did those participants who scored higher in anger
suppression express less ATSS and VI assertiveness difficulties than those who did not
report anger suppression because this is a true finding, or were they simply more likely to
censor their articulations during the anger induction procedures? Previous research has
shown that those who suppress their anger may be more likely to inhibit expression of
other emotions as well (Cumes-Rayner & Price, 1989). Therefore, it is possible that these
individuals are underreporting their experiences in general (e.g., their levels of Trait Anger
or Anxiety).
According to Berry and Pennebaker (1993), researchers must make the distinction
between individuals who are naturally low in emotional expressiveness and those who
actively inhibit emotions. That is, not every person who does not express emotion is
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54
necessarily suppressing it. Thus, a participant in the present study might not have reported
suppression of anger because they genuinely encounter infrequent feelings of anger in their
lives. There likely exists individual differences between those who are simply more relaxed
and those who are emotionally aroused but fail to display it.
The Relationship Between Anger Control and Anger Suppression. A related issue
in the assessment of inhibited anger expression involves the distinction between the
constructs of Anger Control and the suppression of anger. Although the former is
purported to be adaptive and the latter an unhealthy anger expression style, it may be
difficult to discriminate between these variables. For example, the AX item “I keep my
cool” is meant to tap into Anger Control. However, it does not seem unreasonable that an
individual who typically suppresses her or his anger might endorse this item. In this case,
perhaps the “control” of angry feelings is with the goal of concealing the expression of
anger from others (i.e., anger suppression). Although the STAXI manual indicates that the
correlation between the Anger In and Anger Control scales is “essentially zero,” these data
appear to come primarily from one laboratory and have not been examined in a population
characterized by the tendency to suppress anger. Further data are necessary to in order to
confirm the orthogonal nature of these two constructs.
Perhaps to address this issue, Spielberger, Reheiser, and Sydeman (1995) have
developed a new scale that further differentiates the concept of Anger Control. These
researchers have divided the Anger Control Scale into (1) attempts to control the outward
expression of anger (Anger Control-Out; e.g., “I control my urge to express my angry
feelings.”) and (2) efforts to reduce the angry feelings that are being suppressed (Anger
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55
Control-Ill; e.g., “I try to soothe my angry feelings.”). It is not yet known whether or not
this new scale will allow for a more valid test of the constructs.
Although the data of the present investigation generally failed to support the
hypotheses, previous studies utilizing this same sample of men with elevated BP have
produced results that were consistent with the respective predictions. A review of these
studies is provided in the following section in an effort to account for the findings of the
present study.
Comparisons with Published Data from the Larger Study
Three published articles utilizing data from the larger study of which the present
investigation was a part each obtained several significant findings relevant to the present
investigation. For example, a treatment combination of psychoeducation and muscle
relaxation produced significantly greater reductions in BP and ATSS
angry/hostile/aggressive verbalizations than did psychoeducation alone (Davison et al.,
1991; Haaga et al., 1994). In addition, the reductions in these angry articulated thoughts
were significantly correlated with BP reductions (Davison et al, 1991). Another
investigation obtained a significant difference was found between participants classified as
Type A and Type B in self-supportive articulations in response to ATSS scenarios (with
the Type B5 s emitting significantly higher levels of this variable; Williams et al., 1992).
Thus, it seems unlikely that the lack of significant results obtained in the present
study is due to design/methodological problems. Rather, it is possible that the results of
the present study were not consistent with those of the previous studies because of the
focus on disparate constructs (i.e., hostility and trait anger in the earlier studies versus
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56
style of anger expression in the present investigation). For example, two o f the studies
(Haaga et al., 1994; Williams et al., 1992) involved examination of the Type A Behavior
Pattern in these men. Although Davison and colleagues (1991) assessed anger, it was in
the context of observed changes from pre- to post-treatment, and focused on the
experience versus the expression of anger (Le., Trait Anger versus AX Anger-In).
Thus, the larger study was created to assess different variables of interest (e.g.,
reduction in anger following treatment, differences between Type A’s and Type B’s in
articulated thoughts) than those measured in the present study, and may partially explain
why significant relationships were not detected in the present investigation. Perhaps
alterations in the design of the study would have been necessary to adequately assess the
constructs of anger expression and assertiveness. In the next section, recommendations
regarding the future examination of these variables are discussed.
Methodological Considerations
The present study is unique in its examination of anger expression (suppression)
and assertiveness (Constructive Anger Expression) within the same sample. Although the
results of this study are not as encouraging as was expected, these variables deserve
Jprther investigation using participants with a wider range o f BP levels. In addition, the
role of anger expression and assertiveness in elevated BP should be examined in two
understudied populations: ethnic minorities and women.
BP Recovery. In the BP literature, more investigations utilizing clinical samples
(i.e., individuals with EH) are needed. This is especially true o f BP recovery studies, as the
vast majority have assessed recovery in college students with BP levels in the
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57
normotensive range, and often excluded participants with elevated BP (e.g., Faber &
Bums, 1996; Rutledge, Linden, & Paul, 2000). It will not be possible to determine the
nature of BP recovery in those with elevated BP until further investigations are conducted
using such participants.
As noted previously, there is a need for a series of studies varying the length of
recovery time while holding other experimental conditions (e.g., nature of the stimulus
presented) constant. Only then will the complexities associated with the measurement of
BP recovery be adequately addressed. In addition, although anger expression style was not
significantly related to BP recovery in the present study, the role of anger in BP recovery
may still prove to be a fruitful avenue of research. For example, participants scoring high
in hostility (a construct related to anger) have been found to exhibit slower DBP recovery
times following a laboratory stressor than those scoring lower on a measure ofhostility
(Fredrickson et al., 2000). Because hostility is considered an attitudinal construct (as
opposed to anger, which is believed to be a transient emotional state; see Kassinove &
Sukhodolsky, 1995 for more on this distinction), it may be that rumination is more likely
in individuals who are high in hostility, and thus tend to think about an anger-provoking
event long after it has occurred (and the immediate, angry feelings have faded). Perhaps
this finding lends support to the hypothesis that BP recovery times are slowed due to
angry rumination.
It is surprising that BP recovery has only recently received attention in the EH
literature, given the proposed clinical significance of this variable in the
development/progression o f the disease (Brosschot & Thayer, 1998). Although not
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58
demonstrated by the results in the present investigation, anger suppression has been
hypothesized to lead to slower BP recovery following stressors. If researchers are able to
identify a significant relationship between inhibited anger expression and delayed BP
recovery time, this may provide an opportunity to intervene on a cognitive level with those
individuals who suppress angry feelings. That is, it may be possible to target and modify
angry, ruminative cognitions that occur in response to provocation (either actual or
perceived).
Laboratory Stimuli. In future studies, anger expression style (e.g., Anger-Out
versus Anger-In) in response to a specific stimulus should be assessed. As demonstrated in
the present study with the PEQ, obtaining data regarding anger expression style while
people are actually angry may tap into the construct in such a way that may not be
detected using more conventional measures of anger suppression that simply inquire about
a participant’s typical response when angry, across many situations. Indeed, this is a
primary reason that the ATSS paradigm was developed (Davison, Robins, & Johnson,
1983).
Despite data indicating that the use of more externally valid laboratory stressors
yields more consistent results across studies (Fredrickson & Matthews, 1990), researchers
continue to employ artificial stimuli in the study of BP (e.g., mental arithmetic; Rutledge et
al., 2000). In addition, data linking BP reactivity in response to the traditional laboratory
stressors (e.g., mental arithmetic) to ambulatory BP levels is equivocal (Manuck,
Kasprowicz, & Muldoon, 1990). Intuitively, it seems important to utilize stressors that
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59
participants are likely to confront in their daily lives in order to accurately assess anger
expression and assertiveness, as was done in the study from which these data were drawn.
A related issue concerns the use of more relevant scenarios when the goal is to
induce anger in those with elevated BP. For example, arguments with family members and
conflicts at work were the most frequently cited causes of anger in sample of CHD
patients recovering from myocardial infarction believed to be precipitated by an episode of
anger (Mittleman et al., 1995). Researchers should use data such as these to inform the
type of anger induction procedure they create.
Coding Schemes. Further research on the style of variable coding used during
anger induction is needed. For example, the present study utilized a coding scheme which
was relatively narrow in scope (i.e., frequency counts of specific words). However, it may
be necessary to create a more molar coding method in order to fully capture the
phenomena of interest (e.g., instruct coders to focus on patterns of responses versus
tallying the occurrence of certain words verbalized by participants).
General Conclusions
In sum, many of the relationships predicted in the present investigation did not
receive support. Although it is possible that these findings reflect reality, it is premature to
conclude that anger expression (particularly assertive anger expression) does not play an
important role in elevated BP. Whether BP is related to assertiveness difficulties or
Constructive Anger Expression is a question that awaits further empirical scrutiny and
should be examined with consideration of the above methodological recommendations.
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60
In addition to the research implications, further examination of the anger
expression and assertiveness association may be of great clinical relevance. There are data
to suggest that psychological treatment of EH is effective in reducing BP levels relative to
medication. A recent meta analysis (Linden & Chambers, 1994) examining effect sizes for
both drug and nondrug treatment of EH indicated that, for SBP, both weight
reduction/exercise and cognitive behavioral therapy (CBT; included stress/anger
management and cognitive restructuring) were as effective as medication. For DBP, CBT
was equally effective as drug therapy after controlling for pre-treatment differences in
DBP levels. It is possible that an intervention that targets angry rumination and teaches
assertiveness and anger control strategies would be effective in reducing BP.
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61
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APPENDIX A
Spielberger’s AX scale
Directions: A number of statements which people have used to describe themselves when
they feel angry or furious are given below. Read each statement and then circle the
appropriate number to indicate how often you feel or act in the manner described. There
are no right or wrong answers. Do not spend too much time on any one statement. For
each item circle the answer which seems to best describe how you generally act or feel
when you are angry or furious.
WHEN ANGRY OR FURIOUS
1 .1 control my temper.
(1) Almost never_ _ (2) Sometimes (3) Often___(4) Almost always
2 .1 express my anger.
(1) Almost never_ _ (2) Sometimes___ (3) Often_ _ (4) Almost always
3 .1 keep things in.
(1) Almost never_ _ (2) Sometimes___ (3) Often___(4) Almost always
4 .1 make threats I don’t really mean to carry out.
(1) Almost never_ _ (2) Sometimes___ (3) Often___(4) Almost always
5 .1 pout or sulk.
(1) Almost never_ _ (2) Sometimes___ (3) Often___(4) Almost always
6 .1 withdraw from people.
(1) Almost never_ _ (2) Sometimes___ (3) Often___(4) Almost always
7 .1 make sarcastic remarks to others.
(!) Almost never__ (2) Sometimes___ (3) Often___(4) Almost always
8 .1 keep my cool.
(1) Almost never_ _ (2) Sometimes___ (3) Often___(4) Almost always
9 .1 do things like slam doors.
(1) Almost never_ _ (2) Sometimes___ (3) Often___(4) Almost always
10.1 boil inside, but I don’t show it.
(1) Almost never_ _ (2) Sometimes___ (3) Often___(4) Almost always
11.1 argue with others.
(1) Almost never_ _ (2) Sometimes___ (3) Often___(4) Almost always
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69
12.1 tend to harbor grudges that I don’ t tell anyone about.
(1) Almost never___ (2) Sometimes_ _ (3) Often___ (4) Almost always
13.1 strike out at whatever infuriates me.
(1) Almost never___ (2) Sometimes_ _ (3) Often___ (4) Almost always
14.1 am secretly quite critical of others.
(1) Almost never___ (2) Sometimes_ _ (3) Often___ (4) Almost always
15.1 am angrier than I am willing to admit.
(1) Almost never___ (2) Sometimes_ _ (3) Often___ (4) Almost always
16.1 calm down faster than most other people.
(1) Almost never___(2) Sometimes (3) Often___ (4) Almost always
17.1 say nasty things.
(1) Almost never (2) Sometimes (3) Often (4) Almost always
18. I’m irritated a great deal more than people are aware of.
(1) Almost never (2) Sometimes (3) Often___ (4) Almost always
19.1 lose my temper.
(1) Almost never (2) Sometimes_ _ (3) Often___ (4) Almost always
20. If someone annoys me, Fm apt to tell him or her how I feel.
(1) Almost never (2) Sometimes (3) Often___ (4) Almost always
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70
APPENDIX B
Harburg Anger Expression Scale (HAX)
Instructions: Circle one alternative for each question.
1. Imagine that you were at work and your boss got angry and blew up at you for no good
reason. What would you do?
A. a. Just walk away from the situation.
b. Let the thing pass over without saying a word.
c. Report him to the department office.
d. Protest to someone higher up.
e. Protest to him directly.
f. Talk to him about it after he has cooled down.
g. Try to reason with him at the time.
B. Now, suppose you did get angry and showed him that you felt this way. How
would you feel later about this?
a. very guilty or sorry
b. somewhat guilty or sorry
c. a little guilty or sorry
d. not at all guilty or sorry
2. Now imagine that you were doing something outside and a policeman got angry or
blew up at you for something that wasn’t your fault. What would you do?
A. a. Just walk away from the situation.
b. Let the thing pass over without saying a word.
c. Report him to the city department office.
d. Protest to someone higher up.
e. Protest to him directly.
f. Talk to him about it after he has cooled down.
g. Try to reason with him at the time.
B. Now, suppose you did get angry and showed him that you felt this way. How
would you feel later about this?
a. very guilty or sorry
b. somewhat guilty or sorry
c. a little guilty or sorry
d. not at all guilty or sorry
3. Now imagine that you were searching to find another place to live in, and finally found
one for rent or sale which you liked, but the owner very angrily told you that he would not
rent or sell to you because of your religion or national origin or race. What would you do?
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71
A. a. Just walk away from the situation.
b. Let the thing pass over without saying a word.
c. Report him to the city department office.
d. Protest to someone higher up.
e. Protest to him directly.
f. Talk to him about it after he has cooled down.
g. Try to reason with him at the time.
B. Now, suppose you did get angry and showed him that you felt this way. How
would you feel later about this?
a. very guilty or sorry
b. somewhat guilty or sorry
c. a little guilty or sorry
d. not at all guilty or sorry
4. Imagine that you were in a store searching for a part to repair your car and the store
owner angrily told you that he did not want your kind of people in his store. What would
you do?
A. a. Just walk away from the situation.
b. Let the thing pass over without saying a word.
c. Report him to the store’s office.
d. Protest to someone higher up.
e. Protest to him directly.
f. Talk to him about it after he has cooled down.
g. Try to reason with him at the time.
B. Now, suppose you did get angry and showed him that you felt this way. How
would you feel later about this?
a. very guilty or sorry
b. somewhat guilty or sorry
c. a little guilty or sorry
d. not at all guilty or sorry
5. Imagine that your wife got angry and blew up at you for no good reason. What would
you do?
A. a. Just walk away from the situation.
b. Let the thing pass over without saying a word.
c. Storm out of the room.
d. Tell her off.
e. Fight back.
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72
f. Talk to her about it after she has cooled down.
g. Try to reason with her at the time.
B. Now, suppose you did get angry and showed her that you felt this way. How
would you feel later about this?
a. very guilty or sorry
b. somewhat guilty or sorry
c. a little guilty or sorry
d. not at all guilty or sorry
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73
APPENDIX C
PEO (Post VI procedure)
Rate the degree to which this experience made you feel angry (Please circle the number
that best describes your feeling):
1....... 2........... ....3..... 4...............5............... 6.............. .7
Not at all A little Somewhat A fair amount Very much
If these incidents had actually happened to you, rate the likelihood that you would act in
each of the following ways- that is, to what extent would each of these be true for you
(Circle the number that best describes a true answer, for example, circle 1 for completely
false).
Angry Neighbor:
a. I would show my anger.
b. I would hide my anger.
c. I would be calm, not
angry.
Not A A fair Very
At all Little Somewhat amount Much
1..........2..........3..........4.... .....5.......... 6.......... 7
1.........2........ ..3..........4..........5......... .6....... ..7
1......... 2..........3.......... 4..........5...... ....6....... ..7
Difficult Salesperson:
a. I would show my anger.
b. I would hide my anger.
c. I would be calm, not
angry.
Not A A fair Very
At all Little Somewhat amount Much
1......... 2..........3..........4..........5..........6..........7
1.......... 2..........3......... 4......... 5....... ...6..........7
1..........2..........3..........4..........5..........6..........7
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74
APPENDIX D
Transcripts of ATSS Stimulus Tapes
Content of Garage Tape
NARRATOR: It’s 4:30. You’ve left work early to pick up your car from the garage.
They’ve said it should be ready. The secretary speaks to you...
SECRETARY: “Pm awfully sorry, sir, but George, the service manager, needs to talk to
you about your car. He’ll be with you just as soon as he finishes this call and takes care of
a couple of other customers who are before you. Why don’ t you take a seat?”
« 3 0 second pause»
NARRATOR: The secretary calls out to the service manager.
SECRETARY: “George, you’ve got another call on line 2. Oh, the mechanic wants to talk
to you before he leaves and it’s almost times to knock off. I think it’s about this guy’s
car.”
« 3 0 second pause»
NARRATOR: Finally, the service manager completes his call and starts to talk to the
mechanic while fumbling with his clipboard. They are not aware that you are overhearing
their conversation about your car.
SERVICE MANAGER: “Hello...Let’s see...uh...oh, here’s the paper work.
Hmmmm..lube...brakes, o.k....plugs...points...yeah.”
« 3 0 second pause»
NARRATOR: The mechanic speaks.
MECHANIC: “Looks like we got everything except the noise problem. It’s the catalytic
converter. That baby’s shot. Pm afraid he needs to replace it before it messes up the
engine.”
« 3 0 second pause»
SERVICE MANAGER: “You should have told me earlier so I could have called the guy
during the day.”
MECHANIC: “We don’t have that part in stock anyway, so I couldn’t have fixed it.
They’re back ordered. That car over there has been waiting two weeks for one!”
« 3 0 second pause»
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75
SERVICE MANAGER: “Let’s see. Let’s give him the info. Hmtnm, the price for this
model is...tch...tch...549 bucks, and the estimated labor is ‘round 125. ‘Course, it’s up to
him, but I wouldn’t drive this thing far without replacing that converter.”
» 3 0 second pause»
MECHANIC: “We could try and weld it but I can’ t GUARANTEE it’ll hold. He’s going
to have to make up his mind fast. Joe in the parts department is closing right now.”
« 3 0 second pause»
Content of Social Evaluation Tape
NARRATOR: Imagine that you are attending a social function. In the next room you
overhear two acquaintances talking about you. They don’t know that you are listening, but
you know that it’s you they are talking about.
MALE: “Did you see what he was wearing?”
FEMALE: “Yeah, yeah, unbelievable.”
MALE: “I couldn’t believe it, he looked so out of place.”
FEMALE: “I know, everybody must have noticed.”
MALE: “If I’d come like that, I woulda died.”
« 3 0 second pause»
MALE: “You know, and he made a fool of himself on that political stuff.”
FEMALE: “Oh yeah.”
MALE: “Very unaware, closed minded.”
FEMALE: “Yeah.”
MALE: “You have to be blind to the facts o f the universe to talk like that.”
FEMALE: “Yeah, did you see everyone’s reaction?”
MALE: “You’d think he’d realize what was going on I wonder why he just doesn’t keep
quiet.”
« 3 0 second pause»
FEMALE: “And you know, he’s pretty argumentative over a lot of things.”
MALE: “Yeah.”
FEMALE: “Sometimes he can be pretty unreasonable.”
MALE: “ It makes him look really bad. People just don’t want to talk to him”
FEMALE: “Yeah, I know.”
« 3 0 second pause»
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76
MALE: “Do you think he wonders why we don’t talk to Mm very much anymore?”
FEMALE: “ I don’ t know. I’d like to know if he even realizes it. I wonder what he thinks
about himself.”
MALE: “Yeah, and about us, too.”
FEMALE: “Yeah.”
« 3 0 second pause»
FEMALE: “You know what really bugs me though is the way he talks. He just blurts out
the first thing that comes to his mind.”
MALE: “Yeah, yeah.”
FEMALE: “And half the time it’s kinda dumb, you know.”
MALE: “Yeah.”
FEMALE: “ It borders on being stupid. I don’t think he realizes what he’s saying.”
« 3 0 second pause»
MALE: “You know there were a few times when he brought up something that was really
off the wall.”
FEMALE: “Yeah, like that time at the office.”
MALE: “Yeah, it really turned me off. I just couldn’t believe that he would say something
like that.”
FEMALE: “ Yeah, I just don’ t know about him.”
MALE: “Me neither.”
« 3 0 second pause»
FEMALE: “And what’s more, he seems so selfish.”
MALE: “Uh huh.”
FEMALE: “He certainly won’t go out ofhis way to help you.”
MALE: “Yeah, like that day that my car broke down.”
FEMALE: “Yeah, I remember that. He didn’t even offer to give you a ride into town.”
MALE: “Yeah. He could’ve at least done me that one favor.”
FEMALE: “You’re right. It wouldn’t have been such a big deal for him to do that.”
MALE: “Yeah.”
« 3 0 second pause»
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77
APPENDIX E
Transcripts of Videotaped Interaction
Neighbor Scenario
NARRATOR: The past couple of days you have been doing some yard work that
has involved raking up the dead grass and leaves so that the new spring grass can come
through. You have been raking the old grass and leaves into piles on the border of your
property, and yesterday it was a little windy so some of the piles blew into your new
neighbor’s yard. This neighbor just moved in a few weeks ago, hasn’ t seemed at all
friendly, and so you haven’ t said very much to each other. As you are working on the
lawn, you look up to see your neighbor looking stem and marching across the yard to
speak to you.
NEIGHBOR: So you are doing some more yard work again today, huh? You’ve
done a lot of raking this week. You’ve sure got lots of trees.
PARTICIPANT: I’m trying to get my lawn in shape. You know the new grass
comes in much better when the old leaves and stuff are removed.
NEIGHBOR: You know this time of year there’s plenty o f wind. This stuff tends
to blow around. You can see it blowing along the street right now. It makes a real mess.
PARTICIPANT: Well, I’m being careful about keeping it together. I’m making
piles and that’s about all you can do when it comes to raking leaves.
NEIGHBOR: Then you ought to be more careful about where you dump this stuff
because your weeds and leaves are blowing all over my lawn. Just look, my place is a real
mess, and I did my yard work last weekend. When I finished it was perfect. A real credit
to the neighborhood.
PARTICIPANT: Look, Fm real sorry if some of this stuff has blown onto your
yard. Of course I wouldn’t want to mess up your place.
NEIGHBOR: Look fella, if you are so very sorry, then why on earth are you doing
exactly what you did yesterday? You make all your fancy piles and then all this junk and
stuff blows into my nice and clean yard.
PARTICIPANT: Look, I wasn’t aware that the weather was so bad yesterday.
Best that I can remember it was pretty mild and certainly nothing at all has been blowing
around today.
NEIGHBOR: Aren’t you aware that the weather around here changes at the drop
of a hat? You can’t tell from one minute to the next what it is going to do. It’s bad enough
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78
having to put up with this part of the country, all the weirdos and no regular seasons, and
then to have to clean up after your crap.
PARTICIPANT:
NEIGHBOR: You know, really, most people at least think before they do things.
Boy, if you’re just going to let your garbage blow all around here like this, with no regard
for what it does to your neighbor’s property, then Fd sure hate to see the inside of your
house. I can’t even imagine what it must be like.
PARTICIPANT:.... .......
NEIGHBOR: The very last thing I needed was to be living right next door to
someone who doesn’ t care a bit about other people’s property, a real slob. If you have to
make such a mess, then go do It somewhere else. Don’t pick a neighborhood where
people care about how things look.
PARTICIPANT:
NEIGHBOR: There ought to be a law against this sort of thing. People like you
ought to be made to clean up their messes, and then maybe you wouldn’t be so
inconsiderate about where you leave your trash and what happens when the wind blows.
PARTICIPANT: .......
Salesperson Scenario
NARRATOR: You have bought a pair of slacks that were on sale at a newly
opened clothing store, and you soon discover that they have a hole in them that you didn’t
notice when you bought them. The next day, you return the slacks to the store hoping to
exchange them for a pair that isn’t defective. You enter the store holding the pants with
your receipt, but it takes a while before someone comes to wait on you. Finally, the
manager comes along.
MANAGER: Hello, my name is Green. Pm the manager here, you asked for me?
What can I do for you today, sir?
PARTICIPANT: Well, I want to exchange these pants that I bought yesterday.
There’s a problem with them. Can you take care of it for me?
MANAGER: Well, let’s see. Hmm, that was one of our sale items. Gee, I don’t
know. I am very sorry, sir, but you know the sign said all sales are final on sale items.
Didn’t you see that sign? You should have read the sign. A M sales are final
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79
PARTICIPANT: But these have a hole in them. Just because it’s on sale, you can’t
get away with selling defective merchandise.
MANAGER: That is ridiculous. We don’t sell defective merchandise in this store,
sir. All our goods are first quality, whether they’re on sale or not. That is what brings
people in here.
PARTICIPANT: Wei, I’ m sure these pants had a hole in them when I bought
them
MANAGER: Then what did you buy them for? If they had a hole in them, you
shouldn’t have bought them
PARTICIPANT: I didn’t know they had a hole in them I wouldn’t have bought
them if I had seen the hole.
MANAGER: Don’t you look at what you are buying? Most people know what
they are getting when they buy something, especially when the sign clearly says: All sales
are final.
PARTICIPANT: ....
MANAGER: Sir, for all I know you could have put that hole in them yourself.
You got them at a cheap price, and maybe decided that you didn’t want them anymore and
now you are trying to exchange them for a better pair. You know, some people try this
sort of thing all the time.
PARTICIPANT:.........
MANAGER: Sir, it’s really hard for me to believe that they were actually like this
when you got them. We carefully inspect each and every item in this store. We certainly
never put defective or damaged goods out on our tables.
PARTICIPANT:....... .
MANAGER: Sir, the company’s clearly stated policy is not to take back any
merchandise that was purchased on sale. The sign saying that all sales are final was right
on the table where you found the pants. Now Fmjust doing what Pm told to do.
PARTICIPANT:.........
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80
Table 1.
Means and Standard Deviations for Demographic Variables and Blood Pressure Levels.
Variable
M
SD N Ranee/Percentage*
Age 44.44 5.31 89 31-56
DBP 91.91 3.26 89 85-100
SBP 135.43 9.40 89 120-158
Education
High School 2 2.3
Some College 23 25.3
College Graduate 23 25.3
Some Graduate Education 10 11.0
Graduate Degree 29 31.9
Marital Status
Never Married 12 13.2
Married/Living Together 62 68.1
Separated 2 2.2
Divorced 1 1 12.1
Note: DBP=Diastolic Blood Pressure. SBP=Systolic Blood Pressure.
^Percentages do not equal 100 due to missing data from four participants.
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81
Table 2.
Anser Suppressors.
Variable Power Effect Size
Multivariate .94 .23
ATSS Aggression .85 .12
Constructive Anger .71 .09
Aggression (Neighbor) .61 .07
Aggression (Salesperson) .80 .11
Note: PEQ=Post Experimental Questionnaire. ATSS=Articulated Thoughts in
Simulated Situations.
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82
Table 3.
Means and Standard Deviations of Assertiveness Variables for PEQ Low and High
Anger Suppressors.
Low High
Variable
M
SD
M
SD
ATSS Aggression 1.65 1.82 .69 .92
Salesperson Aggression .78 1.00 .25 .55
Neighbor Aggression 1.36 1.41 .63 1.04
Constructive
Anger Expression 4.18 2.20 5.71 2.61
Note: PEQ= Post Experimental Questionnaire. Low= Participants scoring low in PEQ
anger suppression. High= Participants scoring high in PEQ anger suppression.
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83
Table 4.
High and Low PEQ Anger Suppressors by BP Recovery Status.
PEQ Suppression Low High
R NR R NR
SBP 16 20 21 18
DBP 22 14 24 15
Note: Values in table represent numbers of participants in each cell. BP= Blood
Pressure. PEQ=Post Experimental Questionnaire. R=Recovered. NR=Not Recovered.
SBP=Systolic Blood Pressure. DBP=Diastolic Blood Pressure.
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84
Table 5.
Estimated Power and Effect Sizes for Assertiveness Difficulties in Recovered and Non-
Recovered Participants.
Variable Power Effect Size
Multivariate ,63 .12
ATSS Aggression .19 .02
Constructive Anger .15 .01
Aggression (Neighbor) .04 .01
Aggression (Salesperson) .64 .09
Note: PEQ=Post Experimental Questionnaire. ATSS=Articulated Thoughts in
Simulated Situations.
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85
Table 6.
Correlations Between SBP and Assertiveness During Anger Induction.
Variable 1 2 3 4 5
1. ATSS-Ang .29** -.12 .07 -.15
2. ATSS-ACon -.12 .09 .06
3. Vlassert .03 .28*
4. VIconstruct .13
5. SBP _______
Note: *== p<.05. **= g<.0L ATSS= Articulated Thoughts in Simulated Situations.
Ang=Anger Statements. ACon= Anger Control. VIassert=Assertive expressions of
anger during VI. VIconstruct=Constructive Anger Expression during VI. SBP=Systolic
Blood Pressure.
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86
Table 7.
Correlations Between DBF and Assertiveness Daring Anger Induction.
Variable 1 2 3 4 5
1. ATSS-Ang .29** -.12 .07 -.15
2. ATSS-ACon -.12 .09 .06
3. Vlassert .03 .28*
4. VIconstruct .13
5.DBP
Note: *=g<.05. **- ]g<.01. ATSS= Articulated Thoughts in Simulated Situations.
Ang=Anger Statements. ACon=Anger Control. VIassert=Assertive expressions of
anger during VI. VIconstruct=Constructive Anger Expression during VI.
DBPHDiastolic Blood Pressure.
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Table 8.
Correlations Among Anger Questionnaires. ATSS and VI Anger Expression, and BP.
Measures 1 2 3
1.AX .13 .01
2.HAX -.17
3. PEQ
4. ATSS-Ang
5. ATSS-ACon
6. ATSS-Agg
7. Ntotagg
8. Stotagg
9. Vlassert
10. VIconstruct
11. BP (Systolic)
4 5 6 7 8 9 10 1 1 12 13 14
-.20 -.06 -.08 -.35** -.17 -.05 .14 .12 .11
. 39**-.63**
-.06 -.15
i
o
o
-.16 .04 -.02 -.13 .12 .13 -.11 -.10
-.01 -.13 -.30** -.35** -.33** -.21 .27* .15 .29** -.32** -.07
.30** .21 .12 .07 -.12 .07 -.15 .01 .16 .16
.25* -.03 -.12 -.12 .09 .06 .14 .18 .01
.27* .29* .17 -.14 .13 .02 .28* .11
.61** .28* -.33** .13 .13 .43** .01
.26* -.13 .14 .07 .23* .02
.03 .28* -.03 .06 .11
.13 -.11
I*
.13
.47** .06 -.05
00
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12. BP (Diastolic) -11 --07
13. Trait Anger .48**
14. Trait Anxiety
Note: *=£<.05. **= £<.01. ATSS=Articulated Thoughts in Simulated Situations. VI=Videotaped Interaction.
BP=Blood Pressure. AX=Anger Expression Scale. HAX=Harburg Anger Expression Scale. PEQ=Post Experimental
Questionnaire. Ang=Anger Statements. ACon=Anger Control. Agg=Aggressive Statements. Ntotagg=Aggression
during VI Neighbor scenario. Stotagg=Aggression during VI Salesperson scenario. VIassert=Assertive expressions of
anger during VI. VIconstruct=Constructive Anger Expression during VI.
00
00

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Asset Metadata

Creator Barbour, Krista Arlington (author)

Core Title Anger expression in men with elevated blood pressure: Relationships to assertiveness

School Graduate School

Degree Doctor of Philosophy

Degree Program Psychology

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag OAI-PMH Harvest,Psychology, clinical

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Meyerowitz, Beth E. (committee chair), Chambers, Kathleen (committee member), Goodyear, Rodney (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c16-388669

Unique identifier UC11340833

Identifier 3180768.pdf (filename),usctheses-c16-388669 (legacy record id)

Legacy Identifier 3180768.pdf

Dmrecord 388669

Document Type Dissertation

Rights Barbour, Krista Arlington

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus, Los Angeles, California 90089, USA