Journal of Behavioral Medicine,
Vol. 14, No. 6, 1991
Cynical Hostility, Attempts to Exert Social Control, and Cardiovascular Reactivity in Married Couples Timothy W. Smith 1,2 and Peter C. Brown 1
Accepted for publication: January 11, 1991 Chronically hostile persons may be at greater risk of cardiovascular illness, perhaps because of their more pronounced physiologic responses to interpersonal stressors. The present study of married couples examined the association between Cook and Medley Hostility (Ho) Scale scores and cardiovascular reactivity while couples were engaged in a discussion task with or without an incentive to exert control over their partner. Cynical hostility was associated with greater heart rate (HR) reactivity among husbands in both conditions and with greater systolic blood pressure (SBP) reactivity among husbands attempting to influence their wives. Further, husbands' cynical hostility was associated with greater SBP reactivity in their wives. Wives' cynical hostility was unrelated to their own or their husbands' reactivity. These results underscore the importance of social contexts in the association between hostility and psychophysiologic processes and suggest that the motive to exert social control may be important for hostile persons. KEY WORDS: hostility; cardiovascular reactivity; cynicism; blood pressure.
INTRODUCTION In the continuing investigation of coronary-prone behaviors and personality traits, hostility has emerged as a probable coronary risk factor (Dembroski and Williams, 1989; Matthews, 1988). Interview-based ratings of hostility have been found to predict the subsequent development of coronary heart disease (CHD) in prospective studies (e.g., Dembroski et al., 1989; Hecker et al., 1989). Similarly, several questionnaire measures of hostility have been found to be related to manifestations of CHD and other 1Department of Psychology, University of Utah, Salt Lake City, Utah 84112. 2To whom correspondence should be addressed. 581
0160-7715/91/1200-0581506.50 9 1991PlenumPublishingCorporation
582
Smith and Brown
life-threatening illnesses in cross-sectional and longitudinal studies (e.g., Barefoot et al., 1983, 1987; Koskenvuo et al., 1988; Siegman et al., 1987). One of the most widely used questionnaire measures in this context is the Cook and Medley (1954) Hostility (Ho) Scale (Smith and Pope, 1990). The Ho scale is closely correlated with measures of the frequency and intensity of anger, as well as measures of resentment, suspicion, cynicism, and mistrust (Barefoot et al., 1989; Blumenthal et al., 1987; Smith and Frohm, 1985). High scores on the scale are also associated with more overtly hostile or antagonistic behavior during social interactions (Hardy and Smith, 1988; Smith et al., 1990a) and a tendency to view others as likely sources of provocation and mistreatment (Allred and Smith, 1990; Pope et al., 1990; Smith et al., 1990a). As a result, the trait assessed by this scale has been variously labeled cynical hostility, cynical mistrust, or simply cynicism (Costa et al., 1986; Dembroski and Williams, 1989; Smith and Frohm, 1985). Research on the association between cynical hostility as measured by the Ho scale and health outcomes has been inconsistent. Some cross-sectional studies have found a significant association between Ho scores and the severity of cardiovascular illness (Joesoef et al., i989; Williams, et al., 1980), but several others have not (Dembroski et al., 1985; Friedman and Booth-Kewley, 1987; Seeman and Syme, 1987). The mixed results of crosssectional studies can be at least partially attributed to the limitations of such designs for evaluating cardiovascular risk factors (Matthews, 1988; Pickering, 1985). Longitudinal results have also produced inconsistent findings, however. Equal numbers of studies reporting a significant association between Ho scores and subsequent health (Barefoot et al., 1983, 1989; Shekelle et al., 1983) and failing to find such an association (Hearn et al., 1989; Leon et al., 1988; McCranie et al., 1986) have appeared in recent years. However, studies using very similar measures of hostility have found significant prospective associations (Barefoot et al., 1987; Koskenvuo et al., 1988; Ostfeld et al., 1964). Thus, although additional studies are clearly warranted, cynical hostility may increase the likelihood of subsequent health problems. A variety of processes has been suggested as possible mechanisms linking hostility and health, and physiological reactivity is a common element in many approaches. Williams et al. (1985) suggested that hostile individuals are likely to display more frequent and pronounced episodes of neurohormonal and cardiovascular reactivity. Enhanced physiologic reactivity could, in turn, facilitate the development of coronary artery disease (CAD) and precipitate acute manifestations of CHD. Although some studies have not found Ho scores to be related to the magnitude of cardiovascular responses to traditional laboratory stressors such as mental
Hostility and Cardiovascular Reactivity
583
arithmetic (Sallis et al., 1987; Smith and Houston, 1987), studies using interpersonal stressors have found evidence of such an association. Hardy and Smith (1988) found that high levels of cynical hostility were associated with increased blood pressure reactivity during role played interactions involving high levels of interpersonal conflict. Similarly, Smith and AUred (1989) found that cynically hostile subjects displayed heightened blood pressure reactivity during a debate task, and Suarez and Williams (1989) found that cynical hostility was associated with greater cardiovascular reactivity during a provoking social interaction. These results suggest that antagonistic or conflictual social situations are likely to elicit heightened physiologic reactivity in cynically hostile persons.
Hostility and Interpersonal Control Recent theory and research suggests that social interactions involving attempts to exert control over others may be another interpersonal stressor likely to elicit physiologic reactivity in hostile individuals. Averill (1982) has argued that anger and hostility often represent an attempt to regulate or control the behavior of others. That is, one of the functions of anger and hostility may be to reduce unwanted actions by others and increase desired behaviors. Clearly, this view acknowledges that rather than simply a response to frustrating interpersonal circumstances, anger and hostility may have instrumental value in managing or controlling social interactions. One implication of this perspective is that chronically angry or hostile persons may be particularly concerned with controlling others or overreliant on this particular social influence strategy. Effortful attempts to influence or control others have been found to elicit heightened cardiovascular reactivity. A recent series of studies (Smith et al., 1989, Study 1 and 2, 1990b) has indicated that compared to persons engaged in simple discussions, subjects attempting to influence the opinions or behavior of their discussion partners display increased levels of systolic (SBP) and diastolic blood pressure (DBP) and heart rate (HR). Most recently, these cardiovascular consequences of attempting to exert social influence or control have been demonstrated in the context of marital interactions. Brown and Smith (1992) found that compared to husbands simply engaged in a discussion task with their wives, husbands attempting to influence their spouses during this discussion task displayed significantly higher SBP. Interestingly, social influence attempts did not have a consistent effect on cardiovascular reactivity among wives. If hostility, at least in part, reflects a stronger motivation or tendency to exert control over others, then persons with high scores on the Ho scale
584
Smith and Brown
would be likely to show greater cardiovascular reactivity during social influence attempts than would less cynically hostile individuals. That is, like antagonistic or conflictual interpersonal interactions, attempts to infuence or control others are social stressors particularly likely to elicit reactivity among hostile subjects. This hypothesis was evaluated in additional analyses of the marital interaction study described above (Brown and Smith, 1992). The primary focus of that study concerned the main effects of attempts to influence one's spouse on cardiovascular reactivity. In the present paper, we examine the predicted interactive effects of attempts to exert social influence or control and individual differences in cynical hostility on cardiovascular reactivity. Results presented in detail in the previous report (Brown and Smith, 1992) are summarized briefly as necessary in the present paper. The association between subjects' level of cynical hostility and their own cardiovascular reactivity, not reported previously, is the primary focus of the present discussion. A secondary focus of the present paper is the association between subjects' cynical hostility and their spouses' cardiovascular responses. To the extent that interacting with a hostile spouse is stressful, subject's Ho scores may be related to their spouses' reactivity in this marital context.
METHOD Subjects
Married couples were recruited form undergraduate psychology courses. At least one member of each couple was a student. For couples who agreed to participate, students received partial course credit and nonstudent spouses were paid $10.00. Forty-five couples participated. The average age was 27 years for the men and 25 years for the women. On average, couples had been married for 5 years. The sample was over 80% white. Husbands' mean Ho score was 18.6 (range, 6-33), and wives' mean score was 17.3 (range, 5-31). Procedure
U p o n arriving for the e x p e r i m e n t and b e f o r e g o i n g to the psychophysiological laboratory, subjects listened to a description of the study and completed a brief packet of questionnaires which included the Ho scale. Subjects were told that the purpose of the study was to examine
Hostility and Cardiovascular Reactivity
585
the effects of social interactions on cardiovascular processes. After being taken to the psychophysiological laboratory, husbands and wives were seated at opposite sides of a table, separated from view by a movable partition. Inflatable cuffs attached to Dinamap automated oscillometric monitors (Model 8100) were positioned on the nondominant arms of both husbands and wives. The experimenter and monitors were positioned behind a second partition. HR, SBP, and DBP were recorded at 1-min intervals during a 10-min baseline period. After the baseline period, subjects listened to tape-recorded instructions, delivered through separate cassette players and headphones. The instructions described the upcoming discussion task, adapted from Klein and Willerman (1979). The discussion was described as a problem-solving task. In a hypothetical situation, a local school district was about to lay off 8 of 12 teaching specialists (e.g., band director, shop teacher, etc.). The subjects were to discuss the situation and decide which 4 of the 12 specialists should be retained. Both members of the couple were given a list of the 12 specialists, on which one of two sets of four specialists (counterbalanced across husbands and wives) were designated as the ones the subject should advocate for retention. They were also told that their partner would be advocating a different set of specialists. Subjects were also supplied with a sheet of possible arguments for their designated specialists. Subjects then listened to one of two sets of additional instructions, depending on the condition to which they had been randomly assigned. In the Discuss condition (n = 23 couples), subjects were informed that following the experiment there would be a lottery drawing for a $100.00 cash prize. Further, they were told that the number of times their name was entered into the lottery (and as a result their chances of winning) would be determined randomly after the experimental session. In contrast, subjects in the Influence condition (n = 22 couples) were told that the number of times their name was entered was to be determined by how successful they were in persuading their spouse to select the four specialists they themselves were advocating. Subjects were told that actual preferences for retaining specialists would be obtained after the discussion. Subjects in the Influence condition were told that their name would be placed in the lottery O, 1, 5, 10, or 20 times, depending on the number of specialists from their list of four who were nominated for retention by their spouses. These subjects were also told that while they were given this incentive, their spouse was not; the spouse's name was to be entered randomly. Subjects in the Influence condition were further told that they were forbidden to mention this contingency during the discussion: doing so would disqualify them from the lottery. In actuality, both members of couples assigned to this condition received identical instructions. Thus, although members of couples assigned
586
Smith and Brown
to both conditions believed that their name would be entered into a later lottery, only subjects in the Influence condition were given an incentive to influence the choices made by their spouse. At the conclusion of these instructions, subjects completed two selfreport manipulation check items concerning the extent to which their chances in the lottery depended on their partner's choices and the extent to which they cared about their partner's choices. Subjects were then given 4 rain to review the list of possible arguments and prepare for the discussion task. For the discussion task, subjects were encouraged to discuss the problem freely. During this 4-min period, cardiovascular measures were again recorded at 1-mm intervals. At the conclusion of the task, subjects were debriefed, paid, and excused.
RESULTS As noted above, detailed results of the effects of the social influence manipulation on cardiovascular measures are reported elsewhere (Brown and Smith, 1992), as are results of the manipulation check items. It is important to note, however, that compared to subjects in the Discuss condition, both husbands and wives in the Influence condition indicated that their chances in the lottery were more dependent on their partner's choices (p < .001) and that they cared more about their partner's choices (p < .01). Preliminary analyses indicated that hostility scores were not related to baseline HR, SBP, or DBP levels in husbands or wives. To evaluate the main and interactive effects of individual differences in cynical hostility and the social influence manipulation on cardiovascular reactivity, a series of multiple regressions was computed. In each case the average of the last two baseline values was subtracted from the average of the four task period values to generate a mean change score, the dependent variable in the regression analyses. On the first step of each regression, the baseline value was inserted to control the potential influence of initial levels on reactivity (Benjamin, 1967). On the second step, the main effect for the condition variable (i.e., Influence vs. Discuss, dummy coded) was entered. On the third step, cynical hostility (i.e., continuous Ho scores) was included. On the fourth and final step, a product term representing the interaction between condition and cynical hostility was entered. These analyses were conducted for all three cardiovascular measures for husbands and wives separately. Among wives, neither their Ho scores nor the Ho x condition interaction accounted for a significant portion of the variance in HR, SBP, or DBP reactivity. The results for husbands are presented in Table I. As reported elsewhere
Hostility and Cardiovascular Reactivity
587
Table I. Results of Multiple Regression Analyses of Husbands' Cardiovascular Reactivity Dependent variable
Step
Predictor
R 2 change
pa
p
Heart rate change (HR)
1 2 3 4
Baseline HR Condition (C) Hostility (H) C x H Interaction
.02 .16 .10 .01
0.73 8.97 5.90 0.46
ns < .01 < .03 ns
Systolic blood pressure change (SBP)
1
Baseline SBP
.02
0.95
ns
2 3 4
Condition (C) Hostility (H) C • H Interaction
.23 .01 .08
12.76 0.10 4.64
< .01 ns < .05
1
Baseline DBP
.14
6.73
< .02
2 3 4
Condition (C) Hostility (H) C x H Interaction
.12 .01 .06
6.90 0.14 3.49
< .02 ns < ,07
Diastolic blood pressure change (BP)
adf = (1,39) to (1,42).
24 E
E t~= m
16
z w
8
DISCUSS
0 z I 0
4 I
4
8
12
16
20
24
28
32
36
HOSTILITY SCORE
Fig. 1. Interactive effect of cynical hostility and condition on husbands' systolic blood pressure reactivity
( B r o w n a n d Smith, 1992), h u s b a n d s in t h e I n f l u e n c e c o n d i t i o n displayed larger increases in H R d u r i n g the discussion t h a n did h u s b a n d s in t h e Discuss c o n dition. M o r e i m p o r t a n t l y for o u r p r e s e n t purposes, high cynically hostile husb a n d s displayed significantly larger H R increases d u r i n g the discussion t h a n did low cynically hostile h u s b a n d s [partial r(43) = .36, p < .03], a c c o u n t i n g for a p p r o x i m a t e l y 1 0 % o f the v a r i a n c e in H R reactivity. T h e i n t e r a c t i o n b e -
588
Smith and Brown
tween hostility and condition was not significant in the analysis of H R reactivity. Although the main effect of cynical hostility on SBP reactivity was not significant, the Ho x condition interaction did account for a statistically significant 8% of the variance in SBP reactivity. As depicted in Fig. 1, in the Influence condition cynical hostility was positively related to SBP reactivity. In contrast, cynical hostility was negatively related to SBP reactivity in the Discuss condition. As a result, the significant effect of the social influence manipulation (i.e., 23% of the variance in SBP reactivity; p < .01) occurred primarily among high-cynically hostile men. Although the pattern was similar to that obtained for SBP, the Ho x conditions interaction for husbands' DBP was not significant (i.e., 6% of the variance in DBP reactivity; p < .07). To evaluate the association between one spouse's level of cynical hostility and his/her partner's cardiovascular reactivity, an additional series of multiple regression analyses was performed. Subjects' HR, SBP, and DBP change scores again served as the dependent variable, baseline levels were again included on the first step of the analysis, and condition was included on the second step. However, on the third step the spouse's Ho score was included, and the interaction between condition and the spouse's Ho score was included on the final step. Thus, the association between subjects' reactivity and their spouses' Ho scores--as a main effect and as an interaction with condition - was evaluated in these analyses. Wives' Ho scores were unrelated to their husbands' HR, SBP, and DBP responses during the discussion task. However,husbands' Ho scores were positively associated with SBP reactivity among their wives [partial r(43) = .30, p < .05], accounting for 9% of the variance in wives SBP reactivity. This main effect of husbands Ho scores on their wives' SBP reactivity was not qualified by an interaction with conditions. No other effects involving cynical hostility were significant in these cross-spouse analyses.
DISCUSSION The results of the present study are consistent with previous research (Hardy and Smith, 1988; Smith and Allred, 1989; Suarez and Williams, 1989), indicating that cynical hostility is associated with heightened cardiovascular reactivity in potentially stressful social contexts. Further, the present findings indicate that situations in which cynically hostile persons attempt to influence or control others m a y b e likely to elicit this heightened reactivity. For husbands, across both the Discuss and the Influence conditions, cynical hostility was associated with larger H R increases during the
Hostility and Cardiovascular Reactivity
589
social interaction task. Cynical hostility was also associated with more pronounced SBP reactivity when husbands were engaged in effortful attempts to influence their wives. The previously demonstrated effects of effortful attempts to influence or control others on blood pressure reactivity (Smith et al., 1989, 1990b; Brown and Smith, 1992), were observed primarily among high-hostile husbands. Thus, in addition to the antagonistic or conflictual social situations identified in previous research, interactions involving effortful interpersonal control may also be a relevant stressor capable of eliciting enhanced physiologic reactivity in cynically hostile persons. Further, the present results suggest that marital relations may be an interesting context for the examination of psychophysiological correlates of hostility. Previous research indicates that hostility is associated with decreased marital satisfaction in some groups (Smith et aL, 1988; Houston and Kelley, 1989) and that marital distress is related to psychophysiological processes (Levenson and Gottman, 1983, 1985). Several qualifications of these conclusions are in order. First, cynical hostility was related to cardiovascular reactivity only among husbands in the present study. The only significant result for wives was the association between their SBP responses during the task and their husbands' level of cynical hostility. This result certainly supports the validity of the Ho scale for men by indicating that persons interacting with cynically hostile men display heightened cardiovascular arousal. Interactions with cynically hostile men may be sufficiently stressful as to elicit increased blood pressure in their interaction partners. However, the fact that wives' Ho scores were unrelated to cardiovascular reactivity - - either their own or their husbands' raises concerns about sex differences in hostility and its association with various outcomes. One possibility is that the Ho scale is a less valid measure of hostility among women than men (Smith et aL, 1990a). Alternatively, hostility may be less closely related to health or related through different mechanisms in women (Barefoot et al., 1991). However, at least two studies to date have found that Ho scores are related to cardiovascular reactivity in women (Suarez et al., 1990; Weidner et al., 1989). Future research must examine potential sex differences at all levels, including the measurement of hostility, its association with potential mediating mechanisms, and the prediction of health outcomes. A second qualification concerns the source and nature of the hostility • conditions interaction on husbands' blood pressure reactivity. Although it is obviously possible that this represents an interaction between husbands' level of cynical hostility and their motivation to exert control over their spouses, it must be noted that both members of the couple in the Influence condition were given an incentive to influence their partner. As a result, it is possible that the effect on SBP reactivity reflects an interaction between husbands' hos-
-
590
Smith and Brown
tility levels and their spouses' effort to exert control during the interaction. That is, given the present design, it is unclear whether cynically hostile husbands displayed heightened reactivity in response to their own effort to exert control, their perception of their wives' influence attempts, or a combination of these factors. Further, it is possible that high-Ho men are less socially skilled in interactional tasks of this type, and as a result, their heightened arousal may reflect the fact that such interaction tasks are more difficult for them. Thus, while effortful social influence or control appears to be a relevant stressor for cynically hostile persons, additional research will be required to determine if their heightened reactivity in such situations reflects their own motivational state or skill deficits, a reaction to others' behavior, or a dynamic interactional process. Finally, although cynical hostility was associated with increased H R reactivity overall and increased SBP reactivity in the Influence condition, hostile subjects tended to display less blood pressure reactivity when they were simply discussing the hypothetical situation. Similar inverse associations have been reported elsewhere (e.g., Siegman, 1990), but most studies report either a positive association or no association, depending on the type of stressor employed. It may be that without sufficiently provoking or challenging social stimuli, the cynical style of high-Ho subjects is associated with less active engagement in laboratory tasks and occasionally accompanied by lower levels of cardiovascular arousal (Manuck et al., 1985). The extent to which experimental procedures are engaging for cynically hostile subjects may provide a useful framework for delineating the presence and direction of associations between Ho scores and physiological reactivity. These qualifications notwithstanding, the present and previous findings indicate that some social situations elicit heightened cardiovascular reactivity among cynically hostile persons. This enhanced reactivity is consistent with psychophysiological models of the link between hostility and health (Williams et al., 1985). Cynical hostility is associated with increased interpersonal conflict and stress at home and work (Blumenthal et al., 1987; Houston and Kelly, 1989; Smith et al., 1988). Thus, chronic or recurring social situations involving provocation, conflict, and struggles for control may be a central feature of the biopsychosocial process connecting hostility and health.
REFERENCES Allred, K. D., and Smith,T. W. (1991). Socialcognitionin cynicalhostility.Cognitive Therapy and Research 15: 399-412. Averill, J. R. (1982).Anger and Aggression: An Essay on Emotion, Springer-Verlag,New York.
Hostility and Cardiovascular Reactivity
591
Barefoot, J. C., Dahlstrom, W. G., and Williams, R. B., Jr. (1983). Hostility, CHD incidence, and total mortality: A 25-year follow-up of 255 physicians. Psychosom. Med. 45: 59-63. Barefoot, J. C., Siegler, I. C., Nowlin, J. B., Peterson, B., Haney, T. L., and Williams, R. B., Jr. (1987). Suspiciousness, health, and mortality: A follow-up study of 500 older adults. Psychosom. Med. 49: 450-457. Barefoot, J. C., Dodge, K. A., Peterson, B. L., Dahlstrom, W. G., and Williams, R. B., Jr. (1989). The Cook-Medley Hostility Scale: Item content and ability to predict survival. Psychosom. Med. 51: 46-57. Barefoot, J. C., Peterson, B. L., Dahlstrom, W. G., Siegler, I. C., Anderson, N. B., and Williams, R. B., Jr. (1991). Hostility patterns and health implications: Correlates of CookMedley scores in a National Survey. Health PsychoL 10: 18-24. Benjamin, L. (1967). Facts and artifacts in using analysis of covariance to "undo" the law of initial values. Psychophysiology 4: 187-206. Blumenthal, J. A., Barefoot, J., Burg, M. M., and Williams, R. B., Jr. (1987). Psychological correlates of hostility among patients undergoing coronary angiography. Br. Z Med. PsychoL 60: 349-355. Brown, P. C., and Smith, T. W. (1992). Social influence, marriage, and the heart: Cardiovascular consequences of interpersonal control in husbands and wives Health Psychol (in press). Cook, W. W., and Medley, D. M. (1954). Proposed hostility and pharisaic-virtue scales for the MMPI. Z AppL PsychoL 38: 4-418. Costa, P. T., Jr., Zonderman, A. B., McCrae, R. R., and Williams, R. B., Jr. (1986). Cynicism and paranoid alienation in the Cook and Medley Ho Scale. Psychosom. Med. 48: 283-285. Dembroski, T. M., and Williams, R. B., Jr. (1989). Definition and assessment of coronaryprone behavior. In Schneiderman, N., Weiss, S. M., and Kaufman, P. G. (eds.), Handbook of Research Methods in Cardiovascular Behavioral Medicine, Plenum, New York. Dembroski, T. M., MacDougall, J. M., Costa, P. T., and Crandits, G. A. (1989). Components of hostility as predictors of sudden death and myocardial infarction in the Multiple Risk Factor Intervention Trial. Psychosom. Med. 51: 514-522. Friedman, H. S., and Booth-Kewley, S. (1987). Personality, Type A behavior, and coronary heart disease: The role of emotional expression. J. Personal. Soc. PsychoL 53: 783-792. Hardy, J. D., and Smith, T. W. (1988). Cynical hostility and vulnerability to disease: Social support, life stress, and physiological response to conflict. Health PsychoL 7: 447-459. Hearn, M. D., Murray, D. M., and Luepker, R. V. (1989). Hostility, coronary heart disease, and total mortality: A 33-year follow-up study of university students. J. Behav. Med. 12: 105-121. Hecker, M. H. L., Chesney, M. A., Black, G. W., and Frautschi, N. (1989). Coronary-prone behaviors in the Western Collaborative Group Study. Psychosom. Med. 51: 153-164. Houston, B. K., and Kelley, K. E. (1989). Hostility in employed women: Relation to work and marital experiences, social support, stress, and anger expression. Personal Soc. PsychoL Bull. 15: 175-182. Joesoef, M. R., Wetterhall, S. F., DeStefano, F., Stroup, N. E., and Fronek, A. (1989). The association of peripheral arterial disease with hostility in a young, healthy veteran population. Psychosom. Med. 51: 285-289. Klein, H. M., and Willerman, L. (1979). Psychological masculinity and femininity and typical and maximal dominance expression in women. J. Personal Soc. PsychoL 37: 2059-2070. Koskenvuo, M., Kapiro, J., Rose, R. J., Kesaniemi, A., Sarna, S., Heikkila, K., and Langinvainio, H. (1988). Hostility as a risk factor for mortality and ischemic heart disease in men. Psychosom. Med. 50: 330-340. Leon, G. R., Finn, S. E., Murray, D., and Bailey, J. M. (1988). The inability to predict cardiovascular disease from hostility scores or MMPI items related to Type A behavior. Z Consul Clin. PsychoL 56: 597-600. Levenson, R. W., and Gottman, J. M. (1983). Marital interaction: Physiological linkage and affective exchange. J. Personal Soc. PsychoL 45: 587-597. Levenson, R. W., and Gottman, J. M. (1985). Physiological and affective predictors of change in relationship satisfaction. J. Personal Soc. PsychoL 49: 85-94.
592
Smith and Brown
Manuck, S. B., Morrison, R. L., Bellack, A. S., and Polefrone, J. M. (1985). Behavioral factors in hypertension: Cardiovascular responsibility, anger, and social competence. In Chesney, M. A., and Rosenman, R. H. (eds.), Anger and Hostili(y in Cardiovascular and Behavioral Disorders, Hemisphere, New York. Matthews, K. A. (1988). CHD and Type A behaviors: Update on and alternative to the BoothKewley and Friedman quantitative review. Psychol. BuiLt 104: 373-380. McCranie, E. W., Watkin, L. O., Brandsma, J. M., and Sisson, B. D. (1986). Hostility, coronary heart disease (CHD) incidence, and total mortality: Lack of association in a 25-year follow-study of 478 physicians. J. Behav. Med. 9: 119-125. Ostfield, A. M., Lebovitis, B. Z., Shekelle, R. B., and Paul, O. (1964). A prospective study of the relationship between personality and coronary heart disease. J. Chron. Dis. 17: 266-276. Pickering, T. G. (1985). Should studies of patients and undergoing coronary angiography be used to evaluate the role of behavioral risk factors for coronary heart disease? Z Behav. Med. 8: 203-213. Pope, M. K., Smith, T. W., and Rhodewalt, F. (1990). Cognitive, behavioral, and affective correlates of the Cook and Medley Hostility Scale. J. Personal. Assess. 54: 501-514. Sallis, J. F., Johnson, C. C., Trevorrow, T. R., Kaplan, R. M., and Hovell, M. F. (1987). The relationship between cynical hostility and blood pressure reactivity. J. Psychosom. Res. 31: 111-116. Seeman, T. W., and Syme, S. L. (1987). Social networks and coronary artery disease: A comparison of the structure and function of social relations as predictors of disease. Psychosom. Med. 49: 3451-354. Shekelle, R. B., Gale, M., Ostfeld, A. M., and Paul, O. (1983). Hostility, risk of coronary heart disease, and mortality. Psychosom. Med. 45: 109-114. Siegman, A. W. (1990). Components of hostility and cardiovascular reactivity. Paper presented at the American Psychological Association annual meeting. Boston. Siegman, A. W., Dembroski, T. M., and Ringel, N. (1987). Components of hostility and the severity of coronary artery disease. Psychosom. Med. 49: 127-135. Smith, M. A., and Houston, B. K. (1987). Hostility, anger, expression, cardiovascular responsibility, and social support. Biol. PsychoLt 24: 39-48. Smith, T. W., and Allred, K. D. (1989). Blood pressure responses during social interaction in high- and low-cynically hostile males. J. Behav. Med. 12: 135-143. Smith, T. W., and Frohm, K. D. (1985). What's so unhealthy about hostility? Construct validity and psychosocial correlates of the Cook and Medley Ho scale. Health Psychol. 4: 503-520. Smith, T. W., and Pope, M. K. (1990). Cynical hostility as a health risk: Current status and future directions. J. Soc. Behav. Personal. 5: 77-88. Smith, T. W., Pope, M. K., Sanders, J. D, Allred, K. D., and O'Keeffe, J. L. (1988). Cynical hostility at home and work: Psychosocial vulnerability across domains. J. Res. Personal. 22: 525-548. Smith, T. W., Allred, K. D., Morrison, C. A., and Carlson, S. D. (1989). Cardiovascular reactivity and interpersonal influence: Active coping in a social context. Z Personal. Soc. Psychol. 56: 209-218. Smith, T. W., Sanders, J. D., and Alexander, J. F. (1990a). What does the Cook and Medley Hostility Scale measure? Affect, behavior and attributions in the marital context. J. Personal Soc. Psychol. 58: 699-708. Smith, T. W., Baldwin, M., and Christensen, A. (1990b). Interpersonal influence as active coping: Effects of task difficulty on cardiovascular reactivity. Psychophysiology 27: 429~ Suarez, E. C., and Williams, R. B., Jr. (1989). Situational determinants of cardiovascular and emotional reactivity in high and low hostile men. Psychosom. Med. 51: 404-418. Suarez, E. C., Williams, R. B., Jr., Harlan, E. S., and Peoples, M. C. (1990). The relation of hostility and harassment to cardiovascular responses in young women. Paper presented at the annual meeting of the Society for Behavioral Medicine, Chicago. Weidner, G., Friend, R., Ficarrotto, T. J., and Mendell, N. R. (1989). Hostility and cardiovascular reactivity to stress in women and men. Psychosom. Med. 51: 36-45.
Vol. 14, No. 6, 1991
Cynical Hostility, Attempts to Exert Social Control, and Cardiovascular Reactivity in Married Couples Timothy W. Smith 1,2 and Peter C. Brown 1
Accepted for publication: January 11, 1991 Chronically hostile persons may be at greater risk of cardiovascular illness, perhaps because of their more pronounced physiologic responses to interpersonal stressors. The present study of married couples examined the association between Cook and Medley Hostility (Ho) Scale scores and cardiovascular reactivity while couples were engaged in a discussion task with or without an incentive to exert control over their partner. Cynical hostility was associated with greater heart rate (HR) reactivity among husbands in both conditions and with greater systolic blood pressure (SBP) reactivity among husbands attempting to influence their wives. Further, husbands' cynical hostility was associated with greater SBP reactivity in their wives. Wives' cynical hostility was unrelated to their own or their husbands' reactivity. These results underscore the importance of social contexts in the association between hostility and psychophysiologic processes and suggest that the motive to exert social control may be important for hostile persons. KEY WORDS: hostility; cardiovascular reactivity; cynicism; blood pressure.
INTRODUCTION In the continuing investigation of coronary-prone behaviors and personality traits, hostility has emerged as a probable coronary risk factor (Dembroski and Williams, 1989; Matthews, 1988). Interview-based ratings of hostility have been found to predict the subsequent development of coronary heart disease (CHD) in prospective studies (e.g., Dembroski et al., 1989; Hecker et al., 1989). Similarly, several questionnaire measures of hostility have been found to be related to manifestations of CHD and other 1Department of Psychology, University of Utah, Salt Lake City, Utah 84112. 2To whom correspondence should be addressed. 581
0160-7715/91/1200-0581506.50 9 1991PlenumPublishingCorporation
582
Smith and Brown
life-threatening illnesses in cross-sectional and longitudinal studies (e.g., Barefoot et al., 1983, 1987; Koskenvuo et al., 1988; Siegman et al., 1987). One of the most widely used questionnaire measures in this context is the Cook and Medley (1954) Hostility (Ho) Scale (Smith and Pope, 1990). The Ho scale is closely correlated with measures of the frequency and intensity of anger, as well as measures of resentment, suspicion, cynicism, and mistrust (Barefoot et al., 1989; Blumenthal et al., 1987; Smith and Frohm, 1985). High scores on the scale are also associated with more overtly hostile or antagonistic behavior during social interactions (Hardy and Smith, 1988; Smith et al., 1990a) and a tendency to view others as likely sources of provocation and mistreatment (Allred and Smith, 1990; Pope et al., 1990; Smith et al., 1990a). As a result, the trait assessed by this scale has been variously labeled cynical hostility, cynical mistrust, or simply cynicism (Costa et al., 1986; Dembroski and Williams, 1989; Smith and Frohm, 1985). Research on the association between cynical hostility as measured by the Ho scale and health outcomes has been inconsistent. Some cross-sectional studies have found a significant association between Ho scores and the severity of cardiovascular illness (Joesoef et al., i989; Williams, et al., 1980), but several others have not (Dembroski et al., 1985; Friedman and Booth-Kewley, 1987; Seeman and Syme, 1987). The mixed results of crosssectional studies can be at least partially attributed to the limitations of such designs for evaluating cardiovascular risk factors (Matthews, 1988; Pickering, 1985). Longitudinal results have also produced inconsistent findings, however. Equal numbers of studies reporting a significant association between Ho scores and subsequent health (Barefoot et al., 1983, 1989; Shekelle et al., 1983) and failing to find such an association (Hearn et al., 1989; Leon et al., 1988; McCranie et al., 1986) have appeared in recent years. However, studies using very similar measures of hostility have found significant prospective associations (Barefoot et al., 1987; Koskenvuo et al., 1988; Ostfeld et al., 1964). Thus, although additional studies are clearly warranted, cynical hostility may increase the likelihood of subsequent health problems. A variety of processes has been suggested as possible mechanisms linking hostility and health, and physiological reactivity is a common element in many approaches. Williams et al. (1985) suggested that hostile individuals are likely to display more frequent and pronounced episodes of neurohormonal and cardiovascular reactivity. Enhanced physiologic reactivity could, in turn, facilitate the development of coronary artery disease (CAD) and precipitate acute manifestations of CHD. Although some studies have not found Ho scores to be related to the magnitude of cardiovascular responses to traditional laboratory stressors such as mental
Hostility and Cardiovascular Reactivity
583
arithmetic (Sallis et al., 1987; Smith and Houston, 1987), studies using interpersonal stressors have found evidence of such an association. Hardy and Smith (1988) found that high levels of cynical hostility were associated with increased blood pressure reactivity during role played interactions involving high levels of interpersonal conflict. Similarly, Smith and AUred (1989) found that cynically hostile subjects displayed heightened blood pressure reactivity during a debate task, and Suarez and Williams (1989) found that cynical hostility was associated with greater cardiovascular reactivity during a provoking social interaction. These results suggest that antagonistic or conflictual social situations are likely to elicit heightened physiologic reactivity in cynically hostile persons.
Hostility and Interpersonal Control Recent theory and research suggests that social interactions involving attempts to exert control over others may be another interpersonal stressor likely to elicit physiologic reactivity in hostile individuals. Averill (1982) has argued that anger and hostility often represent an attempt to regulate or control the behavior of others. That is, one of the functions of anger and hostility may be to reduce unwanted actions by others and increase desired behaviors. Clearly, this view acknowledges that rather than simply a response to frustrating interpersonal circumstances, anger and hostility may have instrumental value in managing or controlling social interactions. One implication of this perspective is that chronically angry or hostile persons may be particularly concerned with controlling others or overreliant on this particular social influence strategy. Effortful attempts to influence or control others have been found to elicit heightened cardiovascular reactivity. A recent series of studies (Smith et al., 1989, Study 1 and 2, 1990b) has indicated that compared to persons engaged in simple discussions, subjects attempting to influence the opinions or behavior of their discussion partners display increased levels of systolic (SBP) and diastolic blood pressure (DBP) and heart rate (HR). Most recently, these cardiovascular consequences of attempting to exert social influence or control have been demonstrated in the context of marital interactions. Brown and Smith (1992) found that compared to husbands simply engaged in a discussion task with their wives, husbands attempting to influence their spouses during this discussion task displayed significantly higher SBP. Interestingly, social influence attempts did not have a consistent effect on cardiovascular reactivity among wives. If hostility, at least in part, reflects a stronger motivation or tendency to exert control over others, then persons with high scores on the Ho scale
584
Smith and Brown
would be likely to show greater cardiovascular reactivity during social influence attempts than would less cynically hostile individuals. That is, like antagonistic or conflictual interpersonal interactions, attempts to infuence or control others are social stressors particularly likely to elicit reactivity among hostile subjects. This hypothesis was evaluated in additional analyses of the marital interaction study described above (Brown and Smith, 1992). The primary focus of that study concerned the main effects of attempts to influence one's spouse on cardiovascular reactivity. In the present paper, we examine the predicted interactive effects of attempts to exert social influence or control and individual differences in cynical hostility on cardiovascular reactivity. Results presented in detail in the previous report (Brown and Smith, 1992) are summarized briefly as necessary in the present paper. The association between subjects' level of cynical hostility and their own cardiovascular reactivity, not reported previously, is the primary focus of the present discussion. A secondary focus of the present paper is the association between subjects' cynical hostility and their spouses' cardiovascular responses. To the extent that interacting with a hostile spouse is stressful, subject's Ho scores may be related to their spouses' reactivity in this marital context.
METHOD Subjects
Married couples were recruited form undergraduate psychology courses. At least one member of each couple was a student. For couples who agreed to participate, students received partial course credit and nonstudent spouses were paid $10.00. Forty-five couples participated. The average age was 27 years for the men and 25 years for the women. On average, couples had been married for 5 years. The sample was over 80% white. Husbands' mean Ho score was 18.6 (range, 6-33), and wives' mean score was 17.3 (range, 5-31). Procedure
U p o n arriving for the e x p e r i m e n t and b e f o r e g o i n g to the psychophysiological laboratory, subjects listened to a description of the study and completed a brief packet of questionnaires which included the Ho scale. Subjects were told that the purpose of the study was to examine
Hostility and Cardiovascular Reactivity
585
the effects of social interactions on cardiovascular processes. After being taken to the psychophysiological laboratory, husbands and wives were seated at opposite sides of a table, separated from view by a movable partition. Inflatable cuffs attached to Dinamap automated oscillometric monitors (Model 8100) were positioned on the nondominant arms of both husbands and wives. The experimenter and monitors were positioned behind a second partition. HR, SBP, and DBP were recorded at 1-min intervals during a 10-min baseline period. After the baseline period, subjects listened to tape-recorded instructions, delivered through separate cassette players and headphones. The instructions described the upcoming discussion task, adapted from Klein and Willerman (1979). The discussion was described as a problem-solving task. In a hypothetical situation, a local school district was about to lay off 8 of 12 teaching specialists (e.g., band director, shop teacher, etc.). The subjects were to discuss the situation and decide which 4 of the 12 specialists should be retained. Both members of the couple were given a list of the 12 specialists, on which one of two sets of four specialists (counterbalanced across husbands and wives) were designated as the ones the subject should advocate for retention. They were also told that their partner would be advocating a different set of specialists. Subjects were also supplied with a sheet of possible arguments for their designated specialists. Subjects then listened to one of two sets of additional instructions, depending on the condition to which they had been randomly assigned. In the Discuss condition (n = 23 couples), subjects were informed that following the experiment there would be a lottery drawing for a $100.00 cash prize. Further, they were told that the number of times their name was entered into the lottery (and as a result their chances of winning) would be determined randomly after the experimental session. In contrast, subjects in the Influence condition (n = 22 couples) were told that the number of times their name was entered was to be determined by how successful they were in persuading their spouse to select the four specialists they themselves were advocating. Subjects were told that actual preferences for retaining specialists would be obtained after the discussion. Subjects in the Influence condition were told that their name would be placed in the lottery O, 1, 5, 10, or 20 times, depending on the number of specialists from their list of four who were nominated for retention by their spouses. These subjects were also told that while they were given this incentive, their spouse was not; the spouse's name was to be entered randomly. Subjects in the Influence condition were further told that they were forbidden to mention this contingency during the discussion: doing so would disqualify them from the lottery. In actuality, both members of couples assigned to this condition received identical instructions. Thus, although members of couples assigned
586
Smith and Brown
to both conditions believed that their name would be entered into a later lottery, only subjects in the Influence condition were given an incentive to influence the choices made by their spouse. At the conclusion of these instructions, subjects completed two selfreport manipulation check items concerning the extent to which their chances in the lottery depended on their partner's choices and the extent to which they cared about their partner's choices. Subjects were then given 4 rain to review the list of possible arguments and prepare for the discussion task. For the discussion task, subjects were encouraged to discuss the problem freely. During this 4-min period, cardiovascular measures were again recorded at 1-mm intervals. At the conclusion of the task, subjects were debriefed, paid, and excused.
RESULTS As noted above, detailed results of the effects of the social influence manipulation on cardiovascular measures are reported elsewhere (Brown and Smith, 1992), as are results of the manipulation check items. It is important to note, however, that compared to subjects in the Discuss condition, both husbands and wives in the Influence condition indicated that their chances in the lottery were more dependent on their partner's choices (p < .001) and that they cared more about their partner's choices (p < .01). Preliminary analyses indicated that hostility scores were not related to baseline HR, SBP, or DBP levels in husbands or wives. To evaluate the main and interactive effects of individual differences in cynical hostility and the social influence manipulation on cardiovascular reactivity, a series of multiple regressions was computed. In each case the average of the last two baseline values was subtracted from the average of the four task period values to generate a mean change score, the dependent variable in the regression analyses. On the first step of each regression, the baseline value was inserted to control the potential influence of initial levels on reactivity (Benjamin, 1967). On the second step, the main effect for the condition variable (i.e., Influence vs. Discuss, dummy coded) was entered. On the third step, cynical hostility (i.e., continuous Ho scores) was included. On the fourth and final step, a product term representing the interaction between condition and cynical hostility was entered. These analyses were conducted for all three cardiovascular measures for husbands and wives separately. Among wives, neither their Ho scores nor the Ho x condition interaction accounted for a significant portion of the variance in HR, SBP, or DBP reactivity. The results for husbands are presented in Table I. As reported elsewhere
Hostility and Cardiovascular Reactivity
587
Table I. Results of Multiple Regression Analyses of Husbands' Cardiovascular Reactivity Dependent variable
Step
Predictor
R 2 change
pa
p
Heart rate change (HR)
1 2 3 4
Baseline HR Condition (C) Hostility (H) C x H Interaction
.02 .16 .10 .01
0.73 8.97 5.90 0.46
ns < .01 < .03 ns
Systolic blood pressure change (SBP)
1
Baseline SBP
.02
0.95
ns
2 3 4
Condition (C) Hostility (H) C • H Interaction
.23 .01 .08
12.76 0.10 4.64
< .01 ns < .05
1
Baseline DBP
.14
6.73
< .02
2 3 4
Condition (C) Hostility (H) C x H Interaction
.12 .01 .06
6.90 0.14 3.49
< .02 ns < ,07
Diastolic blood pressure change (BP)
adf = (1,39) to (1,42).
24 E
E t~= m
16
z w
8
DISCUSS
0 z I 0
4 I
4
8
12
16
20
24
28
32
36
HOSTILITY SCORE
Fig. 1. Interactive effect of cynical hostility and condition on husbands' systolic blood pressure reactivity
( B r o w n a n d Smith, 1992), h u s b a n d s in t h e I n f l u e n c e c o n d i t i o n displayed larger increases in H R d u r i n g the discussion t h a n did h u s b a n d s in t h e Discuss c o n dition. M o r e i m p o r t a n t l y for o u r p r e s e n t purposes, high cynically hostile husb a n d s displayed significantly larger H R increases d u r i n g the discussion t h a n did low cynically hostile h u s b a n d s [partial r(43) = .36, p < .03], a c c o u n t i n g for a p p r o x i m a t e l y 1 0 % o f the v a r i a n c e in H R reactivity. T h e i n t e r a c t i o n b e -
588
Smith and Brown
tween hostility and condition was not significant in the analysis of H R reactivity. Although the main effect of cynical hostility on SBP reactivity was not significant, the Ho x condition interaction did account for a statistically significant 8% of the variance in SBP reactivity. As depicted in Fig. 1, in the Influence condition cynical hostility was positively related to SBP reactivity. In contrast, cynical hostility was negatively related to SBP reactivity in the Discuss condition. As a result, the significant effect of the social influence manipulation (i.e., 23% of the variance in SBP reactivity; p < .01) occurred primarily among high-cynically hostile men. Although the pattern was similar to that obtained for SBP, the Ho x conditions interaction for husbands' DBP was not significant (i.e., 6% of the variance in DBP reactivity; p < .07). To evaluate the association between one spouse's level of cynical hostility and his/her partner's cardiovascular reactivity, an additional series of multiple regression analyses was performed. Subjects' HR, SBP, and DBP change scores again served as the dependent variable, baseline levels were again included on the first step of the analysis, and condition was included on the second step. However, on the third step the spouse's Ho score was included, and the interaction between condition and the spouse's Ho score was included on the final step. Thus, the association between subjects' reactivity and their spouses' Ho scores--as a main effect and as an interaction with condition - was evaluated in these analyses. Wives' Ho scores were unrelated to their husbands' HR, SBP, and DBP responses during the discussion task. However,husbands' Ho scores were positively associated with SBP reactivity among their wives [partial r(43) = .30, p < .05], accounting for 9% of the variance in wives SBP reactivity. This main effect of husbands Ho scores on their wives' SBP reactivity was not qualified by an interaction with conditions. No other effects involving cynical hostility were significant in these cross-spouse analyses.
DISCUSSION The results of the present study are consistent with previous research (Hardy and Smith, 1988; Smith and Allred, 1989; Suarez and Williams, 1989), indicating that cynical hostility is associated with heightened cardiovascular reactivity in potentially stressful social contexts. Further, the present findings indicate that situations in which cynically hostile persons attempt to influence or control others m a y b e likely to elicit this heightened reactivity. For husbands, across both the Discuss and the Influence conditions, cynical hostility was associated with larger H R increases during the
Hostility and Cardiovascular Reactivity
589
social interaction task. Cynical hostility was also associated with more pronounced SBP reactivity when husbands were engaged in effortful attempts to influence their wives. The previously demonstrated effects of effortful attempts to influence or control others on blood pressure reactivity (Smith et al., 1989, 1990b; Brown and Smith, 1992), were observed primarily among high-hostile husbands. Thus, in addition to the antagonistic or conflictual social situations identified in previous research, interactions involving effortful interpersonal control may also be a relevant stressor capable of eliciting enhanced physiologic reactivity in cynically hostile persons. Further, the present results suggest that marital relations may be an interesting context for the examination of psychophysiological correlates of hostility. Previous research indicates that hostility is associated with decreased marital satisfaction in some groups (Smith et aL, 1988; Houston and Kelley, 1989) and that marital distress is related to psychophysiological processes (Levenson and Gottman, 1983, 1985). Several qualifications of these conclusions are in order. First, cynical hostility was related to cardiovascular reactivity only among husbands in the present study. The only significant result for wives was the association between their SBP responses during the task and their husbands' level of cynical hostility. This result certainly supports the validity of the Ho scale for men by indicating that persons interacting with cynically hostile men display heightened cardiovascular arousal. Interactions with cynically hostile men may be sufficiently stressful as to elicit increased blood pressure in their interaction partners. However, the fact that wives' Ho scores were unrelated to cardiovascular reactivity - - either their own or their husbands' raises concerns about sex differences in hostility and its association with various outcomes. One possibility is that the Ho scale is a less valid measure of hostility among women than men (Smith et aL, 1990a). Alternatively, hostility may be less closely related to health or related through different mechanisms in women (Barefoot et al., 1991). However, at least two studies to date have found that Ho scores are related to cardiovascular reactivity in women (Suarez et al., 1990; Weidner et al., 1989). Future research must examine potential sex differences at all levels, including the measurement of hostility, its association with potential mediating mechanisms, and the prediction of health outcomes. A second qualification concerns the source and nature of the hostility • conditions interaction on husbands' blood pressure reactivity. Although it is obviously possible that this represents an interaction between husbands' level of cynical hostility and their motivation to exert control over their spouses, it must be noted that both members of the couple in the Influence condition were given an incentive to influence their partner. As a result, it is possible that the effect on SBP reactivity reflects an interaction between husbands' hos-
-
590
Smith and Brown
tility levels and their spouses' effort to exert control during the interaction. That is, given the present design, it is unclear whether cynically hostile husbands displayed heightened reactivity in response to their own effort to exert control, their perception of their wives' influence attempts, or a combination of these factors. Further, it is possible that high-Ho men are less socially skilled in interactional tasks of this type, and as a result, their heightened arousal may reflect the fact that such interaction tasks are more difficult for them. Thus, while effortful social influence or control appears to be a relevant stressor for cynically hostile persons, additional research will be required to determine if their heightened reactivity in such situations reflects their own motivational state or skill deficits, a reaction to others' behavior, or a dynamic interactional process. Finally, although cynical hostility was associated with increased H R reactivity overall and increased SBP reactivity in the Influence condition, hostile subjects tended to display less blood pressure reactivity when they were simply discussing the hypothetical situation. Similar inverse associations have been reported elsewhere (e.g., Siegman, 1990), but most studies report either a positive association or no association, depending on the type of stressor employed. It may be that without sufficiently provoking or challenging social stimuli, the cynical style of high-Ho subjects is associated with less active engagement in laboratory tasks and occasionally accompanied by lower levels of cardiovascular arousal (Manuck et al., 1985). The extent to which experimental procedures are engaging for cynically hostile subjects may provide a useful framework for delineating the presence and direction of associations between Ho scores and physiological reactivity. These qualifications notwithstanding, the present and previous findings indicate that some social situations elicit heightened cardiovascular reactivity among cynically hostile persons. This enhanced reactivity is consistent with psychophysiological models of the link between hostility and health (Williams et al., 1985). Cynical hostility is associated with increased interpersonal conflict and stress at home and work (Blumenthal et al., 1987; Houston and Kelly, 1989; Smith et al., 1988). Thus, chronic or recurring social situations involving provocation, conflict, and struggles for control may be a central feature of the biopsychosocial process connecting hostility and health.
REFERENCES Allred, K. D., and Smith,T. W. (1991). Socialcognitionin cynicalhostility.Cognitive Therapy and Research 15: 399-412. Averill, J. R. (1982).Anger and Aggression: An Essay on Emotion, Springer-Verlag,New York.
Hostility and Cardiovascular Reactivity
591
Barefoot, J. C., Dahlstrom, W. G., and Williams, R. B., Jr. (1983). Hostility, CHD incidence, and total mortality: A 25-year follow-up of 255 physicians. Psychosom. Med. 45: 59-63. Barefoot, J. C., Siegler, I. C., Nowlin, J. B., Peterson, B., Haney, T. L., and Williams, R. B., Jr. (1987). Suspiciousness, health, and mortality: A follow-up study of 500 older adults. Psychosom. Med. 49: 450-457. Barefoot, J. C., Dodge, K. A., Peterson, B. L., Dahlstrom, W. G., and Williams, R. B., Jr. (1989). The Cook-Medley Hostility Scale: Item content and ability to predict survival. Psychosom. Med. 51: 46-57. Barefoot, J. C., Peterson, B. L., Dahlstrom, W. G., Siegler, I. C., Anderson, N. B., and Williams, R. B., Jr. (1991). Hostility patterns and health implications: Correlates of CookMedley scores in a National Survey. Health PsychoL 10: 18-24. Benjamin, L. (1967). Facts and artifacts in using analysis of covariance to "undo" the law of initial values. Psychophysiology 4: 187-206. Blumenthal, J. A., Barefoot, J., Burg, M. M., and Williams, R. B., Jr. (1987). Psychological correlates of hostility among patients undergoing coronary angiography. Br. Z Med. PsychoL 60: 349-355. Brown, P. C., and Smith, T. W. (1992). Social influence, marriage, and the heart: Cardiovascular consequences of interpersonal control in husbands and wives Health Psychol (in press). Cook, W. W., and Medley, D. M. (1954). Proposed hostility and pharisaic-virtue scales for the MMPI. Z AppL PsychoL 38: 4-418. Costa, P. T., Jr., Zonderman, A. B., McCrae, R. R., and Williams, R. B., Jr. (1986). Cynicism and paranoid alienation in the Cook and Medley Ho Scale. Psychosom. Med. 48: 283-285. Dembroski, T. M., and Williams, R. B., Jr. (1989). Definition and assessment of coronaryprone behavior. In Schneiderman, N., Weiss, S. M., and Kaufman, P. G. (eds.), Handbook of Research Methods in Cardiovascular Behavioral Medicine, Plenum, New York. Dembroski, T. M., MacDougall, J. M., Costa, P. T., and Crandits, G. A. (1989). Components of hostility as predictors of sudden death and myocardial infarction in the Multiple Risk Factor Intervention Trial. Psychosom. Med. 51: 514-522. Friedman, H. S., and Booth-Kewley, S. (1987). Personality, Type A behavior, and coronary heart disease: The role of emotional expression. J. Personal. Soc. PsychoL 53: 783-792. Hardy, J. D., and Smith, T. W. (1988). Cynical hostility and vulnerability to disease: Social support, life stress, and physiological response to conflict. Health PsychoL 7: 447-459. Hearn, M. D., Murray, D. M., and Luepker, R. V. (1989). Hostility, coronary heart disease, and total mortality: A 33-year follow-up study of university students. J. Behav. Med. 12: 105-121. Hecker, M. H. L., Chesney, M. A., Black, G. W., and Frautschi, N. (1989). Coronary-prone behaviors in the Western Collaborative Group Study. Psychosom. Med. 51: 153-164. Houston, B. K., and Kelley, K. E. (1989). Hostility in employed women: Relation to work and marital experiences, social support, stress, and anger expression. Personal Soc. PsychoL Bull. 15: 175-182. Joesoef, M. R., Wetterhall, S. F., DeStefano, F., Stroup, N. E., and Fronek, A. (1989). The association of peripheral arterial disease with hostility in a young, healthy veteran population. Psychosom. Med. 51: 285-289. Klein, H. M., and Willerman, L. (1979). Psychological masculinity and femininity and typical and maximal dominance expression in women. J. Personal Soc. PsychoL 37: 2059-2070. Koskenvuo, M., Kapiro, J., Rose, R. J., Kesaniemi, A., Sarna, S., Heikkila, K., and Langinvainio, H. (1988). Hostility as a risk factor for mortality and ischemic heart disease in men. Psychosom. Med. 50: 330-340. Leon, G. R., Finn, S. E., Murray, D., and Bailey, J. M. (1988). The inability to predict cardiovascular disease from hostility scores or MMPI items related to Type A behavior. Z Consul Clin. PsychoL 56: 597-600. Levenson, R. W., and Gottman, J. M. (1983). Marital interaction: Physiological linkage and affective exchange. J. Personal Soc. PsychoL 45: 587-597. Levenson, R. W., and Gottman, J. M. (1985). Physiological and affective predictors of change in relationship satisfaction. J. Personal Soc. PsychoL 49: 85-94.
592
Smith and Brown
Manuck, S. B., Morrison, R. L., Bellack, A. S., and Polefrone, J. M. (1985). Behavioral factors in hypertension: Cardiovascular responsibility, anger, and social competence. In Chesney, M. A., and Rosenman, R. H. (eds.), Anger and Hostili(y in Cardiovascular and Behavioral Disorders, Hemisphere, New York. Matthews, K. A. (1988). CHD and Type A behaviors: Update on and alternative to the BoothKewley and Friedman quantitative review. Psychol. BuiLt 104: 373-380. McCranie, E. W., Watkin, L. O., Brandsma, J. M., and Sisson, B. D. (1986). Hostility, coronary heart disease (CHD) incidence, and total mortality: Lack of association in a 25-year follow-study of 478 physicians. J. Behav. Med. 9: 119-125. Ostfield, A. M., Lebovitis, B. Z., Shekelle, R. B., and Paul, O. (1964). A prospective study of the relationship between personality and coronary heart disease. J. Chron. Dis. 17: 266-276. Pickering, T. G. (1985). Should studies of patients and undergoing coronary angiography be used to evaluate the role of behavioral risk factors for coronary heart disease? Z Behav. Med. 8: 203-213. Pope, M. K., Smith, T. W., and Rhodewalt, F. (1990). Cognitive, behavioral, and affective correlates of the Cook and Medley Hostility Scale. J. Personal. Assess. 54: 501-514. Sallis, J. F., Johnson, C. C., Trevorrow, T. R., Kaplan, R. M., and Hovell, M. F. (1987). The relationship between cynical hostility and blood pressure reactivity. J. Psychosom. Res. 31: 111-116. Seeman, T. W., and Syme, S. L. (1987). Social networks and coronary artery disease: A comparison of the structure and function of social relations as predictors of disease. Psychosom. Med. 49: 3451-354. Shekelle, R. B., Gale, M., Ostfeld, A. M., and Paul, O. (1983). Hostility, risk of coronary heart disease, and mortality. Psychosom. Med. 45: 109-114. Siegman, A. W. (1990). Components of hostility and cardiovascular reactivity. Paper presented at the American Psychological Association annual meeting. Boston. Siegman, A. W., Dembroski, T. M., and Ringel, N. (1987). Components of hostility and the severity of coronary artery disease. Psychosom. Med. 49: 127-135. Smith, M. A., and Houston, B. K. (1987). Hostility, anger, expression, cardiovascular responsibility, and social support. Biol. PsychoLt 24: 39-48. Smith, T. W., and Allred, K. D. (1989). Blood pressure responses during social interaction in high- and low-cynically hostile males. J. Behav. Med. 12: 135-143. Smith, T. W., and Frohm, K. D. (1985). What's so unhealthy about hostility? Construct validity and psychosocial correlates of the Cook and Medley Ho scale. Health Psychol. 4: 503-520. Smith, T. W., and Pope, M. K. (1990). Cynical hostility as a health risk: Current status and future directions. J. Soc. Behav. Personal. 5: 77-88. Smith, T. W., Pope, M. K., Sanders, J. D, Allred, K. D., and O'Keeffe, J. L. (1988). Cynical hostility at home and work: Psychosocial vulnerability across domains. J. Res. Personal. 22: 525-548. Smith, T. W., Allred, K. D., Morrison, C. A., and Carlson, S. D. (1989). Cardiovascular reactivity and interpersonal influence: Active coping in a social context. Z Personal. Soc. Psychol. 56: 209-218. Smith, T. W., Sanders, J. D., and Alexander, J. F. (1990a). What does the Cook and Medley Hostility Scale measure? Affect, behavior and attributions in the marital context. J. Personal Soc. Psychol. 58: 699-708. Smith, T. W., Baldwin, M., and Christensen, A. (1990b). Interpersonal influence as active coping: Effects of task difficulty on cardiovascular reactivity. Psychophysiology 27: 429~ Suarez, E. C., and Williams, R. B., Jr. (1989). Situational determinants of cardiovascular and emotional reactivity in high and low hostile men. Psychosom. Med. 51: 404-418. Suarez, E. C., Williams, R. B., Jr., Harlan, E. S., and Peoples, M. C. (1990). The relation of hostility and harassment to cardiovascular responses in young women. Paper presented at the annual meeting of the Society for Behavioral Medicine, Chicago. Weidner, G., Friend, R., Ficarrotto, T. J., and Mendell, N. R. (1989). Hostility and cardiovascular reactivity to stress in women and men. Psychosom. Med. 51: 36-45.
