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Cardiac Autonomic Control and Treatment of Hostility: A Randomized Controlled Trial

From the Division of Behavioral Medicine (R.P.S., E.E.G., F.A.T., C.E.M., P.S.M., I.C.), Department of Psychiatry; Division of Consultation/Liaison Psychiatry (P.A.S.), Department of Psychiatry; Division of Biostatistics (E.B.), Mailman School of Public Health; and Department of Medicine (R.S., J.T.B.), Columbia University, New York, New York; and New York State Psychiatric Institute (R.P.S., C.E.M., P.S.M., M.M.M.), New York, New York.

Address correspondence and reprint requests to Richard P. Sloan, Department of Psychiatry, Columbia University Medical Center, 1150 St. Nicholas Ave., Suite 121, New York, NY 10032. E-mail: rps7{at}columbia.edu

Objective: To test whether reduction in hostility increases autonomic regulation of the heart.

Methods: In this randomized controlled trial, participants were 158 healthy adults, aged 20 years to 45 years, who were 1 standard deviation (SD) above national norms on the Cook-Medley Hostility and the Spielberger Trait Anger Indices. Participants also were interviewed, using the Interpersonal Hostility Assessment Technique (IHAT). They were randomly assigned to a 12-week cognitive behavior therapy program for hostility reduction or a wait-list control condition. The main outcome measure was cardiac autonomic modulation, measured as RR interval variability (RRV) derived from 24-electrocardiographic recordings.

Results: In a multivariate analysis of variance assessing psychological outcomes of hostility, anger, and IHAT scores, there was a significant treatment effect with an average reduction across the three outcomes that was approximately 0.7 SD (ES = 0.685, SE = 0.184, p < .001) greater for the intervention group than for the control group. In contrast, the change in heart rate was –0.14 beat/min (95% Confidence Interval [CI] = –2.43, 2.14) in treatment participants and –1.36 beat/min (95% CI = –3.28, 0.61) in wait-list participants. High-frequency RRV, an index of cardiac parasympathetic modulation, increased by 0.07 ln ms² (95% CI = –0.10, 0.24) for participants in the treatment condition and decreased by 0.04 ln ms² (95% CI = –0.18, 0.10) for participants in the wait-list condition. These differences were not significant. The findings for other indices of RRV were similar.

Conclusions: Reduction of hostility and anger was not accompanied by increases in cardiac autonomic modulation. These findings raise questions about the status of disordered autonomic nervous system regulation of the heart as a pathophysiological mechanism underlying the hostility-heart disease relationship and about whether hostility itself is a mechanism or merely a marker of elevated risk of heart disease.

Key Words: parasympathetic nervous system • hostility • cognitive behavior therapy • randomized controlled trial

Abbreviations: SD = standard deviation; CBT = cognitive behavior therapy; RRV = RR interval variability; ECG = electrocardiogram; HR = heart rate; HF = high frequency; ln = natural log; CI = confidence interval; ANS = autonomic nervous system; STAXI = State Trait Anger Expression Inventory; SDRR = standard deviation of normal to normal RR intervals; ES = effective size; SE = standard error; LF = low frequency; CHD = coronary heart disease.