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Psychosomatic Medicine 63:463-469 (2001)
© 2001 American Psychosomatic Society

ORIGINAL ARTICLES

Defensive Hostility and Coronary Heart Disease: A Preliminary Investigation of Male Veterans

Randall S. Jorgensen, PhD, James J. Frankowski, MS, Larry J. Lantinga, PhD, Kishore Phadke, MD, Robert P. Sprafkin, PhD and Kenneth W. Abdul-Karim, PhD

From Syracuse University (R.S.J., J.J.F., K.W.A.-K.), Veterans Administration Medical Center, and State University of New York, Health Science Center at Syracuse (L.J.L., K.P., R.P.S.), Syracuse, New York.

Address correspondence to: Randall S. Jorgensen, PhD, Center for Health and Behavior, Department of Psychology, Syracuse University, Syracuse, NY 13244-2340. Email: rsjorgen{at}syr.edu


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE: Research and theory link an interpersonal conflict model to cardiovascular disease. Specifically, persons scoring high on cynical hostility and social defensiveness are thought to manifest a defensive need for approval while harboring basic distrust and hostility toward those who could provide such approval. The objective of this study was to assess whether angiographically determined coronary artery disease (CAD) was associated with this combination of high cynical hostility and high social defensiveness.

METHODS: Fifty-nine male patients of a Veterans Administration Medical Center (86% white, mean age = 59.9 years) participated in the study on the day before their angiographic procedure; these men filled out the Cook-Medley Hostility Scale and the Marlowe-Crowne Social Desirability Scale (social defensiveness). They subsequently were categorized as having defensive hostility (DH), high hostility (HH), high social defensiveness (SD), or low psychosocial risk (LRisk; low on both scales).

RESULTS: The four groups did not differ significantly on risk factor status or health status. As predicted, a preplanned contrast showed that the DH group’s mean number of arteries with at least 50% blockage (mean = 2.5) differed significantly from the combined means of the other groups. The HH and SD groups did not differ from the LRisk group.

CONCLUSIONS: When combined with other reports, the approach-avoidance interpersonal conflict model holds the promise of providing additional information about the psychosocial factors contributing to CAD development among men with high cynical hostility.

Key Words: defensiveness • hostility • angiography • coronary artery disease.

Abbreviations: CAD = coronary heart disease; CHD = coronary heart disease; DBP = diastolic blood pressure; DH = defensive–high hostility; HH = high hostility; Ho = Cook-Medley Hostility Scale; LRisk = low psychosocial risk; MCSDS = Marlowe-Crowne Social Desirability Scale; SBP = systolic blood pressure; SD = high social defensiveness.


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The cooccurrence of a hostile cognitive set with angry feelings and expression of agonistic behavior is thought to contribute to the development of stress-related cardiovascular diseases (1–4). In recent years the construct of "cynical hostility" has emerged as a major description of this hostile cognitive set (3, 4). This cognitive set includes the belief that, in general, people cannot be trusted because of their selfish motives and the likelihood of being provoked and harmed by them (5). To assess cynical hostility, the 50-item Ho scale (6), based on the Minnesota Multiphasic Personality Inventory, has been used frequently (4, 5). Although both prospective (7–9) and cross-sectional (10, 11) studies have shown an association between Ho scores and CAD, other prospective (12, 13) and cross-sectional (14, 15) studies have failed to replicate the association. Siegman et al. (16) found a significant association of Ho scores with CHD; however, this relation became nonsignificant after statistical adjustment for socioeconomic status, hypertension, and diabetes. Nevertheless, the recent meta-analysis by Miller et al. (3) showed a weak association between Ho score and CHD and a stronger relationship in predicting all-cause mortality. Recent epidemiological studies using an abbreviated form of the Ho (17–19) also provide some support for the conclusions of Miller et al. Furthermore, Knox et al. (19) showed that the association of cynical hostility with heart disease relates to its combination with other factors linked to social functioning. Thus, one reason for the inconsistency may relate to an inconsistent examination of the combined influence of cynical hostility with other theoretically relevant psychosocial variables.

Social defensiveness has emerged as a possible variable that, when combined with cynical hostility, may help categorize persons at risk for stress-related cardiovascular disease (20–22). Theoretically, this form of defensive coping reflects a safeguarding of self-esteem by avoiding interpersonal conflict and evaluative threat as a means to maintain social approval (21, 23–25). The maintenance of social approval is thought to be associated with a defensive avoidance of the recognition, reporting, and behavioral display of angry feelings (21, 23, 25). Furthermore, this defensive need for approval has been discussed as contributing to CHD-prone reactions, both psychosocial and physiological, when combined with cynical hostility (21, 22, 26). Theoretically, some CHD-prone people harbor a cynical mistrust of others that conflicts with the desire to be validated through the reception of affection and love (21, 22, 26), which is tantamount to an "approach-avoidance" conflict centering on a motivation to obtain the approval of others while distrusting those capable of providing approval and reassurance. This chronic state of social conflict, then, may contribute to a chronic state of physiologic activation conducive to the development of cardiovascular disease (20–22).

Before the introduction of the category of high cynical hostility and high social defensiveness (DH), Weinberger et al. (27) used the MCSDS (23) as a measure of social defensiveness and a measure of manifest anxiety to create the categories of repressors (high MCSDS and low anxiety), low anxious (low MCSDS and low anxiety), high anxious (low MCSDS and high anxiety), and defensive high anxious (high MCSDS and high anxiety). In the report that introduced the DH category, based on an ambulatory blood pressure monitoring study of 33 male paramedics, Jamner et al. (21) created four groups from the MCSDS and Ho scale in a manner that resembles the typological approach of Weinberger et al. (27). Specifically, these men were categorized, on the basis of median splits, as DH (high MCSDS and high Ho), high social defensiveness (SD; high MCSDS but low Ho), high hostility (HH; low MCSDS but high Ho), or nondefensive, low hostility (LRisk; low on both dimensions).

Research supports connections among DH, social stress, physiologic activation, and cardiovascular disease. Jamner et al. (21) found that in the high interpersonal stress of the hospital context, the highest heart rate and DBP levels, obtained by ambulatory blood pressure monitoring, covaried with the DH profile. Regarding severity of coronary disease among patients with CAD, Helmers et al. (28), using the same typing procedures as Jamner et al., showed that the greatest ischemia during mental stress, greatest perfusion defects during thallium exercise scintigraphy, and longest duration of ischemia during daily activities (assessed by ambulatory monitoring) were linked to the DH profile. It is noteworthy that across the three samples, two of the samples were mostly men, the third sample was only men, and the moderating effect of gender was not tested. Among healthy men and women categorized according to the above procedures, Helmers and Krantz (20) found a gender-defensiveness-hostility interaction that approached significance. Subsequent perusal of means suggested that levels of SBP across a baseline and two stress periods (mental arithmetic without harassment and a speech concerning negative personal characteristics) were associated with the DH profile only for men; however, the post hoc comparisons computed showed that the male DH group differed significantly from the HH and SD groups only in baseline SBP. For a group of male university students, Jorgensen et al. (22) reported that the MCSDS score correlated with heart rate and SBP reactivity to a mental arithmetic task with harassment only for the high Ho group (ie, those scoring above the Ho median). All in all, these results are largely consistent with the view that an approach-avoidance orientation to interpersonal relations places DH men at risk for CAD.

It is important to note that recent meta-analyses indicate that high scores on the Ho scale covaried, albeit weakly, with CHD (3) and that social defensiveness was the strongest predictor of elevated blood pressure (2), a major risk factor for CHD (2). Furthermore, Shapiro et al. (29) found that heart rate reactivity covaried significantly with high Ho within low MCSDS men; this association was not obtained for women. In relation to these results, two competing hypotheses emerge for male samples: 1) the expectation of SD or HH profiles showing separate and independent associations with CHD (ie, both groups exhibiting a higher mean number of arteries blocked than the LRisk group) vs. 2) the rival hypothesis of CAD being associated with the combined influence of SD and Ho (ie, the DH group showing a higher mean number of arteries blocked than all remaining groups).

Although data indicate that veterans receiving treatment from Veterans Administration Medical Centers are at greater risk for heart disease (30) and have lower health status (31) than civilians, most studies of the psychosocial correlates of CAD are based on civilian populations (32). Given the importance of assessing factors predisposing at-risk groups to CAD, the purpose of this study was to examine whether the DH profile would covary with the angiographically determined number of arteries blocked for a sample of male veterans. If a combined effect of cynical hostility and social defensiveness exists, then the DH group should show the greatest mean number of arteries blocked in comparison to all other groups (ie, HH, SD, and LRisk). Alternatively, if the independent effects model is supported, then the HH and SD groups should show higher levels of CAD than the LRisk group, with the DH group not differing significantly from the HH and SD groups. In view of the recent findings of Siegman et al. (16), we explored whether the obtained associations persisted after adjustment for factors associated with CAD in our sample. To our knowledge, this study is the first one to examine these questions in a unique group of males at risk for premature mortality and disease, especially disease of the cardiovascular system.


   METHODS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Participants
Of the 75 male patients approached the day before their scheduled angiographic procedure at the Syracuse Veteran Affairs Medical Center (Syracuse, NY), 59 agreed to participate (3 African Americans, 51 whites, 3 Hispanics, and 2 with missing ethnicity data). The patients ranged in age from 35 to 75 years, with a mean and standard deviation of 59.9 and 10.4, respectively.

Procedure
During the late afternoon before the morning angiography procedure, written informed consent was obtained by one of the authors (J.J.F., K.W.A.-K., L.J.L., R.P.S., or R.S.J.). The study was described to each participant as an investigation of the relationships among heart disease, health behaviors, and how people view themselves and others in terms of affective and social responses. After a brief review of the instructions for each questionnaire, participants were assured of the maintenance of confidentiality and reminded of their right to withdraw participation at any time.

The order of questionnaires was randomized. The questionnaire packet was left for the participant to complete that evening and was picked up the next morning by either L.J.L. or R.P.S. Complete psychometric data were available for 54 of the 59 participants.

Self-Report Measures
Cook-Medley Hostility Scale.
This 50-item questionnaire was derived from the Minnesota Multiphasic Personality Inventory. Alpha coefficients average about 0.80, and test-retest correlations for 1- as well as 4-year intervals were greater than 0.80 (4). As stated above, this questionnaire has been linked to mortality from all-causes and coronary disease and taps the construct of cynical hostility (3, 4).

Marlowe-Crowne Social Desirability Scale.
The MCSDS is a 33-item instrument that taps social defensiveness (25). This widely used measure is reported to be reliable ({alpha} coefficient = 0.88, 1-month test-retest correlation = 0.88; see Ref. 23), and, as reported above, the scale has been useful in studying the psychosocial correlates of blood pressure, cardiovascular reactivity, and ischemia. For this study’s sample, the MCSDS showed a statistically significant negative correlation with the Ho scale (r(52) = -0.50, p = .0001).

Assessment of CAD
All patients underwent cardiac catheterization using a modified Seldinger’s technique with an anterior wall puncture of the femoral artery and use of a sheath. Left ventriculography was done in all patients in 30° right anterior oblique projection. Coronary angiography was done in multiple standard projections. Angiograms were interpreted by two experienced cardiologists (a cardiology attending and a cardiology fellow), who jointly performed the cardiac catheterizations. After completion of the procedures the cardiologists independently reviewed the findings and then reached diagnostic consensus. In accordance with standard procedures, significant CAD was considered to be 50% or greater narrowing of one or more of the three major coronary arteries or their branches. Patients with no visible plaques were considered to have normal coronary arteries. The number of vessels with 50% or greater narrowing served as the marker of CAD.

To assess the reliability of the angiographic interpretations, 20 participants were randomly selected from our sample, and a third, senior cardiologist blindly interpreted the angiograms. In 19 of the 20 cases (95%), the senior cardiologist agreed completely with the original interpretations. In the remaining case, disagreement over the percentage of occlusion in one identified artery was noted.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Group Categorization and Data Analytic Strategy
Proc Rank (33) was used to create 1) high vs. low Ho groups and 2) high vs. low MCSDS groups. For each scale, Proc Rank first ordered all scores from high to low; for tied scores, the mean of the corresponding ranks was used. Next, two groups were created from these ranks. MCSDS scores >=21 were categorized as high (sample median = 21), and Ho scores >19 were categorized as high (sample median = 19). As can be seen, these procedures are consistent with the median approach of Jamner et al. (21). These categorical procedures yielded 9 participants for the LRisk group, 17 participants for the HH group, 20 participants for the SD group, and 8 participants for the DH group.

Diagnostic Status
Participants’ charts were reviewed for diagnosed alcoholism, diabetes, hypercholesterolemia, and hypertension. Table 1 shows the percentages of diagnosed medical conditions for each group. Because between-group differences in proportions can be analyzed by a factorial analysis of variance of the arc sine–transformed proportions, an arc sine transformation was applied to each proportion (34). Next, 2 x 2 (high vs. low Ho and high vs. low MCSDS) analyses of variance were computed on the arc sine–transformed proportions for each diagnosis (see Refs. 35 and 36). None of the analyses yielded significant effects (all p values > .05). However, a Ho main effect approached statistical significance for diabetes (F(1,{infty}) = 3.8, p < .055).


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  		Table 1. Percentages of Diagnosed Medical Conditions for Each Groupa
 
Point-biserial correlations were computed between the number of vessels blocked and each diagnosis (0 = no, 1 = yes). None of the correlations achieved statistical significance. However, the correlation involving diabetes approached statistical significance (r(54) = 0.25, p < .07).

Demographic and Health-Related Variables
Table 2 shows the demographic and health-related variables for each group. Height and weight, obtained from the chart, were used to compute the body mass index (kg/m2). Cigarettes smoked per day, education in years, marital status (married vs. unmarried), and income were obtained as a part of the self-report package. Per annum income was categorized as <$10,000, $10,000 to $20,000, and >$20,000, and percentages and proportions for each group were computed for each category. Likewise, the percentage and proportion of married men were computed. Between-group proportions for each income category and marital status, like the analyses of diagnostic categories, were arc sine transformed and then analyzed by a 2 x 2 (high vs. low Ho by high vs. low MCSDS) analysis of variance; no significant main or interactive effects were obtained. To assess whether the number of vessels varied as a function of income category, a one-way analysis of variance was computed with a general linear model using the Type III sums of squares to adjust for unequal cell sizes (33); the test of the income category effect was nonsignificant.


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  		Table 2. Demographic and Health-Related Variables for Each Groupa
 
Body mass index, age, and self-reports of education and cigarettes per day were each analyzed by a 2 x 2 (high vs. low Ho by high vs. low MCSDS) analysis of variance by means of a general linear model, using Type III sums of squares to adjust for unequal cell sizes (33). No significant main or interactive effects were obtained. Next, these variables were correlated with number of vessels blocked. Only age showed a significant correlation coefficient (r(54) = 0.39, p < .0035). However, marital status (0 = unmarried, 1 = married) approached statistical significance (r(54) = 0.25, p < .07).

Number of Vessels Blocked
As stated above, planned comparisons were used to test the a priori expectation that only the DH group mean would differ significantly from the averaged means of the other three groups (contrast = 3, -1, -1, -1). Next, the combined HH and SD means were compared with that of the LRisk group (contrast = 0, 1, 1, -2). To adjust for unequal cell sizes, a general linear model using the Type III sums of squares was computed for each contrast (33). Because of the theoretical and empirical literature presented above, directional tests (ie, one-tailed tests for each 1-df contrast) were used to test each contrast. The "estimate" option of Proc GLM (33) was used to obtain a directional t test for each contrast. Thus, both statistical significance and a positive t value are required to support both hypotheses. A third nondirectional test was planned to compare the DH and HH groups with the DH group only if the second contrast proved significant.

Whereas a significant contrast effect was obtained for the comparison of DH with the other groups (t(50) = 2.7, p < .0055), analyses showed a nonsignificant contrast for the comparison of the HH and SD groups with the LRisk group (t(50) = 1.2, p < .12). As shown in Figure 1, the DH group had a mean of 2.5 arteries with at least 50% narrowing, whereas the SD, HH, and LRisk groups had means of 1.55, 1.47, and 1.0, respectively.



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  		Fig. 1. Mean number of arteries blocked for each psychosocial risk group. Error bars are standard deviations.

 
Because associations involving Ho can be dependent on other variables correlated with CHD (16), three general linear models were recomputed to test whether the contrast comparing the DH group with the other groups remained statistically significant after adjustment of age, diabetes, or marriage. Preliminary analyses of the four groups showed that neither the parallelism nor equal slope intercepts assumptions were violated for the continuous variable of age; thus, the contrast was retested with age as a covariate. This analysis of covariance showed age to be a statistically significant covariate (F(1,49) = 6.2, p < .02) and that the contrast remained statistically significant with this adjustment (t(49) = 2.2, p < .016).

Because diabetes showed a trend of correlating with number of vessels blocked and a very strong trend of being higher in high Ho participants in comparison with low Ho participants, it was entered as a control factor in the analysis of variance testing the contrast. This analysis showed a statistically nonsignificant effect of diabetes (F(1,49) = 2.0, p < .17) with the contrast effect remaining statistically significant (t(49) = 2.5, p < .009). Similarly, marital status (married vs. unmarried) was entered as a control factor in the analysis because of its trend of correlating with the number of vessels blocked; like the analysis of age and diagnosed diabetes, analyses revealed a statistically nonsignificant effect of marital status (F(1,49) = 1.9, p < .18), and the contrast effect remained statistically significant (t(49) = 2.3, p < .012).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
As predicted, the DH group showed a significantly greater number of coronary arteries with at least 50% stenosis than the other groups. However, the difference between the LRisk group and the combined HH and SD groups did not occur. These results are consistent with those of Helmers et al. (28). These researchers showed that the greatest ischemia during mental stress, greatest perfusion defects during thallium exercise scintigraphy, and longest duration of ischemia during daily activities (assessed by ambulatory monitoring) were linked to the DH profile. Jamner et al. (21) showed that among male paramedics, high levels of DBP and HR covaried with the DH profile within the hospital context, a setting of high interpersonal stress. Helmers and Krantz (20) found the DH profile to be linked to elevated baseline SBP for men only. To the extent that the associations with blood pressure and heart rate mark an underlying potential for cardiovascular disease, and given the findings of Helmers et al. (28) and those of our investigation, an approach-avoidance interpersonal conflict model holds the promise of providing additional information about the psychosocial factors contributing to CAD development among men with high cynical hostility.

Fontana et al. (26) present a perspective that is congruent with an approach-avoidance framework discussed by others (20–22). Specifically, these researchers posit that cynical hostility is particularly harmful when it conflicts with the need to be validated as deserving love and affection. On one hand the DH male may desire emotional support to deal with personal insecurities, but on the other hand a basic cynical distrust and expectation of psychological harm may induce a set of cognitive (eg, "Most people do not deserve my friendship"), angry, and behavioral reactions (eg, shouting and blaming others for problems) as a means of avoiding insecure, anxious feelings and attempting to exert social control (cf, Refs. 37 and 38). Thus, within a social context marked by conflict and loss of social approval, the DH male may be at risk for patterns of behavior and physiological reactions characteristic of anger (ie, attack, fight, and effort), anxiety (ie, flight), or depressed mood (ie, loss of control and subordination) (see Ref. 39). Interestingly, a study by Frankowski et al. (40) showed that cynical hostility correlates with self-centeredness, problems with empathy, a general tendency to blame others for problems, and depressed mood; that is, cynical hostility covaried with interpersonal behaviors contrary to the successful resolution of interpersonal conflict and achieving of social approval, as well as the mood associated with loss of control. Taken together, the above empirical findings and theorizing are consistent with a "transactional" model in which agonistic reactions induce loss of desired social support and social relations (41).

In their recent review of evaluative processes, Cacioppo and Berntson (42) articulated the concept of "coactivation" while discussing approach-avoidance conflicts (43). Briefly, both approach and avoidance tendencies can be activated in the eliciting context, which may then induce high levels of the behavioral, cognitive, and physiological concomitants of arousal (cf, Refs. 42 and 44). In the present case, it is possible that both approach (seeking approval) and avoidance tendencies (basic mistrust, resentment, and negative appraisals of others) induce a cooccurrence of fight/effort and loss of control/subordination strivings related to social conflict. That is, at-risk DH males may vacillate between 1) agonistic behavior related to hostile expectations and 2) subordination in relation to not losing social approval with a concomitant triggering of physiological actions linked to each behavioral pattern. For example, in the course of the actual encounter and subsequent ruminative, revivification of the incident, the sympathoadrenal-medullary axis (linked to anger) and the pituitary adrenocortical axis (linked to loss of control/subordination), both of which can foster CAD development or worsen disease status, could be activated (39). Frequent sympathoadrenal-medullary axis reactivity may contribute to endothelial damage and atherosclerotic lesions by means of such factors as high levels of cardiovascular reactivity and circulating catecholamines (45–47). Frequent pituitary adrenocortical axis reactivity could foster atherosclerotic lesions through the effects of cortisol on liberation of free fatty acids and an augmentation of sympathetic nervous system responsiveness (47, 48).

Although the DH males showed, even after statistical adjustment for age, diabetes, and marital status, a significantly greater number of arteries with 50% obstruction, our results must be considered preliminary for a number of reasons. First, our research was conducted in a Veterans Administration Medical Center, which limited our recruitment of women.

Cynical hostility and social defensiveness have been differentially related to cardiovascular activity in men and women. As discussed earlier, Helmers and Krantz (20) found gender to interact with profile type in the prediction of blood pressure measured during baseline and two stressor conditions. Shapiro et al. (29) found that heart rate reactivity covaried with high Ho within low MCSDS men, which was not found for women. The Ho and another measure of defensiveness correlated with higher levels of ambulatory cardiovascular activity in men but were unrelated to ambulatory measures in women (49). Therefore, a necessary step in the evolution of this research is to expand protocols such as ours to include women. Given that women receive CHD diagnoses about 10 years later than men (50), it will be important to examine possible age influences on the associations involving social defensiveness, hostility, and CAD.

Another limitation of the present study pertains to examining a sample of largely white men with suspected CAD. Likewise, the three studies by Helmers et al. (28) reporting an association of DH with severity of CAD evaluated patients with documented or a high probability of CAD. A somatogenic (ie, disease alters psychosocial factors) basis of our results and those presented by Helmers et al. cannot be ruled out. For example, it is possible that a history of vitiated health status and knowledge of greater risk for mortality could elevate cynical hostility and social defensiveness. Additional research is required to assess whether the same pattern of results would emerge in women, nonwhite samples, and persons without diagnosed cardiovascular disease undergoing noninvasive assessments (eg, echocardiography). The retrospective nature of this study limits our ability to differentiate somatogenic from psychogenic factors (ie, psychosocial factors that alter health status). However, like other diseases (eg, primary hypertension), the DH and CAD association is likely to reflect a biopsychosocial synergistic model, whereby factors of environment, constitution, physiology, behavior, affect, and cognition form complex linkages in the development of stress-related cardiovascular diseases (cf, Ref. 2). Longitudinal research is necessary to evaluate the relative strength of somatogenic, psychogenic, and biopsychosocial synergistic influences. Given the above considerations combined with our small sample size, our findings are preliminary. Nevertheless, we believe the findings of this investigation suggest important avenues for future research.

Received for publication October 19, 1999.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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