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Journal of Behavioral Medicine, Vol. 26, No. 5, October 2003 (°

C 2003)

Trait Anger, Anger Expression, and Ambulatory

Blood Pressure: A Meta-Analytic Review
Jennifer L. Schum,1,2 Randall S. Jorgensen,1 Paul Verhaeghen,1
Marie Sauro,1 and Ryan Thibodeau1
Accepted for publication: March 12, 2003

A meta-analysis of 15 studies was conducted to investigate the relationship

between trait anger and ambulatory blood pressure. Overall, the experience of
anger was significantly and positively associated with systolic blood pressure
(r+ = 0.049), but not reliably associated with diastolic blood pressure (r+ =
0.028). After removing an outlier, the expression of anger was found to have a
reliable inverse relationship with diastolic blood pressure (r+ = −0.072). No
reliable relationship between expression of anger and systolic blood pressure
(r+ = −0.041) was found. These results continue to support the modest role of
self-reported trait anger and anger expression in blood pressure levels. Several
suggestions for future research are discussed, including increasing the focus
on the complexity and synergism of these effects.
KEY WORDS: trait anger; anger expression; ambulatory blood pressure; personality.

INTRODUCTION

Researchers have long suspected that trait anger and anger expression
are personality factors associated with the development of hypertension. A
recent meta-analysis by Suls et al. (1995) found that anger experience was
positively associated with higher levels of resting systolic blood pressure.
Elevations of blood pressure observed in clinical and research laboratory

1Department of Psychology and Center for Health and Behavior, Syracuse University, Syracuse,
New York.
2To whom correspondence should be addressed at Department of Psychology, 430 Huntington
Hall, Syracuse, New York 13244.

395

0160-7715/03/1000-0395/0 °
C 2003 Plenum Publishing Corporation
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396 Schum, Jorgensen, Verhaeghen, Sauro, and Thibodeau

contexts are thought to identify individuals who experience recurrent and/or

prolonged elevations in blood pressure in everyday life, a proposed precur-
sor to the development of hypertension (Fredrikson, 1991; Jorgensen et al.,
1996; Kubzansky and Kawachi, 2000; Suls and Wan, 1993). However, re-
search has found blood pressure measurements taken in the clinic and lab-
oratory settings may misrepresent the individual’s daily experience due to
elevations caused by the perceived stress of being in these environments.
This phenomenon, called “white coat hypertension,” raises serious concerns
of whether evidence based on laboratory or clinic values generalizes to the
everyday (Pickering et al., 1994; Pickering and Friedman, 1991).
Because of recent technological advances, researchers are now able
to investigate the association between trait anger and blood pressure in
an individual’s natural setting by using ambulatory blood pressure (ABP)
monitors. By using meta-analytic techniques, this study intended to exam-
ine the strength and consistency of the association between trait anger and
ambulatory blood pressure. The multidimensional nature of trait anger sug-
gested the need to differentiate between the experience and expression of
anger within the analyses (cf. Jorgensen et al., 1996). The results of the meta-
analysis are discussed in light of future research directions.

Personality Theory Linking Trait Anger to High

Blood Pressure: An Overview

The most common theory to explain the relationship between psy-

chosocial factors (e.g., trait anger or anger expression) and increased risk
for hypertension is based on the idea that heightened cardiovascular re-
activity to the environment plays a causal role in the development of hy-
pertension. Cardiovascular reactivity (CVR) refers to the enlarged and/or
recurrent elevations in the magnitude of physiological arousal as measured
using blood pressure, heart rate, etc. (Manuck, 1994; Pickering et al., 1990;
Smith and Christensen, 1992). Normally, as an individual experiences stress,
there is an activation of the sympathetic nervous system and hypothalamic–
pituitary–adrenal–cortical axis system. As a result of this activation, cate-
cholamines (e.g., epinephrine and norepinephrine) and glucocorticoids (e.g.,
cortisol) are released, contributing to rises in blood pressure and heart rate
(Kubzansky and Kawachi, 2000). Although the exact mechanism to explain
the relationship between CVR and high blood pressure (and the subsequent
development of coronary artery disease) is still under debate, research has
focused on the release of catecholamines and glucocorticoids (see Pickering
et al., 1990).
Early research in this field investigated trait anger and whether it was re-
lated to overall increased physiological reactivity (Kubzansky and Kawachi,
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Trait Anger and Ambulatory Blood Pressure 397

2000). These researchers assumed physiological reactivity was a person-

based trait associated with a constellation of emotional, cognitive, and be-
havioral anger reactions. More recently, researchers have suggested that
trait anger may interact with situational factors, thereby causing increased
physiological arousal in certain individuals (Jorgensen et al., 1996). For ex-
ample, a high level of trait anger may affect how an individual perceives
or reacts to an event leading to increased physiological arousal (Smith and
Christensen, 1992). In addition, a transactional model has been proposed,
where a high level of trait anger may lead to the creation of stressful en-
vironments or interactions due to the individual’s thoughts, expectations,
or behaviors (Smith, 1992; Smith and Christensen, 1992). Overall, each of
these theories suggests that trait anger, directly or indirectly, predisposes
individuals to heightened CVR. This CVR may lead to a higher risk for the
development of hypertension (Gerin et al., 2000).

Trait Anger and Ambulatory Blood Pressure

Because the relationship between trait anger and high blood pressure
is hypothesized to depend on CVR, the development of ambulatory blood
pressure monitors extended the capability of researchers in this field by
allowing them to obtain frequent measurements of blood pressure nonin-
vasively, without the confounding influence of a laboratory setting. These
monitors also increased the ability of researchers to investigate the indi-
rect relationship (e.g., transactional model) between trait anger and blood
pressure by allowing researchers to look at individuals’ blood pressure re-
sponses within their natural social environment, eliminating the obstacles of
constructing social stressors within the laboratory. Ambulatory blood pres-
sure monitoring, therefore, provides researchers with more externally valid
evidence regarding an individual’s overall blood pressure reactivity than that
obtained in the laboratory (Pickering et al., 1994).
A common theme among the ambulatory blood pressure research in-
vestigating trait anger is the ambiguity surrounding trait anger’s definition.
Anger has been described as the experience of unpleasant emotion that
ranges in intensity from annoyance to rage. Trait anger refers to the more
stable individual difference to experience anger frequently and intensely
(Miller et al., 1996). The approaches used to measure trait anger vary in
their assessment of the cognitive, affective, and behavioral components of
anger. Another problem adding to the ambiguity is the construct definitions
of trait anger and hostility are often overlapped or used interchangeably
(Spielberger et al., 1983, 1988). Hostility is defined as a stable cognitive
attitude characterized by cynicism and a general lack of trust in others
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398 Schum, Jorgensen, Verhaeghen, Sauro, and Thibodeau

(Raikkonen et al., 1999). Generally, an individual with a high level of hostility

will experience anger more often (Smith and Frohm, 1985). Therefore, hos-
tility can be thought of as a stable cognitive mechanism that triggers anger
(Smith, 1992) that is an integral aspect of trait anger.
Various ambulatory blood pressure studies have been conducted inves-
tigating trait anger and blood pressure, but evidence for a relationship has
been inconsistent. Moreover, the relationship may vary by several moderat-
ing variables (e.g., race, gender). First, several studies have found evidence
supporting a positive association between various dimensions of trait anger
(e.g., anger-in, avoidance, anger arousal, hostility), systolic blood pressure
(Durel et al., 1989; Ewart and Kolodner, 1994; Hogan, 2001; Kornegay, 1998;
Shapiro et al., 1996; Stroup-Benham, 1994), and diastolic blood pressure
(Durel et al., 1989; Ewart and Kolodner, 1994; Helmers et al., 2000; Stroup-
Benham, 1994). However, several of these studies found that this relation-
ship was qualified by the race (Brownley, 1996; Ewart and Kolodner, 1994;
Kornegay, 1998; Shapiro et al., 1996), gender of the participants (Durel et al.,
1989; Guyll and Contrada, 1998; Helmers et al., 2000), type of hostility mea-
sure (subscales of structured interview for Type A behavior vs. Cook–Medley
Hostility questionnaire; Raikkonen et al., 1999), type of blood pressure (i.e.,
systolic or diastolic blood pressure; Benotsch et al., 1997; Durel et al., 1989;
Guyll and Contrada, 1998), and the level of family history of hypertension
(Goldstein and Shapiro, 2000).
In addition, several studies have found that those individuals catego-
rized as having high levels of hostility (using a cutoff score to split into high
vs. low hostile groups) exhibited higher levels of systolic blood pressure
(Benotsch et al., 1997; Brownley, 1996; Goldstein and Shapiro, 2000; Jamner
et al., 1991; Raikkonen et al., 1999) and diastolic blood pressure (Brownley,
1996; Goldstein and Shapiro, 2000; Guyll and Contrada, 1998; Raikkonen
et al., 1999). However, Goldstein and Shapiro (2000) found an inverse rela-
tionship between outward expressed anger (i.e., anger-out) and blood pres-
sure that was moderated by the family history of hypertension. Specifically,
individuals with low levels of anger-out and two parents with hypertension
exhibited the highest systolic and diastolic awake blood pressures. Finally,
other studies have found no relationship between blood pressure and trait
anger (Durel et al., 1989; Friedman et al., 2001), anger-in (Goldstein and
Shapiro, 2000; Hayahsi, 1992; Porter et al., 1999; Williams, 1996), anger-out
(Friedman et al., 2001; Hayashi, 1992; Hogan, 2001; Porter et al., 1999) or
hostility (Friedman et al., 2001; Hayashi, 1992; Hogan, 2001; Lundberg et al.,
1989; Pasic et al., 1994; Rutledge et al., 2000; Shaw, 1998).
Overall, the findings concerning the relationship between trait anger
and blood pressure are mixed. We propose that these inconsistencies could
be solved by refining the definition of trait anger into its affective/cognitive
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Trait Anger and Ambulatory Blood Pressure 399

and behavioral components. Specifically, researchers have, in the past, sep-

arated the measures assessing trait anger into the experience of anger (also
known as neurotic hostility) and expression of anger (also known as antag-
onistic hostility; Miller et al., 1996; Musante et al., 1989; Suls et al., 1995; Suls
and Wan, 1993). The experience of anger can be defined as an individuals’
chronic internal experience of anger, irritation, suspicion, and annoyance.
In contrast, the expression of anger refers to the use of verbal or physical
aggression (Suls et al., 1995). These alternative divisions for trait anger have
been used successfully in several past meta-analyses investigating the rela-
tionships between these dimensions, physical health (Miller et al., 1996), and
laboratory blood pressure (Jorgensen et al., 1996; Suls et al., 1995).

Summary and Objectives

Because of inconsistent findings among studies, a quantitative review

of this literature may help to clarify the relationship between trait anger
and ambulatory blood pressure. The primary purpose of this study was to
conduct a meta-analysis to examine the magnitude and significance of the
effects related to trait anger on ambulatory blood pressure.
For decades, it has been proposed that negative health outcomes, like
hypertension, are related to inhibition of angry feelings, while positive health
outcomes are related to anger expression (Alexander, 1939; Jorgensen et al.,
1996; Suls et al., 1995). The suppression of negative emotions is thought
to induce CVR and, hence, increase the likelihood of hypertension. In view
of the above, we hypothesized that experience of anger would be asso-
ciated with significantly higher levels of systolic and diastolic ambulatory
blood pressure, whereas the expression of anger was expected to be associ-
ated with significantly lower levels of systolic and diastolic ambulatory blood
pressure.

METHODS

Sample of Studies

An automated search of PsycInfo (1967–2001) and Medline (1967–2001)

databases was conducted to find studies using the following keywords: ambu-
latory blood pressure combined with anger and hostility. In addition, articles
and dissertations cited in those sources and the review paper by Carels et al.
(1998) were examined. Only studies published by August 31, 2002 were in-
cluded in the sample.
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400 Schum, Jorgensen, Verhaeghen, Sauro, and Thibodeau

Sample Selection Criteria

To be included in the meta-analysis, studies had to fulfill the following

criteria: (a) the study was published or a doctoral dissertation; (b) written in
English; (c) assessed awake ambulatory blood pressure; (d) contained suf-
ficient information to estimate effect sizes (including sample sizes, descrip-
tion of sample, correlation coefficients or means and standard deviations
of ambulatory blood pressure) or the authors provided this information
by September 31, 2002; (e) used a validated psychometric measure of trait
anger, hostility, or anger expression; (f) the participants in the study were
not on blood pressure medication for at least 2 weeks prior to participating;
(g) the participants were allowed to go through normal daily activities while
assessing ambulatory blood pressure; and (h) sample was not a subset of a
sample within another study.
A total of 28 relevant research articles and dissertations were retrieved
through the search. Eleven studies were not included within the meta-
analysis due to an insufficient amount of information presented in the article
or dissertation. Two studies were not included in the meta-analysis because
the sample used was a subset of a sample within another study also used in
this meta-analysis.

Variables Coded From Each Study

The following information was extracted from each study for primary
analyses and descriptive purposes: (a) year and form of publication;
(b) sample size; (c) gender composition of sample; (d) mean age; (e) race
of participants; (f) hypertension status of participants; (g) occupation of
participant (student, blue collar, white collar, mixed, or unknown); (h) num-
ber of hours ambulatory blood pressure was assessed; (i) type of schedule
for ambulatory blood pressure monitors (random vs. constant); (j) type of
blood pressure assessed (systolic blood pressure, diastolic blood pressure,
both); (k) period blood pressure was taken (sleep, awake); (l) location blood
pressure was taken (work, home); (m) type of trait anger measures used;
(n) whether trait anger was continuous or categorical; (o) if categorical, how
the participants were split into groups (median split, quartiles) and number
of participants in each group; and (p) type of statistical test used. Two raters
separately coded each study to decrease error. Three discrepancies were
found in the coding. Those errors were discussed and resolved.

Anger Dimension Assignment

Because of the multidimensional nature of trait anger, measures used in

the relevant studies were separated into two distinct personality dimensions:
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Trait Anger and Ambulatory Blood Pressure 401

anger expression and anger experience. The eight measures and their sub-
scales included in the meta-analysis were classified into these dimensions by
examining the content of the items on the scale. This procedure of dimension
classification is widely accepted and has been used in other published meta-
analyses (Miller et al., 1996; Suls et al., 1995; Suls and Wan, 1993). Those
scales that contained items that assessed primarily the internal experience
of anger (e.g., irritability, cynicism, frustration, suspicion, and annoyance)
were categorized within the anger experience dimension. Because of the
small number of studies included in this meta-analysis, any measures that
contained a mixture of items were categorized based on what the majority
of items on the scale assessed. The self-report scales assigned to the anger
experience dimension included the Behavioral Anger Response Scale (i.e.,
avoidance subscale; Hogan, 2001), Buss–Durkee Hostility Inventory (i.e.,
overall scale; Buss, 1961), Cook–Medley Hostility scale (i.e., overall scale;
Cook and Medley, 1954), Multidimensional Anger Inventory (i.e., overall
scale, range of anger subscale, hostility subscale, and anger arousal subscale;
Siegal, 1986), Symptom Checklist-90R (i.e., hostility subscale; Derogatis,
1977), Spielberger State Trait Anger Inventory (i.e., trait anger subscale;
Spielberger et al., 1983), and Spielberger’s Anger Expression Inventory (i.e.,
anger-in subscale; Spielberger et al., 1988). In addition, the Structured Inter-
view for Type A behavior (i.e., content hostility and potential for hostility
subscales) is a behavioral measure of hostility included in the experience of
anger dimension (Dembroski and Costa, 1987).
Scales with items that assessed primarily the behavioral component
of anger (i.e., insults, shouting, sarcasm, physically attacking, and covert as-
saulting behaviors) were categorized in the anger expression dimension. The
self-report scales assigned to the expression of anger dimension included the
Behavioral Anger Response Scale (i.e., aggression subscale; Hogan, 2001)
and the Spielberger Anger Expression Inventory (i.e., anger-out subscale;
Spielberger et al., 1988).

Computation of Effect Sizes

The effect size, r , was calculated between each anger dimension and
ambulatory blood pressure using procedures outlined by Hedges and Olkin
(1985). Every effect size was calculated separately for systolic and diastolic
blood pressure. Researchers have stated that it is essential for systolic and
diastolic blood pressure to be investigated independently because they may
react differently (e.g., systolic blood pressure may increase, whereas diastolic
blood pressure may not change), and therefore, not always represent the
same underlying physiological state (Jorgensen et al., 1996). Systolic and
diastolic blood pressure also may have different capacities to predict future
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402 Schum, Jorgensen, Verhaeghen, Sauro, and Thibodeau

cardiovascular events. Specifically, researchers have suggested that systolic

blood pressure is more predictive of morbidity and mortality than diastolic
blood pressure (Applegate, 1989; Pickering, 1982).
For studies that operationalized trait anger as a continuous variable, the
effect size was defined by the correlation between that personality measure
and systolic/diastolic blood pressure. For studies that operationalized trait
anger as a categorical variable, the effect size was derived by transforming the
effect size from the difference in systolic/diastolic blood pressure between
those participants categorized as high and low divided by the pooled standard
deviation as outlined by Hedges and Olkin (1985).

Multiple Effect Sizes From Single Studies

An important statistical assumption is the independence of effect sizes

because lack of independence can increase Type 1 error rate (Hedges and
Olkin, 1985). Every study included information to calculate multiple effect
sizes due to one or more of the following reasons: (a) separating mean levels
of blood pressure by location (e.g., home, work); (b) separating mean levels
of blood pressure by posture (e.g., sit, stand); or (c) using several measures
to assess a given personality dimension (e.g., Cook–Medley Hostility Scale,
Potential for Hostility from Structured Interview for Type A Behavior).
Therefore, effect sizes within studies with multiple measures of anger were
averaged to yield one single effect size per study. Several studies reported
multiple effect sizes with sample sizes that differed by less than five partici-
pants; those multiple effects were averaged within each of those studies and
the average sample size was used in the meta-analysis.

Analysis of Effect Sizes

The analysis of the effect sizes followed the procedures outlined by

Hedges and Olkin (1985). Studies were analyzed separately for two different
outcome variables: systolic blood pressure and diastolic blood pressure.
First, the mean weighted correlation coefficient (r+ ) was calculated,
where each effect size was weighted as a function of sample size. To test
whether the mean weighted correlation coefficient differed significantly from
zero, 95% confidence intervals around r+ were calculated. It was concluded
that the effect size was significantly greater than zero if the 95% confidence
interval did not include zero.
In addition, the homogeneity statistic (QT ) was calculated to test
whether the variation around the mean weighted correlation coefficient was
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Trait Anger and Ambulatory Blood Pressure 403

homogeneous. Homogeneity can be considered an indication that r+ was

a true estimate of the population correlation. Since the QT is chi-squared
distributed with degrees of freedom, k − 1 (k = number of independent ef-
fect sizes from which r+ is calculated), a QT that exceeds this critical value
indicates that the variation is nonhomogeneous.

RESULTS

A total of 15 research articles were included in this meta-analysis. All

of the studies were published within the last 10 years. Participants ranged
in age from 14 to 65 years old. Studies typically included both males and
females with a majority of participants being Caucasian. Most of the studies
measured ambulatory blood pressure at approximately 20 min intervals over
a period of 8–24 h. Table I lists the different coded characteristics recorded
from each study included within the meta-analysis.

Primary Analysis

Tables II and III list the individual effect sizes for each study included
when investigating the effect of the experience and expression of anger on
systolic and diastolic blood pressure, respectively.

Experience of Anger

The mean weighted correlation between experience of anger and sys-

tolic blood pressure (r+ = 0.049) was significantly different from zero, 95%
CI ranging from 0.0064 to 0.092. In addition, there was homogeneity among
these studies, QT (df = 29) = 33.50, p > 0.05.
For diastolic blood pressure, there was no significant relationship be-
tween experience of anger and diastolic blood pressure (r+ = 0.028, 95%
CI ranging from −0.018 to 0.074). These data showed the effect sizes were
homogeneous, QT (df = 23) = 13.16, p > 0.05.

Expression of Anger

The mean weighted correlation’s between the expression of anger, sys-

tolic blood pressure (r+ = −0.035), and diastolic blood pressure (r+ =
−0.041) were both not significantly different from zero (95% CI ranging
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Table I. The Variables Coded for Each Study Included Within the Meta-Analysis

No. No. of Personality ABP ABP

No. African No. Age hypertensive Type of trait categorical length timing ABP
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Authors Year N females American Caucasian range participants participants vs. continuous (h) (min) scheduling

Benotsch et al. 1997 48 24 18–25 0 Students Categorical 9 20 Random

Brownley 1996 129 62 57 72 19–47 0 Adults Categorical 12 15 Random
Durel et al. 1989 135 54 72 63 25–44 46 Adults Continuous 12 20 Nonrandom
Ewart and Kolodner 1994 228 114 137 94 0 High school Continuous 6 10 Nonrandom
students
Friedman et al. 2001 283 0 30–60 84 Adults Continuous 24 15 Nonrandom
Goldstein and Shapiro 2000 203 203 28 118 24–50 0 Nurses Categorical 96 20 Random
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Guyll and Contrada 1998 79 39 4 67 0 Students Categorical 11.7 20 Random

community

404
Hayashi 1992 161 71 48 113 25–54 0 Adults Continuous 13 20 Random
community
Hogan 2001 158 68 158 Adults Continuous 24 20 Nonrandom
Pasic et al. 1994 42 19 7 28 35–65 42 Patients Continuous 24 20 Nonrandom
community
August 28, 2003

Polk et al. 2002 120 64 60 60 23–50 0 Adults Continuous 60 45 Nonrandom

Raikkonen et al. 1999 100 50 10 88 30–45 0 Technical/ Categorical 36 20 Nonrandom
21:7

clerical
Rutledge et al. 2000 329 172 0 230 0 Students Continuous 10 20 Nonrandom
community
Shapiro et al. 1996 144 71 58 86 0 Students Continuous 24 20 Random
Shapiro et al. 1993 54 15 0 44 19–44 0 Paramedic Categorical 92 15 Random

Note. ABP = Ambulatory blood pressure monitoring.

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Table II. Averaged Correlations for Each Study Included When Analyzing Trait Anger Effects on Systolic Blood Pressure

Anger dimension and authors Outcome measures Multiple indicatorsa Nb Gender Race r

Experience of Anger
Benotsch et al. (1997) Cook–Medley Hostility Scale 24 M 0.348
24 F 0.208
Brownley (1996) Multidimensional Anger 35 F C 0.216
Inventory (Hostility subscale)
27 F A −0.077
37 M C 0.219
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30 M A −0.501
Durel et al. (1989) Spielberger Trait Anger Inventory Measures 131 M/F 0.125
(anger-in subscale), Cook–Medley
Hostility Inventory
Ewart and Kolodner (1994) Modified Multidimensional Measures 70 F A 0.051
Anger Inventory—Range of
Anger and Anger Arousal subscales
44 F C −0.041
Trait Anger and Ambulatory Blood Pressure

67 M A −0.005
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Friedman et al. (2001)
Goldstein and Shapiro (2000)
47 M C 0.178
Spielberger Anger Expression Measures 248.3 M 0.003
Scale (anger-in subscale),
Spielberger Trait Anger
Inventory, Symptom Checklist
90-R Hostility Subscale
Cook–Medley Hostility Scale Location 203 F 0.035
August 28, 2003

Guyll and Contrada (1998) Cook–Medley Hostility Scale Posture 32 M 0.033

31 F 0.074
21:7

Hayashi (1992)c Spielberger Anger Expression Scale Measures 60 M C −0.065

(anger-in subscale)/Cook–Medley
Hostility Scale
23 M A −0.090
44 F C −0.020
15 F A −0.050
Hogan (2001) Behavioral Anger Response Measures 90 M −0.015
Questionnaire (Avoidance subscale),
Cook–Medley Hostility Scale
405

68 F 0.114
Pasic et al. (1994) Buss–Durkee Hostility Inventory 35 M/F 0.265
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Table II. Continued

Anger dimension and authors Outcome measures Multiple indicatorsa Nb Gender Race r
406

Polk et al. (2002) Buss–Durkee Hostility Inventory/ Measures 29.5 M C 0.201

Cook–Medley Hostility Scale
27 M A 0.146
29.5 F C −0.250
31.5 F A 0.191
Raikkonen et al. (1999) 13-item Cook–Medley Hostility Measures 100 M/F 0.152
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Scale/Structured Interview for

Type A behavior (Content and
Potential for Hostility subscales)
Rutledge et al. (2000) Spielberger Anger Expression Scale Measures 329 M/F −0.025
(anger-in subscale)/Cook–Medley
Hostility Scale
Shapiro et al. (1996) Cook–Medley Hostility Scale 57 M/F A 0.350
85 M/F C 0.120
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Expression of Anger
Friedman et al. (2001) Spielberger Anger Expression 249 M −0.060
Scale (anger-out subscale)
Goldstein and Shapiro (2000) Spielberger Anger Expression Location 201 F −0.017
Scale (anger-out subscale)
Hayashi (1992)c Spielberger Anger Expression 60 M C −0.040
Scale (anger-out subscale)
August 28, 2003

23 M A 0.130
44 F C −0.090
15 F A
21:7

−0.220
Hogan (2001) Behavioral Anger Response 90 M −0.120
Scale (Aggression subscale)
68 F −0.120
Rutledge et al. (2000) Spielberger Anger Expression 329 M/F −0.050
Scale (anger-out subscale)
Shapiro et al. (1993) Spielberger Anger Expression Location 53 M/F 0.369
Scale (anger-out subscale)

Note. M = male; F = female; A = African American; C = Caucasian.

Schum, Jorgensen, Verhaeghen, Sauro, and Thibodeau

a Effect sizes were averaged across the multiple indicators.

b The average value of N was used when sample sizes for multiple effect sizes differed by less than five participants.
c Only used home values of blood pressure.
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Table III. Averaged Correlations for Each Study Included When Analyzing Trait Anger Effects on Diastolic Blood Pressure

Anger dimension and authors Outcome measure Multiple indicatorsa Nb Gender Race r

Experience of Anger
Benotsch et al. (1997) Cook–Medley Hostility Scale 24 M 0.035
24 F 0.042
Durel et al. (1989) Spielberger Trait Anger Inventory Measures 131 M/F 0.120
(anger-in subscale)/Modified
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Cook–Medley
Ewart and Kolodner (1994) Modified Multidimensional Measures 70 F A 0.010
Anger Inventory—Range of
Anger and Anger Arousal
subscales
44 F C 0.115
67 M A 0.144
47 M C 0.282
Trait Anger and Ambulatory Blood Pressure

Friedman et al. (2001) Spielberger Anger Expression Measures 249.7 M −0.016

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Scale (anger-in subscale),

Goldstein and Shapiro (2000)
Guyll and Contrada (1998)
Hayashi (1992)c
Spielberger Trait Anger
Inventory, Symptom Checklist
90-R Hostility Subscale
Cook–Medley Hostility Scale 203 F −0.007
Cook–Medley Questionnaire 32 M 0.09
Spielberger Anger Expression Measures 60 M C −0.131
August 28, 2003

Scale (anger-in subscale),

Cook–Medley Hostility Scale
21:7

23 M A −0.087
44 F C −0.075
15 F A 0.105
Hogan (2001) Behavioral Anger Response Measures 90 M 0.015
Questionnaire (Avoidance
subscale), Cook–Medley
Hostility Questionnaire
68 F 0.106
Pasic et al. (1994) Buss–Durkee Hostility Inventory 35 M/F 0.227
407
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Table III. Continued 408

Anger dimension and authors Outcome measure Multiple indicatorsa Nb Gender Race r

Polk et al. (2002) Buss–Durkee Hostility Measures 29.5 M C 0.096

Inventory/Cook–Medley
Hostility Scale
27 M A 0.142
29.5 F C −0.060
Journal of Behavioral Medicine [jobm]

31.5 F A 0.223
Raikkonen et al. (1999) 13-item Cook–Medley Hostility Measures 100 M/F 0.027
Scale/Structured Interview for
Type A Behavior (Content and
Potential for Hostility subscales)
Rutledge et al. (2000) Spielberger Anger Expression Measures 329 M/F −0.030
Scale (anger-in subscale)/
Cook–Medley Hostility Scale
Expression of Anger
pp949-jobm-470706

Friedman et al. (2001) Spielberger Anger Expression 249 M −0.109

Scale (anger-out subscale)
Goldstein and Shapiro (2000) Spielberger Anger Expression 201 F −0.013
Scale (anger-out subscale)
Hayashi (1992)c Spielberger Anger Expression 60 M C −0.050
Scale (anger-out subscale)
23 M A 0.080
August 28, 2003

44 F C −0.170
15 F A −0.130
21:7

Hogan (2001) Behavioral Anger Response 90 M −0.040

Inventory (Aggression subscale)
68 F −0.100
Rutledge et al. (2000) Spielberger Anger Expression 329 M/F −0.080
Scale (anger-out subscale)
Shapiro et al. (1993) Spielberger Anger Expression 53 M/F 0.541
Scale (anger-out subscale)

Note. M = male; F = female; A = African American; C = Caucasian.

a Effect sizes were averaged across the multiple indicators.
Schum, Jorgensen, Verhaeghen, Sauro, and Thibodeau

b The average value of N was used when sample sizes for multiple effect sizes differed by less than five participants.
c Only used home values of blood pressure.
Style file version Feb 25, 2000
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Trait Anger and Ambulatory Blood Pressure 409

from −0.093 to 0.024, 95% CI ranging from −0.099 to 0.017, respectively).

There was homogeneity among studies measuring systolic blood pressure
(QT (df = 9) = 11.42, p > 0.05); however, there was heterogeneity among
studies measuring diastolic blood pressure (QT (df = 9) = 24.04, p < 0.05)
indicating considerable variability among the effect sizes.
Upon further visual inspection of Table III, one effect size (r = 0.54)
seemed to be contributing to a majority of the heterogeneity in the effect sizes
among studies measuring diastolic blood pressure as compared to the other
studies. Disjoint cluster analysis (Hedges and Olkin, 1985) indicated that the
identified effect size (r = 0.54), and only this effect size, was significantly
disjoint from the others ( p < 0.05). The only unique component of the
Shapiro et al. (1993) study that may explain the magnitude of this effect
size is that the participants in this study, as compared to the other studies,
were paramedics. They wore the ambulatory blood pressure monitor during
3 workdays and 1 nonworkday. These participants have an unusual work
environment, which may explain the difference in the observed effect size.
After removing that effect size from the analyses, the mean weighted
correlation between expression of anger and diastolic blood pressure (r+ =
−0.072) was significantly different from zero, 95% CI ranging from −0.012
to −0.131. In addition, there was homogeneity among these studies, QT
(df = 8) = 2.14, p > 0.05.

DISCUSSION

Over the last several decades, personality variables have emerged as

possible contributors to the development of hypertension and subsequently
coronary artery disease. This meta-analysis was conducted to investigate
the individual strength and consistency of trait anger on ambulatory blood
pressure.
As expected, this study found that the internal experience of anger was
positively related to systolic blood pressure, but not diastolic blood pressure.
However, the expression of anger was found to be inversely related to di-
astolic blood pressure, but not systolic blood pressure. These findings are in
partial agreement with the meta-analytic results of Suls et al. (1995), which
indicated that the expression of anger was negatively associated with labo-
ratory resting systolic blood pressure and experiential anger was positively
related to laboratory resting systolic and diastolic blood pressure.

Potential Impact on Public Health

Although the magnitude of the overall effects seems quite modest

(|r+ | < 0.07), it is similar to the effect sizes found in other meta-analyses
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410 Schum, Jorgensen, Verhaeghen, Sauro, and Thibodeau

investigating the relationship between anger (Suls et al., 1995), negative af-
fect (Jorgensen et al., 1996), and laboratory/clinic blood pressure. In addition,
these effect sizes are only slightly smaller than those reported on traditional
risk factors (i.e., smoking, elevated serum cholesterol) for coronary artery
disease (Review Panel on Coronary-Prone Behavior and Coronary Heart
Disease, 1978). Even though this effect appears modest, even small effect
sizes have been considered important for public health. For instance, the
effect of aspirin on reducing risk of heart attack has long been supported as
a worthwhile treatment, although the actual effect size is 0.034 (Rosenthal,
1990). Therefore, even small effect sizes may indicate that personality con-
tributes to the development of diseases of the cardiovascular system in some
cases (Booth-Kewley and Friedman, 1987).

Methodological Limitations

It should be noted that the small size of the effect found in this meta-
analysis might be partially due to several methodological limitations of the
included studies and the meta-analysis itself.

Personality Measures

As mentioned in the review, the constructs of anger and hostility often

overlap. Therefore, there is a lot of ambiguity surrounding the definitions and
the different cognitive, affective, and behavioral components of anger and
hostility. In this meta-analysis, measures assessing anger and hostility were
divided into those assessing the internal experience of anger and the expres-
sion of anger. However, several measures contained a mixture of items. For
example, the overall score obtained from the Buss Durkee Hostility Inven-
tory contains a mixture of items assessing the experience and expression of
anger. Research may benefit from the selection of measures that assesses
these constructs in a more clear and distinct way. Additionally, more con-
cern should be placed on investigating the factor structure associated with
the specific measure. For example, the Cook–Medley Hostility scale is widely
used within this literature to assess hostility, yet research has found that it has
a poorly defined internal structure (Contrada and Jussim, 1992). These prob-
lems may have indirectly compromised the integrity of the statistics investi-
gating the relationship between trait anger and ambulatory blood pressure.
In the future, research may benefit from the use of anger measures (e.g.,
Spielberger Anger Expression Inventory) that have more clearly defined
factor structures. In addition, the use of more behavioral based measures
may enhance the predictability of anger (see Jorgensen et al., 1996).
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Trait Anger and Ambulatory Blood Pressure 411

Participant Demographics

Since hypertension is clearly influenced by other risk factors, apart from

trait anger, studies should take into account these factors. For example, re-
search has found that premenopausal women show a lower risk for hyper-
tension (Saab, 1989). In addition, researchers have found higher levels of
ambulatory blood pressure in men as compared to women (De Guademaris
et al., 1987). However, only 5 of the 15 ambulatory blood pressure studies
separated their analyses by gender or included both genders. In addition,
research has shown that African Americans have a higher risk for develop-
ing hypertension in comparison to other racial/ethnic groups in the United
States (Myers and McClure, 1993). However, only 3 of the 15 ambulatory
blood pressure studies separated their analyses by race.
Finally, participant’s family history of hypertension may also be impor-
tant to consider when investigating blood pressure reactivity due to genetic
influences. A meta-analysis performed by Fredrikson and Matthews (1990)
found that individuals with hypertensive parents exhibited elevated systolic
blood pressure, as compared to individuals without a familial history of hy-
pertension, to all laboratory stressors. In addition, Fredrikson et al. (1991)
found that those individuals with a history of parental hypertension exhib-
ited higher levels of ambulatory systolic and diastolic blood pressure.
Hypertension is a complex disease with multiple risk factors, and these
factors may moderate or contribute to the relationship between personality
and blood pressure. It is therefore important for researchers to include rele-
vant information on these factors when investigating the effect of personality
on ambulatory blood pressure.

Methodology of Ambulatory Blood Pressure Monitoring

Because the technology that allows researchers to use ambulatory meth-

ods is relatively new, the methods of assessing blood pressure have not been
consistent. For instance, studies have found that posture affects blood pres-
sure, such that as an individual stands their blood pressure increases as com-
pared to sitting (Jorde and Williams, 1986). Gellman et al. (1990) conducted a
study investigating the effect of posture on ambulatory blood pressure mon-
itoring and found that posture accounted for 33% of within-subject variance
in systolic blood pressure and 47% in diastolic blood pressure. Similarly,
Jorde and Williams (1996) found that blood pressure increased when indi-
viduals changed their posture from sitting to standing.
This meta-analysis did not investigate the effects of posture due to the
small literature base. However, the above studies suggest that posture is
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412 Schum, Jorgensen, Verhaeghen, Sauro, and Thibodeau

an important variable to assess while measuring ambulatory blood pres-

sure. With the development of new statistical methodologies in longitudinal
analysis (e.g. hierarchical mixed modeling), it is possible for researchers to
incorporate posture within their analyses to increase the validity of their
results.

File Drawer Phenomenon

One common limitation of meta-analyses is publication bias, where

studies with nonsignificant results may not be published and therefore are
not included in the meta-analysis. This may limit the results of this study.

Biopsychosocial Synergism

The relationship between trait anger and ambulatory blood pressure is

not straightforward. In fact, Ewart (1991) criticized the field for relying on
global trait self-report measures that do not allow the researcher to capture
the situational components that may be the root of the relationship between
trait anger and elevated blood pressure. Situational factors may not be the
only potential moderator, but other factors (e.g., contextual affect) may
help better explain this relationship between trait anger and elevated blood
pressure.
After conducting a meta-analysis investigating personality effects on
laboratory/clinic blood pressure, Jorgensen et al. (1996) suggested that re-
search needed to move towards a more sophisticated model of personality
effects on blood pressure. This model includes the simultaneous bidirec-
tional relationships between biological and psychological risk factors. This
is a model that researchers can use to help guide the methodology of future
studies to incorporate these complex effects.

Summary

In summary, this quantitative review provided a unique glimpse of the

magnitude and direction of the relationship between trait anger and am-
bulatory blood pressure. We found that trait anger plays a role in elevated
blood pressure levels observed throughout the day. The magnitude of the
associations between trait anger and elevated blood pressure identified the
need for future research to pay attention to the multifaceted nature of fac-
tors that contribute to blood pressure elevation in the natural environment.
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Trait Anger and Ambulatory Blood Pressure 413

Specifically, this review recommends that researchers increase their atten-

tion to the conceptual and measurement choices they make when conducting
ambulatory blood pressure studies in the future. Additionally, more consis-
tent methodology surrounding the use of ambulatory blood pressure moni-
toring is needed to move the literature forward.
Given the prevalence of hypertension and its significant contribution to
cardiovascular disease, it is important to understand whether trait anger may
be a potential risk factor for hypertension. Identification of personality fac-
tors implicated in hypertension is important because appropriate prevention
strategies can be targeted at individuals at-risk for cardiovascular disease to
reduce morbidity and mortality.

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