Hostility, anger, and sense of coherence as predictors of health-related quality of life. Results of an ASCOT substudy

Abstract

Objective

The aim of this study was to investigate the relationship of hostility and anger expression to sense of coherence (SOC) and their role as predictors of health-related quality of life (HQL). It was hypothesised that SOC would mediate the impact of hostility and anger on HQL.

Methods

This is a substudy of the Anglo-Scandinavian Cardiac Outcomes Trial, which evaluates different treatment strategies to prevent cardiovascular disease in hypertensive patients. At baseline, SOC was assessed with a short form measure, and hostility–anger with the Cynical Distrust scale and with the Anger Expression scales. HQL was assessed at 6 months with the RAND-36. The sample comprised of 774 subjects (77.5% men).

Results

Results showed that strong SOC associates with ability to control expression of anger and with low levels of suppressed or openly expressed anger. Anger control and SOC were related to good HQL; cynicism, anger-out, and anger-in correlated negatively with HQL. Path models revealed that SOC was the strongest predictor of HQL while hostility and anger lost their direct impact on HQL.

Conclusions

Given the significant associations of hostility and anger with SOC, it is concluded that the salutogenic theory of Antonovsky (A. Antonovsky, Health, Stress, and Coping: New Perspectives on Mental Health and Physical Well-Being, Jossey-Bass Inc, San Francisco, 1979) should be extended to include hostility-related constructs. The impact of hostility and anger on HQL is, to a great extent, mediated through SOC, which implies that in future studies, the role of hostility as a risk factor of ill health should be reconsidered from the SOC theory perspective.

Introduction

One of the most interesting theoretical constructs in psychosomatic research during the last couple of decades has been the sense of coherence (SOC) concept introduced by Antonovsky [1], [2]. SOC has been defined as a global orientation based on a person's pervasive confidence that internal as well as external stimuli are structured and predictable; that the resources needed to meet these demands are available; and that these demands are seen as challenges, worthy of investment, and engagement [2]. Tentative research evidence seems to be accumulating, which supports the main arguments of Antonovsky's theory about SOC as a health promoting, salutogenic factor [3], [4], [5], [6].

However, several questions about the facets of SOC as well as about the possible mediating factors remain to be answered. For example, the SOC construct has been criticised as a purely cognitive theory leaving important determinants of health—such as emotions—outside of the domain of the construct [7]. So far, the main link from SOC to health has been supposed to work through adaptive and flexible coping resources [2]. At the same time, very little empirical research has been accomplished to clarify the relation of SOC with other well-established psychological determinants of health. For example, various facets of hostility and anger have been shown to be risk factors of ill health, the evidence being especially strong for cardiovascular diseases (see, e.g., Refs. [8], [9]).

From that point of view, it is surprising that so little research has been devoted to explore the possible relation of these constructs. For example, in the study by Pallant and Lae [10], the construct validity of SOC was examined by correlating it with a number of indicators of self-reported health and measures of personality and coping, but no measure of hostility or anger was included.

So far, there seems to be only one study, which has directly focused on the joint impact of hostility and SOC on health [5]. In that longitudinal study, self-rated health and records of sickness absences were used as outcome variables. The authors concluded that low SOC might be an important factor partially explaining the adverse effect of hostility on ill health. The main limitations of this study were that it was based on women only, and their measure of hostility was a narrow, three-item scale essentially assessing irritability [5].

Thus, there seems to be an obvious paucity of research into the relation of different facets of hostility and SOC. Even in Antonovsky's key text on SOC, the hostility concept is mentioned in only one sentence (Ref. [2], p. 6) and anger, not even once. Moreover, given that hostility and anger are well-established risk factors of ill health, and high SOC is supposed to be a protective factor, it seems highly interesting to explore in detail how these constructs are interrelated and what is their impact on health and health-related quality of life (HQL).

Considering the psychological theories on anger and hostility together with the SOC construct, it seems logical to expect that they were related: high SOC would probably involve ability to control anger and to express it in a constructive way. At the same time, one could hypothesize that extreme tendency to openly expressed anger, or excess inhibition of anger expression regardless of the actual subjective experience of the emotion, would correlate negatively with strong SOC. Furthermore, the general level of hostile tendencies, as expressed by the cognitive component of hostility, i.e., by high levels of cynicism, could be expected to associate negatively with high SOC (for more thorough discussion on these concepts; see, e.g., [11], [12], [13]). Finally, based on previous results by Kivimäki et al. [5] and Surtees et al. [6], it was hypothesized that SOC would be the key determinant of HQL mediating the impact of hostility- and anger-related factors on HQL, as illustrated schematically in Fig. 1.

In sum, the aim of this study was to investigate the relationships of cynicism and anger expression with SOC and their role as determinants of HQL. Based on the recent findings on gender differences in HQL [14] and in SOC [10], special attention was paid in this study to compare the possibly different correlative patterns of the study variables in men and women.