Much of the data on hostility has come from research by Dr. Redford Williams at Duke University.10 For example, Williams found that those physicians who had had the highest scores on a test of hostility while still in medical school were seven times as likely to have died by the age of fifty as were those with low hostility scores—being prone to anger was a stronger predictor of dying young than were other risk factors such as smoking, high blood pressure, and high cholesterol. And findings by a colleague, Dr. John Barefoot at the University of North Carolina, show that in heart patients undergoing angiography, in which a tube is inserted into the coronary artery to measure lesions, scores on a test of hostility correlate with the extent and severity of coronary artery disease.
Of course, no one is saying that anger alone causes coronary artery disease; it is one of several interacting factors. As Peter Kaufman, acting chief of the Behavioral Medicine Branch of the National Heart, Lung, and Blood Institute, explained to me, "We can't yet sort out whether anger and hostility play a causal role in the early development of coronary artery disease, or whether it intensifies the problem once heart disease has begun, or both. But take a twenty-year-old who repeatedly gets angry. Each episode of anger adds an additional stress to the heart by increasing his heart rate and blood pressure. When that is repeated over and over again, it can do damage," especially because the turbulence of blood flowing through the coronary artery with each heartbeat "can cause microtears in the vessel, where plaque develops. If your heart rate is faster and blood pressure is higher because you're habitually angry, then over thirty years that may lead to a faster buildup of plaque, and so lead to coronary artery disease."11
Once heart disease develops, the mechanisms triggered by anger affect the very efficiency of the heart as a pump, as was shown in the study of angry memories in heart patients. The net effect is to make anger particularly lethal in those who already have heart disease. For instance, a Stanford University Medical School study of 1,012 men and women who suffered from a first heart attack and then were followed for up to eight years showed that those men who were most aggressive and hostile at the outset suffered the highest rate of second heart attacks.12 There were similar results in a Yale School of Medicine study of 929 men who had survived heart attacks and were tracked for up to ten years.13 Those who had been rated as easily roused to anger were three times more likely to die of cardiac arrest than those who were more even-tempered. If they also had high cholesterol levels, the added risk from anger was five times higher.
The Yale researchers point out that it may not be anger alone that heightens the risk of death from heart disease, but rather intense negative emotionality of any kind that regularly sends surges of stress hormones through the body. But overall, the strongest scientific links between emotions and heart disease are to anger: a Harvard Medical School study asked more than fifteen hundred men and women who had suffered heart attacks to describe their emotional state in the hours before the attack. Being angry more than doubled the risk of cardiac arrest in people who already had heart disease; the heightened risk lasted for about two hours after the anger was aroused.14
These findings do not mean that people should try to suppress anger when it is appropriate. Indeed, there is evidence that trying to completely suppress such feelings in the heat of the moment actually results in magnifying the body's agitation and may raise blood pressure.15 On the other hand, as we saw in Chapter 5, the net effect of ventilating anger every time it is felt is simply to feed it, making it a more likely response to any annoying situation. Williams resolves this paradox by concluding that whether anger is expressed or not is less important than whether it is chronic. An occasional display of hostility is not dangerous to health; the problem arises when hostility becomes so constant as to define an antagonistic personal style—one marked by repeated feelings of mistrust and cynicism and the propensity to snide comments and put-downs, as well as more obvious bouts of temper and rage.16
The hopeful news is that chronic anger need not be a death sentence: hostility is a habit that can change. One group of heart-attack patients at Stanford University Medical School was enrolled in a program designed to help them soften the attitudes that gave them a short temper. This anger-control training resulted in a second-heart-attack rate 44 percent lower than for those who had not tried to change their hostility.17 A program designed by Williams has had similar beneficial results.18 Like the Stanford program, it teaches basic elements of emotional intelligence, particularly mindfulness of anger as it begins to stir, the ability to regulate it once it has begun, and empathy. Patients are asked to jot down cynical or hostile thoughts as they notice them. If the thoughts persist, they try to short-circuit them by saying (or thinking), "Stop!" And they are encouraged to purposely substitute reasonable thoughts for cynical, mistrustful ones during trying situations—for instance, if an elevator is delayed, to search for a benign reason rather than harbor anger against some imagined thoughtless person who may be responsible for the delay. For frustrating encounters, they learn the ability to see things from the other person's perspective—empathy is a balm for anger.
As Williams told me, "The antidote to hostility is to develop a more trusting heart. All it takes is the right motivation. When people see that their hostility can lead to an early grave, they are ready to try."
Stress: Anxiety Out of Proportion and Out of Place
I just feel anxious and tense all the time. It all started in high school. I was a straight-A student, and I worried constantly about my grades, whether the other kids and the teachers liked me, being prompt for classes—things like that. There was a lot of pressure from my parents to do well in school and to be a good role model. . . . I guess I just caved in to all that pressure, because my stomach problems began in my sophomore year of high school. Since that time, I've had to be really careful about drinking caffeine and eating spicy meals. I notice that when I'm feeling worried or tense my stomach will flare up, and since I'm usually worried about something, I'm always nauseous.19
Anxiety—the distress evoked by life's pressures—is perhaps the emotion with the greatest weight of scientific evidence connecting it to the onset of sickness and course of recovery. When anxiety helps us prepare to deal with some danger (a presumed utility in evolution), then it has served us well. But in modern life anxiety is more often out of proportion and out of place—distress comes in the face of situations that we must live with or that are conjured by the mind, not real dangers we need to confront. Repeated bouts of anxiety signal high levels of stress. The woman whose constant worrying primes her gastrointestinal trouble is a textbook example of how anxiety and stress exacerbate medical problems.
In a 1993 review in the Archives of Internal Medicine of extensive research on the stress-disease link, Yale psychologist Bruce McEwen noted a broad spectrum of effects: compromising immune function to the point that it can speed the metastasis of cancer; increasing vulnerability to viral infections; exacerbating plaque formation leading to atherosclerosis and blood clotting leading to myocardial infarction; accelerating the onset of Type I diabetes and the course of Type II diabetes; and worsening or triggering an asthma attack.20 Stress can also lead to ulceration of the gastrointestinal tract, triggering symptoms in ulcerative colitis and in inflammatory bowel disease. The brain itself is susceptible to the long-term effects of sustained stress, including damage to the hippocampus, and so to memory. In general, says McEwen, "evidence is mounting that the nervous system is subject to 'wear and tear' as a result of stressful experiences."21