Expressive/Suppressive Anger-Coping Responses, Gender, and Types of Mortality: a 17-Year Follow-Up (Tecumseh, Michigan, 1971–1988) ERNEST HARBURG,PHD, MARA JULIUS,SCD, NIKO KACIROTI,PHD, LILLIAN GLEIBERMAN,PHD, AND M. ANTHONY SCHORK,PHD Objectives: This study examined prospectively (1971–1988) the relationship between anger-coping responses, gender, and mortality (N = 91) in a representative sample of men (N = 324) and women (N = 372), aged 30 to 69, from the Tecumseh Community Health Study. Methods: Anger-coping was measured by responses to hypothetical unfair anger-provoking situations. Cox proportional hazard regressions were used adjusted for seven health risk factors (age, smoking, relative weight, systolic blood pressure (SBP), bronchial problems, FEV 1 , and cardiovascular (CV) risk). Results: Men’s suppressed anger interacted significantly with SBP and also with bronchial problems to predict both all-cause and CV mortality. Women showed direct relationships between suppressed anger and early mortality (all-cause, CV, and cancer). Women also showed an interaction of spouse-suppressed anger and SBP for all-cause and CV mortality. Data suggest men who expressed their anger died earlier of cancer (N = 16) deaths. Conclusions: Suppressed anger at the time of an unjust attack may become chronic resentment (intermittent rage or hatred) about which little is known and requires research. The design for future research should experimentally measure both suppressed anger-coping responses (after an unfair attack) and morbidity (eg, blood pressure, bronchitis, immune disorder, etc.) to predict prospectively to earlier mortality. Key words: anger, blood pressure, cancer, gender, mortality. CV = cardiovascular; FEV 1 = forced expiratory volume in 1 sec- ond; LCES = Life Change Events Study; SBP = systolic blood pressure; TCHS = Tecumseh Community Health Study. INTRODUCTION A long-standing hypothesis suggests a relationship between anger-hostility and cardiovascular (CV) morbidity or mortality; recent reviews have reexamined the evidence (1–3). This study examines the associations among anger-coping responses, gender, morbidity, and types of mortality (all- cause, CV, and cancer) and is a follow-up to a prior report (4) which could not examine the effects of gender or type of mortality because the total number of deaths was too few to be stratified by gender or type of mortality at that time. A literature search using MEDLINE (1966 –2002) showed 169,478 journal articles with the keyword “mortality;” for “mortality and anger” the number dropped to 54; for “mortal- ity, anger, and gender” the list included two “hits;” however, these two studies did not obtain mortality data and were not prospective. There is no scientific agreement about the definition of anger; anger involves multidisciplinary knowledge and seems to result in more CV reactivity to imagery and exercise tests than happiness, sadness, or fear (5). Few prospective studies have used measures of “anger” as distinct from “hostility” (6, 7). Heuristic distinctions among “hostility,” “anger,” and “ag- gression” by psychologists are proposed by Smith (6). Hos- tility is defined as “a set of negative attitudes, beliefs, and appraisals concerning others...and connotes a view of others as frequent and likely sources of mistreatment, frustration, and provocation.” Anger refers to an “emotion ranging in intensity from irritation to rage, usually in response to perceived mis- treatment or provocation...and can be seen as both an emo- tional state and an enduring personality trait.” Aggression refers to “overt behavior...typically defined as attacking, de- structive, or hurtful actions.” The focus in this article is on anger-coping responses to an imagined unfair aggressive verbal attack. Our heuristic thesis is that psychophysiological anger responses (including hostil- ity) are automatically induced in unjust attack situations. An “attack” exists when a person appraises (8) an actual loss or a threat of loss of something believed to be owned or possessed (one’s rights, health, status, etc.) through perceived arbitrary (unfair or unjust) action by others (person, group, society) or often by natural events (eg, accidents, death of others). When the attack is sudden and the owned object is strongly valued, then anger will be quick and intense. If these assumptions are valid, then anger-coping responses to an anger-inducing attack can be minimally modeled as either overtly “expressive” or “suppressive” of that anger to the attacker. Alternative mea- sures of anger-coping modes were developed after our base- line measure in 1971 (9 –11). The concept of suppressed anger has a long history (12– 14). Our use of the term “suppressed” comes explicitly from Newcomb (15) who conceived that suppression (a semicon- scious process) can be observed by what is omitted in struc- tured communication and interaction; we would add “after structured provocation.” Other studies on cardiovascular out- comes have used the concept of suppressed anger (conceived and measured in different ways), both in multiyear prospective research (16 –18) and in survival after experimental studies (19 –20). Besides the studies just cited relating suppressed anger and hypertension, other research has related suppressed anger to rheumatoid arthritis (21), breast cancer (22), and duodenal ulcers (23). These studies allow us to assume that chronic suppressed anger exacerbates a variety of potential or existent pathologic medical conditions and thus eventually leads to early mortality. The precise process of how this exacerbation “interacts” with medical disorders is yet un- known (24). This conceptual framework was used to construct a dichot- omous measure of anger-coping responses based partially on From the Department of Epidemiology, School of Public Health (E.H., M.J.), Biostatistics, School of Public Health (M.A.S.), Psychology (E.H.), Internal Medicine (L.G.), and the Center for Human Growth and Develop- ment (N.K.), University of Michigan, Ann Arbor, Michigan. Address reprint requests to: Ernest Harburg, PhD, 240 East 10th Street, #9B, New York, NY 10003–7702. Email: ernie@harburgfoundation.org Received for publication February 24, 2002; revision received October 4, 2002. DOI: 10.1097/01.PSY.0000075974.19706.3B 588 Psychosomatic Medicine 65:588 –597 (2003) 0033-3174/03/6504-0588 Copyright © 2003 by the American Psychosomatic Society