The Cardiovascular Effects of Defensiveness

What is Defensiveness and how is it assessed?

Defensiveness has been defined as a coping style characterized by an orientation away from threatening information and a denial or minimization of distress and negative emotions (Jamner et al., 1991). The standard measure of defensiveness is the Marlow-Crowne scale, or the MCSD (Crowne and Marlowe, 1960). Persons scoring high on this scale appear to underreport, deny, or suppress negative emotions such as anxiety and anger (Shapiro et al., 1995).

Previous research has found high scores on the MCSD to represent a defensive or self-deceptive response style which involves avoidance of anxiety-arousing cognitions (Weinberger, 1990; Walsh, 1990; Nicholson and Hogan, 1990; Paulhus, 1984; McCrae and Costa, 1983). High scores on the MCSD have also been shown to be reflective of the individual’s attention to the possibility that the revelation of anxiety-arousing cognitions might threaten social approval (Paulhus, 1984).

Defensiveness and High Blood Pressure

Studies have commonly investigated the relationship between defensiveness and cardiovascular reactivity in combination with other suspected coronary-prone behaviors and characteristics, such as anxiety and anger. High scores on the MCSD, either alone or in combination with low scores of trait anxiety or anger, have been found to be associated with increased blood pressure(BP) and heart rate reactivity to laboratory stressors in both clinical (Warrenburg, et al., 1989) and nonclinical populations (King et al., 1990; Weinberger et al., 1979). These effects were found to be independent of gender and other cardiac risk factors, e.g., weight and smoking history (King et al., 1990).

Defensiveness has also been heavily studied in combination with cynical hostility. Levels of cynical hostility are assessed by scores on the Cook-Medley Ho Scale (Cook and Medley, 1954), and have been shown to predict increased BP reactivity in situations that elicit high interpersonal conflict or suspiciousness and mistrust (Hardy and Smith, 1988; Suarez & Williams, 1989; Weidner et al., 1989). Cynical hostility has been identified as a significant risk factor for coronary heart disease (Barefoot et al., 1983; Barefoot et al., 1989; Williams, 1987), as well as for severity of coronary and peripheral artery disease (Joesoef et al., 1989; Williams et al., 1980).

When reconsidering the definition of defensiveness as assessed by the MCSD, it is evident that denial of anger and hostility occurring in highly defensive individuals may be related to the concept of unexpressed or inhibited anger/hostility, which has been shown to be a risk factor for hypertension and cardiovascular disease processes (Jamner et al., 1991). A number of studies have shown an association between unexpressed anger/hostility and exaggerated cardiovascular stress responses among hypertensives, particularly if the task involves some form of anger provocation (Diamond, 1982; Goldstein, 1981). Not surprisingly when considering that assessments of defensiveness generally taps suppression of anger/hostility, defensiveness has been shown to be negatively associated with cynical hostility (Smith and Frohm, 1985).

These inter-relationships between defensiveness, denial of anger/hostility, and exaggerated cardiovascular reactivity (CVR) have led to studies investigating whether defensiveness acts as a moderating variable in the cynical hostility-BP reactivity association that has been observed in situations that elicit high interpersonal conflict or mistrust (Jamner et al., 1991). Previous research on ambulatory blood pressure and heart rate has been predominantly studied using sample populations of paramedics in work situations (Shapiro et al., 1995).The hypothesis was that those individuals that were high in both cynical hostility and defensiveness would be subject to the most exaggerated CVR. These individuals were theorized to be in an approach-avoidance conflict in which they are both suspicious and mistrusting of others while at the same time looking to others for social approval (Jamner et al., 1991). It was also expected that such conflicting attitudes would most affect cardiovascular functioning in situations that elicit hostility and angry reactions (Engebretson et al., 1989; King and Emmons, 1990). Results from Jamner et al. , 1991, confirmed expectations in that the relationship between cynical hostility and cardiovascular response was improved by taking defensiveness into account. Furthermore, increased levels of diastolic blood pressure and heart rate were even more pronounced for the subgroup of the subjects high in both cynical hostility and defensiveness that also were in a challenging work context, the hospital setting, as opposed to lower stress situations, the station or post (Shapiro et al., 1995). These findings by Jamner et al., 1991, and similar studies such as Shapiro et al., 1993), provide support for the hypothesis that defensiveness leads to increased blood pressure and heart rate when adequate levels of cynical hostility are present to create ambivalence and conflict over the expression of hostility (Shapiro et al., 1995).

Although few null findings exist to conflict these findings, the lack of generalizability of these findings make the conclusion that defensiveness is significantly associated with sustained elevated blood pressure premature. However, a recent meta-analytic review (Jorgensen et al., 1996) examining the relationship between elevated blood pressure and personality has provided stronger evidence that defensiveness may indeed be associated with increased blood pressure in the general population. 19 relevant study effect sizes from 13 separate studies that investigated the relationship between the trait of defensiveness and blood pressure (BP) or essential hypertension (EH) were included in the meta-analysis. The trait of defensiveness was identified by studies involving either defensiveness, denial, repressive coping, etc. Separate meta-analyses were performed on two other trait types, negative affectivity and anger-affect expression. The trait of negative affectivity included studies examining associations between BP and feelings of anxiety-tension, anger-hostility, depression, or neuroticism. The trait of anger-affect expression included studies investigating the relationship between BP and anger-in-out, assertiveness, expressed-suppressed anger, social competence, or submissiveness. The strongest association with higher BP was higher defensiveness (95% for di+ was 0.27-0.51, p<.05). Although their analyses suggest that defensiveness in the most robust predictor of high BP, the mean weighted effect size for defensiveness is based on fewer studies than the other traits. Additional studies are needed to examine whether this association persists with a more diverse set of samples, varying in such important dimensions as awareness, age, and race (Jorgensen et al., 1996).

Possible Interactions between Job stress and Defensiveness and Effects on Blood Pressure

Job stress is considered to be a primary cause of hypertension and cardiovascular disease (Schnall et al., 1990). Work conditions are particularly stressful if they are characterized by being both psychologically demanding and having low decision latitude, or in other words, high in “job strain.” (Karasek, 1982). BP at work is definitely higher in high job strain occupations (Theorell et al., 1985; Shapiro et al. ,1994). Five out of nine studies which have studied the relationship between job strain and ambulatory blood pressure found significant positive correlations, while the remaining four yielded a mixture of insignificantly positive and null results (Schnall et al., 1994). Not included in the review by Schnall et al., 1994 was Landsbergis et al.’s 1994 study. Landsbergis et al., 1994 found employees experiencing job strain had a systolic BP that was 6.7 mm Hg higher and a diastolic blood pressure that was 2.7 mm Hg higher at work than other employees, and that the odds of hypertension were also increased (odds ratio = 2.9, 95% CI).

In the studies previously mentioned that investigated the relationships between cynical hostility, defensiveness, and CVR in paramedics, job stress appears to play an important role in determining blood pressure levels. Increased levels of diastolic blood pressure and heart rate were even more pronounced for those subjects high in both cynical hostility and defensiveness that also were in a challenging work context, the hospital setting, as opposed to lower stress situations, the station or post (Shapiro et al., 1995). It had been also been hypothesized that situations which elicit hostility and angry reactions would have a greater affect on CVR. So, one possible explanation is that the work setting elicited more hostility and anger reactions, which in turn increased diastolic BP and heart rate levels. However, it has not yet been studied what is specifically responsible for this increased CVR among the paramedics in the high stress work setting as opposed to the lower stress work settings. There have been no studies investigating whether job strain is responsible for the strengthened defensiveness-cynical hostility-CVR association seen in the higher stress, hospital setting. Future studies are needed to learn what effects varying levels of job strain would have on CVR in those subjects high in both cynical hostility and defensiveness.

Determinants of Defensiveness

There has been remarkably little research on the determinants of defensiveness, particularly social class and job stress. Such factors might shape personality development in childhood. For example, certain parental behavior patterns (i.e., overly strict, critical and demanding of conformity) are more common in low SES households, and may be viewed as a reflection of the parents’ occupational and other life experiences, which are characterized by low control and insecurity. Similarly, an adult’s experience, which might include stressful, low control jobs, may shape their personality development (Kohn and Schooler, 1982). Thus, research on the social determinants of personality measures believed to be associated with illness outcomes needs to be a major priority in future research.

Conclusions

Defensiveness is emerging as possibly an important psychosocial risk factor for hypertension and future cardiovascular health problems, and as such deserves further study. A recent meta-analysis has found high defensiveness to be strongly associated with elevated blood pressure in comparison to other personality traits studied. Research suggests that high levels of defensiveness alone are less likely to present a threat to cardiovascular functioning than when high levels of defensiveness are acting in concert with other psychosocial risk factors for cardiovascular disease, such as cynical hostility, anger, and anxiety. There is also evidence suggesting that high job stress leads to even more pronounced increases in CVR, specifically in regards to those high in both defensiveness and cynical hostility. Although yet to be studied, high job strain may be responsible for these more pronounced increases in CVR observed in higher stress work settings. Finally, it should be noted that presently defensiveness has been one of the least thoroughly studied hypothesized psychosocial risk factors for hypertension and cardiovascular disease. Other psychosocial risk factors for cardiovascular disease, such as Type A Behavior Pattern, hostility, anger, anxiety, and depression, have all been more convincingly tied to cardiovascular disease risk than has defensiveness. As a result, very little research has focused on elucidating the determinants of defensiveness as well.

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