A critical review of “Anger Management Style and Hostility Among Patients With Chronic Pain: Effects on Symptom-Specific Physiological Reactivity During Anger- and Sadness- Recall Interviews”

Two factors that have been studied in relation to chronic pain are hostility and anger, which have been shown to make chronic pain worse and hinder successful treatment. Burns, Bruehl, and Quartana (2006) wanted to examine how suppression or expression of hostility and anger impact chronic pain patients. Chronic pain patients with high anger and hostility might experience pain in one of two ways: muscle contractions related to tension near the site of pain and heighted sympathetic nervous system response.

Participants were 94 chronic pain patients with lower back pain recruited through postings in pain clinics who received 40 dollars for their participation. They were assessed for muscular tension monitored with an EMG. Blood pressure was also taken. Hostility was measured using the Cook-Medley Hostility Scale (Ho) derived from the MMPI-II. Anger management style was measured with the Anger Expression Inventory which examines both anger-in (suppression) and anger-out (expression) tendencies. Trait anger was measured using the Spielberger Trait Anger Scale (TAS) which was used to control for trait anger apart from anger expression style or hostility.

The literature review is concise, yet detailed enough to follow the logically thought for why the current study is important. However, their hypotheses are not as clearly stated or as specific as they could be. First, (clearly stated), they predicted that muscle contractions related to anger and hostility can create greater pain levels in the lower paraspinal muscles, but not in trapezius muscles. Second, they predicted that the anger variables would produce LP muscle contraction in anger conditions, but not sad ones. The third hypothesis involves examining hostility and anger management as separate constructs such that the interactions of high and low levels of these constructs will have different outcomes.

Methods and Procedure
The participants came in, filled out required paperwork/briefing, were allowed to relax in a chair while hooked up to the equipment to achieve a baseline, and were asked to describe either an angry or sad event that happened to them for five minutes (participants were randomly assigned to angry/sad or sad/angry conditions to avoid order effects). They were then given 10 more minutes to return to baseline before repeating the process with the other story. The story was guided by the interviewer using an adapted version of the “stress interview.” Unfortunately, the authors did not provide sufficient detail about how the interview was conducted, making it hard to determine how structured the interview was and if all participants were subjected to similar conditions in the interview.

The procedure section overall is bare. The measurements used are commendable, as the experimenters used a combinations of physiological and survey-based self-report outcomes to collect their data. Further, they provide a table containing not only basic demographics, but list information about the types of medications prescribed, which could prove to be extraneous variables. Demographic variables seem to be a fair distribution of the general medical population. They asked participants to not take opioid-based medications but did not suggest a way that they made sure participants did not take sedating medications other than to take them at their word.

While some of the exclusion criteria make logical sense on the surface, others do not, and the authors failed to provide specific rationales for their criteria. For example, they allowed patients taking opioid medications, but not those that took it daily. They also did not allow patients who had cardiovascular disorders. Their awareness to counter-balance interview conditions is commendable.

Analyses and Results
The discussion of their analyses is sufficient, clear, and would be easy to replicate. Muscle tension was summed for left and right then averaged. Two baselines were taken for the last three minutes of each 10 minute baseline period and averaged. The values for physiological measures was the mean of each variable for five minutes in which they discussed their stories. It was noted that baseline to interview values were not affected by order. Main analyses were conducted using hierarchical regression by placing averages of hostility and anger-in scores in the first step and hostilityXanger-in two-way interactions in the second step. If this proved to be significant, the final step added in trait anger to ensure that it did not have an influence on the outcomes. The steps were repeated for anger-out. Simple slopes were then calculated for hostility at varying “hypothetical” levels of anger-in and anger-out.

Patients with high hostility and anger-in displayed significant lower paraspinal muscle tension, but not trapezius muscle tension. Participants with high anger-in and high hostility also had significantly higher systolic blood pressure for sad and anger stories (but not those with high anger-in and low hostility). For diastolic, the effect was the same, but only for the anger story. The same was true for high anger-out and high hostility.

The Results section was clearly laid out with informative tables to supplement their section. Statistical copy was sufficient and clear explanations for each finding was provided in simple terms following the data. The authors avoid jargon and the results are clear enough for someone with less experience in research to understand the data.

Their main hypothesis and interaction with their “sub” hypotheses proved to be mostly significant. Patients who have high hostility and high anger-in management experience the greatest amount of LP muscle contraction (but not trapezius). This provides support that muscle contraction might play a role in pain levels and that it can be facilitated by anger. Further, they provided evidence that hostility and anger management style act independently of one another as those high in anger-in with low hostility do not have the LP contractions. Interestingly, expressing anger appears to be helpful for those who have low hostility, but cause greater muscle contractions for those who have high hostility.
Some of the limitations (as described by the authors) included the artificial production of anger in a laboratory setting. The other limitation discussed was the small variability in the anger and sadness LP muscle contractions might have affected the outcomes negatively.
The authors did not discuss areas of future research. However, it would be interesting to see how these conditions relate to other aspects of the client’s lives. For example how does anger and hostility affect their psychological well-being, their relationships outside of the medical field, and their relationships with their medical providers? One could assume that a patient who perceives hostile intentions and responds with counterproductive anger might have poor relationships. A medical provider dealing with such a person might have a hard time relating to the patient and may indirectly provide a lesser standard of care.


Burns, J. W., Bruehl, S., & Quartana, P. J. (2006). Anger management style and hostility among patients with chronic pain:Effects on symptom-specific physiological reactivity during anger- and sadness- recall interviews. Psychosomatic Medicine, 68, 786-793.