EFFICACY OF ANGER MANAGEMENT TRAINING ON ANGER DECREASE OF AND BLOOD PRESSURE REACTIVITY AMONG PATIENTS WITH HYPERTENSION IN ZAHEDAN

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1 Acta Medica Mediterranea, 2018, 34: 607 EFFICACY OF ANGER MANAGEMENT TRAINING ON ANGER DECREASE OF AND BLOOD PRESSURE REACTIVITY AMONG PATIENTS WITH HYPERTENSION IN ZAHEDAN HOSSEIN JENAABADI Associate Professor, Department of Psychology, University of Sistan and Baluchestan, Zahedan, Iran ABSTRACT Background and objective: This study aimed to examine the impact of anger management training on anger and blood pressure among patients with hypertension in Zahedan. Using a simple random sampling method, a total of 30 subjects was selected among patients referred to hospitals in Zahedan and was randomly assigned into two groups: an experimental group and a control group. Measurement tool used in the current study was Spielberger State-Trait Anger Expression Inventory-2 (1999). Moreover, the subjects levels of blood pressure were measured. The present study followed a pretest, posttest, and follow-up quasi-experimental design with a control group. The subjects assigned to the experimental group took part in 10 sessions of anger management training. Pretest, posttest, and one-month follow-up were conducted on both groups. Data was analyzed using univariate and multivariate analyses of covariance. Results demonstrated that anger management training was effective in reducing systolic blood pressure and anger among the patients with hypertension in the experimental group. In addition, results of the follow-up showed stability of the impacts of anger management training on systolic blood pressure and anger among the patients in the experimental group. Keywords: Anger Management Training, Blood Pressure, Anger. DOI: / _2018_2s_95 Received November 30, 2017; Accepted January 20, 2018 Introduction Blood pressure, which has a chronic and progressive nature, is among the main causes of chronic disabilities in the world (1,2). This disease is considered as the most important public health issue around the world and is the third leading cause of death worldwide. World Health Organization has estimated that nearly 233 million people suffer from hypertension and 1.7 million people lose their lives annually as a result of this disease and its complications (3). In fact, blood pressure is an asymptomatic risk factor that is usually diagnosed through the incident of irreversible complications such as strokes and heart attacks. This disease, either regarded as a predisposing factor or an independent disease, has always attracted a lot of attention (4). In the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), hypertensive disorders were categorized as psychosomatic diseases affected by psychological factors. In developing countries, high blood pressure is growing increasingly and up to 21% of adults are living with this disease (5). A meta-analysis study revealed that the prevalence of hypertension in Iran was 25.2%. Several studies introduced psychological factors, including anger and anxiety, as risk factors for hypertension (6,7). On the other hand, violence is associated with activation of the sympathetic nervous system which can lead to hypertension and atherosclerosis. Examining the origin of anger and different forms of expressing it along with its consequences has a special status in fundamental and applied psychological research. From the perspective of evolutionary psychology, anger arises from the history of organisms and is combined with human nature. This emotion has helped the survival of individuals

2 608 Hossein Jenaabadi and human species and is a unique tool in facilitating adaptive responses, especially fight and escape responses, when dealing with dangerous conditions. Nevertheless, evolution and natural selection do not have any foresight and would not necessarily mean progress (8). Accordingly, in the conditions of modern civilization, uncontrollable anger not only does not help the survival of humanity but also threatens it. On the other hand, repressing anger is in conflict with human nature. As studies have shown, repressed anger may put people at risk of various diseases (9). Uncontrolled anger puts a person s adaptation and health at serious risk. This emotion has always affected a large number of interpersonal and social issues and violence is the most predictable outcome of it (9). Researchers believe that if anger is not expressed in a healthy controlled way, it can no longer be considered as a healthy emotion. In particular, this emotion can provide the grounds for the incident of aggressive behaviors (10). Unlike ancient philosophers and thinkers who believed that contemplation and self-restraint could favorably control anger, Freud and Darwin had a pessimistic view about controlling anger. They argued that appeasing anger in one place may not eliminate this emotion; however, anger may appear in another place and situation. Moreover, suppressing and appeasing emotions may lead them to occur in the form of a variety of diseases and behavioral disorders (10). Chronic anger negatively affects physical and mental health, social interactions, and overall quality of life (11). According to a definition proposed by Charles Spielberger, a psychologist who specializes in the study of anger, anger is an emotional state that varies in intensity from mild irritation to intense fury and range. Like other emotions, anger is accompanied by physiological and biological changes. When a person gets angry, his/her heart rate, blood pressure, and levels of energy hormones, including adrenaline and noradrenaline, increase. Anger can be caused by both external and internal factors. A person can be angry with a specific person (a co-worker or a boss) or at an event (a traffic jam or a canceled flight). Moreover, anger could be caused by worrying or brooding about personal issues. Memories of traumatic or enraging events can also inflame anger (12). Through employing programs developed mainly based on the cognitive-behavioral approach, researchers have attempted to provide anger management training. Contents of these anger management programs are relatively similar. These programs are conducted in various situations through observing the principle of flexibility. Many of these programs can be considered as preventive interventions and efforts to complete public education (13). Many anger management programs were proved to be effective in numerous situations (14). These programs constituted of treatments in which cognitive restructuring techniques proposed by Beck (15), rational emotive behavior therapy techniques developed by Ellis ( (15) ), assertiveness training (16), social skills training (Kassinove & Tafrate, 2002), relaxation or stress reduction training (15), and systematic desensitization (17). Training anger management skills aims at achieving the following three goals: 1. Aiding clients to avoid unnecessary anger aggravation and expression, 2. Promoting assertiveness skills and skills to express anger moderately while developing a better control over severe depletion of anger and aggressive behaviors, and 3. Aiding clients to learn appropriate conflict resolution skills (14). Despite all the growing scientific efforts and dedications made to provide anger management skills training, adopting scientific measures for managing anger, which potentially can be either destructive or constructive, was neglected. As a result of this negligence and lack of evidence on processes and outcomes of interaction between therapeutic and training interventions related to anger management, there are serious uncertainties about a series of social and cultural conditions. Hence, providing research evidence aimed at resolving these uncertainties seems essential. To this end, the present study was conducted to examine the impact of anger management training on anger and blood pressure among patients with hypertension. Methods The present study followed a pretest-posttest quasi-experimental design with a control group. Statistical Population, Sample, and Method of Sampling Statistical population of this study included all patients with hypertension in Zahedan. Initially, using a simple random sampling method, 2 healthcare centers were selected in Zahedan and Spielberger State-Trait Anger Expression Inventory-2 (1999) was carried out on patients with

3 Efficacy of anger management training on anger decrease hypertension referred to these two healthcare centers. After scoring the gathered inventories, based on scores of overall anger expression index, 15 patients who obtained the highest scores were chosen from each healthcare center as people who were prone to severe anger. Given the scores on the overall anger expression index and levels of blood pressure measured and recorded with a sphygmomanometer, these patients were matched pairwise and assigned into an experimental group and a control group. Afterwards, ten 90-minute sessions of anger management training, as an experimental factor, were carried out weekly on the experimental group. Then, through applying the Spielberger State-Trait Anger Expression Inventory-2 (1999) and measuring the patients levels of blood pressure, posttest was conducted on both groups. Measurement Tools The State-Trait Anger Expression Inventory- 2 This 57-item inventory was developed by Charles D. Speilberger and was abbreviated as STAXI-2 in It consists of six scales, five subscales, and an anger expression index. Its scales are trait anger, state anger, anger expression-out, anger expression-in, anger control-out, and anger controlin. Its subscales are feeling angry, feeling a strong need to express anger verbally, feeling a strong need to express anger physically, angry mood, and angry reaction. When filling out the inventory, subjects can choose their answers on a 4-point Likerttype scale ranging from almost never (1) to almost always (4). In this way, the subjects can measure the intensity of their feelings of anger at a specific time and the frequency of experience, expression, repression, and control of anger. Scores range from 0 to 96. To examine validity of this inventory (13), implemented STAXI-2 together with the General Health Questionnaire (GHQ) on 170 male high school students. Results of analyses indicated that state anger, trait anger, and anger expression were significantly and directly correlated with incompatibility and symptoms of general health disorders. To determine reliability of this inventory, Cronbach s alpha coefficients were calculated for state anger and trait anger which were respectively 0.92 and Moreover, mean of Cronbach s alpha coefficients of state anger, trait anger, and overall anger expression index was Blood Pressure Measuring Device (Sphygmomanometer) This device was used to measure blood pressure of the patients assigned to the experimental and control groups in the pretest, posttest, and follow-up. Sphygmomanometer is the most prevalent tool used to measure blood pressure. This device is composed of an inflatable cuff that is connected to a tube containing mercury. Through observing the mercury in the column while releasing the air pressure with a control valve, the value of the blood pressure can be read in mm Hg in the range of systolic blood pressure (maximum) and diastolic blood pressure (minimum). Blood only flows in arteries at intervals of each heartbeat and creates some sounds. Procedure After assigning the subjects into the experimental and control groups and conducting the pretest on both groups, ten 90-minute anger management training sessions, as an experimental factor or a dependent variable, were carried out weekly on the experimental group. This is while the subjects in the control group remained on the waiting list and continued their regular programs. The posttest was carried out on both groups. A summary of anger management training sessions is presented in the table 1. Both descriptive and inferential statistics were used to analyze the obtained data. In the descriptive level, mean and standard deviation were applied. In the inferential level, analyses of covariance were employed. Results Table 2 indicates scores on anger and blood pressure obtained by the experimental and control groups in the pretest and posttest. This table presents frequency of the scores, minimum and maximum scores, means, and standard deviations of the experimental and control groups in the pretest and posttest. As can be seen in Table 2, in the pretest, the means and standard deviations of the scores on anger obtained by the subjects in the experimental and control groups are respectively 54.85, 7.29, 54.5, and 7.29, in the posttest, they are respectively 45.42, 7.9, 54.78, and 7.14, and in the follow-up, they are respectively 42.28, 6.15, 39.19, and 5.92.

4 610 Hossein Jenaabadi Considering systolic blood pressure, in the pretest, the means and standard deviations of the scores obtained by the subjects in the experimental and control groups are respectively , 11.84, , and 20.02, in the posttest, they are respectively , 18.17, , and 14.75, and in the follow-up, they are respectively , 12.08, , and Moreover, with regard to diastolic blood pressure, in the pretest, the means and standard deviations of the scores obtained by the subjects in the experimental and control groups are respectively 88.00, 11.02, 88.15, and 13.89, in the posttest, they are respectively 95.70, 20.47, 90.10, and 8.79, and in the follow-up, they are respectively 89.60, 14.03, 82.45, and Results obtained from univariate and multivariate analyses of covariance are presented in Tables 3 and 4. As presented in Table 3, through controlling the pretest, the levels of significance of all these tests indicate that there are significant differences in anger and blood pressure between the experimental group and the control group (F=16.51, P<0.0001). To realize which one of the variables leads to such differences between the two groups, three one-way analyses of covariance were carried out in the context of MANCOVA, results of which are presented in Table 4. The value of the effect or difference is equal to Other words, a total of 68% of the differences in the scores of anger and blood pressure in the posttest occurs as a result of anger management training. The statistical power is equal to This shows that there is no possibility of type II error. Table 3: The results of the multivariate analysis of covariance (MANOVA) conducted on the mean posttest scores of anger and blood pressure obtained by the patients in the experimental and control groups through controlling the pretest. Table 1: General structure of anger management training sessions. Table 2: The means and standard deviations of the scores of anger and blood pressure obtained by the patients in both groups in the pretest, posttest, and follow-up. Table 4: The results of univariate analyses of variance (MANCOVA) conducted on the mean scores of anger and blood pressure obtained by the patients in both groups. According to Table 4, through controlling the pretest, there are significant differences in systolic blood pressure (F=4.31, P>0.045) and anger (F=58.82, P>0.001) among the patients with hypertension in the experimental and control groups. However, no significant difference is found between these two groups with regard to diastolic blood pressure (F=0.018, P=0.893). Results obtained from the univariate and multivariate analyses of covariance conducted on mean scores of the experimental and control groups on systolic blood pressure, diastolic blood pressure, and anger in the follow-up are presented in Table 5. As presented in this table, through controlling the pretest, the levels of significance of all these test in the follow up indicate that with regard to one of the dependent variables (systolic blood pressure,

5 Efficacy of anger management training on anger decrease diastolic blood pressure, and anger), there is at least a significant difference among the patients with hypertension in the experimental and control groups (F=20.94, P>0.001). To realize which one of the variables leads to such a difference, three univariate analyses of covariance were carried out in the context of MANCOVA, results of which are presented in Table 6. Table 5: The results of the multivariate analysis of covariance (MANCOVA) conducted on the mean posttest scores of anger and blood pressure obtained by the patients in the experimental and control groups in the follow-up. According to Table 6, through controlling the pretest, there are significant differences in systolic blood pressure (F=11.5, P>0.030) and anger (F=60.31, P>0.001) among the patients with hypertension in the experimental and control groups. However, no significant difference is found between these two groups with regard to diastolic blood pressure (F=2.56, P=0.172). Table 6: The results of the univariate analyses of variance (MANCOVA) conducted on the mean posttest scores of anger and blood pressure obtained by the patients in both groups in the follow-up. Discussion and conclusion The results of this study demonstrated that anger management training increased anger selfregulation skills and decreased blood pressure among the patients. This finding that anger management training significantly and positively affected high blood pressure and anger is consistent with results of McCraty, Atkinson, Tomasino, Goelitz, and Mayrovitz (18), Mehrizi (17), who implemented emotional management skills training on years old students and revealed the effectiveness of this training on managing anger and stress. A training program includes techniques, strategies, and skills of monitoring emotional self-regulation. The results of this study indicated that through learning and practicing techniques which are effective in managing emotions, the students statuses, with regard to acquiring behavioral skills and psychosocial functioning, improved significantly. Considering their academic success, these students were in good conditions and they were satisfied with themselves. Moreover, they were able to efficiently control and manage stress, anger, and other negative feelings. These findings are in line with results of a study carried out by Navidi (13) aimed at examining the effectiveness of anger management training on anger self-regulation skills, adaptability, and general health among male high school students in Tehran. In the mentioned study, the results obtained from statistical tests showed that there were significant differences in anger self-regulation skills, adaptability, and general health among the subjects before and after conducting the training program. These results indicated that the developed training program reduced anger and increased general health. To explain the results obtained from this study, it can be noted that an increase in anger selfregulation modified the intensity, duration, and frequency of expressing anger and facilitated giving non-aggressive and community-friendly responses to interpersonal issues. Furthermore, through fostering anger management skills, reconstructing cognitive processes, and promoting social skills, this training significantly and positively affected emotional and impulsive responses given when dealing with issues that may inflame anger, assertiveness, and appropriate expression of anger (19). Dealing with tension and stressful situations is inevitable and leads to growth and development; however, high levels of tension or improper methods of dealing with tension are destructive and may bring about negative results (19). What is important in the process of facing diseases attributed to high levels of stress is the method of dealing with them (20). Several studies indicated that training stress management skills were effective in the treatment of high blood pressure (21). To explain this finding, through reviewing the training contents, it can be mentioned that they include techniques that are effective in reducing anger. These techniques, which include reducing expectations, creating positive thinking, being optimistic, expressing feelings, reducing negative feelings, refraining from worries and putting an end to discomfort, enhancing social relationships, strengthening close interactions, increasing taking part in various activities, making happiness a priority, developing a good social char-

6 612 Hossein Jenaabadi acter, being creative and getting involved in meaningful activities, fostering a healthy personality, planning affairs, focusing on the present, improve positive mood and decrease systolic blood pressure. According to the obtained results, anger management training was not effective in reducing diastolic blood pressure among the patients. In this regard, it can be stated that some factors that affect blood pressure cannot be changed and only fluctuations in blood pressure can be prevented and controlled. Diastolic blood pressure is under the influence of several factors including heredity, race, gender, and a number of diseases such as diabetes and renal diseases. Hence, unlike systolic blood pressure, diastolic blood pressure cannot be controlled very well (11). Overall, since ischemic heart diseases and strokes significantly contribute to mortality and disability and a significant part of the health sector budget is allocated to them, it is necessary to pay special attention to the role of blood pressure which makes a significant contribution to these diseases (22). To judge the success of treatment measures, a new viewpoint focused on improving the quality of life and returning to society should be taken instead of traditional therapy-based approaches. Taking such a viewpoint is not only the duty of authorities and managers of the health system but also all groups working in this area should take part in changing the current viewpoint. References 1) Aghaei, E., Bakhtiari, A., & Jamali Paghalei, S. (2013). The effectiveness of stress management therapy on depression and blood pressure among patients with hypertension. Psychology of Health, 2(7), ) Argyle, M. (2001). Psychology of happiness. Translated by: Kalantari, M., Gohari Anaraki, M., Neshatdoost, H.T., Paalahang, H., & Bahrami, F. (2003). Isfahan: Jahad-e-Daneshgahi Publication. 3) Bagheri, N. (2006). The effect of aerobic exercise in self-concept, self-approval, happiness, and acceptance among women in Rasht. MA thesis of Psychology, Islamic Azad University, Ahvaz. 4) Bagherian, R., Baghbanian, A., Kheirabadi, G.R., Heidarinejad, D., & Moshkani, M.A. (2010). Comparing the prevalence of symptoms of depression among patients with high blood pressure and healthy subjects. Journal of Psychiatry and clinical psychology, 52, ) Bahrami, M., Alipour, A., Jonbozorgi, M., & Barzegar Ghazi, K. (2013). The effectiveness of progressive muscle relaxation training on perceived stress among patients with essential hypertension. Journal of Clinical Psychology, 3(9), ) Buehler, C. (2006). Parents and peers in relation to early adolescent problem behavior. Journal of Marriage and Family, 68, ) Dahlen, E. R., & Deffenbacher, J. L. (2001). Anger management: Empirically supported cognitive therapies; Current status and future promise. New York: Springer Publishing Company. 8) Davydov, D.M., Stewart, R., Ritchie, K., & Chaudieu, I. (2012). Depressed mood and blood pressure: The moderating effect of situation-specific arousal levels. International Journal of Psychophysiology, 85(2), ) Eysenck, M. (1990). Always be happy. Translated by: Jelonegar, Z. (2005). Tehran: Nasl-e-Noandish Publication. 10) Feindler, E. L., & Weisner, S. (2005). Youth anger management treatments for school violence prevention. Journal Family Violence, 4, ) Haghdoost, A.A., & Sadeghirad, B. (2006). A metaanalysis on blood pressure in Iran. Journal of Kerman University of Medical Sciences, 13(2), ) Hergenhahn, B.V., & Olson, Kh. M. (2003). Introduction to the learning theories. Translated by: Saif, A.A. Tehran: Agah Publication. 13) Lau, B.V. K. (2001). Anger in our age of anxiety: What clinicians can do. The Hong Kong Practitioner, 23, ) McCraty, R., Atkinson, M., Tomasino, D., Goelitz, J., & Mayrovitz, H. N. (1999). The impact of an emotional self-management skills course on psychosocial functioning and autonomic recovery to stress in middle school children. Integrative physiological & behavioral science, 34(4), ) Navid, A. (2006). Investigating the effect of anger management training on anger self-regulation skills, adaptability, and general health among male high school students in Tehran. PhD thesis, Allameh Tabatabaei University, Tehran. 16) Navidi, A. (2008). Examine the effects of anger management training on coping skills among male secondary school students in Tehran. Iranian Journal of Psychiatry and Clinical Psychology, 14(4), ) Navidi, M. (2006). Examine the prevalence of high blood pressure in Gonabad. Journal of Gonabad University of Medical Sciences, 1, ) Seifzadeh, M. (2009). The Relationship between aggression and marital satisfaction among thalassemia patients in Kolachai. MA thesis, Payam-e-Nour University, Roodsar. 19) Smith, J.C. (2002). Stress Management: A Comprehensive Handbook of Techniques and Strategies. New York: Springer Publishing Company. 20) Spielberger, C. D. (1999). State-Trait Anger Expression Inventory-2TM: Professional Manual (2nd ed.). Florida: Psychological Assessment Resources, Inc. 21) Stern, S. B. (1999). Anger management in parent-adolescent conflict. The American Journal of Family Therapy, 27, ) World Health Organization. (2006). Cause of death, Center for Global. Into Regional Studies (CGIRS) at the University of California Santa C, Corresponding author HOSSEIN JENAABADI hjenaabadi@ped.usb.ac.ir (Iran)