The intent of this paper is to discuss the research on the health effects of anger in men. The paper will review studies on the effects of various types of men’s anger and anger expression on the cardiovascular system, which is the most well-studied system affected by anger, including acute coronary pathologies, as well as chronic conditions secondary to anger. Research studies on the effects of men’s anger on the immune system, pain, erectile dysfunction, and risky health behaviors will also be discussed. Understanding the many negative consequences of anger on a man’s body will highlight the importance of addressing this aspect of men’s health when caring for our male patients.
Since earliest known cultures, anger was believed to be a source of illness, whether by projection of anger onto supernatural beings or as a method for keeping “moral order.”1 Disease was purported to be the result of anger as a retribution for transgressions of unwanted behavior. In the early 20th century, research began to emerge on these speculations and inquiry about the health effects of anger began. For example, in 1939 Franz Alexander, a psychoanalyst and a physician, looked at anger as a causative factor for hypertension.2 Subsequently, evidence has accumulated showing that anger has detrimental effects in the body. It is important that physicians know specifically the health risks of both inwardly directed anger and rage expression.
An oft-used aphorism (often incorrectly attributed to the Buddha) says, “You will not be punished for your anger, you will be punished by your anger.” How might the body be taking the punishment of an angry temperament? As naturopathic medicine is rooted in understanding cause of disease, importantly, it is necessary to understand the root of anger in men’s hearts. When a man’s masculinity is challenged he is more likely to act out in anger, which, in turn, makes him feel more masculine.3 Further, a perceived affront to his ability to “have control” versus “to be controlled” stimulates a response of anger.4
Anger is simply an emotion, which in itself may not cause harm, if appropriately managed. The problem with anger seems to be in the expression or withholding of expression. Many studies discussed in this article look at trait anger vs state anger; in the former, anger is a character trait, in the latter, it is an acute emotional state.5 In other studies, the effects of anger are assessed based on how it is expressed by the individual experiencing it. When outwardly expressed toward another, anger is commonly referred to in the literature as “anger-out,”5 which is less socially acceptable because at its extreme it causes physical and emotional harm toward women, children, other men, animals, and so on. Angry feelings also get outwardly directed as criticism of others, blaming or shaming others, and preaching to others in the form of outrage.
The immune system is also affected by anger, especially suppressed anger… Given that anger is a common response to a cancer diagnosis, it may be useful to design studies to look at the potential immune system benefits of more effective anger expression in men with various cancers.
Conversely, anger may be directed inwardly toward the self, possibly even being suppressed or repressed, which is denoted commonly in research literature as “anger-in.”5 Anger-in is also known as enragement, which may take the form of obsessing or fixating on a thought, holding resentments, or an inability to “let go.”6 Self-medicating is another, more subtle articulation of anger-in, which may be germane to naturopathic medicine. Given the social stigma of anger-out, one might anticipate a rise in maladies resulting from non-expression or anger-in, so both anger pathways will be considered.
The studies reviewed in this article look specifically at anger, hostility, and cynicism, but it is important to note that depression, anxiety, and anger are difficult to distinguish, especially in men. Some studies have found that anger was a significant indicator of depression in men,7 especially in men who uphold traditional masculine ideologies. Indeed, anger and hostility were found to be significant predictors of depressive symptoms in a 2015 study of college men who adhere to hegemonic or traditional masculine gender norms.8
Cardiovascular Effects of Anger
Most research on the health consequences of anger has focused on the cardiovascular system. Given that cardiovascular disease (CVD) is the leading cause of mortality in men,9 a thorough exploration of the relationship between anger and CVD is warranted, specifically including the manner in which anger-out and anger-in acutely and chronically affect the multifarious cardiac and vascular pathologies.
The Framingham Heart Study is a prospective, longitudinal cohort study that began in 1948 and was foundational in cardiovascular epidemiology. Among the findings of the study was the effect of psychosocial factors, including anger, on the cardiovascular system.10 The anger effects on the sympathetic nervous system include increased blood pressure, vasoconstriction of arterioles, and increased blood clotting mechanisms, all of which increase the risk of heart attack and stroke. In addition to increased sympathetic activation, it has been established that anger is associated with greater prothrombotic responses, including more platelet activation and less fibrinolysis, which increases likelihood of a thrombotic occlusion.11-14
In the 1970s, an offshoot of the Framingham Heart Study looked at offspring and spouses of those in the original longitudinal cohort in an attempt to make a predictive relation of anger and hostility to coronary heart disease (CHD), atrial fibrillation (AF), and total mortality risk.15 The study of 1,769 men and 1,913 women (mean age 48.5), found that for men but not women, hostility was positively associated with AF, especially premature AF (prior to age 70). Additionally, the authors found that trait anger was not related to incident CHD but was significantly correlated to total mortality in men, which contradicts some other studies.16,17 In other words, anger as a character trait didn’t increase acute coronary syndromes, but was a contributing factor in overall cardiovascular mortality. One limitation of the study was its predominantly white, middle-aged cohort. A 2015 study, however, at the University of Michigan’s Center for Research on Ethnicity, Culture and Health, showed significant interactions of race and anger.18 Specifically, anger-in, but not anger-out, was associated with cardiovascular mortality in both Blacks and Whites, but more strongly for Whites than Blacks. It was unclear from this study if the cause of the anger association was biological, cultural, or socioeconomic, or if outcomes were related to access to health care.
When looking at the issue of episodic anger explosions, while trait (chronic) anger may not increase the incidence of CHD, an older study (1995) found that anger was capable of triggering a myocardial infarction (MI) within 2 hours.19 Subsequently, a study at the University of Sydney found that there was an 8.5 times higher risk of a coronary event such as atypical pain, heart failure, ST elevation, T-wave inversion and unstable angina within 2 hours of an anger episode.20 The study was an evaluation of data from the National Israel Survey of Acute Coronary Syndromes, conducted in 2004 and completed by 1,849 participants, of which 1,377 were men. Potential triggers were looked at as predictors of a coronary event, including triggers such as physical exertion, emotional stress, anger, and heavy meals prior to the coronary incident. It is possible that men of older generations would identify more with the term “emotional stress” than specifically with “anger,” which may have influenced the results. Anger was not found to have a significant effect on mortality or rehospitalization, though emotional stress did. Further, the results indicated that anger was a more frequent trigger in subjects younger than 65.
Some criticized this study because of its case-crossover design, rather than a case-control design. The study design may have had recall bias, such that patients were trying to pin the coronary event to a specific external source such as an argument, rather than looking at long-term personal lifestyle choices such as dietary or exercise habits. What wasn’t included in the discussion was that looking for external causes of anger, rather than internal causes, is typical behavior in men, especially those adhering to traditional masculine norms.8
Perhaps the most comprehensive review and meta-analysis of studies, especially as associated with acute anger, was conducted by European researchers in 2014. The authors concluded that, compared to other periods of time, the risk of MI, acute coronary syndrome (ACS), ischemic and hemorrhagic stroke, and arrhythmia are higher in the 2 hours following outbursts of anger, although the magnitude of the association varied among the reviewed studies.21 This affirms a fairly convincing argument for the implication of acute anger as a risk factor for a cardiovascular event.
With respect to mechanisms affecting the vasculature, suppressed anger (anger-in) has been implicated as a risk factor for the development of aortic (P<0.01) and carotid artery (P<0.05) stiffness due to increased intimal-media thickness. The Baltimore Longitudinal study, a small study of only 200 participants, 95 of which were men, used the Spielberger Anger Expression Inventory to look at the effect of anger on intimal thickness.22 Findings demonstrated that the effects of anger contributed to increased vessel thickening. The likely cause of the thickness was secondary to hypertension, whereas neither trait anger nor outwardly expressed anger showed a correlation.
A peculiar finding involves the physiologic acclimation of chronic trait anger, where individuals with high trait anger may actually be less susceptible to cardiovascular risks of an anger outburst because the body acclimates to the chronically heightened sympathetic nervous system. However, those with higher trait anger do have an increased frequency of rage outbursts and also may have greater absolute risk.19 Another pathway for greater cardiovascular mortality due to anger outburst is via increased cortisol levels.23 A 2000 study showed that anger (anger-out) secondary to job strain (high demand with low job control) increased salivary cortisol levels, which has been shown to be a predictive marker for cardiovascular mortality.24 Although the impact of decreasing stress, increasing relaxation, and incorporating mindfulness are all valuable, job strain is inevitable for some. For these patients, it would be useful for physicians to know the mortality risks due to cardiovascular disease, and to provide naturopathic support for the cardiovascular system.
Additionally, the intensity of anger correlated to greater risk for ventricular arrhythmia and MI, thus clinical support toward decreasing anger intensity would be paramount. Those with other known risk factors for cardiovascular disease are at greater risk with anger outbursts.19 Evidence from a 2009 study showed that anger and hostility not only affect healthy individuals, but also contribute to poorer prognosis in those with established CHD.25 In this review of 25 studies on healthy individuals and 19 studies on those with existing CHD, the latter showed a greater risk for the development of harmful effects due to anger.
A 2013 review of the Nova Scotia Health Survey looked at anger, cynical distrust, and antagonistic behavior and CHD, and found that even after adjusting for traditional risk factors, men with low constructive anger scores and high destructive anger scores had increased 10-year incident CHD risks.26 Additionally, chronic hostility was found to be a chronic risk factor for the development of hyperlipidemia, hypertension, and heightened sympathetic activity—leading to atherosclerosis. Behavioral and pharmacological interventions were positively correlated with reductions in hostility and diastolic blood pressure, supporting the theoretical use of naturopathic interventions such as botanical medicines, nutritional supplements, and behavior/lifestyle counseling in the primary care setting.
Several studies showed that lower levels of education were more commonly found in individuals with anger-associated cardiovascular events.15,19 According to Boylan and colleagues this may be due to greater stressors, along with decreased “cognitive flexibility,” in that those with higher education and higher ability to control their anger were “better able to look at the situation from a different perspective, more likely to communicate with the target of anger, and more likely to use active problem solving once angry.”27
All primary care clinicians should recognize that although education level can be a risk factor for cardiovascular events associated with anger, interventions can be crafted to include skills for working with anger, especially in boys and young men, regardless of education level.
Many of the aforementioned studies have focused on the acute effects of anger/rage on cardiovascular health, especially in the aging population, but there are other studies that point to the importance of protecting our young men from future development of CVD. In a 2002 prospective study, Chang and colleagues followed 1,055 men for 32 to 48 years and found that a high level of anger in young men in response to stress is associated with premature (prior to age 55) CHD and MI.28 Cardiovascular disease is often associated with aging, but this study shows that prevention of CVD includes moderating anger expression at any age.
Anger, in addition to having negative effects on the coronary vessels, can be a causative and an accelerating factor for microvascular disease such as retinal arteropathies.29 Anger, depression (which can be expressed as anger, hostility, and aggression in men), cynicism, and other psychosocial factors are associated with retinopathy, secondary to retinal vascular damage. Retinopathy includes hemorrhages, microaneurysms, ischemia of the retina, and necrosis of the endothelial cells. One study found that participants who had both depressive symptoms and hypertension had 60% greater odds of developing retinopathy, while depressed patients without hypertension had 30% greater odds, compared to controls. This finding does 2 things: it demonstrates the correlation of retinopathy and anger, and it shows that previous history increases the relationship between retinopathy and anger. Interestingly, men with less emotional support showed greater risk for developing retinopathy.27 This is noteworthy because some populations of men, especially those men who tend toward traditional hegemonic masculinities, tend to seek emotional support less frequently. Practitioners must be alert to these associations in male patients with current retinopathy, diabetics who have increased risks for the development of retinopathy, and those with a tendency toward anger, hostility, depression, or social isolation.
These studies affirm that anger is a threat to men’s cardiovascular system and provides evidence that there is much more than simply hypertension as a cause and effect of anger in men.
Immune System Effects of Anger
The immune system is also affected by anger, especially suppressed anger. A 2006 study of 61 men with localized prostate cancer suggested a relationship between suppression of anger and natural killer cell cytotoxicity (NKCC).30 Natural killer cell cytotoxicity has been used as a prognostic indicator for cancer progression,31 and while other psychosocial factors have been considered in relationship to NKCC, this study was the first of its kind to look at the effect of anger expression on immune cells in older men. Results of the study showed that less anger suppression, as measured by The Courtauld Emotional Control Scale, was related to greater NKCC.28 Given that anger is a common response to a cancer diagnosis, it may be useful to design studies to look at potential immune system benefits of more effective anger expression in men with various cancers.
Another study looked at inflammatory activity (interleukin [IL]-1, IL-6, and interferon gamma [IFN-gamma]) based on induced anxiety and anger. In this 2015 study, researchers found that anxiety, but not anger, increased IFN-gamma and IL-1ß levels in oral mucosal transudate samples following induction by writing about a situation that was anxiety-producing or anger-producing.32 The investigators made the distinction between anxiety as an “avoidant emotion” and anger as an “approach emotion.” However, because not all people experience anger as an approach emotion, and don’t feel “certain and relatively in control of a situation” when in an angry state, the investigators may have made an assumption bias such that anger as an avoidant emotion could also produce increases in proinflammatory cytokines. This may have skewed the results toward what they arbitrarily defined as “anxious” events.
Anger and Pain
Many studies have affirmed a relationship between anger and pain, which over the course of years has become more nuanced, depending on the manner in which anger manifests (anger-in or anger-out). Those who express anger outwardly show greater pain sensitivity than those who express anger inwardly.33,34 In a 2014 study, Burns, Bruehl, and Chont looked more specifically at the physiologic mechanisms that may determine pain response to anger. The study of 146 participants (54% men) looked at the role of endogenous opioid system dysfunction in those with high trait anger, when induced into a state of acute anger. Results of this intricate and quite complex study indicated that people with high trait anger and anger-out tendencies, when induced into an acute episode of anger, actually show lower pain intensity.35 This is intriguing in that it may indicate that people with high trait anger have compromised endogenous opioid analgesia and therefore an anger outburst may be a way to moderate pain, albeit not the optimum way, given the totality of anger’s effects.
Anger and Rheumatoid Arthritis/Asthma
An April 2016 study looked at anger expression styles and symptom severity in rheumatoid arthritis (RA; joint pain, stiffness, and physical limitation) and asthma (coughing and wheezing). The results showed that especially in men, those with high anger-in had increased frequency and intensity of momentary anger throughout the day.36 The authors also observed that high trait anger-in predicted increased physical limitations and asthma-specific symptoms in daily life, while high trait anger-out predicted reduced RA-specific symptoms. One clinical application of this study would be to employ therapies that encourage anger expression (eg, talk therapy, support groups) to moderate symptoms in men with RA.
Anger and Erectile Dysfunction
Although psychosocial factors have correlated strongly with erectile dysfunction (ED) in many studies, a clear correlation has not been established. In a 1991 study, Bozman et al found that anger significantly caused negative penile tumescence and sexual desire, especially during foreplay.37 Researchers suggested that anger may be the main mechanism responsible for the inhibition of desire and arousal in cases of hypoactive sexual desire. Incidence of impotence (ED) correlated with both increasing expression and suppression of anger.
In 2000, an examination of the Massachusetts Male Aging Study found that neither anger-in nor anger-out predicted the occurrence of ED,38 contradicting the Bozman study. However, this study was also designed to look at dominant vs submissive personality and the correlation to ED. The aim of the study was to determine if the trait of dominance independently contributed to the risk of ED 8.8 years later. The results suggest that new cases of ED are much more likely to occur among men who exhibit a submissive personality. Again, this doesn’t correlate to anger, but given the link to masculine roles, it is worth mentioning. One could infer that the lack of a prospective relationship between ED and anger suggests the effects of anger may be more short-lived, an observation that could shed light on many of the acute cardiovascular effects of anger.
In a 2010 Italian study of both men and women, trait anger was not found to significantly affect sexual motivation; however, trait anger was positively correlated to sexual interpersonal behavior, especially in men.39 These behavioral variants included neurotic sex, impersonal sex and aggressive sex (P<0.002 for all 3 variants). Another study, also Italian, found that anger-prone individuals are more interested in seeking sexual pleasure than committing to a deep relationship, aiming to satisfy their own needs and desires while neglecting their partner’s, engaging in sex without emotional intimacy, commitment, or love.40 In other words, the study found that angry men are more egocentric sexually, less interested in giving to their partner during sex, more likely to take pleasure in humiliating their partner during sex, and lack desire for tenderness. Discussing sexual practices with male patients is a sensitive topic; while it may take years to develop such rapport, remaining open to the conversation and listening for clues may help identify anger as an issue to be addressed.
Risky Health Behaviors and Anger
In 2004 Fessler et al established that anger increased risk-taking in males, but not in females.41 Subsequently, a study originally published in 2016, in 3 experiments, as well as a meta-analysis, determined that incidental anger in men increased risky behavior. The authors hypothesized that men are more likely to respond to disasters and aggression with anger.42 Based on the experimental design, anger would also lead to real-world correlates such as smoking, substance and alcohol use, gambling, and risky sexual behavior, which carry their own serious health effects. Authors of a 2010 study offer another possible explanation for why men may have more risky behavior with aggression. They found that higher levels of testosterone led to an increase in aggression through a decrease in activity in the medial orbitofrontal cortex during a (non-risky) decision-making paradigm.43
Over the course of history, research has shown a more clear connection of anger, not simply overt expression but inward expression as well, to a wide array of pathologies. Most of the research has been on cardiovascular pathologies and secondary conditions of poor cardiovascular health. While the evidence is strongest for acute coronary vessel pathologies such as MI and the cardiovascular effects of increased sympathetic nerve stimulation, especially in the 2 hours following an anger episode, there is also convincing support for consequential effects of trait anger toward cardiovascular damage. As such, physicians would be well-advised to consider anger, hostility, and depressive symptoms as risk factors for the development of CVD, and especially for patients with established CVD.
There is evidence for correlations of anger, in its diverse forms, to decreased immune function, specifically NKCC, and increases in pro-inflammatory cytokines. Also, angered patients who express outwardly have greater sensitivity to pain with the interesting finding that those with high trait anger may have dysfunctional endogenous opioid systems. Given the current focus on pain and addictions to opioid pain medications, this is another area that needs further large-scale research.
Anger also increases symptomatic expression of RA and asthma, especially in men who tend to hold anger in, which may become increasingly common because of the current decrease in tolerance of men negatively expressing outward anger. There was sparse evidence for a strong connection of anger to ED, though more stirring data linked anger to variant sexual behavior in men. Finally, anger in men leads to risky health behaviors, possibly due to the effect of anger on decision-making areas of the brain.
In conclusion, there is evidence that anger, in the form of acute anger explosions, chronic hostile anger, or various methods of anger expression, is detrimental to men’s health. Clinicians should heed the evidence on the ramifications of anger in the body and consider therapies that address this aspect of health in men.