PsycbologicalReports, 1991, 68, 1059-1066.
O Psychological Reports
1991
COOK-MEDLEY HOSTILITY, ANGER, AND T H E TYPE A BEHAVIOR PATTERN I N FINLAND ',*" ESTHER R. GREENGLASS York UniversiQ Toronto, Canada
AND
JUHANI JULKUNEN Rehabilitation Foundation Helsinki, Finland
Summary.-According to research, hostility is a reliable predictor of coronary heart disease. Cook-Medley-defined hostility in particular has been seen as a significant precursor of coronary disease. It is important to specify the kind of hostility measured by the Cook-Medley scale. The present study examined the construct validity of the Cook-Medley scale for a sample of 219 university students in Finland, a country with a high incidence of coronary heart disease. The results supported the interpretation of the Cook-Medley scale primarily as a measure of cynicism and distrust. On the basis of our previous research, a subscale of the Cook-Medley scale was formed. This 9-item scale, a measure of Cynical Distrust, correlated positively with cynicism and negatively with trust. Moreover, the over-all pattern of correlations between the new 9-item factor, cynical distrust, and other variables assessing hostility, anger, and trust, was similar to the one obtained for our previous sample of students. I t is suggested that this new %item scale is a shorter and more specific alternative to the longer Cook-Medley scale as a measure of cynical distrust.
The Type A behavior pattern has been shown to predict coronary heart disease independently of traditional risk factors (17). This personality pattern is characterized by competitive drive, a persistent striving for recognition and advancement, involvement in multiple activities involving deadlines, and excessive hostility. While the Type A concept comprises many components, not all of them predict coronary heart disease. So far, research has indicated that one, hostility, is the best predictor of incidence of coronary heart disease (18). Williams, Haney, Lee, Kong, Blumenthal, and Whalen (24) measured Type A behavior and hostility in a group of heart patients. Findings were that the hostility levels were better predictors of coronary blockage than Type A. These findings have been extended in three other studies (1, 2, 22), all indicating that hostility scores predicted both coronary heart disease morbidity and total mortahty. Also, in a rneta-analysis of studies on Type A behavior, Matthews (17) concludes that hostility is a reliable predictor of events of coronary heart disease in population-based prospective studies. 'This research was sup orted by a grant from the Signe and Ane Gyllenberg Foundation to Juhani J u h n e n . ~ r a t e f ? dacknowledgement is also due to the Faculty of Arts, York University @ their support of this research in a grant to Esther Greenglass. Thanks are due to Pirjo Kaikkonen and Markette Kokkinen, University of J vaskyla, Finland, for assistance in collecting the psychological data and to Mirka Ondrack andlthe Institute for Social Research, York University for assistance with the data analyses. Address correspondence to Esther R. Greenglass, Department of Psychology, York University, 4700 Keele Street, North York, Ontario, M3J 1P3, Canada or to Juhani Julkunen, Rehabilitation Foundation, Pakarituvantie 4, SF-00410, Helsinki, Finland.
1060
E. R. GREENGLASS & J. JULKUNEN
While hostility and anger may be predictive of risk of coronary heart disease, at the same time it is important to specify those aspects of hostility and anger that are involved in this relationship. In examining the type of hostility discussed by Cook and Medley (4) and subsequently employed by Williams, et al. (24) and Shekelle, Gale, Ostfeld, and Paul (22), i t is evident that what is being described in their research is a kind of "cynical contempt." The hostility scale seems to reflect an attitude that one cannot depend on others to be honest. I t is important to point out that host&ty, in the sense of a mistrust of others (as defined by Cook-Medley), was not part of the original description of Type A behavior (18). The hostility associated with Type A reflected in the Structured Interview was described as free-floating. Also, the Jenkins Activity Survey, one of the most widely used measures of Type A behavior, contains only a few items which assess anger and hostility. Although Cook-Medley hostility appears to have important health implications, there are relatively few studies of the psychometric properties of the scale or its validity. The items give evidence that the scale covers a broad spectrum of features, ranging from openly expressed aggressiveness to suspiciousness and paranoia. For example, in a study of 132 angiography patients, Blumenthal, Barefoot, Burg, and Williams ( 3 ) concluded that the Cook-Medley hostility scale may be viewed as tapping four general behavioral dimensions including anger and hostility, neuroticism, social maladjustment, and ineffective coping style (Blumenthal, et al. [3]). I t is an empirical question, however, as to which of these dimensions might be predictive of the development of coronary heart disease. I n a study of the inner structure of the Cook-Medley scale, Greenglass and Julkunen (9) report the results of factor analyses of the Cook-Medley hostility scale which yielded a general factor relating to distrust and cynicism. The nine items with the highest loadings on this factor could be added to form a new subscale with a relatively high internal coherence (a= 0.75). This subscale was interpreted as a measure of cynical distrust. While correlating quite highly with the total Cook-Medley scale ( r = ,771, it seemed to be a more pure measure of cynicism (9, p. 216). These results were based on a sample of Canadian students. Moreover, most of the studies of the Type A behavior pattern have been carried out in the United States. I t is important, however, to carry out similar studies in other countries. To the extent that the same pattern of results is obtained, the findings are generalizable. I t is also important to analyze the components of hostility in a country with a high incidence of coronary heart disease. According to WHO-statistics for coronary heart disease mortality in men and women from 1980-82 in 38 countries, Finnish men ranked third and Finnish women ranked 15th (5). The aim of the present study was to analyze the construct validity of the
COOK-MEDLEY HOSTILITY, ANGER, TYPE A
1061
Cook-Medley hostility scale in a sample of Finnish students. Another goal of this study was to cross-validate the newly developed subscale, Cynical which is expected to be a more specific measure of cynicism Distrust (9, and distrust than the total Cook-Medley scale.
Respondents were undergraduate students at a Finnish university in central Finland. One-third of the sample were first-year students, one-third were in the second year, and another third were in the third year of an undergraduate degree program. Students were enrolled in both Arts and Science Faculties. The mean age of the students was 22 years (SD = 1.8, N = 219). Seventy-four percent were single, 17% were cohabiting, and 9% were married. One hundred twenty-four smdents were women and 95 were men. Measures All respondents were given questionnaires with the following self-report measures: (a) Hostility (4), (b) the Student Version of the Type A Scale (16), (c) Anger Expression (23), (d) Cynicism ( l l ) , (e) Hostility ( l l ) , (f) Irritability ( l l ) , (g) Ideas of Persecution ( l l ) , (h) Defensiveness ( l l ) , (i) Interpersonal Relationship Scale (21), and (j) Cynical Distrust (9).' Cook-Medley Hostility.-Cook and Medley (4) have constructed the Hostility (Ho) Scale based upon their identification of MMPI items that differentiated teachers with good rapport from those with poor teacher-pupil rapport. Having analyzed the content of the items endorsed by those who scored high on the scale, Cook and Medley (4) describe the hostile person as one who has little confidence in others, sees others as dtshonest, ugly, mean, and unsocial. For Cook and Medley, this kind of "hostility" amounts to chronic hate and anger. The new 9-item cynical distrust measure was computed using the Cook-Medley items as reported by Greenglass and Julkunen (9). This new measure has an acceptable reliability of 0.75. Type A.-The student version of the Jenkins Activity Survey (12) which is a modification for use with student populations (7, 16) was given to assess Type A behavior. Yarnold, Mueser, Grau, and Grimm (25) report that the Student Jenkins Survey has acceptable internal consistency and high retest reliability over a 2-wk. and a 3-mo. period. The Anger Expression (AX) Scale.-In assessing anger, the experience and expression of anger have co be separated. Anger f e e h g s may be expressed in behavior, inhibited, or controlled in many ways. People differ in the extent to which they express their anger openly and in how these feelings are held in. They also differ in the extent to which they try to control their anger. The AX Scale (23) is comprised of 20 items and yields four different scores. The Anger Expression (AXIEX) score, which is based on all 20 items, provides a general index of how often anger is expressed or suppressed, irrespective of the direction of expression. The three AX subscales assess individual differences in the tendency to (a) express anger toward other people or objects i n the environment (AX/OUT), (b) hold in (suppress) angry feelings (AXIIN), and (c) control the experience and expression of anger (AXICON). There are eight items each in the AXIOUTand AX/IN subscales and three items in the experimental AXICON subscale. Cynicism, Hostility, Irriiability, Ideas of Persecution, and Defensiveness (111.-Subjects were also asked to complete items comprising five subscales of the Differential Personality Inventory, a true-false questionnaire designed to assess a relatively normal person's neurotic or emotional disturbance (11). These scales are Cynicism, Hostility, Irritability, Ideas of Persecution, and Defensiveness. According to Jackson and Messick (111, a high scorer on Cynicism is skeptical of the sincerity of other people's motives and believes others are dishonest, unreliable, and only
'All measures were translated into Finnish with permission of the authors.
1062
E. R. GREENGLASS
& J.
JULKUNEN
concerned with their own interests. High scorers on Hostility manifest h g h animosity, frequently antagonize others, and hurt them through malicious conversation or actual conflict. A person scoring high on Irritability is often extremely annoyed by small inconveniences, frustrations, disappointments, or the mannerisms of associates. A person high on Ideas of Persecution believes that certain people are against him and are trying to make his Life unpleasant. This person also feels that others may have power over his thoughts. Highly Defensive individuals try to present themselves in an unrealistically favourable light and deny having common, unfavourable traits. The validity of these subscales is reported by Jackson and Carlson (10) who showed significant correlations between the ratings of an individual's behavior (by self and others) and that person's scores on the Differential Personality Inventory. The interpersonal Rekztionshrp Scale.-The Interpersonal Relationship Scale (21) is intended to measure the quality of interpersonal relationships, particularly, trust and intimacy. This is a 52-item questionnaire with 5-point response alternatives ranging from "strongly agree" to "strongly disagree." Rappaport (19) reported a rest-retest Pearson correlation of 0.92 after administering the scale to 40 subjects (20 married couples) after a 2-mo. interval. Evidence of validity is provided by Schlein (20) as summarized by Ginsberg and Vogelsong (6). For 96 subjects, Schlein (20) noted significant correlations between the scores on the Interpersonal Relationship Scale and a number of measures of communication and the quality of interpersonal relationships.
RESULTS The internal consistency ratings of all of the composite measures were acceptably high-most exceeded 0.70 (7, 15). Table 1 presents means and standard deviations for the composite measures. t tests indicated that there were sex differences on Angerlout, Anger/ Control, AngerlExpression, and Ideas of Persecution. Women were significantly higher than men on Angerlout, Anger/Expression, and Ideas of Persecution. Men had significantly greater Anger/Control. TABLE 1 MEANS,STANDARD DEVIATIONS, A N D f TESTSON AU MEASURES, MENVERSUSWOMEN Measure
Total Sample N: 219 M
Cook-Medley Type A Angerlout AngerIIn Angericon Anger/Ex Irritability Ideas of Persecution Hostility (Jackson & Messick) Cynicism Defensiveness Interpersonal Relatiol Scale
SD
Women n: 124 M SD
Men n: 95
M
t
SD
1063
COOK-MEDLEY HOSTILITY, ANGER, TYPE A
TABLE 2 PEARSONCORRELATIONS BETWEENCOOK-MEDLEY HOSTILITY,TYPEA, CYNICAL DISTRUST SCORES A N D OTHERMEASURES: TOTALSAMPLE,WOMEN,AND MEN Measure
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Total Sample d f = 217 2 1 1 3
Type A Cook-Medley Angerlout AngerlIn Anger/Con Anger/Ex Irritability Ideas of Persecution Hostility (Jackson&Messick) .40$ .29$ .27$ Cynicism .54$ .10 .56$ Defensiveness -.29$-.OO -.23$ Interpersonal Relationship Scale -.33$ .07 -.34$ Cynical Distrust
Women d f = 122 2 1 1
,383 .50$ -.22*
3
.20* .20f .04 .51$ .O1 -.I4
-.37$ -.01
-.36$
2
Men d f = 93 1 1
3
.45$ .40$ .36$ .59$ .17 .61$ -.38$-.04 -.32$ -.28t
.14
-.30t
13. *p
O Psychological Reports
1991
COOK-MEDLEY HOSTILITY, ANGER, AND T H E TYPE A BEHAVIOR PATTERN I N FINLAND ',*" ESTHER R. GREENGLASS York UniversiQ Toronto, Canada
AND
JUHANI JULKUNEN Rehabilitation Foundation Helsinki, Finland
Summary.-According to research, hostility is a reliable predictor of coronary heart disease. Cook-Medley-defined hostility in particular has been seen as a significant precursor of coronary disease. It is important to specify the kind of hostility measured by the Cook-Medley scale. The present study examined the construct validity of the Cook-Medley scale for a sample of 219 university students in Finland, a country with a high incidence of coronary heart disease. The results supported the interpretation of the Cook-Medley scale primarily as a measure of cynicism and distrust. On the basis of our previous research, a subscale of the Cook-Medley scale was formed. This 9-item scale, a measure of Cynical Distrust, correlated positively with cynicism and negatively with trust. Moreover, the over-all pattern of correlations between the new 9-item factor, cynical distrust, and other variables assessing hostility, anger, and trust, was similar to the one obtained for our previous sample of students. I t is suggested that this new %item scale is a shorter and more specific alternative to the longer Cook-Medley scale as a measure of cynical distrust.
The Type A behavior pattern has been shown to predict coronary heart disease independently of traditional risk factors (17). This personality pattern is characterized by competitive drive, a persistent striving for recognition and advancement, involvement in multiple activities involving deadlines, and excessive hostility. While the Type A concept comprises many components, not all of them predict coronary heart disease. So far, research has indicated that one, hostility, is the best predictor of incidence of coronary heart disease (18). Williams, Haney, Lee, Kong, Blumenthal, and Whalen (24) measured Type A behavior and hostility in a group of heart patients. Findings were that the hostility levels were better predictors of coronary blockage than Type A. These findings have been extended in three other studies (1, 2, 22), all indicating that hostility scores predicted both coronary heart disease morbidity and total mortahty. Also, in a rneta-analysis of studies on Type A behavior, Matthews (17) concludes that hostility is a reliable predictor of events of coronary heart disease in population-based prospective studies. 'This research was sup orted by a grant from the Signe and Ane Gyllenberg Foundation to Juhani J u h n e n . ~ r a t e f ? dacknowledgement is also due to the Faculty of Arts, York University @ their support of this research in a grant to Esther Greenglass. Thanks are due to Pirjo Kaikkonen and Markette Kokkinen, University of J vaskyla, Finland, for assistance in collecting the psychological data and to Mirka Ondrack andlthe Institute for Social Research, York University for assistance with the data analyses. Address correspondence to Esther R. Greenglass, Department of Psychology, York University, 4700 Keele Street, North York, Ontario, M3J 1P3, Canada or to Juhani Julkunen, Rehabilitation Foundation, Pakarituvantie 4, SF-00410, Helsinki, Finland.
1060
E. R. GREENGLASS & J. JULKUNEN
While hostility and anger may be predictive of risk of coronary heart disease, at the same time it is important to specify those aspects of hostility and anger that are involved in this relationship. In examining the type of hostility discussed by Cook and Medley (4) and subsequently employed by Williams, et al. (24) and Shekelle, Gale, Ostfeld, and Paul (22), i t is evident that what is being described in their research is a kind of "cynical contempt." The hostility scale seems to reflect an attitude that one cannot depend on others to be honest. I t is important to point out that host&ty, in the sense of a mistrust of others (as defined by Cook-Medley), was not part of the original description of Type A behavior (18). The hostility associated with Type A reflected in the Structured Interview was described as free-floating. Also, the Jenkins Activity Survey, one of the most widely used measures of Type A behavior, contains only a few items which assess anger and hostility. Although Cook-Medley hostility appears to have important health implications, there are relatively few studies of the psychometric properties of the scale or its validity. The items give evidence that the scale covers a broad spectrum of features, ranging from openly expressed aggressiveness to suspiciousness and paranoia. For example, in a study of 132 angiography patients, Blumenthal, Barefoot, Burg, and Williams ( 3 ) concluded that the Cook-Medley hostility scale may be viewed as tapping four general behavioral dimensions including anger and hostility, neuroticism, social maladjustment, and ineffective coping style (Blumenthal, et al. [3]). I t is an empirical question, however, as to which of these dimensions might be predictive of the development of coronary heart disease. I n a study of the inner structure of the Cook-Medley scale, Greenglass and Julkunen (9) report the results of factor analyses of the Cook-Medley hostility scale which yielded a general factor relating to distrust and cynicism. The nine items with the highest loadings on this factor could be added to form a new subscale with a relatively high internal coherence (a= 0.75). This subscale was interpreted as a measure of cynical distrust. While correlating quite highly with the total Cook-Medley scale ( r = ,771, it seemed to be a more pure measure of cynicism (9, p. 216). These results were based on a sample of Canadian students. Moreover, most of the studies of the Type A behavior pattern have been carried out in the United States. I t is important, however, to carry out similar studies in other countries. To the extent that the same pattern of results is obtained, the findings are generalizable. I t is also important to analyze the components of hostility in a country with a high incidence of coronary heart disease. According to WHO-statistics for coronary heart disease mortality in men and women from 1980-82 in 38 countries, Finnish men ranked third and Finnish women ranked 15th (5). The aim of the present study was to analyze the construct validity of the
COOK-MEDLEY HOSTILITY, ANGER, TYPE A
1061
Cook-Medley hostility scale in a sample of Finnish students. Another goal of this study was to cross-validate the newly developed subscale, Cynical which is expected to be a more specific measure of cynicism Distrust (9, and distrust than the total Cook-Medley scale.
Respondents were undergraduate students at a Finnish university in central Finland. One-third of the sample were first-year students, one-third were in the second year, and another third were in the third year of an undergraduate degree program. Students were enrolled in both Arts and Science Faculties. The mean age of the students was 22 years (SD = 1.8, N = 219). Seventy-four percent were single, 17% were cohabiting, and 9% were married. One hundred twenty-four smdents were women and 95 were men. Measures All respondents were given questionnaires with the following self-report measures: (a) Hostility (4), (b) the Student Version of the Type A Scale (16), (c) Anger Expression (23), (d) Cynicism ( l l ) , (e) Hostility ( l l ) , (f) Irritability ( l l ) , (g) Ideas of Persecution ( l l ) , (h) Defensiveness ( l l ) , (i) Interpersonal Relationship Scale (21), and (j) Cynical Distrust (9).' Cook-Medley Hostility.-Cook and Medley (4) have constructed the Hostility (Ho) Scale based upon their identification of MMPI items that differentiated teachers with good rapport from those with poor teacher-pupil rapport. Having analyzed the content of the items endorsed by those who scored high on the scale, Cook and Medley (4) describe the hostile person as one who has little confidence in others, sees others as dtshonest, ugly, mean, and unsocial. For Cook and Medley, this kind of "hostility" amounts to chronic hate and anger. The new 9-item cynical distrust measure was computed using the Cook-Medley items as reported by Greenglass and Julkunen (9). This new measure has an acceptable reliability of 0.75. Type A.-The student version of the Jenkins Activity Survey (12) which is a modification for use with student populations (7, 16) was given to assess Type A behavior. Yarnold, Mueser, Grau, and Grimm (25) report that the Student Jenkins Survey has acceptable internal consistency and high retest reliability over a 2-wk. and a 3-mo. period. The Anger Expression (AX) Scale.-In assessing anger, the experience and expression of anger have co be separated. Anger f e e h g s may be expressed in behavior, inhibited, or controlled in many ways. People differ in the extent to which they express their anger openly and in how these feelings are held in. They also differ in the extent to which they try to control their anger. The AX Scale (23) is comprised of 20 items and yields four different scores. The Anger Expression (AXIEX) score, which is based on all 20 items, provides a general index of how often anger is expressed or suppressed, irrespective of the direction of expression. The three AX subscales assess individual differences in the tendency to (a) express anger toward other people or objects i n the environment (AX/OUT), (b) hold in (suppress) angry feelings (AXIIN), and (c) control the experience and expression of anger (AXICON). There are eight items each in the AXIOUTand AX/IN subscales and three items in the experimental AXICON subscale. Cynicism, Hostility, Irriiability, Ideas of Persecution, and Defensiveness (111.-Subjects were also asked to complete items comprising five subscales of the Differential Personality Inventory, a true-false questionnaire designed to assess a relatively normal person's neurotic or emotional disturbance (11). These scales are Cynicism, Hostility, Irritability, Ideas of Persecution, and Defensiveness. According to Jackson and Messick (111, a high scorer on Cynicism is skeptical of the sincerity of other people's motives and believes others are dishonest, unreliable, and only
'All measures were translated into Finnish with permission of the authors.
1062
E. R. GREENGLASS
& J.
JULKUNEN
concerned with their own interests. High scorers on Hostility manifest h g h animosity, frequently antagonize others, and hurt them through malicious conversation or actual conflict. A person scoring high on Irritability is often extremely annoyed by small inconveniences, frustrations, disappointments, or the mannerisms of associates. A person high on Ideas of Persecution believes that certain people are against him and are trying to make his Life unpleasant. This person also feels that others may have power over his thoughts. Highly Defensive individuals try to present themselves in an unrealistically favourable light and deny having common, unfavourable traits. The validity of these subscales is reported by Jackson and Carlson (10) who showed significant correlations between the ratings of an individual's behavior (by self and others) and that person's scores on the Differential Personality Inventory. The interpersonal Rekztionshrp Scale.-The Interpersonal Relationship Scale (21) is intended to measure the quality of interpersonal relationships, particularly, trust and intimacy. This is a 52-item questionnaire with 5-point response alternatives ranging from "strongly agree" to "strongly disagree." Rappaport (19) reported a rest-retest Pearson correlation of 0.92 after administering the scale to 40 subjects (20 married couples) after a 2-mo. interval. Evidence of validity is provided by Schlein (20) as summarized by Ginsberg and Vogelsong (6). For 96 subjects, Schlein (20) noted significant correlations between the scores on the Interpersonal Relationship Scale and a number of measures of communication and the quality of interpersonal relationships.
RESULTS The internal consistency ratings of all of the composite measures were acceptably high-most exceeded 0.70 (7, 15). Table 1 presents means and standard deviations for the composite measures. t tests indicated that there were sex differences on Angerlout, Anger/ Control, AngerlExpression, and Ideas of Persecution. Women were significantly higher than men on Angerlout, Anger/Expression, and Ideas of Persecution. Men had significantly greater Anger/Control. TABLE 1 MEANS,STANDARD DEVIATIONS, A N D f TESTSON AU MEASURES, MENVERSUSWOMEN Measure
Total Sample N: 219 M
Cook-Medley Type A Angerlout AngerIIn Angericon Anger/Ex Irritability Ideas of Persecution Hostility (Jackson & Messick) Cynicism Defensiveness Interpersonal Relatiol Scale
SD
Women n: 124 M SD
Men n: 95
M
t
SD
1063
COOK-MEDLEY HOSTILITY, ANGER, TYPE A
TABLE 2 PEARSONCORRELATIONS BETWEENCOOK-MEDLEY HOSTILITY,TYPEA, CYNICAL DISTRUST SCORES A N D OTHERMEASURES: TOTALSAMPLE,WOMEN,AND MEN Measure
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.
Total Sample d f = 217 2 1 1 3
Type A Cook-Medley Angerlout AngerlIn Anger/Con Anger/Ex Irritability Ideas of Persecution Hostility (Jackson&Messick) .40$ .29$ .27$ Cynicism .54$ .10 .56$ Defensiveness -.29$-.OO -.23$ Interpersonal Relationship Scale -.33$ .07 -.34$ Cynical Distrust
Women d f = 122 2 1 1
,383 .50$ -.22*
3
.20* .20f .04 .51$ .O1 -.I4
-.37$ -.01
-.36$
2
Men d f = 93 1 1
3
.45$ .40$ .36$ .59$ .17 .61$ -.38$-.04 -.32$ -.28t
.14
-.30t
13. *p
