Journal of Psvcho.somurh Prmted m Great Bntain.

Remmh.

Vol.

34. No

4. ,,p.

3935399.

1990

00??-39Y9:90 163 00 + .oo dj 1990 Pergamon Press plc

INDIVIDUAL AND CROSS-SPOUSE CORRELATIONS OF PERCEPTIONS OF FAMILY FUNCTIONING, BLOOD PRESSURE AND DIMENSIONS OF ANGER LINDA MUSANTE, FRANK A. TREIBER, WILLIAM B. STRONG and MAURICE LEVY (Receil>cd 30 Augusl

1989: accepted 22 Nol%emher 1989)

Abstract-individual and cross-spouse correlations of perceptions of family cohesiveness, emotional expressiveness and conflict with blood pressure and five dimensions of anger were examined in 85 couples. Wives’ perceptions of family cohesiveness were negatively related to their diastolic blood pressure. whereas husbands’ perceptions of all three dimensions of family functioning were unrelated to their blood pressure. Cross-spouse correlations showed that both husbands’ and wives’ perceptions of emotional expressiveness were negatively related to their spouses’ blood pressure, and husbands’ perceived family cohesiveness was negatively related to wives’ diastolic blood pressure. Individual and cross-spouse correlations with dimensions of anger were also obtained. These findings are discussed in terms of prior cross-spouse correlational research. and gender differences in the pattern of relationships are discussed.

INTRODUCTION EPIDEMIOLOGICAL research has identified a number of attributes that increase an individual’s risk for cardiovascular disease (CVD), including age, blood pressure, smoking, cholesterol and components of the Type A behavior pattern, particularly anger and hostility [l]. Since even the best combination of these individual characteristics does not predict most new cases of CVD [2], investigators have recently begun to look for environmental and situational correlates of CVD risk. Most of this research has focused on aspects of the work environment, such as job overload and stress [3]. Less attention has been given to the impact of marital and family environments on cardiovascular health. A notable exception in this regard is a recent series of studies on the cross-spousal correlates of CVD risk. This research adopts a systemic approach by assuming that the family constitutes a dynamic interactive system [4] in which one member’s CVD risk may be influenced by sociodemographic and behavioral characteristics of other family members and/or patterns of relationships among members [5]. In analyses of data from the Framingham Heart Study, Haynes, Eaker and Feinleib [6] found that coronary heart disease (CHD) incidence was higher among men whose wives were educated beyond high school and employed outside the home. Further analyses showed heightened CHD risk only among blue collar Type A males whose wives were Type B and employed, while white collar Type A males’ CHD risk was unrelated

Departments of Pediatrics. Psychiatry and Health Behaviors and the Georgia Institute for the Prevention of Human Disease and Accidents, Medical College of Georgia, Augusta, Georgia 30912-3770. U.S.A. Address all correspondence to Frank A. Treiber, Ph.D., Georgia Prevention Institute, Medical College of Georgia, Augusta, Georgia 30912-3770, U.S.A. This research was supported by funds from the National Heart. Lung and Blood Institute (HL 35073, HL 41781). 393

394

LINIIA MUSANTE et

~1.

to their wives’ attributes [7]. Cross-sectional studies that compare CHD case and non-case couples have found CHD case wives to be more dominant, active, less flexible [3] and more socially mobile and pessimistic [8] than the wives of non-case husbands. Cross-spouse associations have also been obtained for CVD risk factors such as blood pressure (BP). Carmelli, Swan and Rosenman [5] found significant correlations between one spouse’s personality characteristics (measured by the Thurstone Temperament Scale) and his/her partner’s blood pressure. Specifically, the systolic blood pressure (SBP) of husbands was positively associated with their wives’ preference for planning and order. and negatively correlated with their impulsivity. Wives’ SBP was positively correlated with their husband’s dominance. In a conceptually similar study of a larger and more heterogeneous sample, Carmelli et al. [9] found that wives’ speed of activity and perceptions of workload and social support were positively correlated with their husband’s SBP. Interestingly, these attributes in husbands were related to wives’ diastolic, rather than systolic blood pressure. Collectively, these studies show that an individuals’ CVD risk is influenced not only by his.or her own attributes, but by the characteristics of other individuals with whom he or she frequently interacts. One limitation of the cross-spouse research to date is that it has focused only on individual characteristics, which ignores the potential influence that characteristics of the relationship itself may have on CVD risk. For many individuals, the marital or family relationship is a primary source of social interaction and support, as well as a major source of conflict and stress. Marital partners interact in the context of an interdependent social relationship. and beliefs about the quality and dynamics of this environment may be at least as strongly associated with CVD risk as are the attributes of the individual partners. The present study examined whether perceptions of family functioning are associated with CVD-relevant physical and psychosocial attributes in marital partners. As part of a longitudinal study on the development of CVD risk factors in families, we have obtained data on husbands’ and wives’ perceptions of family cohesiveness. emotional expressiveness and conflict. Individual and cross-spouse correlations between these family functioning variables, blood pressure and dimensions of anger were examined. These attributes were chosen because they have been empirically associated with CVD [I, IO].

METHOD

Subjects were 85 middle-class couples who are parents of children participating in a 5-year multi-sate study of the development of CVD risk factors in children (Project SCAN-Studies of Children’s Activity and Nutrition). Family Health History questionnaires were administered to 24.882 preschool through 8th grade children in the Richmond County Georgia public school system in March 1986. From the 13,990 completed questtonnanes. famtlies were recruited for participation in the SCAN study using the following criteria: (I) documented positive or negative history of CHD; (2) one or more children 3 or 4 years of age at the time of the screening: (3) parents not students or in military service.* *For mote detail regarding

the recruitment

and characteristics

of the SCAN sample see Treiber ct a/. [I I].

Family

functioning,

blood

pressure

and anger

395

All husbands and wives were seen by a research assistant on four occasions during a period of two and a half years. The third assessment took place in a laboratory setting and all other assessments were conducted in the families’ homes. The first three visits were separated by approxtmately six months (+ 2.6 months) and the fourth visit occurred one year (k2.3 months) after the third visit. Both parents had height. weight. skiniold measurements and blood pressure assessed on each visit. After completion of the vital,‘anthropometric assessment the parents individually completed various CVD-related lifestyle questionnaires. The questionnaires used in the current study were administered on the second visit.

~umi/~,/irncfionin~. Perceptions of family functioning were measured with the Family Relations Index (FRI: [12]). The FRI was derived from the Family Environment Scale [13]. and contains three IO-item subscales that tap: (1) family cohesiveness. which is the extent to which family members support one another (e.g. ‘There is a feeling of togetherness in our family’); (2) emotional expressiveness, which is the degree to which members openly express their feelings (e.g. ‘Family members often keep their feelings to themselves’): and (3) conflict. which is the degree to which family members fight (e.g. ‘We fight a lot in our family’). The FRI has been shown to have adequate internal consistency (alpha = 0.89) and 12 month test-retest reliability (0.66; 12). A,iger. Dimensions of anger were measured with the 38-item Multidimensional Anger Inventory (MAI; 14). which was developed to measure anger as a multidimensional construct. Siegel’s factor analysis of the scale items produced five dimensions of anger [14]. Two of these, anger-in/brood and anger-out/brood, tap the suppression and expression of feelings of anger, respectively. Both of these dimensions have been associated with manifestations ofCVD, including CHD and hypertension [IO]. The three other MA1 scales measure: (I) frequency and ease of becoming angered (general anger); (2) situations that are likely to provoke anger (range of anger-eliciting situations); and (3) resentful and suspicious attitudes toward others (hostile outlook). Internal consistencies of the MA1 subscales are acceptable (alphas = 0.64-4.84), and preliminary evidence for the convergent and discriminant validity of the scale is encouragmg [14].

Individual readings of blood pressure are often unreliable because of variability in such factors as location (i.e. home, physician’s office) and method of assessment [15]. In order to attain as stable an estimate of resting blood pressure as possible, a composite score was computed by averaging the four sets of blood pressure readings that were obtained over the two and a half year interval. Blood pressure measures were taken by research assistants based on the American Heart Association guidelines [16]. The subject was seated, the right arm placed at heart level, and after a 5 min rest period, three readings of systolic and diastolic blood pressure were taken at 2 min intervals. The mean of the three readings was used to represent each set of measurements in the data analyses. A Marshall Medical Mercury Sphygmomanometer (Model 100 Velcro) was used for BP assessment during the first two visits and the fifth phase Korotkoff sound used for assessment of DBP. Dinamap Model 1864SX Adult/Pediatric Vital Signs Monitors (Critikon. Inc., Tampa, FL) were used during the last two visits. The Dinamap has been validated with significant correlations obtained between its readings and simultaneous intra-arterial and mercury sphygmomanometer readings [17]. Research assistants received extensive instruction in the use of both instruments. Their training with the Marshall sphygmomanometer included successful completion of a videotaped BP assessment test (developed by Henry Kahn. M.D.. Emory University) and periodic inter-observer reliability checks using a Hawksley random zero sphygmomanometer and the double stethoscope method.

RESULTS

Table I displays the intercorrelations of husbands’ and wives’ scores on the family functioning variables, BP, and the MAI scales. * Significant correlations were obtained between husbands’ and wives’ perceptions of family cohesiveness, expressiveness and conflict. There was no relationship between spouses’ BP, and only the MAI Range of anger-eliciting situations scale was significantly correlated for spouses. *The data from 20 husbands were incomplete because they had two or fewer sets of blood pressure readings. Correlations involving husbands’ BP are thus based on a sample size of 65. No difference in FRI or MA1 scores between these husbands and those who had all readings were observed.

396

LINDA MUSANTE~~

al.

TABLE I.-SPOUSE-PAIR CORRELATIONS OE FAMILY FUNCTIOISIKG VARIABLES, BLOOD PRESSURE AND ANGER DIMENSIONS

FRI scales Cohesiveness Expressiveness Conflict

o.L%** 0.47** 0.4x**

BP SBP DBP

0.05 0.10

MA1 scales General anger Range of anger Hostile outlook Anger-in/brood Anger-out!brood

0.09 0.31* 0.16 0.24 0.07

*p < 0.05. **p < 0.01.

Table II shows individual and cross-spouse correlations of husbands’ and wives’ perceptions of family functioning with BP and anger. Among wives, perceptions of family cohesiveness and emotional expressiveness were negatively related to their BP (SBP and DBP). On the other hand, husbands’ perceptions of family functioning were unrelated to their own BP. Cross-spouse correlation coefficients (husbands’ perceptions of family functioning with wives’ attributes and vice versa) showed that both husbands’ and wives’ perceptions of family emotional expressiveness were negatively correlated with their spouses’ SBP and DBP. Also, husbands’ perceptions of cohesiveness were negatively related to their wives’ DBP. Table I II displays individual and cross-spouse correlations of husbands’ and wives’ perceptions of family functioning and MAI-assessed dimensions of anger. Wives’ perceptions of cohesiveness and emotional expressiveness were negatively associated with their levels of general anger, hostile outlook, anger-in and anger-out, and their perceptions of conflict were positively related to their levels of general anger, hostile outlook and anger-in. Similar relationships between perceived emotional expressiveness and the anger dimensions were obtained for husbands. However, for the husbands only anger-out was associated with perceived cohesiveness, and perceived conflict was not associated with any of the anger scales. TABLE

II.--I~UIVIIICAL AW C‘ROSS-SPOUSE CORRLLATIONS OF FUNCTIONING WITH BLOOD PRESSURF

Husband Cohesive Husband SBP DBP Wife SBP DBP

*p < 0.05. **p

< 0.01,

Expressive

PERUPTI~NS

OF FAMILY

Wife Conflict

Coheswe

Expressive

Conflict

0.04 0.00

0.10 0.09

0.00

-009

-0.25*

0.06

- 0.15

-0.20*

-0.07 0.12

-0.12 -0.20*

-0.22* -0.25*

0.06 0.10

-0.17* -0.20*

-0.21* -OX**

-0.01 -0.05

Family

functioning,

blood

pressure

and anger

391

TABLE III.-INDIVIDUAL AND CROSS-SPOUSE CORRELATIONSOF PERCEPTIONS OF FAMILY FUNCTIONING WITH ANGERDIMENSIONS

Wife

Husband Cohesive

Expressive

Conflict

Husband General anger Range of anger Hostile outlook Anger-in/brood Anger-out/brood

-0.06 -0.05 -0.05 -0.06 -0.29*

-0.28* -0.28* -0.33** - 0.30* -0.08

0.15 0.11 0.18 0.10 0.14

Wife General anger Range of anger Hostile outlook Anger-in/brood Anger-out/brood

-0.29* 0.03 -0.11 -0.21 -0.08

-0.16 -0.03 -0.08 -0.16 ~ 0.04

0.29* 0.03 0.12 0.27* 0.03

Cohesive

Expressive

Conflict

-0.04 -0.02 -0.10 -0.02 -0.17

-0.12 -0.14 -0.14 -0.10 0.02

0.17 0.12 0.11 0.05 0.30*

-0.48** -0.11 -0.35+* -0.44** -0.26*

-0.37: -0.06 -0.26* -0.40* -0.31*

0.48* 0.14 0.37’ 0.35* 0.16

*p < 0.05. **p < 0.01.

Few significant cross-spouse correlations between the family functioning variables and the anger dimensions were obtained. Wives’ general anger scores were negatively related to their husbands’ perceptions of cohesiveness and positively related to their perceptions of family conflict. Husbands’ conflict scores were positively associated with wives’ anger-in scores, but wives’ perceptions of conflict were positively associated with anger-out in their husbands.

DISCUSSION

In the present study significant relationships were obtained between one partner’s perceptions of emotional expressiveness in the family and his/her spouse’s blood pressure. The more emotionally expressive a husband or wife perceived the family to be, the lower was his/her spouse’s SBP and DBP. Interestingly, while wives’ perceptions of expressiveness were negatively related to their husband’s (and their own) BP, husband’s perceptions of expressiveness were negatively related to their wive’s BP, but unrelated to their own. These results parallel those of Carmelli et al. [9], who found cross-spousal correlates of blood pressure in perceptions of social support, speed of activity and workload. In that study, however, husbands’ attributes predicted wives’ DBP and wives’ attributes were related to their husbands’ SBP, whereas we found parallel relationships for SBP and DBP. There were few significant cross-spouse correlations between the family functioning variables and dimensions of anger, but where relationships were significant, interesting gender differences occurred. This was particularly true for the relationship between perceived family conflict and anger expression. Both husbands’ and wives’ perceptions of conflict were positively related to wives’ anger-in, which is a measure of anger suppression. On the other hand, wives’ conflict scores were positively related to husbands’ anger expression, rather than suppression. These data are correlational, therefore the causal direction of the relationship between family conflict and anger coping style cannot be determined. Conflict among marital partners may result in the adoption of different styles to deal with negative affect that occurs with conflict,

such that husbands outwardly express these feelings while wives suppress them. This would be consistent with traditional gender-role stereotyping that deems it inappropriate for females to openly express negative affect. However, research on marital relationships has found wives more likely to explicitly acknowledge marital conflict than their husbands [18]. It is also possible that differences in how marital partners express their anger may produce conflict and stress in the relationship. Swan, Carmelli and Rosenma? [3] found that CHD case couples were dissimilar in personality traits, while non-CHD case couples were similar in traits re!ated to social behavior. Also, dissimilar personality characteristics have been found to typify recovering male MI patients and their wives [I91 and couples whose marriages are unstable [20]. These significant cross-spouse associations between blood pressure and attributes of family functioning provide further evidence for the relationship between emotional expressiveness and physical health. Also interesting were differences in the relationships between the family functioning variables and anger dimensions for husbands and wives. These relationships were generally stronger for wives than husbands. Higher scores on emotional expressiveness were associated with lower scores on all dimensions of anger for husbands and all but the range of anger scale for wives. However. wives’ perceptions of greater cohesiveness and less conflict were also associated with lower scores on some of the anger dimensions, which was not the case for husbands. Again, it cannot be determined whether healthy family relationships reduce anger and hostility among women, whether less hostile and/or angry women create or promote healthy family relationships, or an interaction of both occurs. In any event, these findings may be related to gender difrerenccs in the role of the family. A woman’s identity has traditionally been largely defined in terms of the characteristics and quality of her family/interpersonal relationships [21]. Given a traditionally stronger family orientation among women, perceptions about the quality of this relationship may have a stronger association with a woman’s personality attributes than they do with a man’s, This may also explain the stronger relationships between perceptions of family functioning and BP among wives. It was also interesting to observe that marital parLners’ perceptions of their families were only moderately correlated. While some couples had very similar views of their family’s cohesiveness, expressiveness and conflict, others showed substantial disagreement in their perceptions of the same environment. Future research might examine the intuitively plausible hypothesis that the extent of agreement between spouses about their marital or family relationship is correlated with indices of physical health. Finally. future research should continue to adopt a family-based approach in studying CVD risk factors. Consideration of the attributes of individuals in one’s immediate social milieu may account for some of the variance in CVD risk that is not adcounted for by classic risk factors. Furthermore, even classic CVD risk factors might be better understood from a family systems perspective. For example, while it is known that family dynamics in part predict the success of weight loss programs [22], less is known about the influence of familial/marital factors on the development of obesity [23]. Anger and hostility, which have long been believed to play a role in CVD [IO], might also be better understood through a systemic approach. Anger is most likely to occur in the context of meaningful social relationships [24], and closer

Family

examination of this context and physical health.

functioning.

blood

pressure

may help clarify

and anger

the relationship

399

between

this emotion

il(.klzO,~k,f~~~rnent.v~The authors wish to express their gratitude to Pamela Hawkins and Brigid Parsley for secretarial assistance, David Soul. Jennifer Kenrick, Ellen Wilson and Leonteen McNeal for collection of data and Thomas Rhodes for statistical support. REFERENCES I

7

8

9 IO.

1I. 12. 13. 14.

15.

16 I7 I8 19 20 21 22 23 24

D~MBR~SKI TM. Overview of classic and stress-related risk factors: Relationship to substance effects on reactivity. In Hmdhook of’Stress, Reucrivity and Cardioroscular Disease (Edited by MATTHEWS KA. WFISSSM. DETRA T, DEMBR~SKITM. FALKNER B. MANUCK SB and WILLIA~IS RB). New York: John Wiley and Sons, 1986. JENKIXS CD. Recent evidence supporting psychologic and social risk factors for coronary disease. II’ Gzgl J Mcd 1976; 294: 987 ~994. 1033 1038. SWAN GE, CARMELLI D, R~SENMAN RH. Spouse-pair similarity on the California Psychological Inventory with reference to husband’s coronary heart disease. Ps~~chosorn Med 1986; 48: 172-186. GOTTMAN JM. Murirul Intmmion: E.~pcvinxwtu/ Inws/ip/ion.r. Academic Press: New York. 1979. CARMELLI 0, SWAN GE. ROSENMANRH. Cross-family correlates of blood pressure in the Western Collaborative Group Study. J Behur &fed 1986; 9: 325~-340. HAYNES SG, EAKER ED, FEINLEIBM. Spouse behavior and coronary heart disease in men: Prospective results from the Framingham Heart Study I. Concordance of risk factors and the relationship of psychological status to coronary incidence. Am J Epidmliol 1983; 118: l--22. EAKEK ED, HAVVESSG, FEINLEIBM. Spouse behavior and coronary heart disease in men: Prospective results from the Framingham Heart Study II. Modification of risk in Type A husbands accordmg to the social and psychological status of their wives. Am J Epidemiol 1983; 118: 2341. C~RMELLI D. SWAK GE. ROXNMAN RH. The relationship between wive’s social and psychological statvs and their husband’s coronary heart disease: A cast-control family study from the Western Collaborative Group Study. Am J Epidemml 1985: 122: 90 100. CARMELLI D, SWAN GE, HUNT SC. WILLIAMS RR. Cross-spouse correlates of blood pressure in hypertension-prone families in Utah. J Ps~~cho.som Rcs 1989; 33: 75-84. DI.AMONI~ EL. The role of anger and hostility in essential hypertension and coronary heart disease. P.sI.(./I Bull 1982; 92: 410 433. TKEIUERFA. MABL PA. RILCY WT. MrDupp~~ M. STROVC WB. LEVYM. Children’s Type A behavior: The role of parental hostility and family history of cardiovascular disease. J Pm Sot Bchnr, 1990; 5: 183 199. H~LLAHAN C. Moos RH. Social support and adjustment: Predictive benefits and social climate indices. Am J Convmn P.~wh 1982; IO: 403 415. Moos RH, Moos BS. F&;/V Emironwmi SW/~ Manutrl (2nd Edn). Palo Alto, CA: Consulting Psychologists Press. 1986. SIEGELJM. The measurement of anger as a multi-dimensional construct. In Angrr md Hostility in Cordim rr.scu/rr und Brhac~iorcrl Dmrdws (Edited by CHFSNEY MA and ROSENMANRH). New York: Hemisphere Publishing Corporation. 1985. MANUA CT, FFRRAKI A. GRFC~ORINIL. PORATI G, POMIIIOSSIG, BER~IN~ERSG, GRASSI G. RIETXXIM. PEDOTIIA, ZAX~HEXI A. Blood pressure and heart rate variabilities in normotensive and hypertensive human beings. Gin Rev 1983; 53: 96-104. KIRKIXUALL WM. F~INLEIB M. FRESIS E. MARK A. Recomr?lendatio,,.r for Human Blood frr.wuw Det[,rnli/ltrtron.F /I), Sph~~~Sr,zomuilonIctrr.\. Dallas: American Heart Association, 1980. PARK MK. MEXARU SM. Accuracy of blood pressure measurement by the Dinamap Monitor in infants and children. Pediutrics 1987; 79: 907-914. GcrrThfAii JM. KROKOFF 1-J. Marital interaction and satisfaction: A longitudinal view. J Cr~rzsul/ C/in Psyhol 1989: 57: 47 -52. C&O