Journal of Psychosomatic Research 61 (2006) 33 – 39

Hostility, anger, and sense of coherence as predictors of health-related

quality of life. Results of an ASCOT substudy
Juhani Julkunen4, Richard Ahlstrfm
University of Helsinki, Helsinki, Finland
Received 15 June 2005; received in revised form 21 November 2005; accepted 13 December 2005

Abstract
Objective: The aim of this study was to investigate the
relationship of hostility and anger expression to sense of coherence
(SOC) and their role as predictors of health-related quality of life
(HQL). It was hypothesised that SOC would mediate the impact of
hostility and anger on HQL. Methods: This is a substudy of the
Anglo-Scandinavian Cardiac Outcomes Trial, which evaluates
different treatment strategies to prevent cardiovascular disease in
hypertensive patients. At baseline, SOC was assessed with a short
form measure, and hostility–anger with the Cynical Distrust scale
and with the Anger Expression scales. HQL was assessed
at 6 months with the RAND-36. The sample comprised of
774 subjects (77.5% men). Results: Results showed that strong
SOC associates with ability to control expression of anger and with
low levels of suppressed or openly expressed anger. Anger control
and SOC were related to good HQL; cynicism, anger-out, and
anger-in correlated negatively with HQL. Path models revealed
that SOC was the strongest predictor of HQL while hostility and
anger lost their direct impact on HQL. Conclusions: Given the
significant associations of hostility and anger with SOC, it is con-
cluded that the salutogenic theory of Antonovsky (A. Antonovsky,
Health, Stress, and Coping: New Perspectives on Mental Health
and Physical Well-Being, Jossey-Bass Inc, San Francisco, 1979)
should be extended to include hostility-related constructs. The
impact of hostility and anger on HQL is, to a great extent,
mediated through SOC, which implies that in future studies, the
role of hostility as a risk factor of ill health should be reconsidered
from the SOC theory perspective.
D 2006 Elsevier Inc. All rights reserved.

Keywords: Anger expression; Cardiovascular diseases; Health-related quality of life; Hostility; Sense of coherence

Introduction which supports the main arguments of Antonovsky’s theory

One of the most interesting theoretical constructs in
psychosomatic research during the last couple of decades
has been the sense of coherence (SOC) concept introduced
by Antonovsky [1,2]. SOC has been defined as a global
orientation based on a person’s pervasive confidence that
internal as well as external stimuli are structured and
predictable; that the resources needed to meet these
demands are available; and that these demands are seen as
challenges, worthy of investment, and engagement [2].
Tentative research evidence seems to be accumulating,
4 Corresponding author.
about SOC as a health promoting, salutogenic factor [3– 6].
However, several questions about the facets of SOC
as well as about the possible mediating factors remain to
be answered. For example, the SOC construct has been
criticised as a purely cognitive theory leaving important
determinants of health—such as emotions—outside of the
domain of the construct [7]. So far, the main link from SOC
to health has been supposed to work through adaptive and
flexible coping resources [2]. At the same time, very little
empirical research has been accomplished to clarify the
relation of SOC with other well-established psychological
determinants of health. For example, various facets of
hostility and anger have been shown to be risk factors of

0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpsychores.2005.12.005
34 J. Julkunen, R. Ahlström / Journal of Psychosomatic Research 61 (2006) 33 – 39
Fig. 1. A hypothetical model of predictors of HQL.
ill health, the evidence being especially strong for cardio-
vascular diseases (see, e.g., Refs. [8,9]).
From that point of view, it is surprising that so little
research has been devoted to explore the possible relation of
these constructs. For example, in the study by Pallant and
Lae [10], the construct validity of SOC was examined by
correlating it with a number of indicators of self-reported
health and measures of personality and coping, but no
measure of hostility or anger was included.
So far, there seems to be only one study, which has
directly focused on the joint impact of hostility and SOC on
health [5]. In that longitudinal study, self-rated health and
records of sickness absences were used as outcome variables.
The authors concluded that low SOC might be an important
factor partially explaining the adverse effect of hostility on ill
health. The main limitations of this study were that it was
based on women only, and their measure of hostility was a
narrow, three-item scale essentially assessing irritability [5].
Thus, there seems to be an obvious paucity of research
into the relation of different facets of hostility and SOC.
Even in Antonovsky’s key text on SOC, the hostility
concept is mentioned in only one sentence (Ref. [2], p. 6)
and anger, not even once. Moreover, given that hostility and
anger are well-established risk factors of ill health, and high
SOC is supposed to be a protective factor, it seems highly
interesting to explore in detail how these constructs are
interrelated and what is their impact on health and health-
related quality of life (HQL).
Considering the psychological theories on anger and
hostility together with the SOC construct, it seems logical
to expect that they were related: high SOC would probably
involve ability to control anger and to express it in a
constructive way. At the same time, one could hypothesize
that extreme tendency to openly expressed anger, or excess
inhibition of anger expression regardless of the actual sub-
jective experience of the emotion, would correlate negatively
with strong SOC. Furthermore, the general level of hostile
tendencies, as expressed by the cognitive component of
hostility, i.e., by high levels of cynicism, could be expected to
associate negatively with high SOC (for more thorough dis-
cussion on these concepts; see, e.g., [11–13]). Finally, based
on previous results by Kivim7ki et al. [5] and Surtees et al.
[6], it was hypothesized that SOC would be the key deter-
minant of HQL mediating the impact of hostility- and anger-
related factors on HQL, as illustrated schematically in Fig. 1.
In sum, the aim of this study was to investigate the
relationships of cynicism and anger expression with SOC
and their role as determinants of HQL. Based on the recent
findings on gender differences in HQL [14] and in SOC
[10], special attention was paid in this study to compare the
possibly different correlative patterns of the study variables
in men and women.
Methods
This study is part of a substudy of the Anglo-
Scandinavian Cardiac Outcomes Trial (ASCOT), which
examines prevention of coronary heart disease (CHD) and
vascular events by blood-pressure-lowering and by choles-
terol-lowering therapy. Inclusion criteria for the ASCOT
cohort were elevated blood pressure and three other risk
indicators of cardiovascular diseases; a more detailed
description of the inclusion criteria, design, and methods
of the main study have been published elsewhere [15].
The present substudy monitored changes in HQL during a
2-year follow-up in the Finnish sample in the ASCOT trial,
as well as psychosocial risk factors of CHD in long-term
follow-up [16]. The focus of this part of the substudy was to
establish personality factors related to SOC and, supposedly,
to predict HQL 6 months after baseline assessments.
Psychological factors and HQL were assessed using a
self-report questionnaire, which was given to participants at
the screening visit, to be returned in a reply paid envelope.
Follow-up questionnaires to monitor changes in HQL were
administered to participants at the 6-month follow-up visit.
For the present analysis, the 6-month follow-up was chosen
because we tried to minimise the common variance
contamination of hypothesised predictors with the outcome
measure likely to occur with self-report methods.
At the screening visit, a leaflet and oral information
about the present substudy was given to potential partic-
ipants together with the questionnaire. Concomitantly, it
was made clear that nonresponse would not in any way
influence their participation to the main study. Exclusion
criteria for this substudy were notable difficulties in under-
standing spoken and/or written Finnish and refusal to
participate. The study plan was approved by the ethical
committees concerned.
Measures
In addition to items covering relevant sociodemographic
data (e.g., education and marital status), the following self-
report measures were included in this study:
 J. Julkunen, R. Ahlström / Journal of Psychosomatic Research 61 (2006) 33 – 39 35

Table 1 while the Mental Component Summary (MCS) equals the

Summary of sociodemographic variables of the study sample (n = 774)
mean value of the four psychosocial subscales, i.e., scales
Sociodemographic variable % 5 to 8. This procedure has been indicated by several
Gender previous studies on RAND-36 [24 –26].
Male 77.5
Female 22.5
Education
Primary school 71.8 Subjects
Secondary school 18.0
High school 10.2 A total of 929 subjects (39% of those who volunteered to
Marital status participate in the main study) agreed to participate in this
Single 6.0 substudy and returned the baseline questionnaire. Due to
Married/cohabiting 77.4
missing data (n =44) or not meeting the inclusion criteria
Divorced 10.6
Widowed 6.1 (n =44) in later checking, 88 questionnaires were excluded
from the final baseline study sample (N = 841). Out of them,
774 (92.0%) subjects returned the 6-month follow-up
Cynicism, the cognitive component of hostility, was questionnaire: men, 600 (77.5%) and women, 174
assessed with the 8-item Cynical Distrust Subscale derived (22.5%); they were included in the present study. Mean
from the Cook-Medley hostility scale [17]. In previous age of the sample was 60.3 years (S.D., 7.9, range, 40 –79).
research, this scale has been shown to predict 2-year A summary of the sociodemographic variables is presented
progression of carotid atherosclerosis [18] as well as incident in Table 1.
myocardial infarction and mortality [8]. The internal Mean age for men was 59.6 years (S.D., 7.98), and for
consistency (Cronbach’s alpha) in this sample was 0.80. women, 62.5 years (S.D., 7.21). Women were significantly
Anger expression, another facet of the general hostility older than men (t = 4.35, P b.001). In the level of education,
construct, was measured by the 24-item Spielberger Anger there was no significant gender difference. For the later
Expression scale [12]. It has been widely used in studies of statistical analyses, marital status was dichotomised into
psychological risk factors of CHD, as well as in studies of persons living alone (single, divorced, and widowed) and
coronary patients. It yields three subscales [anger-out into those cohabiting (married/cohabited). There were more
(AX-out), anger-in (AX-in), and anger control (AX-con)]. cohabiting men (82.1%) than women (60.9%) in the sample
The Finnish adaptation has been shown in previous studies ( P b.001).
to have good psychometric properties [19]. In the present
sample, Cronbach’s alpha coefficients for the subscales were
as follows: AX-in: 0.69, AX-out: 0.79, and AX-con: 0.88. Statistical analyses
Sense of coherence was assessed with a short, 12-item
version of the original scale. It covers the three components Chi-square and t tests were used to test gender differ-
of the SOC concept: i.e., comprehensibility, manageability, ences. Relations of study variables were explored with
and meaningfulness [20]. The 12-item version is identical to Pearson’s correlation coefficient. Predictors of HQL for
the frequently used 13-item shortened version except of one men and women were analysed by using path analysis of
item (item 25 in the original scale). In our other studies, the the LISREL 8.50 software [27]. All other analyses were
12-item scale has been shown to have good psychometric performed with the SPSS 11.0 software package. Accord-
properties; in this study, the internal consistency of the SOC ing to the SOC theory (1–2), age, level of education
scale was good (Cronbach’s alpha=0.85). (1=elementary. . .3 =high school), and living alone versus
Health Related Quality of Life was assessed at baseline cohabiting were included in path analyses as possible
and at 6 months with the Finnish adaptation of the RAND-
36 generic HQL scale, for which there are reliability data Table 2
and reference values available for the Finnish population Mean values (S.D.) of baseline psychological variables and quality of life
[21]. The RAND-36 is a widely used and validated scale, summary scores at 6-month follow-up
which yields scores for eight dimensions of HQL: (1) Variables Women (n=174) Men (n=600) Pa
general health, (2) physical functioning, (3) role function- Anger expression:
ing/physical, (4) bodily pain, (5) emotional well-being, (6) AX-con 24.89 (4.54) 25.00 (4.65) .791
role functioning/emotional, (7) social functioning, and (8) AX-in 16.90 (3.56) 16.41 (3.43) .099
energy. The scores for each domain range from 0 to 100, 0 AX-out 14.16 (3.12) 15.09 (3.54) .002
Cynical distrust 18.64 (4.34) 19.41 (4.04) .031
being the poorest and 100, the best possible health status SOC 61.76 (11.29) 62.36 (10.70) .527
[22,23]. To reduce the number of outcome variables in Quality of life:
multivariate analyses, two summary scores were used: the PCS 61.23 (20.88) 69.08 (19.87) .000
Physical Component Summary (PCS), which equals the MCS 68.01 (21.35) 74.39 (19.20) .000
a
mean value of the physical, i.e., the four first subscales Independent samples t test.
36 J. Julkunen, R. Ahlström / Journal of Psychosomatic Research 61 (2006) 33 – 39

Table 3
Correlations between study variables by gendera
1. 2. 3. 4. 5. 6. 7. 8. 9.
1. Age .12 .04 .2444 .194 .09 .2344 .12 .02
2. Education .1444 .2044 .01 .07 .09 .12 .06 .11
3. Cynical distrust .1344 .1844 .3544 .09 .14 .2244 .09 .2044
4. SOC .07 .01 .2944 .3144 .3944 .3144 .2744 .4944
5. AX-con .02 .03 .08 .3644 .11 .5744 .10 .2444
6. AX-in .05 .084 .1644 .4144 .1744 .06 .03 .14
7. AX-out .084 .04 .1444 .2844 .6344 .2044 .08 .154
8. PCS (6 months) .1744 .2044 .1944 .2344 .1144 .104 .04 .6944
9. MCS (6 months) .04 .04 .2444 .4644 .2344 .2444 .1744 .6444
a
Men (n=600) below diagonal; women (n=174) above diagonal.
4 Pb.05.
44 Pb.01.

confounding factors. In previous studies, these factors have
also been shown to relate with HQL [21,26].
Results
Mean values of the baseline psychological variables and
the 6-month HQL composite scores for men and women are
presented in Table 2.
There was a statistically significant gender difference in
the mean values for PCS and MCS, showing considerably
lower quality of life scores for women. Comparison with
population-based reference values [21] also indicated that
women in this sample had more limitations in their
functional capacity than the population sample. Statistically
significant gender differences were also found in AX-out as
well as in cynical distrust, indicating that men were higher
on hostility.
Zero-order correlations between psychological variables
and background variables are presented in Table 3.
The observed correlations supported all the main
assumptions of the relationships between the study variables
as presented in Fig. 1. As expected, all the anger expression
variables and cynical distrust had statistically significant
correlations with SOC. Furthermore, all but one of these
hostility-related variables had a statistically significant
correlation with the mental composite score of HQL; for
anger control, the correlation was positive while cynical
distrust; AX-in and AX-out showed negative association
with MCS.
Path analyses
Path analysis was then applied to test the proposed model
presented in Fig. 1. It was expected that the impact of
hostility on HQL would be mediated by SOC. Furthermore,
high level of education, cohabiting, and old age were
expected to associate positively with SOC, while old age
would associate negatively with quality of life.
Due to a strong correlation of AX-out with AX-con
indicative of multicollinearity problems, AX-out was not
included in the models. Separate path analyses were
performed for men and women to establish the predictors
of PCS and MCS scores of HQL at 6 months. The final
models for men and women are illustrated in Figs. 2
and 3, respectively, and the fit statistics are summarized
in Table 4.
Results indicated that the fit of the initial theoretical
models with the data were good or excellent (see Table 4).
No modifications were done for the model of women, and
the modifications for the model of men were minimal: the
statistically significant associations of education on PCS as

Fig. 2. The final path model for men; numbers in figure are standardized Fig. 3. A path model for women; numbers in figure are standardized path
path coefficients; nonsignificant paths are indicated with dotted arrows. coefficients; nonsignificant paths are indicated with dotted arrows. CynDis,
CynDis, cynical distrust; marstat, dichotomised marital status (1=living cynical distrust; marstat, dichotomised marital status (1= living alone;
alone; 2 = cohabiting). 2 = cohabiting).
 J. Julkunen, R. Ahlström / Journal of Psychosomatic Research 61 (2006) 33 – 39
Table 4
Summary of the goodness of fit indexes of the path models for men
and women
Chi-square df P NFI CFI AGFI
Model
Men 1 41.12 10 .00 .96 .97 .93
Men 2 16.17 9 .063 .98 .99 .97
Women 16.33 10 .091 .94 .98 .91
Men 1, original theoretical model for men; Men 2, final modified model for
men. NFI, normed fit index; CFI, comparative fit index; AGFI, adjusted
goodness of fit index; RMSEA, root mean square error of approximation.
well as the positive impact of cohabiting on SOC were
added in the model 2 for men (see Fig. 2).
The main hypotheses were supported, indicating that
high SOC scores were predicted with high anger control and
low levels of AX-in and cynicism. A relatively large
proportion of the variance in SOC was explained by the
variables in the model both for men and for women
(R 2=0.33 and 0.37, respectively).
For both sexes, SOC scores at baseline predicted
statistically significantly both components of HQL at
6 months; the impact on the psychological aspects (MCS)
of HQL were more pronounced (see Figs. 1 and 2). High
level of education (for men) and young age (for women) had
a positive impact of PCS. Furthermore, the results did not
show any statistically significant direct links from cynicism
or anger measures to HQL.
Discussion
Based on the psychological theories of anger and
hostility as well as on the salutogenic theory of the SOC
construct, a model was proposed. Our results supported all
the main hypothesised links in the model.
Firstly, we expected anger-hostility to be related to SOC.
Zero-order correlations (all N0.3 for women, and varying
from 0.28–0.41 for men) showed that there would be about
10–15% shared variance in SOC, with each of the various
aspects of anger and hostility included in the proposed
model. Furthermore, it is important to note that the items of
SOC include no reference to aggression or hostility,
indicating a genuine relationship of these constructs.
However, because all the constructs were assessed with
self-report measures, a shared method variance cannot be
completely ruled out.
To our knowledge, there are only two previous studies
that have reported on this issue. The observed zero-order
correlations of SOC with hostility are in line with the results
of the recent population study by Surtees and coworkers [6],
where a graded negative association was found between
SOC and a single dimension measure of hostility both in
men and in women. While the psychological implications of
this finding were not extensively discussed in their paper
focused on establishing a link between SOC and mortality,
they pointed out the potential importance of clustering of
37
psychosocial risk factors and the need to assess SOC in the
context of other social and psychological factors [6].
Considering the fact that they used different measures for
RMSEA
both SOC and hostility, the clear correspondence of their
results with the present study is remarkable. Also, Kivim7ki
.071
and coworkers [5] found a significant negative relationship
.035
.057 of SOC with a short measure of hostility, which was again
different from our measure as well as from the measure used
by Surtees and coworkers. Thus, three independent studies
with large samples and using different indicators of the
hostility construct have found a significant negative associ-
ation of hostility with SOC. Furthermore, our results, based
on three measures of anger expression styles, support and
extend the suggested important role of anger and hostility
for the SOC theory.
Considering our theoretical model, one could propose an
alternative way of constructing it, i.e., to have SOC as a
latent variable to explain anger-hostility variables. However,
from the developmental point of view, SOC is supposed to
emerge and stabilise rather late, not much before 30 years of
age [2], whereas anger-hostility-related features are usually
considered to evolve already during the early years of
childhood and to have, at least partly, a genetic background
[28]. Thus, despite the cross-sectional, simultaneous assess-
ment of anger-hostility and SOC in this study, we argue for
the hypothesis that vicissitudes of hostility and aggressive
behaviour play a part in the development of SOC. It remains
for future longitudinal studies to confirm this argument and
to demonstrate in detail their role and possible interaction as
risk factors of ill health.
The other key finding in this study, as we see it, is that
the impact of anger-hostility variables on HQL seems to be
mediated by SOC. When hostility, anger, and SOC were
analysed together, the zero-order significant correlations of
hostility–anger variables with HQL were totally accounted
for by SOC.
These results are consistent with those reported by
Kivim7ki and coworkers [5]. Based on their longitudinal
study on female employees’ sickness absences, they
concluded that low SOC might be an important factor
partially explaining the adverse effect of hostility on ill
health. Their study, however, examined only women, and
their measure of hostility was a short, three-item generic
measure of hostility giving no information of separate
aspects of anger. In our study, we were able to compare the
patterns of relations in men and women. Results indicated
that the main pattern of associations were very much alike
for both genders. Some differences were found in the way
sociodemographic variables associated with SOC and HQL.
For example, for men being married, cohabiting had a
positive impact on SOC, while for women, no such
relationship was found. This finding needs to be confirmed
by other studies; there might well be cultural or age-
dependent differences in various populations.
Moreover, women in the present sample showed sig-
nificantly lower levels of functional capacity, i.e., in HQL.
38 J. Julkunen, R. Ahlström / Journal of Psychosomatic Research 61 (2006) 33 – 39
This is probably explained by the inclusion criteria of the
main study, which was recruiting subjects at high risk for
cardiovascular diseases. Consequently, women were about
3 years older than men, which may partly explain the
difference in mean levels of HQL, at least in PCS. Recently,
however, Emery and coworkers [14] have reported that
women with cardiac disease experienced significantly lower
quality of life, as indicated by the same composite scales of
the RAND-36 as in the present study. Thus, a response bias
favouring men could also be a plausible explanation for the
reported gender differences.
Study limitations
Despite the relatively large sample size in this study, one
has to notice that the sample was not a representative
population sample but a selected, high-risk sample of people
with elevated blood pressure who had volunteered to
participate in a medical trial. Furthermore, the results for
women need to be generalised cautiously due to the relatively
small number of women in the present study sample.
Another obvious limitation of this study is that all
assessments were self-reports, and no objective health
outcome data could be incorporated because the main study
data set was not yet closed at this stage of the project. This
issue will be addressed in our future reports.
Although we choose the 6-month HQL as the outcome
measure, the results should be interpreted basically as
derived from a cross-sectional design. When we included
the baseline HQL in path analyses (results not shown), the
baseline HQL was the only significant predictor of the
follow-up HQL. However, the relations of the study
variables were the same or even stronger, as compared with
those reported in the present study. Thus, we are not pre-
dicting changes in HQL, but instead, our results show a
rather stable pattern of relationships between anger-hostility,
SOC, and HQL.
It has also been argued that the SOC construct is
confounded by its correlating highly with measures of
depression and anxiety [29]. Therefore, these factors should
be controlled for in future studies.
Conclusions
It is concluded that the results support the proposed
hypotheses of a significant association of hostility and anger
with SOC. A strong SOC seems to go together with ability
to control and constructively express feelings of anger, and
with low levels of suppressed or openly expressed anger.
The impact of anger on quality of life is, to a great extent,
mediated through SOC. This result implies that the previous
results of the role of hostility and anger as risk indicators of
ill health should be reconsidered from the SOC theory
perspective, and also, the salutogenic theory of SOC should
be extended to include hostility-related constructs.
Acknowledgments
Data collection and data management of this ASCOT
substudy were supported by Finnish Pfizer.
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