Emotion suppression and mortality risk over a 12-year follow-up

Abstract

Objective

Suppression of emotion has long been suspected to have a role in health, but empirical work has yielded mixed findings. We examined the association between emotion suppression and all-cause, cardiovascular, and cancer mortality over 12 years of follow-up in a nationally representative US sample.

Methods

We used the 2008 General Social Survey–National Death Index (GSS–NDI) cohort, which included an emotion suppression scale administered to 729 people in 1996. Prospective mortality follow up between 1996 and 2008 of 111 deaths (37 by cardiovascular disease, 34 by cancer) was evaluated using Cox proportional hazards models adjusted for age, gender, education, and minority race/ethnicity.

Results

The 75th vs. 25th percentile on the emotional suppression score was associated with hazard ratio (HR) of 1.35 (95% Confidence Interval [95% CI] = 1.00, 1.82; P = .049) for all-cause mortality. For cancer and cardiovascular disease mortality, the HRs were 1.70 (95% CI = 1.01, 2.88, P = .049) and 1.47 (95% CI = .87, 2.47, P = .148) respectively.

Conclusions

Emotion suppression may convey risk for earlier death, including death from cancer. Further work is needed to better understand the biopsychosocial mechanisms for this risk, as well as the nature of associations between suppression and different forms of mortality.

Introduction

Emotion suppression, defined as a tendency to inhibit the expression of emotion [1], has long been suspected to influence health [2], with recent meta-analytic evidence linking suppression and chronic disease supportive of this long-held notion [3]. Emotion suppression involves intentionally avoiding distressing feelings by thinking of other things or holding things in, while emotion repression is defined by lack of conscious awareness of negative emotion [4], [5].

Suppression is believed to operate on health first at a behavioral level, by inducing unhealthy coping behaviors such as over-eating as substitutes for healthy emotional expression [6]. Second, at a physiological level, higher levels of autonomic reactivity to stress – measured both electrodermally and through blood pressure changes – have been reported among suppressors [7]. Direct correlations between suppressive defensive styles and both catecholamines and glucocorticoids have also been reported [8], [9] and are reviewed in [10], [11]. In turn, neuroendocrine dysregulation, whether induced by stress processes or habitual health-damaging behaviors, has been implicated in the progression of a number of chronic diseases, and ultimately earlier death [12].

Epidemiologic evidence for links between suppression and mortality appeared initially in a Yugoslavian cohort study conducted in the 1970 by Grossarth-Maticeck [13]. Specifically, a suppression-prone personality style called “anti-emotionality” predicted 10-year all-cause and Cardiovascular Disease (CVD) mortality [13]. In other work, Grossarth-Maticeck noted associations between this personality style and cancer death [13], [14]. Grossarth-Maticeck's studies were subsequently the center of controversy around data collection and analysis [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], although he and his collaborator Hans Eysenck vigorously defended the results [25]. “Type C” personality style—also defined by a tendency to suppress emotion—was linked to poor health outcomes in the 1980s [26], [27], [28]. In the 1990s “Type D” personality, which involves affective distress in conjunction with social inhibition (presumably limiting emotional disclosure to others), was linked to both CVD death and numerous other health problems [29]. Other studies on the suppression of anger in particular have noted increased all-cause mortality over 17 years in a US community sample [30], 6 years in Dutch CVD patients [31], and 8.5 years in a German sample [32]. Yet there may also be a strong cultural contingency of suppression effects: in a Japanese community sample, lower levels of emotion suppression were linked to worse health [33], and in Japanese cancer patients, moderate, rather than high or low suppression levels were associated with survival [34]. The construct of repression conveyed a survival advantage in male veterans of the American army followed for 16 years [35], hinting at differential acculturation and gender variability in mortality risk of constructs in the suppression/repression family [6].

In short, while studies on the mortality risk of emotion suppression have been suggestive, they have been far from definitive, underscoring the need for new data in broadly diverse population samples. Our primary aim was to examine whether emotion suppression was associated with death from any cause over a 12-year follow-up in a nationally-representative US sample. We also assessed links between emotion suppression and the two leading specific causes of death in the US, CVD and cancer. Finally, we explored whether suppression of anger in particular [30], or other indicators of more specific types of suppression, were linked to mortality.