# Hostility in the ICU Waiting Room: Extrapunitive and Intropunitive Reactions Among Family Members

## TL;DR

This study explores how hostility, both outward and inward, affects families of ICU patients and identifies factors like age, gender, and education that influence these reactions.

## Contribution

The study identifies two distinct hostility patterns in ICU families: externalized anger in young men and internalized hostility in those with lower education.

## Key findings

- Male relatives showed higher acting-out hostility compared to female relatives.
- Lower educational attainment was linked to higher total hostility and self-criticism.
- Younger age was associated with increased acting-out hostility.

## Abstract

Background/Objectives: Families of ICU patients endure intense psychological strain. While anxiety and depression are well documented, less attention has been given to hostility—expressed both outwardly as anger and inwardly as guilt or self-criticism. Hostility, however, often shapes the climate of the ICU waiting room and the collaboration between families and staff. This study examined the levels and forms of hostility among ICU relatives, focusing on demographic predictors that may influence extrapunitive and intropunitive reactions. Methods: A cross-sectional study was conducted between June 2018 and December 2019 with 215 family members of ICU patients. Hostility was assessed using the Hostility and Direction of Hostility Questionnaire (HDHQ). Descriptive statistics, t-tests, ANOVAs, and multivariate regression analyses were performed to examine the effects of age, gender, and education on hostility subscales. Results: Male relatives exhibited higher acting-out hostility (M = 4.80, SD = 2.63) compared with female relatives (M = 4.12, SD = 2.21; t(216) = 1.96, p = 0.05, Cohen’s d = 0.28). Relatives with lower educational attainment showed significantly higher total hostility (β = −1.23, 95% CI [−1.78, −0.67], p < 0.001) and greater self-criticism (β = −0.44, 95% CI [−0.84, −0.03], p = 0.037). Younger age was associated with increased acting-out hostility (β = −0.029, 95% CI [−0.055, −0.002], p = 0.035). The regression models explained 12–26% of the variance across subscales (R2 range = 0.12–0.26). These findings suggest two vulnerability trajectories: an externalized (extrapunitive) pattern in younger men and a broad internalized (intropunitive) pattern in relatives with lower education. Conclusions: Hostility in ICU families emerges in two distinct trajectories: externalized anger among young men and broad hostility in relatives with lower education. Recognizing these patterns is vital for preventing conflict, addressing hidden guilt and self-blame, and developing subgroup-sensitive interventions. The ICU waiting room is a space not only of fear and uncertainty but also of anger, guilt, and fragile attempts at psychological survival—dimensions that deserve systematic attention in both clinical practice and research.