Which component of a Type A personality is most strongly correlated with cardiovascular disease?

Type A Behavior

The type A behavior pattern was originally described by cardiologists Friedman and Rosenman in the 1950s as a behavior pattern characterized by agitation, hostility, rapid speech, and an extremely competitive nature. The contrasting type B behavior pattern consists of a more laid-back style and a lack of the type A characteristics mentioned previously. A structured interview was developed to measure type A behavior based on behaviors such as speech characteristics and subjects' responses to various questions.

In the 1960s and 1970s, many studies were conducted to probe the relationship between type A behavior and heart disease. Most of the studies revealed a correlation between type A behavior and coronary heart disease in both men and women, which is comparable and independent of the effects of smoking and hypertension. For example, two major studies obtained results supporting the findings that type A behavior is a risk factor for heart disease. The Western Collaborative Group Study (WCGS) followed initially healthy men for 8.5 years. The men were given questionnaires and took part in interviews to determine their type A status at the outset of the study. Those individuals who were identified as type A were more likely to have developed heart disease over the course of the 8.5 years of the study than the type B group. The Framingham Heart Study also showed that type A behavior was a predictor of CHD among white-collar men and women who worked outside of the home.

Since the 1980s, however, most studies have not corroborated the relationship between type A behavior and heart disease. The Multiple Risk Factor Intervention Trial (MRFIT) assessed whether interventions to reduce coronary risk factors, such as high blood pressure, smoking, or high cholesterol levels, decreased the potential for coronary disease in high-risk men and women. After 7 years, the results did not show a relationship between these measures of type A behavior and the incidence of the first heart attack. Further, there were reports from research that indicated that, after a heart attack, type B patients were more likely to die than type A patients. This finding could be explained as the result of healthier type A patients being the ones who initially survived their first heart attack. Regardless, however, this result certainly presented doubts about type A behavior as a coronary risk factor.

It is unclear why these studies resulted in such inconsistent findings. Some have suggested that type A behavior may be a risk factor for younger individuals rather than for older or high-risk individuals, such as the ones tested in the MRFIT study. Still, it seems that there are certain aspects of type A behavior, particularly anger and hostility, that remain correlated with coronary disease, even in studies in which overall type A behavior was not related to CHD.

2.7 The Hysterical Personality

A personality type, first clearly described by Janet at a time when hysteria was still regarded as an almost exclusively feminine condition, which is assumed to be particularly susceptible to develop conversion and other hysterical symptoms. As described, the characteristic features are attention-seeking behavior, shallow, labile emotions, and self-centered, demanding, interpersonal behavior. A variety of tactics are used to attract and retain the attention of others, including striking or sexually provocative clothing, flirtatious behavior, flattery, dramatized accounts of their past lives or current circumstances, and extravagant gestures.

Despite the linkages between these seven meanings the inevitable consequence of this diversity of usage was confusion and serious ambiguity. The situation was summarized trenchantly by the American psychiatrist Chodoff (1974): ‘Entities that are clinically quite different are being held together artificially by little more than the authority of an ancient name’ he asserted; ‘the diagnosis (of hysteria) has become a balloon filled with air rather than substance … it is a fossil encrusted with and obscured by successive layers of meaning.’ For good measure he reminded his audience that the term ‘hysteric’ was used widely by young male psychiatrists to describe almost any attractive female patient.

“Type A” personality

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Type A behavior: extreme sense of time urgency, competitiveness, impatience, and aggressiveness.

Twofold increase in CHD risk.

Damaging to cardiovascular system is regular expression of anger.

Positive correlation exists between serum cholesterol level and aggression. The higher the aggression score, the higher the cholesterol level.

A negative correlation exists between ratio of LDL-C to HDL-C and controlled affect score—the greater the ability to control anger, the lower this ratio. Those who learn to control anger experience reduction in risk for heart disease, whereas an unfavorable lipid profile is linked with aggressive (hostile) anger coping style.

Anger expression plays a role in CRP levels. Greater anger and severity of depression, separately and in combination with hostility, are linked to elevations in CRP.

Other mechanisms linking emotions, personality, and CVD: increased cortisol secretion, endothelial dysfunction, hypertension, and increased platelet aggregation and fibrinogen.

Ten tips that help improve coping strategies:

Do not starve your emotional life. Foster meaningful relationships. Provide time to give and receive love in your life.

Learn to be a good listener. Allow the people in your life to really share their feelings and thoughts uninterruptedly. Empathize with them; put yourself in their shoes.

Do not try to talk over somebody. If you find yourself being interrupted, relax; do not try to outtalk the other person. If you are courteous and allow someone else to speak, eventually (unless he or she is extremely rude) he or she will respond likewise. If not, explain that he or she is interrupting the communication process. You can do this only if you have been a good listener.

Avoid aggressive or passive behavior. Be assertive, but express your thoughts and feelings in a kind way to help improve relationships at work and at home.

Avoid excessive stress in your life as best you can by avoiding excessive work hours, poor nutrition, and inadequate rest. Get as much sleep as you can.

Avoid stimulants such as caffeine and nicotine. Stimulants promote the fight-or-flight response and tend to make people more irritable in the process.

Take time to build long-term health and success by performing stress-reduction techniques and deep breathing exercises.

Accept gracefully those things over which you have no control. Save your energy for those things that you can do something about.

Accept yourself. Remember that you are human and will make mistakes from which you can learn along the way.

Be more patient and tolerant of other people. Follow the golden rule.

8.08.2.3.2 Anger and hostility

As noted above, type A behavior consists of several behaviors, including competitiveness, time urgency, and hostility, yet it is possible that not all these behaviors contribute equally to coronary risk. What have consistently emerged as correlates of CHD in these studies are characteristics relating to hostility, anger, and certain speech characteristics derived from the structured interview, as well as the characteristic of not expressing anger or irritation or “anger-in.” For example, a reanalysis of data from the WCGS described above showed that “potential-for-hostility,” vigorous speech, and reports of frequent anger and irritation were the strongest predictors of CHD (Matthews, Glass, Rosenman, & Bortner, 1977). Even in the MRFIT study, which was not able to relate type A behavior to CHD, hostility characteristics in MRFIT subjects were associated with increased CHD risk (Dembroski, MacDougall, Costa, & Grandits, 1989).

The Cook and Medley Hostility Inventory (Cook & Medley, 1954), a scale derived from the Minnesota Multiphasic Personality Inventory (MMPI), has been shown in two studies to be related to occurrence of coronary disease. This scale appears to measure attitudes such as cynicism and mistrust of others (Barefoot & Lipkus, 1994). In one study involving a 25-year follow-up of physicians who completed the MMPI while in medical school, high Cook-Medley scores measured in college students predicted incidence of CHD as well as mortality from all causes, and the relationship was independent of the individual effects of smoking, age, and presence of high blood pressure (Barefoot, Dahlstrom, & Williams, 1983) (Figure 5). There is also evidence that low hostility scores are associated with decreased death rates during a subsequent 20-year follow-up of nearly 1900 participants in the Western Electric Study (Shekelle, Gale, Ostfeld, & Paul, 1983). In other studies it was shown that traits of hostility (e.g. assessed in terms of behaviors and attitudes indicative of hostility derived from the type A behavior structured interview) were related to the development of CHD in initially healthy men and in high-risk participants in the MRFIT study (for a review see Helmers, Posluszny, & Krantz, 1994). Subsequent research has further suggested that hostility scores on the Cook and Medley (1954) scale are higher in low socioeconomic status groups, higher in men and non-whites in the USA, and also positively related to the prevalence of smoking (Siegler, 1994). Thus, it is possible to hypothesize that hostility may account for some of the socioeconomic and gender differences in death rates from cardiovascular diseases (Stoney & Engbretson, 1994).

C The Coronary Personality

The concept of a coronary-prone behavior pattern is also not new. Even before the turn of the century, Osler (1896) described the pernicious combination of a certain configuration of personality traits and the mounting pressures of environment. In his experience the typical patient with coronary disease was “a keen and ambitious man, the indicator of whose engines is always set at ‘full speed ahead.’” This description was later supported by the independent observations of Arlow (1945), Kemple (1945), and others and more recently by Wolf (1958) and Russek (1959). Arlow observed “a compulsive striving for achievement and mastery which never seems to end.” Kemple found the coronary patient to be an aggressive, ambitious individual with intense physical and emotional drive, unable to delegate authority or responsibility with ease, possessing no hobbies, and concentrating all his thoughts and energy in the narrow groove of his career. Wolf similarly described the coronary-prone individual as one who not only meets a challenge by expending extra effort, but who takes little satisfaction from his accomplishments. This unrelenting striver who seemingly meets with frustration and lack of rewards for his efforts (Sisyphus reaction) may be suffering from debilitated ego defenses that culminate in psychic exhaustion and emotional drain (Bruhn et al., 1969). We also found the young coronary patient frequently to have been a victim of overwork, often as a result of his excessive drive, intense desire for recognition, or profound sense of obligation to his employer, his family, or others, but more commonly, simply as a consequence of meeting life's challenges with maximum and unstinting effort. Compulsive about time and overmeticulous, these patients were often concerned about trivia, impatient with subordinates, and worrisome. As perfectionists, they generally chose to do the work themselves rather than delegate it to others. It was their usual practice to take on more responsibilities at an occupational, social, or domestic level than good judgment would dictate. Many had never learned to say “no.” They minimized their symptoms and neglected prudent rules of health. Perhaps most characteristic was a restlessness during leisure hours and a sense of guilt during periods of “relaxation.” Consequently, the young coronary patient rarely took vacations, and such leisure time as he did possess was frequently regimented by obligatory participation in an assortment of social, civic, or educational activities. It seemed evident, therefore, that behavior patterns, quite independently of the demands of the job itself, could generate high degrees of emotional stress.

Because of the retrospective nature of these studies, others have challenged the existence of a coronary-prone behavior pattern, asserting that its alleged characteristics may follow rather than precede the coronary event. Negating this claim are the findings of Friedman and Rosenman (1959) and Rosenman et al. (1966) in a long-term prospective study of more than 3500 male subjects. Thus these authors observed a significantly higher coronary morbidity and mortality among men previously identified as possessing a certain well-defined action-emotion complex that has been designated and now popularized as the Type A behavior pattern.

Such behavior is observed in individuals who are engaged in a relatively chronic struggle to obtain an unlimited number of poorly defined things from their environment in the shortest period of time and, if necessary, against the opposing resistance of other persons or things in this same environment. In addition to intense ambition, competitive drive, sense of urgency, and preoccupation with deadlines, more than 80% were alleged to manifest “excessively rapid body movement, tense facial and bodily musculature, explosive conversational intonations, hand or teeth clenching, excessive unconscious gesturing, and a general air of impatience.” These visible manifestations were not frequently encountered in our own series of young patients. Such features would appear to represent a caricature rather than a portrait of the average coronary patient under the age of 40 in our experience. In fact, most of the young patients seemed to show a striking degree of self-control, dignified reserve, and outward complacency during interrogation. in many of these subjects, psychological factors would have remained unrecognized had we not made a special inquiry regarding their presence.

Despite such differences, it is now widely acknowledged that subjects possessing the Type A behavior pattern suffer twice as frequently from coronary attacks as individuals with the converse behavior pattern B, who are defined as being free from Type A characteristics and who therefore experience no pressing conflict with either time or other individuals. In confronting life situations they are also free of any habitual sense of time urgency. The value of such classification is evident from the fact that the predictive strength of the Type A behavior pattern for the risk of developing coronary heart disease was found to be at least as potent as that of the other major risk factors, including serum cholesterol, cigarette smoking, and high blood pressure (Rosenman et al., 1966).

It has been found in both clinical and epidemiologic studies that anxiety, depression, and neurotic defenses are linked with the risk of developing angina pectoris and possibly also with the risk of myocardial infarction. However, the presence of Type A behavior pattern and its association with coronary heart disease appears to be quite independent of these factors. Correlational studies of several different groups of coronary patients and healthy individuals have sought to measure anxiety, depression, and neurosis. Distinction therefore has been made between the Type A individual and the subject suffering from anxiety. The Type A person is said rarely to despair of approaching failure, although he strongly strives to win. On the other hand, the subject with a classic anxiety state is commonly thought to seek assistance when the demands appear overwhelming. Similarly, Type As advance while subjects with anxiety tend to retreat in comparably challenging situations.

The divergent styles of living associated with Type A and Type B behavior have been correlated with different patterns of response to acute stress and differing predisposition to coronary attacks. Type A men exhibited a larger increase in plasma norepinephrine before, during, and after a problem-solving task than Type B men, who are relatively resistant to coronary heart disease (Rosenman et al., 1966). This suggests that Type A individuals overreacted to the situation in comparison with reactions of Type B subjects. Of further significance is the ability or inability of Type A or Type B individuals to master a continuing emergency situation, which is the important determinant of whether or not a sustained fight or flight reaction takes place. This will be dealt with in sections to follow.

The Coronary-Prone (Type A) Behavior Pattern

The coronary-prone (Type A) behavior pattern refers to a complex set of behaviors including hostility, competitiveness, time urgency, impatience, and aggressiveness. Type B behavior is defined as the relative absence of these characteristics. Type A behavior is an independent risk factor for cardiovascular disease as demonstrated in retrospective and prospective epidemiological studies (Brand et al., 1976; Friedman & Rosenman, 1959; Jenkins et al., 1975). Recent prospective data from the Framingham study have demonstrated these associations both for men and for women (Haynes, Feinlieb, & Kannel, 1980). Type A behavior has been related to the incidence and prevalence of clinical coronary heart disease (CHD) in men and women (Haynes et al., 1980), angiographically determined severity of atherosclerosis (Blumenthal et al., 1978; Friedman et al., 1968), and the progression of atherosclerosis in men (Krantz et al., in press).

Of interest in recent years has been the investigation of physiological pathways by which Type A behavior results in disease. Psychophysiological studies demonstrate that Type A men show greater average increases than Type B men in norepinephrine, serum triglycerides, urinary catecholamines, and blood pressures in competitive and challenging situations (Glass et al., 1980; Herd, 1978; Williams, 1978).

Considerable attention has been devoted to the relationship between coronary-prone behavior and blood pressure reactivity. Systolic blood pressure, diastolic blood pressure, and heart rate increases are typically higher in Type A than in Type B subjects when they are performing challenging tasks in competitive situations (Manuck, Craft, & Gold, 1978; Dembroski, MacDougall, Shields, Petitto, & Lushene, 1978).

Type A behavior and blood pressure reactivity have also been related in children and adolescents. Siegel and Leitch (1981) found a positive correlation between elevated systolic blood pressure and Type A behavior in adolescents. Children and adolescents in the Bogalusa Heart Study who reported that they do things quickly showed mean total serum cholesterol levels that were higher than students who gave a negative answer to this question. Students who reported that they felt an exaggerated sense of time urgency had higher mean arterial blood pressure than students who responded negatively to this item (Hunter, Wolf, Sklov, & Berenson, 1980). Lawler, Allen, Critchner, and Standard (1980) asked 18 male and 20 female 6th graders to solve anagrams and at the same time depress a response button as quickly as possible. Type A girls, but not boys, as measured by the Matthews Youth Test for Health (MYTH) (Matthews, 1978) tended to have larger elevations in systolic blood pressure and in heart rate than Type B girls during both tasks.

Spiga and Petersen (1980) studied 4th and 5th grade children in a Catholic school. The MYTH was used and the 18 highest and the 18 lowest scoring males were selected to participate. These students were matched in dyads so that there were 6 AA, 6 AB, and 6 BB dyads. The dyads played a mixed motive game in which each player could choose to compete or cooperate on each trial; rewards for individual players were contingent upon both players' choices. Type As in AA dyads showed more competitiveness than Type As in AB dyads and Type Bs in BB dyads. Type As in AA dyads also exhibited greater fluctuations in blood pressure during the tasks than other subjects.

In the late 1950s, the Type A behavior pattern was described as a contributing factor in the development of coronary heart disease (CHD). Comprised of impatience, achievement striving, competitiveness, and hostility, this pattern does predict the development of CHD. However, inconsistencies in the available research have led to the study of individual elements of the pattern. Hostility, and more recently dominance, have emrged in such studies as significant risk factors for CHD and premature mortality. Psychophysiological stress responses are a likely mechanism linking such behavioral traits with disease, and related interventions have been found effective in preventing recurrent coronary events.

History of the Concept

In the 1960s, the concept of the type A behavior pattern was introduced by cardiologists Meyer Friedman and Ray Rosenman to describe individuals who possessed excessive time urgency and free-floating hostility and who, by virtue of this behavior pattern, were believed to be coronary-prone. This conceptualization fostered hundreds of investigations in the 1970s and 1980s aimed at replicating early associations with coronary disease, refining its measurement, and understanding its physiological underpinnings. In 1980, a classic paper was published by Williams and his colleagues that suggested that the hostility component of the type A behavior pattern was its toxic core (Figure 1). Angiography patients were divided by gender, type A behavior, and hostility, and these classifications were related to occlusive disease. For both males and females, hostility was a better predictor of ≥75% occlusion than type A behavior. This seminal investigation was subsequently replicated in a large number of studies using a variety of subjects and study designs and resulted in a shift in thinking away from type A behavior toward hostility as a key coronary-prone behavior.

8.13.3.3.1 Modifying Hostility and Type A Behaviors

A variety of clinical intervention studies have attempted to decrease type A behavior either in persons with elevated CHD risk factors or in samples of coronary patients. Most of these early, small studies demonstrated that elements of type A behavior can be decreased to some extent in subjects who are motivated to change (Allan and Scheidt, 1996; Suinn, 1982). Accompanying changes in type A behavior, some studies also measured changes in traditional CHD risk factors such as serum cholesterol levels or blood pressure.

The Recurrent Coronary Prevention Project (RCPP; Friedman et al., 1986), is a large study of CHD patients conducted to determine whether modification of type A behaviors of anger, impatience, and irritability, lower the recurrence of heart attacks and deaths. Type A counseling included drills to change specific type A behaviors, focused discussions on beliefs and values underlying type A behavior, rearrangements of home and work demands, and relaxation training to decrease physiologic arousal. After 4.5 years, the rate of heart attack recurrence for the type A behavioral counseling group was significantly lower than for the cardiology counseling and control groups (Friedman et al., 1986). However, in light of the recent negative evidence regarding associations of type A behavior with CHD, it is possible that the beneficial effects of the RCPP study resulted from more general salutary effects of the interventions in reducing chronic distress and increasing coping skills and social support among patients.

Personality

The time-urgent, competitive, easily angered type A personality enjoyed a long vogue as a potential marker of cardiovascular risk, especially while white collar occupational groups continued to experience a high rate of coronary events. That epidemiological picture has since undergone a radical change, with people of lower socioeconomic position now being at greater risk of CVD in many developed countries. The focus on personality as a cardiovascular risk factor has also faded because of the difficulties in classifying individuals' personalities reliably. There is also only limited evidence that personalities can be changed, although new ways of responding to the stresses of everyday life can be learned, and the evidence that attempting to do so results in a meaningful reduction in cardiovascular events is scant indeed.