RAPID COMMUNICATION Emotional Correlates of Type A Behavior Pattern JOEL E. DlMSDALE, MD, THOMAS P. HACKETT, MD, PETER C. BLOCK, MD, AND ADOLPH M. HUTTER, JR., MD
ment (as measured by the 16-Personality Factor Test) and with responsibility and Type A behavior pattern is reported to social class (6). In contrast, Shekelle be associated with increased coronary found that Type A pattern, as measured by heart disease, independent of traditional the Jenkins Activity Survey (JAS), was risk factors such as smoking history, high significantly associated with social class cholesterol and triglyceride levels, and (2). Recent literature suggests that Type A hypertension (1, 2). There has been con- is a particular behavioral pattern of copsiderably less analysis of the relationship ing with uncontrollable stress (7), is frebetween Type A behavior and other quently associated with hostility (8), but psychosocial variables, such as social is not associated with "social insecurity" class, stress experience, anxiety, and de- and "depression tension" (9). pression, which have also been impliThe study briefly described here concated as relevant factors associated with siders the association between Type A becoronary disease (3-5). As a result, we havior and several emotional factors: tenlack information about the frequency of sion, depression, anger, vigor, fatigue, association between Type A behavior and confusion, denial of cardiac illness, and other relevant psychosocial risk factors. accumulation of stressful life events. How often are Type A individuals troubled by anxiety, depression, or stress as METHODS compared to Type B individuals? Patients were selected from those awaiting cardiac Studies of the relationship between Type A behavior and other psychosocial catheterization at Massachusetts General Hospital. of these patients presented for catheterization variables are sparse and contradictory. Most with presumptive coronary artery disease manCaffrey found that Type A behavior as ifested by angina. Patients were included for study measured by semistructured interviews according to the following criteria: English speakwas not associated with personal adjust- ing, between the ages of 18 and 70, average intelliINTRODUCTION
From the Department of Psychiatry (Drs. Dimsdale and Hackett) and the Department of Cardiology (Drs. Block and Hutter), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114. Received for publication May 1, 1978; revision received July 28, 1978. 580 0033-3174/78/07056703/501.75
gence, consent of primary physician, and willingness to participate in a follow-up. We excluded from study those patients who had other forms of heart disease (such as valvular disease or cardiomyopathy), patients with other severe illnesses (e.g. malignancy), or those in critical medical condition (e.g. cardiogenic shock). All exclusions were made prior to the measurement of psychosocial variables.
Psychosomatic Medicine Vol. 40, No. 7 (November 1978) Copyright " 1978 by the American Psychosomatic Society, In Published by Elsevier North-Holland, Inc.
RAPID COMMUNICATION In a 1-yr period, contact was attempted on 118 patients. Three patients' physicians refused participation, three patients were ineligible, and three patients refused participation; 109 patients completed the evaluation. Participating subjects therefore account for 90% of the population approached for study. The study included 99 men and 10 women. The average age was 49 yr, with a standard deviation of 9 yr. Type A behavior pattern was assessed with the JAS Form B (10). Denial of cardiac illness was assessed by the Hackett-Cassem semistructured interview for denial (11). Stress experience in the 4 mo before hospitalization was measured in life change units obtained from a 42-item Schedule of Recent Events (12). Tension, depression, anger, vigor, fatigue, and confusion were measured by the Profile of Mood States (POMS) (13). Rather than being selfadministered, use of the latter instrument was modified by reading each adjective on the check list aloud to the patient and having him indicate his response verbally. The distribution of the variables was studied. For those variables where the distribution was reasonably normal, a correlation analysis examined the relationship between JAS Type A scores and emotional variables. For those variables having a non-normal distribution. Kendall's rank correlation was used.
RESULTS
Table 1 lists the means and standard deviations of the psychosocial variables. Type A was significantly correlated with accumulation of stressful life events (r = 0.26, p < 0.011) and current tension (r = 0.28, p < 0.005). In the nonnormal distributions, significant correlations were found between Type A and depressive mood (r = 0.18, p < 0.008) and anger (r = 0.19, p < 0.007). Denial of significant cardiac disease trended to a significant inverse relationship with Type A (r = -0.16, p < 0.1). None of the other variables (vigor, fatigue, confusion) were correlated with Type A behavior. 'All p values are two-tailed tests.
TABLE 1.
Distribution of Psychosocial Variables
Variable
Mean
SD
Tension Depression Anger Vigor Fatigue Confusion Stress Type A Denial
11 7 4 14 6 6 187 1.7 -0.34
6.8 7.6 6.2 5.9 6.1 4.2 108 9.7 0.86
DISCUSSION
Our study parallels a carefully designed study of Jenkins et al. on cardiac catheterization patients (9); however, the results are contradictory. The studies differ in their choice of psychometric tests for tension and depression; ours using the POMS, theirs using a total of three MMPI items as a combined measure for tension and depression. Although we have demonstrated definite associations between Type A behavior pattern and stress, tension, and depressed mood, these associations are modest and account for only 5-8% of the variance. They should not be interpreted as indicating that the variables are alternate measures for Type A; rather we would conclude that Type A is rooted in a psychosocial matrix. We find such associations in a precisely delimited population; further study is necessary to demonstrate if Type A is regularly associated with these psychosocial variables or whether this association is somehow unique in precatheterization patients. We doubt that coming to cardiac catheterization acts to confound the association between Type A and other psychosocial factors; Types A and B came to catheterization in approximately equal numbers. If the A's were more tense and
Psychosomatic Medicine Vol. 40, No. 7 (November 1978)
581
JOELE. DIMSDALEETAL.
sought catheterization because they had more cardiac symptoms, our findings. Could be confounded by symptomatology. However, angina symptomatology (as measured by the New York Heart Association functional scale) was not associated with behavior pattern (r = -0.07, NS). In the epidemiological study of heart disease which focuses on physiological factors, most researchers believe that coronary disease is caused by multiple factors (14, 15). This multifactorial causation usually refers to simultaneous consideration of blood lipids, smoking history, hypertensive history, etc. By investigating the psychosocial correlates of coronary disease, it would be helpful to pursue a similar multifactor approach. Is Type A behavior the central psychosocial variable related to coronary disease? Is Type A pattern related to an underlying psychosocial variable that in itself is the causative factor? Or is Type A behavior causal only in interaction with other psychosocial variables? This area requires further study. Rather than at-
tempting to analyze particular psychosocial risk factors in isolation, more fruitful results can emerge from a framework wherein research design and methodology permit simultaneous consideration and analysis of several variables to determine the relationships among them. As a first step, it would be helpful to analyze the association between Type A and other psychosocial factors, using various measures for Type A (JAS vs. semistructured interview) and also for the other psychosocial variables, (e.g., MMPI, POMS, and Hamilton scales). If such analyses demonstrate a constant association, it would be important to study the relative associations and the interactions of these variables with clinical manifestations of coronary disease. This work was supported by Grant No. HL19567 from the National Heart, Lung, and Blood Institute. The authors would like to thank Steve Zyzanski and David Jenkins for processing the JAS question-
REFERENCES 1. Rosenman RH, Brand RG, Jenkins CD, et al: Coronary heart disease in the western collaborative group study: Final follow up experience of 8V2 years. JAMA 233:872-877, 1975 2. Shekelle RB, Schoenberger J, Stamler J: Correlates of the JAS type A behavior pattern score. J Chronic Dis, 29:381-394,1976 3. Jenkins CD: Recent evidence supporting psychologic and social risk factors for coronary disease. N Engl J Med, 294:987-994, 1033-1038, 1976 4. Parkes CM: Bereavement. International University Press, 1972 5. Dimsdale JE: Emotional causes of sudden death. Am J Psychiatry 134:1361-1366, 1977 6. Caffrey B: A multivariate analysis of sociopsychological factors in monks with myocardial infarctions. Am J Public Health 60:452-458, 1970 7. Glass DC: Behavior Patterns, Stress, and Coronary Disease. LEA Press, Hillsdale 1977 8. Williams R, Haney T, Gentry D, et al. Relation between hostility and arteriographically documented coronary atherosclerosis in type A and non-type A patients. Psychosom Med 40:88, 1978 (Abstract) 9. Jenkins CD, Zyzanski S, Ryan T, et al. Social insecurity and coronary prone type A responses as identifiers of seven allerosclerosis. J Consult Clin Psychol. 45:1060-1067, 1977 10. Jenkins CD, Rosenman RH, Friedman M: Development of an objective psychological test for the determination of the coronary prone behavior pattern in employed men. J Chronic Dis 20:371-379, 1967 582
Psychosomatic Medicine Vol. 40, No. 7 (November 1978)
RAPID COMMUNICATION 11. Hackett TP, Cassem N: Development of a quantitative rating scale to assess denial. J Psychosom Res 18:93-100, 1974 12. Rahe R, Floistad I, Tergan T, Ringdahl R, Gerhardt R, Gunderson E, Arthur R: A model for life changes and illness research. Arch Gen Psychiatry 31:172-177, 1974 13. McNair D, Lorr M, Droppleman L: Profile of Mood States. San Diego, Calif., Educational and Industrial Testing Services, 1971 14. Gordon T, Garcia-Palmieri M, Kagan A, et al. Differences in coronary heart disease in Framingham, Honolulu, and Puerto Rico. J Chronic Dis 27:329-344, 1974 15. American Heart Association: Coronary Risk Handbook, 1973
Psychosomatic Medicine Vol. 40, No. 7 (November 1978)
583
ment (as measured by the 16-Personality Factor Test) and with responsibility and Type A behavior pattern is reported to social class (6). In contrast, Shekelle be associated with increased coronary found that Type A pattern, as measured by heart disease, independent of traditional the Jenkins Activity Survey (JAS), was risk factors such as smoking history, high significantly associated with social class cholesterol and triglyceride levels, and (2). Recent literature suggests that Type A hypertension (1, 2). There has been con- is a particular behavioral pattern of copsiderably less analysis of the relationship ing with uncontrollable stress (7), is frebetween Type A behavior and other quently associated with hostility (8), but psychosocial variables, such as social is not associated with "social insecurity" class, stress experience, anxiety, and de- and "depression tension" (9). pression, which have also been impliThe study briefly described here concated as relevant factors associated with siders the association between Type A becoronary disease (3-5). As a result, we havior and several emotional factors: tenlack information about the frequency of sion, depression, anger, vigor, fatigue, association between Type A behavior and confusion, denial of cardiac illness, and other relevant psychosocial risk factors. accumulation of stressful life events. How often are Type A individuals troubled by anxiety, depression, or stress as METHODS compared to Type B individuals? Patients were selected from those awaiting cardiac Studies of the relationship between Type A behavior and other psychosocial catheterization at Massachusetts General Hospital. of these patients presented for catheterization variables are sparse and contradictory. Most with presumptive coronary artery disease manCaffrey found that Type A behavior as ifested by angina. Patients were included for study measured by semistructured interviews according to the following criteria: English speakwas not associated with personal adjust- ing, between the ages of 18 and 70, average intelliINTRODUCTION
From the Department of Psychiatry (Drs. Dimsdale and Hackett) and the Department of Cardiology (Drs. Block and Hutter), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114. Received for publication May 1, 1978; revision received July 28, 1978. 580 0033-3174/78/07056703/501.75
gence, consent of primary physician, and willingness to participate in a follow-up. We excluded from study those patients who had other forms of heart disease (such as valvular disease or cardiomyopathy), patients with other severe illnesses (e.g. malignancy), or those in critical medical condition (e.g. cardiogenic shock). All exclusions were made prior to the measurement of psychosocial variables.
Psychosomatic Medicine Vol. 40, No. 7 (November 1978) Copyright " 1978 by the American Psychosomatic Society, In Published by Elsevier North-Holland, Inc.
RAPID COMMUNICATION In a 1-yr period, contact was attempted on 118 patients. Three patients' physicians refused participation, three patients were ineligible, and three patients refused participation; 109 patients completed the evaluation. Participating subjects therefore account for 90% of the population approached for study. The study included 99 men and 10 women. The average age was 49 yr, with a standard deviation of 9 yr. Type A behavior pattern was assessed with the JAS Form B (10). Denial of cardiac illness was assessed by the Hackett-Cassem semistructured interview for denial (11). Stress experience in the 4 mo before hospitalization was measured in life change units obtained from a 42-item Schedule of Recent Events (12). Tension, depression, anger, vigor, fatigue, and confusion were measured by the Profile of Mood States (POMS) (13). Rather than being selfadministered, use of the latter instrument was modified by reading each adjective on the check list aloud to the patient and having him indicate his response verbally. The distribution of the variables was studied. For those variables where the distribution was reasonably normal, a correlation analysis examined the relationship between JAS Type A scores and emotional variables. For those variables having a non-normal distribution. Kendall's rank correlation was used.
RESULTS
Table 1 lists the means and standard deviations of the psychosocial variables. Type A was significantly correlated with accumulation of stressful life events (r = 0.26, p < 0.011) and current tension (r = 0.28, p < 0.005). In the nonnormal distributions, significant correlations were found between Type A and depressive mood (r = 0.18, p < 0.008) and anger (r = 0.19, p < 0.007). Denial of significant cardiac disease trended to a significant inverse relationship with Type A (r = -0.16, p < 0.1). None of the other variables (vigor, fatigue, confusion) were correlated with Type A behavior. 'All p values are two-tailed tests.
TABLE 1.
Distribution of Psychosocial Variables
Variable
Mean
SD
Tension Depression Anger Vigor Fatigue Confusion Stress Type A Denial
11 7 4 14 6 6 187 1.7 -0.34
6.8 7.6 6.2 5.9 6.1 4.2 108 9.7 0.86
DISCUSSION
Our study parallels a carefully designed study of Jenkins et al. on cardiac catheterization patients (9); however, the results are contradictory. The studies differ in their choice of psychometric tests for tension and depression; ours using the POMS, theirs using a total of three MMPI items as a combined measure for tension and depression. Although we have demonstrated definite associations between Type A behavior pattern and stress, tension, and depressed mood, these associations are modest and account for only 5-8% of the variance. They should not be interpreted as indicating that the variables are alternate measures for Type A; rather we would conclude that Type A is rooted in a psychosocial matrix. We find such associations in a precisely delimited population; further study is necessary to demonstrate if Type A is regularly associated with these psychosocial variables or whether this association is somehow unique in precatheterization patients. We doubt that coming to cardiac catheterization acts to confound the association between Type A and other psychosocial factors; Types A and B came to catheterization in approximately equal numbers. If the A's were more tense and
Psychosomatic Medicine Vol. 40, No. 7 (November 1978)
581
JOELE. DIMSDALEETAL.
sought catheterization because they had more cardiac symptoms, our findings. Could be confounded by symptomatology. However, angina symptomatology (as measured by the New York Heart Association functional scale) was not associated with behavior pattern (r = -0.07, NS). In the epidemiological study of heart disease which focuses on physiological factors, most researchers believe that coronary disease is caused by multiple factors (14, 15). This multifactorial causation usually refers to simultaneous consideration of blood lipids, smoking history, hypertensive history, etc. By investigating the psychosocial correlates of coronary disease, it would be helpful to pursue a similar multifactor approach. Is Type A behavior the central psychosocial variable related to coronary disease? Is Type A pattern related to an underlying psychosocial variable that in itself is the causative factor? Or is Type A behavior causal only in interaction with other psychosocial variables? This area requires further study. Rather than at-
tempting to analyze particular psychosocial risk factors in isolation, more fruitful results can emerge from a framework wherein research design and methodology permit simultaneous consideration and analysis of several variables to determine the relationships among them. As a first step, it would be helpful to analyze the association between Type A and other psychosocial factors, using various measures for Type A (JAS vs. semistructured interview) and also for the other psychosocial variables, (e.g., MMPI, POMS, and Hamilton scales). If such analyses demonstrate a constant association, it would be important to study the relative associations and the interactions of these variables with clinical manifestations of coronary disease. This work was supported by Grant No. HL19567 from the National Heart, Lung, and Blood Institute. The authors would like to thank Steve Zyzanski and David Jenkins for processing the JAS question-
REFERENCES 1. Rosenman RH, Brand RG, Jenkins CD, et al: Coronary heart disease in the western collaborative group study: Final follow up experience of 8V2 years. JAMA 233:872-877, 1975 2. Shekelle RB, Schoenberger J, Stamler J: Correlates of the JAS type A behavior pattern score. J Chronic Dis, 29:381-394,1976 3. Jenkins CD: Recent evidence supporting psychologic and social risk factors for coronary disease. N Engl J Med, 294:987-994, 1033-1038, 1976 4. Parkes CM: Bereavement. International University Press, 1972 5. Dimsdale JE: Emotional causes of sudden death. Am J Psychiatry 134:1361-1366, 1977 6. Caffrey B: A multivariate analysis of sociopsychological factors in monks with myocardial infarctions. Am J Public Health 60:452-458, 1970 7. Glass DC: Behavior Patterns, Stress, and Coronary Disease. LEA Press, Hillsdale 1977 8. Williams R, Haney T, Gentry D, et al. Relation between hostility and arteriographically documented coronary atherosclerosis in type A and non-type A patients. Psychosom Med 40:88, 1978 (Abstract) 9. Jenkins CD, Zyzanski S, Ryan T, et al. Social insecurity and coronary prone type A responses as identifiers of seven allerosclerosis. J Consult Clin Psychol. 45:1060-1067, 1977 10. Jenkins CD, Rosenman RH, Friedman M: Development of an objective psychological test for the determination of the coronary prone behavior pattern in employed men. J Chronic Dis 20:371-379, 1967 582
Psychosomatic Medicine Vol. 40, No. 7 (November 1978)
RAPID COMMUNICATION 11. Hackett TP, Cassem N: Development of a quantitative rating scale to assess denial. J Psychosom Res 18:93-100, 1974 12. Rahe R, Floistad I, Tergan T, Ringdahl R, Gerhardt R, Gunderson E, Arthur R: A model for life changes and illness research. Arch Gen Psychiatry 31:172-177, 1974 13. McNair D, Lorr M, Droppleman L: Profile of Mood States. San Diego, Calif., Educational and Industrial Testing Services, 1971 14. Gordon T, Garcia-Palmieri M, Kagan A, et al. Differences in coronary heart disease in Framingham, Honolulu, and Puerto Rico. J Chronic Dis 27:329-344, 1974 15. American Heart Association: Coronary Risk Handbook, 1973
Psychosomatic Medicine Vol. 40, No. 7 (November 1978)
583
