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Journal of Human Stress Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzhs20
Physiologic Reactions to Social Challenge in Persons Evidencing the Type a Coronary-Prone Behavior Pattern a
Dr. Theodore M. Dembroski Ph.D. , Dr. James M. MacDougall Ph.D. & Dr. Jim L. Shields Ph.D. a
b
Eckerd College , St. Petersburg, Florida, 33733, USA
b
Prevention, Education, and Control , National Heart, Lung and Blood Institute: National Institutes of Health , Bethesda, Maryland, 20014, USA Published online: 09 Jul 2010.
To cite this article: Dr. Theodore M. Dembroski Ph.D. , Dr. James M. MacDougall Ph.D. & Dr. Jim L. Shields Ph.D. (1977) Physiologic Reactions to Social Challenge in Persons Evidencing the Type a Coronary-Prone Behavior Pattern, Journal of Human Stress, 3:3, 2-9, DOI: 10.1080/0097840X.1977.9936087 To link to this article: http://dx.doi.org/10.1080/0097840X.1977.9936087
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PHYSIOLOGIC REACTIONS TO SOCIAL CHALLENGE IN PERSONS EVIDENCING THE TYPE A CORONARY-PRONE BEHAVIOR PATTERN
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THEODORE M. DEMBROSKI, Ph.D., JAMES M. MACDOUGALL, Ph.D., and JIM L. SHIELDS. Ph.D.
Phvsiologic tneasures were recorded in Type A 1 ( 1 1 = 10) atid Tvpe B ( t i = 14) subjects while the-v eriguged in u reuctiori-time tusk after receiving iristructioris emphasiziiig the rieed for rapid urid ucciirute perjhrniuiice. Although resting levels were iiot significantly different. Type A ' s resporided with significantl-v greater increases thiiti B's irr both heart rute urid svstolic blood pressure. suggest irig greuter s-vrnpath et ic uro usul. A significant baseline difference betweeri the Tvpes in heurt rate variability MUS also observed suggesting greater lability in svmputheticpurusymputhetic junction iri Type A's. No differerices between the Types were obtainedJbr either galvunic skiii poteiitiul (GSP) or speed of reactiori. It is suggested thut the purudigni used in the present studv ojfers uii iriexpetisivc urid qfficierit means b-v which curdiovasculur reactivity in Tvpe A's und B'S tnuy he explored in other U F Ilargergroups ~ qfsuhiects.
It is often suggested that modern civilization presents frequent challenges that evoke defensive physiological arousal without providing opportunities for musculoskeletal discharge of this arousal state.' ' There is good reason to believe that such chronic arousal, in the long run. is damaging to the cardiovascular system.' ' Another related impression, based upon both empirical and theoretical considerations, is that some individuals are more prone than others to be affected by such challenges and to evidence the potentially damaging physiological responses. I Drs. Dembroski and MacDougall are Associate Profesrorc of Psychology at Eckerd College. St. Petersburg, Florida
33733. Dr. Shields is Assistant Director for Prevention. Education, and Control. National Heart. Lung and Blood lnrtitute: National Institutes of Health. Bethesda. Maryland 20014.
2 Journal of Human Stress
During the past decade, research on the Type A coronary-prone behavior pattern has provided convergent evidence that individuals manifesting the pattern may be particularly susceptible to this pathological process. The Type A pattern is characterized by excessive activity, competitiveness, aggressiveness, hostility, impatience, and time urgency that is readily evoked by a variety of challenges in the social and physical ' The Type B pattern is characterized by the relative absence of these attributes. Epidemiological research has demonstrated both prospectively and retrospectively that knowledge of the Type A pattern significantly increases prediction of the major manifestations of coronary heart disease (CHD), independently of traditional risk factors.' l o " In addition, data derived from autopsy and coronary arteriography have September. 1977
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DEMBROSKI, MacDOUGALL, SHIELDS shown that the atherosclerotic process is more fully developed in Type A's than in B's.12 l 3 Both clinical impression and laboratory studies suggest that Type A subjects respond to environmental challenges in a manner indicative of greater behavioral arousal than Type B subjects. For example, in a program of research designed to confirm clinical impressions of the Type A syndrome, observations of Type A's and 9's in a laboratory setting revealed that the former were significantly more aggressive, more time urgent. and more active when confronted with pronounced environmental challenges requiring problemsolving activities.14 As yet there are little direct data concerning whether this behavioral arousal is accompanied by potentially damaging autonomic and endocrinological consequences. A notable exception is a study by Friedman et al, in which fully developed Type A's compared to B's, although evidencing no baseline differences in plasma catecholamine levels, did show significantly greater increases in plasma levels of norepinephrine in response to involvement in a competitive problemsolving task.Is It is also noted that differences in reactivity of blood platelets between Type A's and B's were more pronounced in response to a submaximal exercise test than during baseline conditions.16 If the mechanisms by which the Type A pattern translates into CHD are to be identified and understood it is likely that much more research is needed on physiologic responses to environmental challenge. The present study was designed to assess changes in heart rate, blood pressure, and GSP in Type A and Type B subjects while they engaged in a reaction-time task in which the instructions emphasized the necessity for rapid, accurate performance. I t was hypothesized that in the face of even this relatively mild challenge, the competitive, aggressive tendencies of the Type A subjects would lead to enhanced activity of the cardiovascular system. METHODS Subjects
The 24 subjects included in this report were selected from a larger pool of volunteer college students participating in an ongoing study of September, I977
environmental determinants of physiological arousal in Type A individuals. The present subjects include all of those students who, to date, have been unambiguously classified as Type B ( n = 14) or Type A l , i.e.. fully developed A's, (n = lo), according to the interview criteria established by Friedman and Rosenman, which are described elsewhere in detail." All subjects were male undergraduates. ranging in age from 18 to 22 years, who had received the diagnostic interview administered by one of two females according to the procedures currently used by Rosenman and Friedman. The interviewers were trained by T.D., who was trained by Rosenman and Associates. The rationale for using only subjects with the fully developed form of the Type A pattern has been discussed in detail elsewhere." Procedures
Upon reporting to the laboratory the subject was met by one of the experimenters (T.D.) who greeted and escorted him to the test room, and explained that the general purpose of the experiment was '' . . . to assess how people respond physiologically while working on straightforward tasks." It was further explained that the measurements to be taken were completely painless, and that the only sensation which would be felt was a slight pressure each time the blood pressure cuff was inflated. At this point the subject was requested to signify his willingness to participate by signing an appropriate Informed Consent Agreement. To date, no subject has declined to participate. Following this, the subject was seated comfortably at a desk and prepared by the second experimenter (J.M.) with (a) ECG leads placed on the chest (approximately 10 cm. to the right of the midline at the fourth intercostal space) and left ankle, with a ground electrode on the right ankle; (b) GSP leads (Ag/AgCI discs) attached approximately 5 cm. apart on the palmar surface of the left hand; and (c) a microphone-triggered sphygmomanometer cuff (Sphygmostat, Model 250) attached to the left arm. The ECG and GSP leads were routed to desk-mounted Grass Instruments AC Journal of Human Stress 3
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PHYSIOLOGIC REACTIVITY IN TYPE A Preamplifiers (Model P-15) and thence to an adjacent room where the signals were displayed continuously on a Narco Biosyztems 4Channel Physiograph. The sphygmomanometric cuff was connected to the adjacent room by copper tubing and a microphone extension cable. The ECG signal was displayed directly on one channel and routed secondarily to a cardiotachometer channel which displayed the beat-to-beat rate and variability of the heart (20 BPMICM). The GSP signal was recorded at a standard amplitude of 2mV/CM. Following attachment and testing of the recording apparatus the first experimenter returned and indicated that a period of baseline physiological measurements was needed and requested that the subject ". . . relax and sit quietly for a few minutes." Baseline recordings of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were taken at 90-second intervals. with the sampling times noted directly on the chart record. Typically the pressure readings required 15-20 seconds to complete. Baseline recording continued until SBP and DBP readings remained constant across two sample periods ( f 5 mmHg) and heart rate (HR), indicated by the cardiotachometer signal, had stabilized. At this point the first experimenter (T.D.), who was blind to the subject's A-B classification, reentered the test room and described the reaction-time task to the subject. The following instructions were employed: "The task you will be working on is a choice reaction-time task. We will be testing your speed of reaction. When the green light comes on you are to depress this key as quick/-v as possible. When the red light flashes, you are not to respond. In order to do well at this task it is important that you pay close attention to the lights because the time varies between flashes. For example, it might vary from 3 to 30 seconds between flashes. Remember. when the green light flashes, respond as quick/+v as possible. When the red light flashes try to avoid the mistake of false responding." (Italics indicate emphasized words.) The stimuli consisted of 40 msec flashes of 4
Journal of Human Stress
either of two panel lights mounted horizontally on a small display board in front of the subject. Sequencing and timing of the flashes was programmed using random generators which produced positive (green) and negative (red) stimuli with equal frequency and with the following interstimulus intervals: 4 sec. (SO percent); 8 sec. (25 percent): I2 sec. (12.5 percent); and 16 sec. (12.5 percent). Testing continued until 30 stimuli had been presented. Stimulus order and interstimulus intervals were displayed on the event channel of the Physiograph, w i t h response latencies, measured to the nearest 10 msec. recorded manually on the record. Blood pressure readings were taken 30 sec. after the beginning of the task and every 90 sec. thereafter until the task ended. Typically. only two such readings were obtained. RESULTS
Heart rate and GSP data were obtained from 30-sec. sample periods taken immediately prior to each of the last two baseline measures of blood pressure and each of the two blood pressure measures taken during the reaction-time task. Data from the two baseline and the two task sample periods were then averaged to yield a single baseline value and task value for each physiological measure. Heart rate was counted directly from the ECG record while GSP was quantified by counting the number of potentials i n each sample period whose peak-to-peak voltage exceeded .8 mV. In the course of these analyses we observed clear differences between Type A and €3 subjects in the magnitude of the beat-to-beat variability (changing heart rhythm) seen in the cardiotachometer records. Typically, Type A subjects evidenced what appeared to be greater sinus arrhythmia than did Type B subjects. In many instances the rate variations appeared to be related to respiratory cycles: but. in a number of cases. the period of variation was clearly longer in duration. Since respiration was not directly measured, precise relationship between these variables could not be established. We attempted to quantify the magnitude of the heart rate variability (HRV) by measuring the largest peak-to-inflection point September, 1977
DEMBROSKI, MacDOUGALL, SHIELDS
TABLE 1 MEAN HEART RATE AND HEART RATE VARIABILITY CHANGES FOR TYPE A AND B SUBJECTS
Condition
n
Type A
10
HEART RATE Baseline (6) Task IT)
-
X = 81.0
[M:;
[+
Change ( T - 6) **;X;;
S = 11.4 If
Type B
14
X =
s
74.2
= 10.9
L76.8 11.7
‘i
+ 2.6 7.1
r
HEART RATE VARIABILITY Baseline ( B I Task (T) Change ( T - B) 16.3
14.1
- 2.2
8.6
8.3
6.9
8.6 5.8
9.9 4.3
+ 1.3 4.2
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~ _ _ _
NOTE: Asterisks indicate statistical significance of within-group change or between-group differences. = p < .02, * * = p < .01.
drop in the cardiotachometer record for each of the three consecutive 10-sec. intervals making up the sample period. The final variability measure for the sample period was taken as the arithmetic average of the three measures. Table I presents the mean HR and HRV data for the baseline and task portions of the experiment. During baseline, Type A and B subjects did not differ significantly in their average resting HR, but did show significant differences in the HRV measure (t = 2.64, df = 22, p < .02). This difference is illustrated in Fig. 1, which presents representative baseline cardiotachometer tracings for Type A and B subjects. By contrast, during performance of the reaction-time task, Type A subjects evidenced large and statistically significant increases in average HR (t = 3.72, df = 9, p < . O l ) , while Type B subjects showed only small, nonsignificant changes ( t = 1.37, df = 13. p < .20). A statistical comparison of the magnitude of the increases for both groups (change scores) yielded a , value of 2.99, which is significant at p < . O l . titart rate variability during the task was still numerically greater for the Type A subjects, although the difference was not statistically significant (t = 1.65, df = 22. p < .lo). Blood pressure data are given in Table 2 and present a pattern of effects somewhat parallel to those for average heart rate. No statistically significant group differences were observed
September. 1977
during baseline for either SBP or DBP. although Type A subjects did show somewhat higher average values for both measures. During performance of the reaction-time task, both groups evidenced statistically significant increases in SBP (Type A: t = 11.28. df =9. p < .01: Type B: t = 4.17. df = 13. p < .Ol); however, the magnitude of the average increase for Type A subjects (20.9 mmHg) was markedly greater than that for the Type B subjects (10.2 mmHg). A t-test between groups on the magnitude of the change scores indicated that the increase for Type A subjects was significantly greater than that seen for Type B subjects (t = 3.28. df = 22, p < .01). Increases in DBP while working on the task were of a much smaller magnitude and reached commonly accepted levels of significance only for the Type B subjects (t = 2.75, df = 13, p < .05). The average increase of DBP for Type A subjects, although numerically larger, failed to reach the .05 level of statistical significance due to much greater variability in individual scores within the group (t = 2.19. df = 9. p < .08). A t-test comparison of the DBP change scores between the groups was nonsignificant ( t = 1.39, df = 22, p < .20). Analysis of the GSP data yielded no significant group differences of any sort, either during baseline or during performance of the task, although both groups did evidence large and statistically significant increases in GSP proJournal of Human Stress 5
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PHYSIOLOGIC REACTIVITY I N TYPE A
Fig. 1. Illustrative baseline cardiotachometer records from five subjects. Records A and B are from Type B subjects. while C. D. and E are ftom Type A subjects. Several Type B subjects evidence records similar to C. but in no case did a Type B subject show variability as severe as that illustrated in D and E. Conversely. no Type A subject achieved the minimal variability illustrated in record A .
duction from baseline to working on the task (Type A: t = 3.87. df = 9, p < .01; Type B: t = 3.66, df = 13, p < .01). Correlations (Pearson r) were computed among the various cardiovascular measures separately for the two experimental groups. Table 3 presents the intercorrelations among HR. HRV, SBP, and DBP during baseline and the churzgv score values of these measures from baseline to working on the reaction-time task. Change scores rather than absolute task values were chosen, since the apparent difference between the Types lies in the greater reactivity of
6 Journal of Human Stress
Type A subjects to situational demands. Due to the small samples employed in the present experiment, numerical values of r were required to exceed .63 for the Type A group and .53 for the Type B group to be significant at the .05 level. Given this degree of sampling instability, it seems sensible to focus on only the most general trends manifest in the Table. These include: (a) a tendency during baseline for HR and SBP to be positively correlated for Type A's and negatively correlated for B's; (b) positive correlations for both Types between baseline SBP and task increases in HR and September, 1977
DEMBROSKI, MacDOUGALL, SHIELDS
TABLE 2 MEAN SYSTOLIC AND DIASTOLIC BLOOD PRESSURE CHANGES FOR TYPE A AND B SUBJECTS
Condition
n
Type A
10
r
Systolic Blood Pressure Baseline (€3) Task (T) Change fT - B)
X = 127.0
s
=
I:(
11.0
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14
x
68.3
74.3
+ 6.0
5.5
7.4
10.5
10.4
10.2""
65.1
69.1
+ 4.0"
9.9
7.0
9.9
5.5
x*
X X
Type B
+ 20.9'"
Diastolic Blood Pressure Baseline ( 6 ) Task IT) Change IT - B)
= 119.9
L13O.l
S = 14.5
16.4
L+
NOTE: Asterisks indicate statistical significance of within-group change or between-group differences. = p < .02, "' = p < .01.
DBP: (c) a tendency for baseline DBP to be negatively correlated with task increases in HR, SBP, and DBP for Type A's and positively correlated with increases in these measures for Type B's; (d) positive correlations for both Types between amount of increase in HR and amount of increase in SBP: and (e) inverse correlations for both Types between amount of increase in HRV and baseline levels of both HR and HRV. Precise quantification of the strength of these relationships must await replication with appreciably larger samples. Despite previous research suggestions that Type A subjects are slower to respond in a choice reaction-time test than Type B subject^,'^. l9 the present study found no differences in response latency (Type A's = 390 msec vs B's 400 msec). No explanation is immediately obvious for this failure to replicate earlier research.
DISCUSSION The present data appear to suggest that while both Type A and B subjects respond to environmental challenges with activation of the cardiovascular system, the magnitude of this response is appreciably greater for the Type A individual. Although appropriate pharmacological controls are lacking, it seems most reasonable to conclude that the physiologic arousal observed in Type A subjects was September, 1977
primarily mediated by activation of the sympathetic nervous system and likely via direct nervous action on the myocardium. This interpretation is supported by the fact that the major increases were seen in HR and SBP with only minimal alteration in DBP, and that the magnitude of changes in HR was positively correlated with quantitative shifts in SBP, but unrelated to changes in DBP. The enhanced HRV in Type A relative to Type B subjects is less easily interpreted, although it is suggestive of some imbalance between parasympathetic and sympathetic control of S-A node (pacemaker) function. Evidence does exist which indicates that patients with coronary heart disease show substantially impaired parasympathetic regulation of heart rate." The differential arousal shown by Type A's is particularly striking since the challenge used in the present study was not particularly strong. There was no threat of shock, promise of reward, or direct social competition involved: subjects were simply asked in a serious tone to do well. In view of this observation, it seems likely that the more rigorous demands that may be encountered in everyday social or work-related situations could produce in Type A individuals excessive and sustained levels of physiological arousal of a potentially damaging nature. This interpretation is consistent with the fact that Type A subjects have evidenced Journal of Human Stress 7
PHYSIOLOGIC REACTIVITY I N TYPE A
TABLE 3 PEARSON r VALUES FOR TYPE A (UPPER) AND TYPE B (LOWER) GROUPS COMPUTEDAMONG HR, HRV, SBPAND DBP DURING BASELINE AND CHANGE SCORE VALUES OF THESE MEASURES FROM BASELINE TO TASK Base HRV Base HA
Base HRV
Base SBP
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Base DBP
A HR
A HR
.31
-
.61
-
-
.22 Base SBP
Base DBP
-
A HRV - .58
-
.20
-
~
-
-
.44
.38
-
.66
.54 .63
~
.26
-
.38
.31 -
A DBP
-
.23 .45
~
~
.24
.29
~
.45 .24
-
A HRV
A SBP
.35 .50
.33 -
-
.60 .36
.45 -
.33 .25
~
-
.44 .21
A SBP
NOTE: Dashed lines indicate that r was less than t .20. Critical value of r for p < .05 is .63 for Type A's and .53 for Type B's.
higher levels of urinary ~ a t e ~ h o l a r n i n 'eI ~ ~ ~in other populations of Pattern A individuals. Given the small sample used in this study, adand plasma ACTH" than Type B subjects durditional investigations with such subjects are ing day-to-day activity. In this regard, it has necessary to determine the generality of the been suggested that the observed failure of Type A's' relative to B's to respond with inpresent findings and thence to elucidate the creased urinary excretion of 17-hydroxy- specific neurobehavioral and physiologic mechanisms responsible for the observed carcorticosteroids to an injection of ACTH may be diovascular changes. Although it is tempting due to a greater chronic discharge of ACTH in to speculate as others have done", ". ". lB their everyday life.z3 Although much more work is necessary before the role of the CNS in about the possible emotional-motivational states which may mediate these cardiovascular CHD is fully understood, there is suggestive effects. we are in agreement with Obrist' in evidence that sympathetic arousal and associpreferring, at least initially. to focus on the ated endocrine activity (e.g., catecholamines) situational variables and response modes may be related to the development of athero24 which characterize enhanced reactivity. As sclerosis rirzd acute clinical events. I Pattern A behavior becomes recognized as a In any case, the paradigm used in the presclinically useful risk factor for CHD. research ent investigation offers a relatively efficient of this type will become essential to the and inexpensive opportunity to explore the development of efficient behavioralz9 and/or social and/or physical conditions under which pharmac~logic~" interventions. physiological arousal is enhanced and reduced
8 Journal of Human Stress
September, I977
DEMBROSKI, MacDOUGALL, SHIELDS Rosenman. "Plasma Catecholamine Response of Coronary-Prone Subjects (Type A ) to a Specific Challenge." Metabolisni. Vol. 24, 1975. pp. 205-210.
INDEX TERMS Type A, coronary-prone behavior, stress and coronary heart disease, physiological arousal and coronary heart disease.
REFERENCES
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I . Obrist. P.A. "The Cardiovascular-Behavioral Interaction - As I t Appears Today." fs?,chophvsioloR.v. Vol. 13. 1976. pp. 95-107. 2. Gilmore, J.P. "Physiology of Stress." Sfrrss uird f h r Hrurr. R.S. Eliot. ed.. pp. 69-90. Futura Publishing, Mount Kisco, N.Y.. 1974. 3. Brod, 1. "Mechanisms of Hypertension." Circ. Rrs.. Vol. 27. 1970. SUPPI.I . 1-63 - 1-66, 4. Schiffer. F., L.H. Hartley. C.L. Schulman. and W.H. Abelniann. "The Quiz Electrocardiogram: A New Diagnostic and Research Technique for Evaluating the Relation Between Emotional Stress and Ischemic Heart Disease," Am. J . Curdid.. Vol. 37. 1976. pp. 41-47. 5. Williams, R.B. "Physiological Mechanism, Underlying the Association Between Psychosocial Factors and Coronary Disease." fsyelrolci~iculA s p e t s o/'Mvocurdiul Iitjiurcfioii urrd Coroiiun Cur(,. W.D. Gentry and R.B. Williams. eds.. pp. 37-50. Mosby. St. Louis. Mo.. 1975. 6. Friedman. M. fufhogrnesis n / Coroiru? Ar/eqi Disecisc,. McGraw-Hill. New York. 1969. 7. Rosenman. R.H.. and M. Friedman. "Neurogenic Factors in Pathogenesis of Coronary Heart Disease." Mud. Clin. Norrh Am.. Vol. 58. 1974. pp. 269-279. 8. Rosenman. R.H.. R.J. Brand. C.D. Jenkins. M. Friedman. R. Straus. and M. Wurm. "Coronary Heart Disease in the Western Collahorative Group Study: Final Follow-up Experience of 8.5 Years." J.A. M.A.. VOI. 233. 1975. pp. 872-877. 9. Brand. R.J., R.H. Rosenman. R.I. Stoltz. and M. Friedman. "Multivariate Prediction (if Coronary Heart Disease in the Western Collaborative Group Study Compared to the Findings of the Framingham Study." Circrilurioir. Vol. 53. 1976. pp. 348-355. 10. Shekelle. R.. J . Schoenberger. and J. Stamler. "Correlates of the JAS Type A Behavior Pattern Score."J. Chronic D ~ s .vol. . 29. 1976. pp. 381-394. Evidence Supporting I I . Jenkins. C.D. "Recent Psychologic and Social Risk Factors for Coronary Disease." N. ErrgI. J. Med.. Vol. 294. 1976. pp. 987-994. 1033-1038. 12. Blumenthal, J.A.. R.B. Williams. Y. Kong. L.W. Thompson. C.D. Jenkins, and R.H. Rosenman. "Coronary-Prone Behavior and Angiographically Documented Coronary Diseaw." P.yw/irisoin. M r d . . Vol. 37. 1975. Abstract #102. 13. Friedman. M.. R.H. Rosenman. R. Straus. M. Wurm. and R. Kositchek. "The Relationship of Behavior Pattern A to the State o f the Coronary Vasculaturc: A Study of 51 Autopsied Subjects." Am. J. M d . . Vol. 44, 1968. p. 525. 14. Glass. D.C. Srrcm crnd Coronury f r o m , Bc4rovior. Lawrence Erlbaum Associates. Hillsdale. N.J.. in Press. 15. Friedman. M.. S.O. Byers. J. Diamant, and R.H.
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Journal of Human Stress Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vzhs20
Physiologic Reactions to Social Challenge in Persons Evidencing the Type a Coronary-Prone Behavior Pattern a
Dr. Theodore M. Dembroski Ph.D. , Dr. James M. MacDougall Ph.D. & Dr. Jim L. Shields Ph.D. a
b
Eckerd College , St. Petersburg, Florida, 33733, USA
b
Prevention, Education, and Control , National Heart, Lung and Blood Institute: National Institutes of Health , Bethesda, Maryland, 20014, USA Published online: 09 Jul 2010.
To cite this article: Dr. Theodore M. Dembroski Ph.D. , Dr. James M. MacDougall Ph.D. & Dr. Jim L. Shields Ph.D. (1977) Physiologic Reactions to Social Challenge in Persons Evidencing the Type a Coronary-Prone Behavior Pattern, Journal of Human Stress, 3:3, 2-9, DOI: 10.1080/0097840X.1977.9936087 To link to this article: http://dx.doi.org/10.1080/0097840X.1977.9936087
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PHYSIOLOGIC REACTIONS TO SOCIAL CHALLENGE IN PERSONS EVIDENCING THE TYPE A CORONARY-PRONE BEHAVIOR PATTERN
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THEODORE M. DEMBROSKI, Ph.D., JAMES M. MACDOUGALL, Ph.D., and JIM L. SHIELDS. Ph.D.
Phvsiologic tneasures were recorded in Type A 1 ( 1 1 = 10) atid Tvpe B ( t i = 14) subjects while the-v eriguged in u reuctiori-time tusk after receiving iristructioris emphasiziiig the rieed for rapid urid ucciirute perjhrniuiice. Although resting levels were iiot significantly different. Type A ' s resporided with significantl-v greater increases thiiti B's irr both heart rute urid svstolic blood pressure. suggest irig greuter s-vrnpath et ic uro usul. A significant baseline difference betweeri the Tvpes in heurt rate variability MUS also observed suggesting greater lability in svmputheticpurusymputhetic junction iri Type A's. No differerices between the Types were obtainedJbr either galvunic skiii poteiitiul (GSP) or speed of reactiori. It is suggested thut the purudigni used in the present studv ojfers uii iriexpetisivc urid qfficierit means b-v which curdiovasculur reactivity in Tvpe A's und B'S tnuy he explored in other U F Ilargergroups ~ qfsuhiects.
It is often suggested that modern civilization presents frequent challenges that evoke defensive physiological arousal without providing opportunities for musculoskeletal discharge of this arousal state.' ' There is good reason to believe that such chronic arousal, in the long run. is damaging to the cardiovascular system.' ' Another related impression, based upon both empirical and theoretical considerations, is that some individuals are more prone than others to be affected by such challenges and to evidence the potentially damaging physiological responses. I Drs. Dembroski and MacDougall are Associate Profesrorc of Psychology at Eckerd College. St. Petersburg, Florida
33733. Dr. Shields is Assistant Director for Prevention. Education, and Control. National Heart. Lung and Blood lnrtitute: National Institutes of Health. Bethesda. Maryland 20014.
2 Journal of Human Stress
During the past decade, research on the Type A coronary-prone behavior pattern has provided convergent evidence that individuals manifesting the pattern may be particularly susceptible to this pathological process. The Type A pattern is characterized by excessive activity, competitiveness, aggressiveness, hostility, impatience, and time urgency that is readily evoked by a variety of challenges in the social and physical ' The Type B pattern is characterized by the relative absence of these attributes. Epidemiological research has demonstrated both prospectively and retrospectively that knowledge of the Type A pattern significantly increases prediction of the major manifestations of coronary heart disease (CHD), independently of traditional risk factors.' l o " In addition, data derived from autopsy and coronary arteriography have September. 1977
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DEMBROSKI, MacDOUGALL, SHIELDS shown that the atherosclerotic process is more fully developed in Type A's than in B's.12 l 3 Both clinical impression and laboratory studies suggest that Type A subjects respond to environmental challenges in a manner indicative of greater behavioral arousal than Type B subjects. For example, in a program of research designed to confirm clinical impressions of the Type A syndrome, observations of Type A's and 9's in a laboratory setting revealed that the former were significantly more aggressive, more time urgent. and more active when confronted with pronounced environmental challenges requiring problemsolving activities.14 As yet there are little direct data concerning whether this behavioral arousal is accompanied by potentially damaging autonomic and endocrinological consequences. A notable exception is a study by Friedman et al, in which fully developed Type A's compared to B's, although evidencing no baseline differences in plasma catecholamine levels, did show significantly greater increases in plasma levels of norepinephrine in response to involvement in a competitive problemsolving task.Is It is also noted that differences in reactivity of blood platelets between Type A's and B's were more pronounced in response to a submaximal exercise test than during baseline conditions.16 If the mechanisms by which the Type A pattern translates into CHD are to be identified and understood it is likely that much more research is needed on physiologic responses to environmental challenge. The present study was designed to assess changes in heart rate, blood pressure, and GSP in Type A and Type B subjects while they engaged in a reaction-time task in which the instructions emphasized the necessity for rapid, accurate performance. I t was hypothesized that in the face of even this relatively mild challenge, the competitive, aggressive tendencies of the Type A subjects would lead to enhanced activity of the cardiovascular system. METHODS Subjects
The 24 subjects included in this report were selected from a larger pool of volunteer college students participating in an ongoing study of September, I977
environmental determinants of physiological arousal in Type A individuals. The present subjects include all of those students who, to date, have been unambiguously classified as Type B ( n = 14) or Type A l , i.e.. fully developed A's, (n = lo), according to the interview criteria established by Friedman and Rosenman, which are described elsewhere in detail." All subjects were male undergraduates. ranging in age from 18 to 22 years, who had received the diagnostic interview administered by one of two females according to the procedures currently used by Rosenman and Friedman. The interviewers were trained by T.D., who was trained by Rosenman and Associates. The rationale for using only subjects with the fully developed form of the Type A pattern has been discussed in detail elsewhere." Procedures
Upon reporting to the laboratory the subject was met by one of the experimenters (T.D.) who greeted and escorted him to the test room, and explained that the general purpose of the experiment was '' . . . to assess how people respond physiologically while working on straightforward tasks." It was further explained that the measurements to be taken were completely painless, and that the only sensation which would be felt was a slight pressure each time the blood pressure cuff was inflated. At this point the subject was requested to signify his willingness to participate by signing an appropriate Informed Consent Agreement. To date, no subject has declined to participate. Following this, the subject was seated comfortably at a desk and prepared by the second experimenter (J.M.) with (a) ECG leads placed on the chest (approximately 10 cm. to the right of the midline at the fourth intercostal space) and left ankle, with a ground electrode on the right ankle; (b) GSP leads (Ag/AgCI discs) attached approximately 5 cm. apart on the palmar surface of the left hand; and (c) a microphone-triggered sphygmomanometer cuff (Sphygmostat, Model 250) attached to the left arm. The ECG and GSP leads were routed to desk-mounted Grass Instruments AC Journal of Human Stress 3
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PHYSIOLOGIC REACTIVITY IN TYPE A Preamplifiers (Model P-15) and thence to an adjacent room where the signals were displayed continuously on a Narco Biosyztems 4Channel Physiograph. The sphygmomanometric cuff was connected to the adjacent room by copper tubing and a microphone extension cable. The ECG signal was displayed directly on one channel and routed secondarily to a cardiotachometer channel which displayed the beat-to-beat rate and variability of the heart (20 BPMICM). The GSP signal was recorded at a standard amplitude of 2mV/CM. Following attachment and testing of the recording apparatus the first experimenter returned and indicated that a period of baseline physiological measurements was needed and requested that the subject ". . . relax and sit quietly for a few minutes." Baseline recordings of systolic blood pressure (SBP) and diastolic blood pressure (DBP) were taken at 90-second intervals. with the sampling times noted directly on the chart record. Typically the pressure readings required 15-20 seconds to complete. Baseline recording continued until SBP and DBP readings remained constant across two sample periods ( f 5 mmHg) and heart rate (HR), indicated by the cardiotachometer signal, had stabilized. At this point the first experimenter (T.D.), who was blind to the subject's A-B classification, reentered the test room and described the reaction-time task to the subject. The following instructions were employed: "The task you will be working on is a choice reaction-time task. We will be testing your speed of reaction. When the green light comes on you are to depress this key as quick/-v as possible. When the red light flashes, you are not to respond. In order to do well at this task it is important that you pay close attention to the lights because the time varies between flashes. For example, it might vary from 3 to 30 seconds between flashes. Remember. when the green light flashes, respond as quick/+v as possible. When the red light flashes try to avoid the mistake of false responding." (Italics indicate emphasized words.) The stimuli consisted of 40 msec flashes of 4
Journal of Human Stress
either of two panel lights mounted horizontally on a small display board in front of the subject. Sequencing and timing of the flashes was programmed using random generators which produced positive (green) and negative (red) stimuli with equal frequency and with the following interstimulus intervals: 4 sec. (SO percent); 8 sec. (25 percent): I2 sec. (12.5 percent); and 16 sec. (12.5 percent). Testing continued until 30 stimuli had been presented. Stimulus order and interstimulus intervals were displayed on the event channel of the Physiograph, w i t h response latencies, measured to the nearest 10 msec. recorded manually on the record. Blood pressure readings were taken 30 sec. after the beginning of the task and every 90 sec. thereafter until the task ended. Typically. only two such readings were obtained. RESULTS
Heart rate and GSP data were obtained from 30-sec. sample periods taken immediately prior to each of the last two baseline measures of blood pressure and each of the two blood pressure measures taken during the reaction-time task. Data from the two baseline and the two task sample periods were then averaged to yield a single baseline value and task value for each physiological measure. Heart rate was counted directly from the ECG record while GSP was quantified by counting the number of potentials i n each sample period whose peak-to-peak voltage exceeded .8 mV. In the course of these analyses we observed clear differences between Type A and €3 subjects in the magnitude of the beat-to-beat variability (changing heart rhythm) seen in the cardiotachometer records. Typically, Type A subjects evidenced what appeared to be greater sinus arrhythmia than did Type B subjects. In many instances the rate variations appeared to be related to respiratory cycles: but. in a number of cases. the period of variation was clearly longer in duration. Since respiration was not directly measured, precise relationship between these variables could not be established. We attempted to quantify the magnitude of the heart rate variability (HRV) by measuring the largest peak-to-inflection point September, 1977
DEMBROSKI, MacDOUGALL, SHIELDS
TABLE 1 MEAN HEART RATE AND HEART RATE VARIABILITY CHANGES FOR TYPE A AND B SUBJECTS
Condition
n
Type A
10
HEART RATE Baseline (6) Task IT)
-
X = 81.0
[M:;
[+
Change ( T - 6) **;X;;
S = 11.4 If
Type B
14
X =
s
74.2
= 10.9
L76.8 11.7
‘i
+ 2.6 7.1
r
HEART RATE VARIABILITY Baseline ( B I Task (T) Change ( T - B) 16.3
14.1
- 2.2
8.6
8.3
6.9
8.6 5.8
9.9 4.3
+ 1.3 4.2
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~ _ _ _
NOTE: Asterisks indicate statistical significance of within-group change or between-group differences. = p < .02, * * = p < .01.
drop in the cardiotachometer record for each of the three consecutive 10-sec. intervals making up the sample period. The final variability measure for the sample period was taken as the arithmetic average of the three measures. Table I presents the mean HR and HRV data for the baseline and task portions of the experiment. During baseline, Type A and B subjects did not differ significantly in their average resting HR, but did show significant differences in the HRV measure (t = 2.64, df = 22, p < .02). This difference is illustrated in Fig. 1, which presents representative baseline cardiotachometer tracings for Type A and B subjects. By contrast, during performance of the reaction-time task, Type A subjects evidenced large and statistically significant increases in average HR (t = 3.72, df = 9, p < . O l ) , while Type B subjects showed only small, nonsignificant changes ( t = 1.37, df = 13. p < .20). A statistical comparison of the magnitude of the increases for both groups (change scores) yielded a , value of 2.99, which is significant at p < . O l . titart rate variability during the task was still numerically greater for the Type A subjects, although the difference was not statistically significant (t = 1.65, df = 22. p < .lo). Blood pressure data are given in Table 2 and present a pattern of effects somewhat parallel to those for average heart rate. No statistically significant group differences were observed
September. 1977
during baseline for either SBP or DBP. although Type A subjects did show somewhat higher average values for both measures. During performance of the reaction-time task, both groups evidenced statistically significant increases in SBP (Type A: t = 11.28. df =9. p < .01: Type B: t = 4.17. df = 13. p < .Ol); however, the magnitude of the average increase for Type A subjects (20.9 mmHg) was markedly greater than that for the Type B subjects (10.2 mmHg). A t-test between groups on the magnitude of the change scores indicated that the increase for Type A subjects was significantly greater than that seen for Type B subjects (t = 3.28. df = 22, p < .01). Increases in DBP while working on the task were of a much smaller magnitude and reached commonly accepted levels of significance only for the Type B subjects (t = 2.75, df = 13, p < .05). The average increase of DBP for Type A subjects, although numerically larger, failed to reach the .05 level of statistical significance due to much greater variability in individual scores within the group (t = 2.19. df = 9. p < .08). A t-test comparison of the DBP change scores between the groups was nonsignificant ( t = 1.39, df = 22, p < .20). Analysis of the GSP data yielded no significant group differences of any sort, either during baseline or during performance of the task, although both groups did evidence large and statistically significant increases in GSP proJournal of Human Stress 5
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PHYSIOLOGIC REACTIVITY I N TYPE A
Fig. 1. Illustrative baseline cardiotachometer records from five subjects. Records A and B are from Type B subjects. while C. D. and E are ftom Type A subjects. Several Type B subjects evidence records similar to C. but in no case did a Type B subject show variability as severe as that illustrated in D and E. Conversely. no Type A subject achieved the minimal variability illustrated in record A .
duction from baseline to working on the task (Type A: t = 3.87. df = 9, p < .01; Type B: t = 3.66, df = 13, p < .01). Correlations (Pearson r) were computed among the various cardiovascular measures separately for the two experimental groups. Table 3 presents the intercorrelations among HR. HRV, SBP, and DBP during baseline and the churzgv score values of these measures from baseline to working on the reaction-time task. Change scores rather than absolute task values were chosen, since the apparent difference between the Types lies in the greater reactivity of
6 Journal of Human Stress
Type A subjects to situational demands. Due to the small samples employed in the present experiment, numerical values of r were required to exceed .63 for the Type A group and .53 for the Type B group to be significant at the .05 level. Given this degree of sampling instability, it seems sensible to focus on only the most general trends manifest in the Table. These include: (a) a tendency during baseline for HR and SBP to be positively correlated for Type A's and negatively correlated for B's; (b) positive correlations for both Types between baseline SBP and task increases in HR and September, 1977
DEMBROSKI, MacDOUGALL, SHIELDS
TABLE 2 MEAN SYSTOLIC AND DIASTOLIC BLOOD PRESSURE CHANGES FOR TYPE A AND B SUBJECTS
Condition
n
Type A
10
r
Systolic Blood Pressure Baseline (€3) Task (T) Change fT - B)
X = 127.0
s
=
I:(
11.0
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14
x
68.3
74.3
+ 6.0
5.5
7.4
10.5
10.4
10.2""
65.1
69.1
+ 4.0"
9.9
7.0
9.9
5.5
x*
X X
Type B
+ 20.9'"
Diastolic Blood Pressure Baseline ( 6 ) Task IT) Change IT - B)
= 119.9
L13O.l
S = 14.5
16.4
L+
NOTE: Asterisks indicate statistical significance of within-group change or between-group differences. = p < .02, "' = p < .01.
DBP: (c) a tendency for baseline DBP to be negatively correlated with task increases in HR, SBP, and DBP for Type A's and positively correlated with increases in these measures for Type B's; (d) positive correlations for both Types between amount of increase in HR and amount of increase in SBP: and (e) inverse correlations for both Types between amount of increase in HRV and baseline levels of both HR and HRV. Precise quantification of the strength of these relationships must await replication with appreciably larger samples. Despite previous research suggestions that Type A subjects are slower to respond in a choice reaction-time test than Type B subject^,'^. l9 the present study found no differences in response latency (Type A's = 390 msec vs B's 400 msec). No explanation is immediately obvious for this failure to replicate earlier research.
DISCUSSION The present data appear to suggest that while both Type A and B subjects respond to environmental challenges with activation of the cardiovascular system, the magnitude of this response is appreciably greater for the Type A individual. Although appropriate pharmacological controls are lacking, it seems most reasonable to conclude that the physiologic arousal observed in Type A subjects was September, 1977
primarily mediated by activation of the sympathetic nervous system and likely via direct nervous action on the myocardium. This interpretation is supported by the fact that the major increases were seen in HR and SBP with only minimal alteration in DBP, and that the magnitude of changes in HR was positively correlated with quantitative shifts in SBP, but unrelated to changes in DBP. The enhanced HRV in Type A relative to Type B subjects is less easily interpreted, although it is suggestive of some imbalance between parasympathetic and sympathetic control of S-A node (pacemaker) function. Evidence does exist which indicates that patients with coronary heart disease show substantially impaired parasympathetic regulation of heart rate." The differential arousal shown by Type A's is particularly striking since the challenge used in the present study was not particularly strong. There was no threat of shock, promise of reward, or direct social competition involved: subjects were simply asked in a serious tone to do well. In view of this observation, it seems likely that the more rigorous demands that may be encountered in everyday social or work-related situations could produce in Type A individuals excessive and sustained levels of physiological arousal of a potentially damaging nature. This interpretation is consistent with the fact that Type A subjects have evidenced Journal of Human Stress 7
PHYSIOLOGIC REACTIVITY I N TYPE A
TABLE 3 PEARSON r VALUES FOR TYPE A (UPPER) AND TYPE B (LOWER) GROUPS COMPUTEDAMONG HR, HRV, SBPAND DBP DURING BASELINE AND CHANGE SCORE VALUES OF THESE MEASURES FROM BASELINE TO TASK Base HRV Base HA
Base HRV
Base SBP
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Base DBP
A HR
A HR
.31
-
.61
-
-
.22 Base SBP
Base DBP
-
A HRV - .58
-
.20
-
~
-
-
.44
.38
-
.66
.54 .63
~
.26
-
.38
.31 -
A DBP
-
.23 .45
~
~
.24
.29
~
.45 .24
-
A HRV
A SBP
.35 .50
.33 -
-
.60 .36
.45 -
.33 .25
~
-
.44 .21
A SBP
NOTE: Dashed lines indicate that r was less than t .20. Critical value of r for p < .05 is .63 for Type A's and .53 for Type B's.
higher levels of urinary ~ a t e ~ h o l a r n i n 'eI ~ ~ ~in other populations of Pattern A individuals. Given the small sample used in this study, adand plasma ACTH" than Type B subjects durditional investigations with such subjects are ing day-to-day activity. In this regard, it has necessary to determine the generality of the been suggested that the observed failure of Type A's' relative to B's to respond with inpresent findings and thence to elucidate the creased urinary excretion of 17-hydroxy- specific neurobehavioral and physiologic mechanisms responsible for the observed carcorticosteroids to an injection of ACTH may be diovascular changes. Although it is tempting due to a greater chronic discharge of ACTH in to speculate as others have done", ". ". lB their everyday life.z3 Although much more work is necessary before the role of the CNS in about the possible emotional-motivational states which may mediate these cardiovascular CHD is fully understood, there is suggestive effects. we are in agreement with Obrist' in evidence that sympathetic arousal and associpreferring, at least initially. to focus on the ated endocrine activity (e.g., catecholamines) situational variables and response modes may be related to the development of athero24 which characterize enhanced reactivity. As sclerosis rirzd acute clinical events. I Pattern A behavior becomes recognized as a In any case, the paradigm used in the presclinically useful risk factor for CHD. research ent investigation offers a relatively efficient of this type will become essential to the and inexpensive opportunity to explore the development of efficient behavioralz9 and/or social and/or physical conditions under which pharmac~logic~" interventions. physiological arousal is enhanced and reduced
8 Journal of Human Stress
September, I977
DEMBROSKI, MacDOUGALL, SHIELDS Rosenman. "Plasma Catecholamine Response of Coronary-Prone Subjects (Type A ) to a Specific Challenge." Metabolisni. Vol. 24, 1975. pp. 205-210.
INDEX TERMS Type A, coronary-prone behavior, stress and coronary heart disease, physiological arousal and coronary heart disease.
REFERENCES
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