Personality, type A behavior, and coronary heart disease: the role of emotional expression

The nature of the relation between personality factors and coronary heart disease (CHD, the nation's greatest killer) is one of the most important if controversial issues in the field of psychology and health. Although there is still a great deal of conceptual confusion, progress is being made in refining the key components of a predisposition to heart disease. In this article we examine the construct of a coronary-prone personality in the context of the relations among personality, emotional expression, and disease. Special consideration is given to mode of measurement of the Type A behavior pattern--Structural Interview (SI) versus Jenkins Activity Survey (JAS)--and to components and non-Type A correlates of the general coronary-prone construct. Fifty middle-aged men who had had a myocardial infarction were compared with 50 healthy controls in terms of relevant aspects of their psychological functioning. Results indicate that the SI is better than the JAS as a predictor of coronary heart disease (CHD) because of its attention to emotional expressive style. Traditional emphases on hurry sickness in coronary proneness are deemed wholly inadequate. Furthermore, the results indicate that depression, anxiety, or both may relate to CHD independently of and in addition to Type A behavior. Other aspects of personality and social support are also discussed in the context of improving the construct of coronary proneness.     

Humor and the coronary-prone behavior pattern

The belief is widely held that humor is related to recovery from, and perhaps an increased resistance to, coronary and other stress-related diseases. Such generalizations do not typically distinguish between benign and hostile humor. In the present research, the relationship between a measure of proneness to coronary heart disease (CHD) and appreciation of hostile and nonhostile humor is examined. In two studies, one with college students and one with patients suffering from CHD, the relationship between humor preferences and the coronary-prone (Type A) behavior pattern was examined. Each subject was given the Jenkins Activity Survey as a measure of the coronary-prone personality type, and aggressive and nonaggressive jokes to rate for funniness. Hostile humor was preferred to nonhostile humor by all groups, but among those suffering from CHD, those who could be classified as “Type B’s” preferred nonhostile humor. The results indicate that those less prone to CHD appreciate both hostile and nonhostile humor, while Type A’s seem to enjoy hostile humor only.     

A critical evaluation of some commonly-employed methods for the assessment of type a coronary-prone behaviour

Type A coronary-prone behaviour has been repeatedly associated with an increased incidence of coronary heart disease (CHD) amongst middle-aged men and women. This association appears to be independent of other standard CHD risk factors such as smoking, high blood pressure and elevated serum cholesterol levels. This paper presents normative and correlational data for a number of commonly-employed self-report measures of Type A behaviour and the structured interview. These data replicate U.S. findings that self-report measures tend to correlate only moderately with the Structured-Interview method of assessment of Type A behaviour. The implications of these data for researchers attempting to assess Type A behaviour, especially with limited resources, are discussed.     

Coronary Prone Behavior: Components of the Type A Pattern and Hostility

Traditional and nontraditional risk factors for coronary heart disease (CHD) are discussed with special attention devoted to the Type A behavior pattern (TABP). Positive and negative epidemiological evidence bearing on the risk factors status of global TABP is reviewed. Results of the review suggest that component scoring of the multidimensional global TABP in attempts to uncover "toxic" components, particularly Potential for Hostility, is a profitable research strategy. Similarly, evidence is presented that suggests merit in component scoring of hostility, also a multidimensional construct. To explicate more fully the nature of Potential for Hostility and its categories, correlations between the SI-derived ratings and ratings of established dimensions of individual differences based on the five-factor taxonomic model of personality from subsamples of the MRFIT and WCGS studies are presented. Total Potential for Hostility and especially the Style of interaction category show highly significant relations to Low Agreeableness or Antagonism. High ratings of Potential for Hostility identify individuals who can be described as uncooperative, antagonistic, rude, disagreeable, unsympathetic, callous, and the like. Implications of the evolving concept of coronary-prone behavior, as distinguished from TABP, are briefly considered.     

Linkages between facial expressions of anger and transient myocardial ischemia in men with coronary artery disease

The authors examined whether facial expressions of emotion would predict changes in heart function. One hundred fifteen male patients with coronary artery disease underwent the Type A Structured Interview, during which time measures of transient myocardial ischemia (wall motion abnormality and left ventricular ejection fraction) were obtained. Facial behavior exhibited during the ischemia measurement period was videotaped and later coded by using the Facial Action Coding System (P. Ekman & W. V. Friesen, 1978). Those participants who exhibited ischemia showed significantly more anger expressions and nonenjoyment smiles than nonischemics. Cook-Medley Hostility scores did not vary with ischemic status. The findings have implications for understanding how anger and hostility differentially influence coronary heart disease risk.     

Depression

Patients with myocardial infarction who suffer from a depression are at increased risk of dying of a subsequent heart attack or some other complication of coronary artery disease (CAD). A considerable body of research has provided evidence that a major depression, which is found in 16 to 23 percent of patients with CAD, but also subliminal depressive symptoms are independent risk factors for an unfavourable outcome of CAD. However, it is not yet clear whether depression is a causal risk factor having impact on the course of the heart disease or merely a prognostic marker that allows predicting the outcomes of interest, without any causal influence on them. Several pathways between depression and CAD have been discussed. These include behavioral mechanisms such as low compliance with both medical treatment and life style recommendations as well as neurobiological links. Much attention has been paid to the hypothalamic-pituitary-adrenocortical and sympathomedullary hyperactivity found in depression. Other possible links include diminished heart rate variability, stress-induced ischemia, platelet activation, and immunological dysregulation. To resolve the issue whether depression is a causal risk factor or only a prognostic marker, experimental studies are needed to evaluate interventions aimed at improving depression and test whether mortality is subsequently reduced. Such studies brought in the past mixed results. Whereas comprehensive intervention programs including risk factor management have produced a reduction in both coronary morbidity and mortality, a recent multicenter study providing either cognitive-behavioral therapy or usual care to depressed patients with CAD could not demonstrate a survival benefit among the participants of the intervention. Finally, results of evaluation studies regarding integrated disease management programs for patients with comorbid depression are presented.     

Socioeconomic Differences in Psychosocial Factors Contributing to Coronary Heart Disease: A Review

Psychosocial factors have been shown to play an important role in the aetiology of coronary heart disease (CHD). A strong association between CHD and socioeconomic status (lower-level education, poor financial situation) has also been well established. Socioeconomic differences may thus also have an effect on psychosocial risk factors associated with CHD, and socioeconomic disadvantage may negatively affect the later prognosis and quality of life of cardiac patients. The aim of this study was to review the available evidence on socioeconomic differences in psychosocial factors which specifically contribute to CHD. A computer-aided search of the Medline and PsycINFO databases resulted in 301 articles in English published between 1994 and 2007. A comprehensive screening process identified 12 empirical studies which described the socioeconomic differences in CHD risk factors. A review of these studies showed that socioeconomic status (educational grade, occupation or income) was adversely associated with psychosocial factors linked to CHD. This association was evident in the case of hostility and depression. Available studies also showed a similar trend with respect to social support, perception of health and lack of optimism. Less consistent were the results related to anger and perceived stress levels. Socioeconomic disadvantage seems to be an important element influencing the psychosocial factors related to CHD, thus, a more comprehensive clarification of associations between these factors might be useful. More studies are needed, focused not only on well-known risk factors such as depression and hostility, but also on some lesser known psychosocial factors such as Type D and vital exhaustion and their role in CHD.     

Interactive effects of behavior and reproductive hormones on sex differences in risk for coronary heart disease

It is well known that women in the United States, as in most industrialized countries in the world, are protected from coronary heart disease (CHD), relative to men. It is thought that this protection is by and large due to the effects of female reproductive hormones (i.e., estrogens) on lipid and lipoprotein metabolism and blood pressure, although women's relatively low rates of cigarette smoking are also thought to play a role. However, epidemiological studies that statistically adjust for sex differences in lipids, blood pressure, and smoking status cannot explain sex differences in CHD morbidity and mortality. Also, inconsistent with a simple main-effect model of reproductive hormones are data showing elevated risk of myocardial infarction and stroke among women who use oral contraceptives. Men who are prescribed estrogens have elevated risk of CHD, and case-control studies show that male CHD patients have elevated estradiol, compared to controls. This article suggests that simple main-effect models of female protection from CHD are inadequate. It argues that reproductive hormones are important determinants of protection from CHD, in interaction with behavioral characteristics. It also demonstrates that reproductive hormones can influence behavioral characteristics and that behavioral characteristics can influence the effects of reproductive hormones on CHD risk factors.     

The Relationship Between Religious Service Attendance and Coronary Heart Disease and Related Risk Factors in Saskatchewan, Canada

Research suggests that attending religious services could provide small yet important protective benefits against coronary heart disease (CHD) and CHD risk factors (e.g., diabetes, hypertension). The extent to which these benefits apply to Canada deserves study because approximately one-third of adult Canadians attend religious services at least monthly. Therefore, the objective of this study is to examine the association between frequency of religious service attendance and prevalence of (1) CHD, (2) diabetes, and (3) hypertension in Canada. We used the Saskatchewan sample (n = 5,442) of the Canadian Community Health Survey (CCHS-4.1) and built multivariable logistic regression models to evaluate associations between religious service attendance and self-reported CHD, diabetes, and hypertension. After controlling for demographic, socioeconomic and health behavior variables, the association between religious service attendance and prevalence of CHD was not significant (OR = 0.82; 95 % CI 0.61–1.11). However, persons who attended religious services more than once a week exhibited lower prevalence odds of diabetes (OR = 0.60; 95 % CI 0.45–0.80) and hypertension (OR = 0.82; 95 % CI 0.68–0.99) compared to persons who attended less than once a year. The findings of this study are the first to suggest religious service attendance may be associated with a lower prevalence of CHD risk factors in Canada.     

Depression Screening,Assessment, and Treatment for Patients with Coronary Heart Disease: A Review for Psychologists

Depression prevalence is between 15% and 20% in coronary heart disease patients, such as those with angina, or after a myocardial infarction or coronary artery bypass graft surgery. The presence of depression places a coronary heart disease patient at twofold higher risk for further major cardiac events and death, as well as poor quality of life and early exit from the labour force. As a consequence, several learned societies, including the National Heart Foundation of Australia, have published guidelines that recommend questionnaire screening to improve identification and management strategies for depression in coronary heart disease patients. Psychologists in hospitals, community settings, and private practice can have a key role in the realisation of the National Heart Foundation of Australia's aims. We review the recent guidelines and outline implications for psychologists to identify and manage depression in coronary heart disease patients. The evidence reviewed suggests that cognitive‐behavioural therapy and problem‐solving therapy are frontline non‐pharmacological interventions for depression in CHD patients.     

The synergistic effect of smoking and serum cholesterol on coronary heart disease

Cigarette smoking is a strong predictor of coronary heart disease (CHD), but much of the variance in determining which smokers will, and which will not, suffer from CHD remains unexplained. This review examines evidence of a synergistic interaction effect of smoking and elevated serum cholesterol on CHD morbidity and mortality. Evidence is also presented to support the notion that, in part, serum cholesterol, like smoking, is an index of a behavioral risk factor. Such a synergistic interaction is determined to exist, although improvements in methodology are needed to more clearly identify its magnitude. The review suggests that behavioral treatments aimed at smoking cessation and dietary modification should be focused specifically on the more than 25 million young and middle-aged Americans who smoke and have elevated serum cholesterol. In this way, such treatments may increase their effectiveness in lowering the risk of CHD (benefit) without necessarily increasing their effort (cost).     

Personality as a risk factor in coronary heart disease

The pioneering work of the authors of the Type A personality concept has now been shown to be seriously flawed, with only the traits of anger, aggression, and hostility remaining as risk factors for coronary heart disease (CHD). There is now evidence for a much stronger relationship between CHD and personality involving a rather different set of concepts and theories. The evidence for such a relationship is summarized, and a causal link suggested. It is also shown that the CHD-prone type of behaviour can be changed by behaviour therapy, decreasing considerably the risk of dying from CHD.     

For Better and Worse: Social Influences on Coronary Heart Disease Risk

From the neighborhoods we live in to those we marry, other people are a part of our everyday lives. Mounting evidence suggests that these social factors constitute risk and resilience influences for coronary heart disease (CHD). The current aim is to summarize the literature into four representative categories relating to CHD risk: social environments, social roles, social resources, and close relationships. The argument is made that these factors moderate and mediate stress and associated physiological responses constituting a psychosomatic pathway to disease.     

The independent roles of diet and serum lipids in the 20th-century rise and decline of coronary heart disease mortality

Risk factors are causally related to coronary heart disease (CHD), but in widely varying historic, geographic, socioeconomic, and individual relationships. Serum cholesterol is only one of many risk factors that, even when considered together in prospective studies, account for well under half of the CHD incidence. It is neither primarily regulated by the diet nor significantly related to it. Many findings discordant with widespread beliefs about a causal role of the diet in CHD are reviewed. It may be concluded that dietary fats are largely not responsible for relationships of serum cholesterol to CHD, or for its 20th-century rise and decline.     

冠心病患者的抑郁和焦虑

许多临床研究表明,冠心病患者常发生抑郁及焦虑。而在严重精神症状（如抑郁或/和焦虑）者中有较高的冠心病发生率。抑郁增加冠心病患者的不良心血管事件发生率,影响预后。其机制有如下几个方面：对医疗措施及生活方式改变的依从性差、血小板功能异常、血管内皮功能紊乱以及心率变异性降低。选择性5-羟色胺再摄取抑制剂由于其较好的耐受性且无明显的心血管副作用而应用于冠心病合并抑郁及焦虑的药物治疗并改善患者的生活质量。但仍需要更大规模的临床研究以确定抑郁及焦虑对冠心病预后的影响。临床上应更加关注焦虑对冠心病的影响,进一步探讨焦虑能否作为冠心病的危险因素。     

Hostility, the metabolic syndrome, and incident coronary heart disease.

This invesgation examined the impact of hostility and the metabolic syndrome on coronary heart disease (CHD) using prospective data from the Normative Aging Study. Seven hundred seventy-four older, unmedicated men free of cardiovascular disease were included in the study. The total Cook-Medley Hostility (Ho) Scale score, anthropometric data, serum lipids, fasting insulin concentrations, blood pressure, cigarette smoking, alcohol consumption, and total dietary calories were used to predict incident CHD during a 3-year follow-up interval. Multivariate analysis indicated that only Ho positively predicted and high-density lipoprotein cholesterol level negatively predicted incident CHD. Ho's effects on CHD may be mediated though mechanisms other than factors that constitute the metabolic syndrome.     

Differences in perceptions of coronary disease among Hong Kong Chinese: implications for the societal readiness in disease prevention

Perceptions of coronary heart disease (CHD) influence individual health behavior, which is central to preventing the disease. Not enough is known about the demographic differences in perceptions of CHD among Chinese communities. This study examined these differences in the perceived seriousness and risk of CHD among Hong Kong Chinese. A self-developed questionnaire was administered to a convenient sample (n = 236). Significant differences were identified in the perceived seriousness and risk of CHD between younger and older age groups (p < 0.001) and groups with lower and higher education levels (p < 0.001), but not between genders (p > 0.05). Over 50% of participants expressed greater concern about infectious disease than about CHD, while two-thirds to over half of female, older, and less educated participants were more concerned about stroke. This study highlighted populations with lower levels of CHD perception that need increased public education. The findings have implications for the societal readiness to establishing ongoing public healthcare strategies to increase awareness of CHD.     

Attentional bias and anxiety in individuals with coronary heart disease

This study examined whether in an emotional Stroop task, individuals with coronary heart disease (CHD) would show greater attention towards the threatening words related to their disease than healthy persons, and if such an attentional bias is associated with anxiety. An emotional Stroop task with threatening words related to CHD as well as positive, negative and neutral words was administered to 35 individuals with CHD and 35 healthy controls. Additionally, the original Stroop task, the Beck anxiety inventory and the state-trait anxiety inventory were administered. The results indicated an attentional bias towards threatening words related to CHD in the individuals with CHD. They experienced higher interference than healthy participants from threatening words related to CHD but not from positive or negative words. Moreover, the level of interference was associated with their level of anxiety, and a vicious circle may exist in this association. In addition, results indicated a possible deficit of executive functioning among individuals with CHD. Attentional bias, as well as its association with anxiety, and an indication of deficit in executive functioning among individuals with CHD might be the risk factors for these individuals’ quality of life and for further development of their disease.     

Socioeconomic Status and Coronary Heart Disease Risk: The Role of Social Cognitive Factors

The aim of this study is to examine existing research on social cognitive factors that may, in part, mediate the relationship between socioeconomic status (SES) and coronary heart disease (CHD). We focus on how social status is 'carried' in the mental systems of individuals, and how these systems differentially affect CHD risk and associated behaviors. To this end, literatures documenting the association of various social cognitive factors (e.g., social comparison, perceived discrimination, and self-efficacy) with cardiovascular disease are reviewed as are literatures regarding the relationship of these factors to SES. Possible mechanisms through which social cognitions may affect health are addressed. In addition, directions for future research are discussed, and a model identifying the possible associations between social cognitive factors, SES, and coronary disease is provided.     

Genetics of emotional regulation: the role of the serotonin transporter in neural function

Identifying biological mechanisms through which genes lead to individual differences in emotional behavior is paramount to our understanding of how such differences confer risk for neuropsychiatric illness. The emergence of techniques such as in vivo imaging of brain function in humans and genetic engineering in rodents has provided important new insights into the impact of serotonin (5-HT), a key modulator of emotional behavior, on neural systems subserving anxiety and depression. A major finding has been the discovery of genetic variation in a crucial regulatory molecule within the 5-HT system, the 5HT transporter (5-HTT), and its influence on emotional traits. The study of the 5-HTT provides a new foundation for understanding the neurobiological and genetic basis of emotional regulation and affective illness.