Cognitive-behavioral modification of coronary-prone behaviors: Proposal for a treatment model and review of the evidence

The Type A behavior pattern (TABP) has been proposed as a causal risk factor in coronary heart disease (CHD), and Cognitive-Behavioral treatment procedures have been proposed as a means of altering TABP. However, recent research suggests that only one component of TABP, hostility and anger, is the primary pathogenic factor in CHD. We review the research literature addressing the relationship of cognitive dysfunction and TABP and the relationship between cognitive dysfunction and anger expression. We then review the cognitive-behavioral therapy research literature regarding the modification of cognitive dysfunction, TABP and anger expression. While sparse, the research suggests that cognitive-behavioral treatments for anger and hostility hold promise for the treatment of individuals at risk for CHD.Jeffrey M. Lohr, Ph.D., is an Associate Professor of Psychology at the University of Arkansas-Fayetteville. His research interests are in the assessment of irrational beliefs and their association with dsyphoric motivational statesL. Kevin Hamberger, Ph.D., is an Associate Professor in the Department of Family Medicine of the Medical College of Wisconsin. His clinical and research interests are in the cognitive-behavioral treatment of male spouse abusers     

Modifying the Type A behavior pattern

The Type A behavior pattern (TABP), a complex of personality traits characterized by insecurity of status, hyperaggressiveness, sense of time urgency, free-floating hostility, and a tendency toward self-destruction, has been linked to coronary heart disease in both prospective and clinical studies. Attempts to modify the TABP are complicated by conceptual understandings of the behavioral complex. However, intervention studies, such as the San Francisco Recurrent Coronary Prevention Project, have shown that modification is possible. Both psychological and religious factors need to be taken into consideration when exploring the modification of the TABP.     

Heart and Lifestyle: A Type A Treatment Program for Myocardial Infarction Patients

Abstract

Despite almost thiry years of research on the Type A Behavior Pattern (TABP), only a few controlled treatment studies have been performed. Even fewer of them have been designed as long-term programs, the best known and most carefully controlled being the Recurrent Coronary Prevention Project (RCPP) at Mt. Zion Hospital, San Francisco (Friedman et al. 1982, Friedman et al. 1984, Thoresen et al. 1982). In Scandinavia, a study on TABP was published in 1980 (Orth-Gomér et al.), comparing the frequency of TABP among myocardial infarction patients, hypertensive patients, and healty controls. The results indicated more TABP among MI patients, thereby suggesting that TABP may be associated with Coronary Heart Disease (CHD) in Sweden.     

Gender differences in type a behavior and hostility within an organizational setting

Abstract

Recent investigations suggest that the hostility component of the Type A behavior patter (TABP) is a greater detriment to health than the overall pattern. Some researchers suggest that certain Type A characteristics (e.g., job-involvement) are actually adaptive. This study compared the relative relationship of the TABP and hostility to career-related achievement and psychosocial adjustment among 223 service-delivery employees. Male and female participants completed the Jenkins Activity Survey and the MMPI Hostility Scale as part of a cardiovascular disease risk factor screening. The TABP was positively associated with managerial status for both men and women. However, the TABP was positively related to psychosocial adjustment variables among men only. Hostility was significantly related to undesirable outcomes including lower job status, life dissatisfaction, and unfavorable perceptions of the workplace for both men and women. Discussion addresses organizational factors which might perpetuate hostility and the TABP, as well as gender differences in the experience of these constructs.     

Societies should not ignore their incel problem

Involuntarily celibate men (‘incels’) commonly advocate for societal disruption, including violence toward women. Their anger can make them susceptible to radicalization, revolution, or reactionary hostility. Research efforts aimed at identifying the causes and consequences of incels’ beliefs are needed to address this growing problem.     

Sex differences in the relation of depressive symptoms, hostility, and anger expression to indices of glucose metabolism in nondiabetic adults.

This study examined the relation of depressive symptomatology, hostility, and anger expression to indices of glucose metabolism and tested whether gender moderates these associations in a sample of 135 healthy, nondiabetic adults (75 men, 60 women). The severity of depressive symptoms, hostility, and anger expression was positively associated with estimated insulin resistance (IR) and insulin in women but not in men. Anger expression was positively associated with glucose in women only. A summary score of depressive symptoms, hostility, and anger expression was positively associated with estimated IR, insulin, and glucose in women but not in men. Hence, in women, IR and elevated levels of fasting insulin and glucose may be one pathophysiological mechanism mediating the increased risk of cardiovascular disease and Type 2 diabetes associated with these psychological attributes.     

Associations of blood pressure with self-report measures of anger and hostility among black and white men and women

This study examined associations between blood pressure (BP) and dispositional variables pertaining to anger and hostility. Black and White 25- to 44-year old male and female normotensives and unmedicated mild to moderate hypertensives completed four reliable self-report scales--the Cook-Medley Hostility (Ho) Scale, the Trait Anger subscale of the State-Trait Anger Scale (STAS-T), and the Cognitive Anger and Somatic Anger subscales of the Cognitive-Somatic Anger Scale--plus the Framingham Anger Scale and the Harburg Anger Scale. They also engaged in three laboratory tasks--Type A Structured Interview (SI), a video game, and a cold pressor task--that elicit cardiovascular reactivity. Ambulatory BP readings at home and at work were also obtained from most subjects. Blacks had significantly higher Ho and lower STAS-T scores than did Whites. Women reported higher levels of somatic anger than did men. White women showed significant positive correlations between STAS-T and systolic BP (SBP) and diastolic BP (DBP) both at rest in the laboratory and during the SI. Black women revealed significant positive relationships between STAS-T and SBP and DBP at rest in the laboratory and at work as well as with DBP during the cold pressor test. For Black men, cognitive anger and DBP at rest were positively related. In contrast, White men revealed significant negative correlations between Ho scores and SBP at rest and during the video game; these men also showed significant negative relationships between somatic anger and SBP and DBP reactivity during the cold pressor test. Women, but not men, showed significant positive relationships between all four anger measures and ambulatory BP at work. Whereas main effects relating anger and cardiovascular measures were not apparent as a function of race, Blacks demonstrated significantly greater SBP and DBP reactivity than Whites during the cold pressor test, with the converse occurring during the SI. Men demonstrated significantly greater DBP reactivity than women during the video game. The present findings indicate that self-reports on anger/hostility measures and cardiovascular responses to behavioral tasks differ as a function of race but that relationships between anger and BP regulation need to take into account possible race-sex interactions and selection of anger/hostility measures.     

Type A behavior and parenting stress in mothers with young children

Type A Behavior Pattern (TABP) is characterized by competitiveness, a sense of time-urgency, impatience, and aggression/hostility and it has been associated with coronary heart disease and occupational stress in men. Recently, research had begun to examine TABP in women. However, the majority of studies focus on women as student or employee and not in the role of mother. Thus, although women spend a significant proportion of their adult lives bearing and raising children, little is known about TABP relationships in these roles. Further, the parenting adjustment literature amply describes the stressful nature of parenting a young child but with little attention paid to the relationship between maternal individual characteristics and parenting stress. This study investigated maternal adjustment and TABP in order to provide a clearer picture of Type A women as mothers as well as to expand information on individual characteristics which contribute to or mediate a woman’s adjustment to motherhood. Because of its presumed relationship to TABP and stress, maternal employment status was a control variable. One hundred twenty-six women with children between the ages of 9–24 months completed questionnaires reporting maternal stress, maternal perceptions of her child and somatic complaints. TABP was assessed by two measures, the Framingham Type A Scale (FTAS) and a recent measure, the Adolescent/Adult Type A Behavior Scale (AATABS), which yields factor scores as well as a global TABP rating. Overall, Type A women reported higher levels of child-related stress and personal stress than Type B women. Certain factors such as Hurry, Control, and Hostility were also associated with stress indices. There was qualified support for a relationship between the TABP factor, Hurry, and self-reported somatic complaints. Directions for future research are discussed.     

Type A behavior and parenting stress in mothers with young children

Type A Behavior Pattern (TABP) is characterized by competitiveness, a sense of time-urgency, impatience, and aggression/hostility and it has been associated with coronary heart disease and occupational stress in men. Recently, research had begun to examine TABP in women. However, the majority of studies focus on women as student or employee and not in the role of mother. Thus, although women spend a significant proportion of their adult lives bearing and raising children, little is known about TABP relationships in these roles. Further, the parenting adjustment literature amply describes the stressful nature of parenting a young child but with little attention paid to the relationship between maternal individual characteristics and parenting stress. This study investigated maternal adjustment and TABP in order to provide a clearer picture of Type A women as mothers as well as to expand information on individual characteristics which contribute to or mediate a woman’s adjustment to motherhood. Because of its presumed relationship to TABP and stress, maternal employment status was a control variable. One hundred twenty-six women with children between the ages of 9–24 months completed questionnaires reporting maternal stress, maternal perceptions of her child and somatic complaints. TABP was assessed by two measures, the Framingham Type A Scale (FTAS) and a recent measure, the Adolescent/Adult Type A Behavior Scale (AATABS), which yields factor scores as well as a global TABP rating. Overall, Type A women reported higher levels of child-related stress and personal stress than Type B women. Certain factors such as Hurry, Control, and Hostility were also associated with stress indices. There was qualified support for a relationship between the TABP factor, Hurry, and self-reported somatic complaints. Directions for future research are discussed.     

Psychological characteristics of aggressive drivers with and without intermittent explosive disorder

We compared two groups of aggressive drivers, those who met criteria for Intermittent Explosive Disorder (IED) (n=10) and comparable aggressive drivers who did not meet IED criteria (n=20), to a group of non-aggressive driving controls (n=20) on measures of psychological distress, anger, hostility, and Type A behavior as well as measures of aggressive driving and driving anger and their driving records. There were few differences between the aggressive drivers with IED and those without IED. The IED positive aggressive drivers endorsed more assaultiveness and resentment as well as more impatience and showed trends to have more hostility and angry temperament. When all aggressive drivers were compared to controls, differences emerged on anxiety, hostility, and anger as well as on measure specific to aggressive driving (competitiveness) and driving anger (at slow drivers and traffic obstructions).     

Does harboring hostility hurt? Associations between hostility and pulmonary function in the Coronary Artery Risk Development in (Young) Adults (CARDIA) study.

OBJECTIVE: To examine the cross-sectional association between hostility and pulmonary function (PF) and its consistency across race/ethnicity-gender groups. DESIGN: Data were from the Coronary Artery Risk Development in (Young) Adults (CARDIA) cohort study (N=4,629). Participants were recruited from 4 metropolitan areas in the United States, ages 18-30 years at baseline in 1985-1986, approximately balanced across race/ethnicity (Black, White) and gender. MAIN OUTCOME MEASURES: Main outcome measures were percent predicted values for forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC). RESULTS: In full-sample multiple linear regression analyses, each 1 standard deviation (SD) increase in hostility was associated with a 0.66% decrease in FEV-sub-1 (p=.0002) and a 0.60% decrease in FVC (p=.0006). This inverse association of hostility with PF remained after controlling for age, height, current socioeconomic status (SES), participant smoking status, and asthma and is more consistent than that of smoking and PF. In stratified analyses, each 1 SD increase in hostility predicted statistically significant reductions in PF for Black women, White women, and Black men. For White men, hostility showed no statistically significant relation with PF, although the pattern relating hostility to PF was similar to the pattern in the other three groups. Further, both of the post hoc three-way interaction terms for hostility, race/ethnicity, and gender predicting FEV-sub-1 and FVC were nonsignificant. CONCLUSION: PF was inversely associated with hostility across race/ethnicity and gender, independent of age, height, current SES, smoking, and asthma. On the basis of these cross-sectional findings, the authors hypothesize that higher hostility will predict a more rapid decline in PF.     

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.     

The assessment of anger and hostility: a critical review

While the emotion of anger has become an increasingly important part of clinical assessment, the theoretical and psychometric adequacy of the instruments used to assess anger and hostility have long been questioned. In the present review, we first provide definitions of anger and hostility in order to provide a theoretical context from which to evaluate the scope of current measures of these constructs. Second, we review the major self-report scales used to assess anger and hostility in light of these definitions and provide a detailed evaluation of psychometric evidence concerning their reliability and validity. Finally, we offer specific recommendations concerning how anger and hostility assessment instruments can be improved and expanded. In particular, we note the need for (a) an expansion of anger assessment methods beyond traditional endorsement approaches, (b) scales to assess specific domains of anger experience, (c) scales that assess unique content domains of anger experience and expressions, such as spouse-specific or driving-related anger scales, and (d) scales that assess the clinical aspects of the anger construct.     

Violent video games exposure and aggression: The role of moral disengagement,anger, hostility,and disinhibition

Based on the General Aggression Model (GAM), the current study investigated the interactive effect of personal factors (e.g., sensation-seeking) and situational factors (e.g., violent video games exposure [VVGE]) on the trait aggressive behavior, and the mediating role of individual difference trait (e.g., moral disengagement, anger, and hostility). We recruited 547 undergraduates (48.45% male) from five Chinese universities. The results showed that VVGE was positively associated with moral disengagement, disinhibition, and the four aggressive traits (physical aggression, verbal aggression, anger, and hostility), which were positively associated with each other. Moral disengagement was positively associated with both the disinhibition and the four aggressive traits. Disinhibition was positively associated with the four aggressive traits as well. When controlled for gender, moral disengagement, anger, and hostility wholly mediated the relationship between VVGE and aggression, but the moderation effect of disinhibition was not significant. These findings support the framework of GAM and indicate that moral disengagement, anger, and hostility may be the factors that increase the risk of a higher level of aggression following repeated exposure to violent video games.     

Problem Anger in Psychotherapy: An Emotion-Focused Perspective on Hate, Rage, and Rejecting Anger

This paper explores applies emotion-focused theory, for the first time, to the emotions of hate, rage, and destructive anger. The general case formulation proposed in this paper is that these emotions are always an elaboration of secondary anger. The body of the paper describes three clinical case formulations. First, problem anger is described in terms of an individual’s self-criticism. Second, we present a form of secondary anger, in which hostility and rage are reactive feelings to avoid more vulnerable (primary) experiences. An unfortunate example of this is has been described as a common underlying process in domestic violence. A alternate manifestation of secondary anger results from the deterioration of what may have initially been adaptive anger; thus, excessive arousal and the loss of meaning or focus that one’s anger embodied also leads to rage or destructive anger. Finally, the experience and expression of hate is described as a primary maladaptive and/or instrumental anger. This appears in-session particularly among those with certain personality disorders. The paper highlights implications for research and practice.     

Aggression,anger and hostility: Evaluation of moral disengagement as a mediational process

This study examines how the mechanisms underlying moral disengagement serve as a mediator between anger and hostility and physical and verbal aggression. The study was carried out on 424 participants (61.1% females), aged 15 to 25 years, assessing the direct and indirect effects of the distinct variables using a hierarchical multiple regression analysis and structural equation modeling. The findings suggest that anger and hostility contribute independently and positively to physical and verbal aggression. Moreover, the relationships between anger, hostility, and aggression appear to be mediated by moral disengagement. Indeed, this process of mediation was invariant across sexes, and it tended to be stronger for physical – as opposed to verbal – aggression.     

Moderators and mediators of the stress-aggression relationship: executive function and state anger

The present study examined the effects of executive function (i.e., EF) and anger/hostility on the relationship between stress (across individual stress domains, as well as at the aggregate level) and aggression. Two independent groups of participants-a college sample and a low-income community sample-were administered a battery of self-report measures concerning the subjective experience of stress, aggressive behaviors, and feelings of state anger and hostility in the last month, along with a battery of well-validated neuropsychological tests of EF. Across both samples, the stress domains that demonstrated the strongest associations with aggression were those involving chronic strains of daily living (e.g., job, financial, health) versus interpersonal stressors (e.g., family, romantic). In the community sample, analyses also revealed a significant interaction between perceived stress (aggregated across domains) and EF in predicting aggressive behavior. Specifically, participants with relatively low EF abilities, across different EF processes, showed a stronger relationship between different domains of stress and aggression in the last month. Similar effects were demonstrated in the college sample, although the interaction was not significant. In both samples, experiences of anger and hostility in the last month mediated the relationship between perceived stress (aggregate) and aggressive behavior among those low, but not high, in EF. These findings highlight the importance of higher-order cognitive processes in regulating appropriate affective and behavioral responses across different types of individuals, particularly among those experiencing high levels of stress.     

Are All Hostility Scales Alike? Factor Structure and Covariation Among Measures of Hostility1

Few studies have examined the correlational and structural relationships between measures of hostility that may predict coronary heart disease. Using data from a population-based study (N= 2,682), we examined the factor structure among the five subscales from Siegel's (1986) Multi-dimensional Anger Inventory, the three subscales from Spielberger et al.'s (1985) anger expression scales, a Cook-Medley (Cook & Madley, 1954) hostility subscale that measures cynicism, and items measuring hostility from four scales that assess Type A behavior. Eight separate factors were identified: hostile anger expression, perceived control over the expression of one's anger, frequency of anger, ease of anger provocation, brooding, hostile outlook, cynicism, and sullenness. These results suggest that the structure of hostility measures is more complex than previous factor analyses have suggested. Our findings point to the dangers in assuming that a factor structure can be generalized beyond the data on which it is based to provide theoretical statements about psychological structure. The new scales appear to be valid because they correlate with demographic variables and indicators of social support in the expected directions.     

Distinguishing narcissism and hostility: similarities and differences in interpersonal circumplex and five-factor correlates

Narcissism and hostility are both characterized by dysfunctional social interactions, including tendencies to perceive slights, experience anger, and behave aggressively. The aim of this study was to examine the similarities and differences of narcissism and hostility, using 2 conceptual tools-the interpersonal circumplex and the Five-factor model. In a sample of 292 undergraduate men and women, composite measures of hostility (i.e., Buss-Perry Aggression Questionnaire [Buss & Perry, 1992] and Cook-Medley Hostility [Cook & Medley, 1954] total scores) were inversely correlated with affiliation and unrelated to dominance. In contrast, composite narcissism scores (i.e., Narcissistic Personality Inventory) were positively correlated with dominance and inversely correlated with affiliation. Examination of components of these traits revealed additional similarities and differences, as did associations with other dimensions of the Five-factor model. These findings suggest that the traits of narcissism and hostility are distinguishable by their interpersonal referents, as are their components.     

Anger and hostility from the perspective of the Big Five personality model

Sanz, J., García‐Vera, M. P. & Magán, I. (2010). Anger and hostility from the perspective of the Big Five personality model. Scandinavian Journal of Psychology, 51, 262–270. This study was aimed at examining the relationships of the personality dimensions of the five‐factor model or Big Five with trait anger and with two specific traits of hostility (mistrust and confrontational attitude), and identifying the similarities and differences between trait anger and hostility in the framework of the Big Five. In a sample of 353 male and female adults, the Big Five explained a significant percentage of individual differences in trait anger and hostility after controlling the effects due to the relationship between both constructs and content overlapping across scales. In addition, trait anger was primarily associated with neuroticism, whereas mistrust and confrontational attitude were principally related to low agreeableness. These findings are discussed in the context of the anger‐hostility‐aggression syndrome and the capability of the Big Five for organizing and clarifying related personality constructs.