Models of personality and disease: an interactional approach to type A behavior and cardiovascular risk

Type A behavior has been established as a risk factor for coronary heart disease. Enhanced cardiovascular and neuroendocrine responsiveness to stressors has been suggested as a pathophysiological link between the behavior pattern and disease. The present article describes a model that places this link in an interactional context. Specifically, it is hypothesized that via cognitive and overt behaviors, Type As construct a subjective and objective environment rich in those classes of stimuli known to elicit enhanced physiological reactivity. This approach differs from previous ones by emphasizing that the Type A pattern represents an ongoing process of challenge and demand engendering behavior. That is, Type A persons do not simply respond to challenges and demands; they seek and create them through their cognitions and actions. This constructed environment also elicits and maintains further Type A behavior. The present view of Type A behavior as a challenge and demand engendering style is contrasted with other conceptual approaches, and implications are discussed.     

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.     

Anger in type a women: Implications for coronary heart disease

The present study examines the relationship between Type A behaviour and anger in a sample of managerial women. The Type A behaviour pattern is hard driving, job-devoted lifestyle which is associated with a significantly increased risk of coronary heart disease in men as in women. Anger and hostility have been reported to be critical components of the Type A behaviour pattern which contribute to coronary heart disease. This research also examines the relationship between occupational demands and job anger in managerial women. Occupational demands include demands particularly unique to women in non-traditional occupational roles such as inequity of pay, underutilization of skills, low boss support and perceived sex discrimination. State (job) and Trait Anger were also assessed as were various psychological and behavioural outcomes such as state anxiety, depression, job satisfaction, absenteeism, and “intention to turnover”. Results showed that sex discrimination was a significant occupational stressor in Type As only. Further results of a multiple regression analysis indicated tha for Type As only, sex discrimination was positively associated with job anger when social support from one's boss was low. However, with increasing support, Type As were less likely to report anger when discrimination was high. In conclusion, the results of this study have demonstrated that social support can function as a buffer against anger, thus extending the buffering hypothesis originally put forth to refer to the buffering effects of social support and anxiety.     

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.     

Would a Type A Date Another Type A?: Influence of Behavior Type and Personal Attributes In the Selection of Dating Partners1

Certain behavior type patterns in couples have been associated with heightened interpersonal distress and coronary heart disease risk. However, the factors that lead to such pairings seldom have been investigated. The present study examined the associations between personal behavior type and gender-role self-concept related to the selection of hypothetical dating partners. Eighty-one male and 116 female heterosexual college students completed questionnaires to assess behavior type (Jenkins Activity Survey) and gender-role self-concept (Personal Attributes Questionnaire, PAQ). Participants chose a preferred “dating partner” from vignettes differing in the degree of Type A-Type B behavior displayed. Results of CATMOD and chi-square analyses were generally consistent with the similarity theory of interpersonal attraction. Type A and B males as well as Type B females preferred hypothetical dating partners identical to their own behavior type. Type A females with high PAQ Masculinity scores selected Type A dates, whereas Type A females with low PAQ Masculinity preferred Type Bs. Implications for the selection of actual dating partners, spouses, potential interpersonal distress, and coronary heart disease risk are discussed.     

Type A personality, self-control, and vulnerability to stress

Type A behavior (hard-driving, competitive, time-urgent, hostile-irritable) has been linked to high stress levels and the risk of eventual cardiovascular problems (i.e., coronary heart disease, CHD). However, this pattern of behavior closely resembles the traditional masculine instrumental (goal-oriented) orientation, and, if kept within limits, may be viewed as adaptive in success-oriented, middle-class college students. Hypothetically then, Type A behavior may be displayed by a broad group of individuals, and only in those cases when it is allowed to reach extreme proportions is stress sufficient enough to confer risk. This article considers two lines of reasoning. Is greater self-control required for college women to be Type As, because it involves crossing into traditional male role behavior? Type A women displayed significantly better self-control then Type B women; the opposite result was disclosed for college men with Type As displaying poorer self-control than Type Bs. The question of whether risk-conferring Type A behavior would result from poorer self-control was answered in the affirmative. Self-control assumed moderator status; poorer self-control in both male and female Type As was associated with high levels of day-to-day stress relative to Type As with better self-control. Self-control did not influence stress level in Type Bs. This moderator effect suggests that only Type As who cannot contain their behavior within adaptive limits will be vulnerable to excessive stress and at risk for CHD.     

Relationship of type A behavior pattern in smokers to carbon monoxide exposure and smoking topography

Stress-related physiological factors have been proposed to mediate the Type A behavior pattern (TABP) and coronary heart disease (CHD). However, collateral behavioral factors, such as the exaggerated consummatory response patterns of Type As, may also be involved. Study 1 examined this hypothesis by comparing exposure to cigarette smoke in 42 graduate and undergraduate student smokers assessed for the TABP. After controlling for smoking rate and Federal Trade Commission cigarette carbon monoxide yield, Type As' alveolar carbon monoxide (COa) levels were higher than Type Bs', and Jenkins Activity Survey scores were correlated with COa. To determine the source of this difference, we measured smoking topography in 10 Type As and 10 Type Bs in Study 2. Type As and Type Bs did not differ in number of puffs taken or puff volume, but Type As' inhalation duration was 70% longer than Type Bs'. These results suggest that consummatory behaviors of Type As may help account for the Type A-CHD relationship for smokers. Due to increased smoke exposure, Type A smokers may also be at greater risk for cancer and lung disease than Type B smokers.     

The framingham Type A Scale: Cardiovascular and cognitive-behavioral responses to interpersonal challenge

Most of the primary measures of Type A behavior have been found to be associated with physiological reactivity to stressors, as well as coronary heart disease (CHD). While it does predict CHD, the Framingham Type A Scale (FTAS) has not been conclusively linked to physiological reactivity. Similarly, in contrast to other Type A measures, little is known concerning the cognitive behaviors associated with the FTAS in stressful situations. The present study was conducted to evaluate the cardiovascular and cognitive-behavioral responses to interpersonal challenge of Type A versus Type B subjects, as classified by the FTAS. Type A's evidenced increased systolic blood pressure (SBP) reactivity and a greater degree of negatively toned cognitive activity than did Type B's. The SBP findings are consistent with those obtained with other measures of Type A behavior, and with the hypothesis that neuroendocrine reactivity mediates the link between the behavior pattern and CHD. The somewhat unique cognitive-behavior findings, however, may reflect important psychological differences among the various Type A measures.Portions of this paper were presented at the meeting of the Society of Behavioral Medicine, Philadelphia, 1984.     

The Type A Structured Interview: A behavioral assessment in the rough

The Type A behavior pattern is the focus of considerable research in behavioral medicine because of its causal relevance to coronary heart disease. The primary assessment of Type A behavior is a global rating made from a structured interview. From the perspective of behavioral assessment, this Structured Interview (SI) is important for two reasons. First, it provides an example of the superiority of an observed behavioral measure compared to self-report questionnaires for the assessment of an overt behavior pattern. Second, it provides a unique opportunity for the application of behavioral assessment technology. However, while the SI has demonstrated its clinical and research utility as a diagnostic procedure, its usefulness could be further enhanced in the areas of treatment selection and evaluation. The historical relationship between behavior and coronary heart disease is described. The development of the SI and the strengths of this assessment relative to other measurement approaches are reviewed. The standard questions and administration procedures for the interview are presented, along with several variations and modifications. Following this overview, the SI is discussed from the perspective of behavioral assessment.     

Modification of Type A behavior through aerobic exercise

This psychophysiological evaluation of an aerobic exercise program examined specifically whether aerobic training modified Pattern A for those individuals at behavioral risk for developing coronary heart disease, i.e., young Type A individuals. At pretest and posttest of this secondary prevention study, Type A and Type B subjects were assessed in three conditions: aerobic exercise program, nonaerobic activity (Aikido, a martial art) control, and notreatment control. After 10 weeks, Type A but not Type B subjects exhibited lower Pattern A behavior in the aerobic program than in control conditions. Average workout pulse rates and differentially reliable increases in aerobic capacity indicated that aerobic training was indeed aerobic, whereas aikido activity was not. Even though selected nonaerobic factors, such as locus of control and group participation, did not mediate the Pattern A decrease for Type A's when comparing aikido and aerobic conditions, changes in aerobic capacity may have been the mediator. Generalizability of the results and implications for theoretical development and clinical intervention are discussed.     

Interpersonal dominance and coronary prone behavior

Type A “coronary-prone behavior” is a risk factor for coronary artery and heart disease. Questionnaire research indicates that interpersonal dominance is one of the strongest behavioral correlates of the Type A behavior pattern, although little effort has been made to demonstrate a link between the behavioral manifestations of interpersonal dominance and Pattern A responding. This study was conducted to establish such a link. All possible combinations of extreme As (N = 42) and Bs (N = 42) were matched in dyads that negotiated extreme bipolar opposite positions on a “teacher dismissal” issue. Analysis of process and outcome behaviors suggested that type A individuals are unilaterally more dominant than their Type B counterparts. Possible physiological mechanisms mediating dominance and cardiovascular disease 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.     

Components of type A behavior and two-year prognosis of patients with acute coronary syndrome

We investigated prospectively the relationship of Type A behavior and its subcomponents with cardiac mortality and recurrent nonfatal cardiac events in a 2-yr. follow-up of 90 patients [69 men and 21 women, M age=56.4 yr., SD=8.4] after acute coronary syndrome. Type A behavior was assessed via the general Bortner Type A Index. Each patient completed the Bortner's scale before hospital discharge. During the first 2-yr. follow-up, there were 14 cardiac deaths among patients with myocardial infarction. 8 patients had recurrent cardiac events and were hospitalized, and 19 patients had an effort-induced angina pectoris. Patients with acute myocardial infarction who died during follow-up had a significantly lower Bortner score than patients with a secondary cardiac event. Bortner scores of patients with acute myocardial infarction who died indicated Type B behavioral patterns. Mortality was significantly higher in the patients classified as showing Type B (21.8%) behavior than in the patients classified as showing Type A (12.0%) behavior. Patients with a secondary cardiac event had more common Type A behavior patterns and higher Bortner scores than patients without a secondary cardiac event. The items on Bortner's scale "very competitive, ever rushed, tries to do too many things at once, fast in daily activities and expresses feelings" were inversely associated with cardiac deaths. These findings suggest that patients with acute coronary syndrome classified by scores on the Bortner scale as Type B behavior have a greater probability of death, and patients classified on the Bortner scale as Type A behavior have a greater probability of secondary cardiac events during follow-up. This finding may have implications for the treatment of patients with acute coronary syndrome. The inferior survival of patients with Type B personalities argues against attempts to modify Type A behavior in postinfarction patients.     

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,irritability, and cardiovascular response

Previous research suggests that high levels of hostility may augment the cardiovascular reactivity and risk of coronary heart disease (CHD) associated with Type A behavior. In contrast, other research indicates that the tendency to deny or suppress anger is associated with enhanced cardiovascular reactivity and risk of CHD. To delineate further the combined role of anger processes and Type A behavior in CHD risk, this study examined the interactive effects of Type A behavior and self-reported irritability on cardiovascular response to a challenging mental task. Type A and Type B college students were further classified as either high or low in self-reported irritability. Type A subjects who were low in self-reported irritability evidenced greater cardiovascular reactivity (i.e., systolic blood pressure and pulse rate) than did Type B subjects low in irritability. However, Type A subjects who were high in irritability tended to demonstrate less cardiovascular response than Type B subjects high in irritability. Further, Type A's low in self-reported irritability evidenced greater cardiovascular response than high-irritability Type A's. It is suggested that reduced reporting of irritability by Type A's may reflect suppression or denial, and further that this reduced reporting is associated with enhanced cardiovascular responsivity.     

Type D personality,but not Type A behavior pattern,is associated with coronary plaque vulnerability

Personality traits are associated with major adverse coronary events (MACE) in patients with coronary artery disease (CAD). However, the link between personality traits and intravascular morphology in CAD patients is poorly understood. This study investigated the relationship between personality traits, specifically Type A behavior pattern and Type D personality, and plaque vulnerability. After adjustment for demographic and clinical factors, multivariable regression analysis showed no association between Type A and optical coherence tomography indices. However, Type D personality was independently associated with lipid plaque, thin cap fibroatheroma (TCFA), and fibrous cap thickness. More specifically, negative affectivity of Type D was related to lipid plaque, TCFA and fibrous cap thickness, and social inhibition was associated with plaque rupture. Our results show that Type D personality was associated with plaque vulnerability, independent of clinical factors. Measurement of negative affectivity and social inhibition will increase our understanding of the progressive phase of the plaque vulnerability, which can contribute to the early identification of high risk patients and reduce the incidence of MACE.     

Fetal programming of stress responses

Epidemiological studies have shown that small size at birth is associated with an increased risk of coronary heart disease and its risk factors, including hypertension and Type 2 diabetes.It is suggested that these observations linking low birthweight with disease result from an imbalance between fetal nutrient demand and supply. This imbalance results in metabolic and endocrine adaptations, which benefit the fetus in the short term by reducing fetal growth and increasing fuel availability, but in the longer term they are maladaptive leading to an increased risk of coronary heart disease. Experimental data in animals and recent human observations have suggested that alterations in the set point of the hypothalamic-pituitary-adrenal axis and sympathoadrenal system are important long-term changes that occur in association with reduced fetal growth. These data suggest that the nature and amplitude of the stress response may be determined by intrauterine factors.     

Psychometric properties of the Type D scale (DS14) in Norwegian cardiac patients

Bergvik, S., Sørlie, T., Wynn, R. & Sexton, H. (2010). Psychometric properties of the Type D scale (DS14) in Norwegian cardiac patients. Scandinavian Journal of Psychology. The combination of negative affectivity (NA) and social inhibition (SI) – the Type D Personality – is associated with poor outcomes in coronary artery disease (CAD) patients. A Norwegian translation of the standard instrument measuring Type D (DS14) was tested on 432 CAD patients receiving coronary revascularization treatment. Factor analysis produced two factors with high inter‐item reliability, indicating that the Norwegian DS14 has acceptable psychometric properties. Eighteen percent were classified as Type D, lower than has been reported elsewhere. Type D was associated with anxiety, depression, and passive coping. NA correlated positively with depression, anxiety, and passive coping. SI correlated positively with depression and anxiety, and negatively with active coping. The prevalence of Type D was higher among women, and negatively correlated with time since treatment. The variation in Type D prevalence among studies needs further elucidation as does the predictive power of continuous scoring of the Type D trait.     

The Role of Perceived Social Support and Stress in the Type A Cognition-Symptom Relationship

The two main objectives of this research were to determine whether Type A cognitions are related to a broader range of symptoms than has traditionally been studied and to determine possible mediating variables. Past research and theory suggest that Type A individuals not only experience but also generate stress and interpersonal conflict (i.e., in keeping with a psychosocial vulnerability model). This psychosocial vulnerability may put Type A individuals at greater risk of experiencing a wide array of physical and psychological symptoms well beyond coronary heart disease (CHD), the health outcome typically investigated. Stress, interpersonal and non-interpersonal in nature, and perceived social support, were explored as possible mediators in the Type A cognition-symptoms relationship using structural equation modelling (SEM) in a university sample. Non-interpersonal stress and interpersonal stress mediated both the Type A cognition-psychological symptoms relationship and the Type A cognition-physical symptoms relationship. However, perceived social support only mediated the Type A cognition-psychological symptoms relationship. Results indicate that Type A individuals may experience psychosocial vulnerability, particularly reporting stress, which may put them at risk for the experience of negative health outcomes. Implications for cognitive therapy are discussed.

An application of the interpersonal models developed by Karen Horney and Timothy Leary to Type A-B behavior patterns

Using Horney's clinical concepts and Leary's circle matrix procedures, this study investigated the Type A and B patterns of personality. Significant findings showed the Type A-B continuum to represent two distinct poles, with the Type A direction reflecting the expansive personality pattern (power and aggressiveness) and the Type B direction reflecting the self-effacing pattern (helplessness and affiliation) for self-perceived roles. For behavioral roles, the power-versus-helplessness traits described the two contrasting directions of personality involvement. Three subgroups were identified for behavioral role in each A and B extreme group. The shift in affect between the ACL and MMPI instruments may reflect two factors: the degree of ambiguity set up by the nature of the tests and the responding "pull" of the individual, which was described as an "active" or "quiescent" form of the A and B patterns. Hence, it may be more effective to diagnose individuals in terms of a specific behavioral subtype and active or quiescent enactments. Three maladjustment indicators were investigated. Significant findings showed the A2 group as exhibiting increasing rigidity of behavioral role with lower Type A scores and the A1 group as exhibiting greater discrepancies with increasing Type A scores. The lack of discrepancy for the Type B groups may reflect a dysfunction in that these individuals may be stagnated in their work situations and complacent in the docile-dependent role. The three findings of behavioral subgroups, rigidity of role, and discrepancy were discussed as possible mediating psychosocial factors associated with coronary heart disease. Since this was the first major examination and use of Leary's model (to the author's knowledge) since the late 1950s, it is important to consider these results tentative and heuristic, until replications can be conducted. It is hoped that representative norms from diverse samples can be obtained for developing standard scores on Leary's circle matrix axes. The present study was limited by the narrow demographic characteristics of its subjects, who were mostly white-collar workers in professional, technical, or management positions.