Type A Behavior Pattern
KeywordsCoronary Heart Disease Negative Health Outcome Coronary Heart Disease Incidence Multiple Risk Factor Intervention Trial Time Urgency
Type A is an action-emotion complex characterized by impatience, sense of time urgency, competitiveness, striving for achievement, aggressiveness, hyperalertness, restlessness, explosive speech, and abruptness of gesture (Rosenman 1977).
Intense, sustained drive to achieve self-selected but poorly defined goals
Profound inclination and eagerness to compete
Persistent drive for recognition and advancement
Continuous involvement in multiple and diverse functions constantly subject to time restrictions (deadlines)
Habitual propensity to accelerate the rate of execution of many physical and mental functions
Extraordinary mental and physical alertness
The opposite type of personality was defined as the Type B. In general, Type A issue was mainly addressed in relation with health, especially cardiovascular disorders. In contrast, isolated psychosocial aspects of Type A were analyzed much less.
TABP as a Risk Factor
An extensive number of studies have been published on possible effects of the Type A behavior pattern (TABP) on health. Most of them have analyzed the association between TABP and cardiovascular diseases (CVD), especially coronary heart disease. Although the first studies of this kind emerged about 60 years ago, there is no clear consistency in findings and clear evidence about effects on health risks. The associations of TABP with other diseases have been investigated much less than with CVD.
Risk effects of TABP
Based on their clinical observations, Friedman and Rosenman (1959) originally stated that TABP evokes an increased risk for CHD incidence through behavioral features. They observed that there are CHD cases that cannot be explained by dietary factors such as fat or cholesterol, but rather by socioeconomic factors such as occupational pressure or stress at work. With this hypothesis they launched a study which led to the first evidence about predictive nature of TABP. The study was a prospective epidemiological Western Collaborative Group Study (WCGS), followed up for 22 years. This was the study where Friedman and Rosenman devised the structured interview (SI) as a tool for measurement of TABP. The results from 8-year follow-up showed that Type A men had more than double risk of CHD incidence compared to Type B (Rosenman et al. 1975). The data from longer follow-up were similar, but less consistent.
Another one prospective study, the Framingham Heart Study (FHS), assessed the TABP with a special self-report measure – the Framingham Type A Scale – which predicted CHD incidence during 8-year follow-up both in men and women. The TABP was most strongly related to coronary diagnoses in which angina pectoris symptoms were present (Haynes and Feinleib 1982). However, later it was found that TABP within 10-year follow-up is not predictive. The results with positive associations were also found in other studies, including the studies from Europe. For instance, the Belgian-French Pooling Project (1984) showed that Type A has an increased relative risk for CHD independently from age, smoking, blood pressure, serum cholesterol, body build, and socioeconomic status. Another one study revealed that TABP is not only a specific coronary-prone, but a general disease-prone condition – Type As reported not only more CHD but also peptic ulcers, thyroid problems, asthma, and rheumatoid arthritis (Rime et al. 1989). The study showed that more Type As than Type Bs reported having been ill. It was observed in spite of the fact that the Type As were markedly younger than Type Bs, and despite the empirically based reputation of the former to be symptom deniers rather than symptom reporters.
The status of TABP was changing throughout decades of research. In the first stage, after introduction of construct, the general opinion was rather skeptical with harsh criticism (Friedman and Rosenman 1974). The positive relationships from prospective studies made the general approach to change quite rapidly with an enthusiasm to launch new studies. The climax of strong acceptance occurred in expert panel meeting by the National Heart, Lung, and Blood Institute of the National Institutes of Health in 1978, where the Type A was added to the official list of risk factors for CHD (Cooper et al. 1981). The relative risk was estimated to be equal to the risk of such conventional risk factors as high cholesterol level, hypertension, or smoking. Some research went even further – Jenkins and Zyzanski (1980) made a systematic review of studies and suggested that TABP or cultural variations of it are associated with CHD despite genetic, social, geographical, political, or economic differences.
Prevailing of TABP studies with positive relationships in the first decades of research could be explained by publication bias and population-based samples. However, after the wave of positive findings, a number of major studies failed to show the relationship of TABP and CHD. An increasing number of negative findings have been published. One of the best-known examples of this kind was the Multiple Risk Factor Intervention Trial which was a carefully conducted clinical trial designed to alter cardiovascular risk factors in high-risk men (Shekelle et al. 1985). The results failed to show any significant prospective association between TABP and the first major coronary events. These and other negative results reopened the debate about validity of TABP as a risk factor of CHD. Another example of a study with null association was the Honolulu Heart Program, including men of Japanese descent (Cohen and Reed 1985). These men were followed up for 8 years to develop CHD. Overall, no relationships between TABP and incidence of total CHD, myocardial infarction, or angina were observed. Likewise, even recent research with longitudinal data from Kuopio Ischemic Heart Disease Risk Factor Study revealed no association of Type A with cardiovascular and all-cause mortality, though the data from first decade of follow-up within that study were partly suggesting the risk effects (Šmigelskas et al. 2015).
Evidence from Reviews and Meta-Analyses
Accumulating evidence of the ambiguity of Type A led the researchers to conduct meta-analyses. They pointed different reasons for ambiguity of findings. One of the first challenges for TABP and CHD association was by Matthews (1988). Her results showed that the Type A is not a reliable predictor of CHD incidence, when the number of independent studies and number of participants in those studies are weighted. However, she concluded that those associations are significant in population-based studies. Meanwhile, Schwalbe (1990) compared five well-known prospective cohort studies and stated that it is impossible to conclude that the Type A personality is a risk factor for CHD. Another problem was related with clear specification of studies based with healthy and high-risk samples, since the majority of population studies seemed to support the role of TABP as a risk factor for CHD, while many negative findings came from studies with patient samples. However, recent research found null effects even in a representative sample (Šmigelskas et al. 2015). Another possible explanation of conflicting results was the difference in assessment techniques of TABP. Mostly it is agreed that self-report methods tend to produce more null findings than the studies with the structured interview. Consequently, the validity of self-report measures of TABP as indicators of coronary-prone behavior and as predictors of myocardial infarction or cardiac death has been questioned. Nevertheless, due to practical reasons in large-scale population studies, the use of self-report measures is persisting.
In the twenty-first century, several meta-analyses were conducted, and they revealed that TABP is very weakly associated with negative health outcomes (e.g., Chida and Steptoe (2009)).
Even though the TABP was considered a risk factor for negative outcomes, the intervention studies were very rare. Quite unique approach was presented by one of the concept authors Friedman et al. (1986). In a 4.5-year randomized trial of patients who suffered acute myocardial infarction, they reported that TABP can be modified and thus subsequently lead to decreased levels of cardiovascular risk. However, it is not clear about the long-term maintenance of altered behavior. Moreover, the potential for bias exists when re-reporting the personal traits after intervention program with awareness of its goals.
Physiology of TABP
The mechanisms by which the Type A exerts a pathogenic influence were largely investigated. The main hypothesis under study is that Type A chronically responds to various environmental events with greater sympathetic nervous system and adrenomedullary activity which accounts for higher coronary risk. Zyzanski et al. (1976) showed that men with greater occlusion in blood vessels had higher Type A scores than others. However, some others (e.g., Dimsdale et al. 1979) were not able to find straight or inverse relationships between TABP score and various indicators of atherosclerosis.
Still, it is not clear how the Type A is linked to CHD. Recent research has more investigated this issue and has focused on heightened neuroendocrine activity of the Type A person, which is related to the stress and development of CHD. The Type A subjects tend to have more sympathetic activity and catecholamine secretion during stress, while the Type Bs have more parasympathetic activity. Over time the heightened sympathetic reaction occurring during the stress or being angry or hostile may cause damage to cardiovascular system. Excessive epinephrine and norepinephrine lead to vasoconstriction that may cause the heart to work harder and produce small lesions in artery walls, which in turn results in a buildup of atherosclerotic deposits. These catecholamines also affect platelet aggregation involved in clotting. Overall, many investigators assumed that TABP acts through development of atheroma.
In general it can be stated that Type A seems to have a specific pattern of response to stressful stimuli; however, the long-term effects and possible personal or biological accommodation do not seem that negative.
Measurement of TABP
One of the core issues in TABP research has been the quantitative assessment of the construct. The construct is evaluated using the structured interview or self-report questionnaires such as Jenkins Activity Survey, Framingham Type A Scale, Bortner Rating Scale, etc. The diffuse findings on associations between TABP and health can partly be explained by inconsistency of measurements, since the studies used different assessment tools which resulted in complexity of comparison of findings.
Originally the assessment of TABP was based on the structured interview, a sort of “golden standard.” It is managed by an instructed expert and contains the questions by which a person is asked about his manner of reacting to various situations with the purpose to elicit impatience, competitiveness, and hostility (Matthews and Haynes 1986). Some questions are presented deliberately in a way to elicit features of behavior indicative of TABP. As a result, the classification of behavior pattern is based not only on subject’s self-reports but also on speech stylistics and behavioral manners observed during the interview. Carroll (1995) stated that speech characteristics (such as interruptions, rapid speech, or overt hostility) are more important than the answers themselves. The result of interview is a classification to one of four categories – A1, A2 (both Type A, but the former more expressed than the latter), B (Type B or the absence of Type A features), and X (intermediate between Types A and B).
Unfortunately, the application of the SI demands a properly trained interviewer, what makes this assessment expensive and time consuming, especially in large-scale population studies. This aspect is commonly acknowledged in justifying the use of self-report questionnaires. Another issue is the potential for subjectivity of interviewer and scoring. Thus, the scales were developed for use where it was not feasible to train large number of interviewers necessary and to invest the time to individual interviews with an entire study population.
The first well-known scale was designed by Jenkins team and is the most common questionnaire to evaluate the TABP. This was called the Jenkins Activity Survey for Health Prediction (Jenkins et al. 1965). Almost by the same time, Bortner constructed another scale and called it the Bortner Rating Scale (Bortner 1969). There are also some more novel types of testing, such as the Framingham Type A Scale (Haynes et al. 1980). There are also some country specific scales, for instance, in Finland or Japan. Even though the Bortner and Jenkins scales were claimed to fail to include the total psychomotor behavioral dimension which includes the voice, nevertheless, they both agree satisfactorily with the structured interview.
Still, as one of the biggest confounders in failing to assess the association between TABP and CHD is the use of different assessment tools. And even though the different assessment scales partially overlap, they measure different aspects of personality. More to that many questionnaires have developed subscales, measuring narrower psychological concepts. The reasons for this emerged during later research, which indicated that some aspects of TABP can be more strongly correlated with CHD than the others. Moreover, the hostility as one of such factors seems to be related to atherosclerosis independently of the Type A. Another aspect of TABP is anger, specifically, suppressed anger, which is supposed to predict atherosclerosis. Together, hostility and anger interact so that people high on both have higher levels of atherosclerosis. However, there is some controversy whether both expressed and suppressed anger is predictive.
Regarding the stability of Type A construct, there were very rare studies presenting the retest of Type A during the follow-up. The first study (Carmelli et al. 1991) found that in more than 20 years, 61% of the WCGS subjects left within the same group like baseline, while 39% changed (more from B to A than from A to B, which rather supports the shift of the Western society toward A-prone or A-tolerant style). Type Bs compared to As were younger, retired earlier, had better health, and less managerial or professional positions. Another study by the same team found that there exists only a modest test-retest correlation of the SI components over a period of over two decades – from 0.29 to 0.55. All this suggests that the exposure measurement based on baseline status only has potential for bias in analysis since it omits possible exposure changes in later years.
Components of TABP
Although Type A was originally defined as a global construct, several authors tried to identify specific pathogenic aspects in the construct. For example, Matthews et al. (1977) labeled competitive drive and impatience as associated with a subsequent occurrence of CHD. Results of another reanalysis of two data sets showed that hostility and anger were also predictive (Matthews and Haynes 1986). There also have been some other components presented, such as job involvement, hard driving and competitive, and speed and impatience (Jenkins et al. 1979). The analysis of the Finnish Type A Scale resulted in identification of two factors that were later called impatience-irritability and ambition-energy (Julkunen et al. 1993). The presence of possibly contradictive elements for health in self-report scales is a question which could partly explain a number of contradictory results with these measures.
Investigations on “toxic” components of TABP have been mostly done on hostility. It is an amalgam of such concepts as anger, hostility, aggression, disgust, suspicion, and cynicism. It is typically characterized by a suspicious, mistrustful attitude or disposition toward interpersonal relationships and wider environment. The results on hostility and health outcomes have been slightly less ambiguous and more consistent, showing likely risk effect of hostility on CHD and all-cause mortality. However, the most recent meta-analysis suggests small effect sizes in both healthy individuals and patients with CHD (Chida and Steptoe 2009). Regarding its causal explanations, in recent studies hostility was found to be positively associated with inflammatory markers, suggesting another psychophysiological mechanism linking hostility with CHD and other negative health outcomes as well as with increased exposure to interpersonal stressors and reduced social support. These psychosocial conditions could all contribute to negative health outcomes. In general it can be noted, that hostility seems more associated with negative health aspects than Type A, even though it also has relatively many supporting and objecting studies.
The research on Type A has been widely conducted relating with health outcomes. However, the findings are ambiguous – if early decades of research showed clearly negative effects of TABP on health (especially considering cardiovascular outcomes), later studies revealed no such associations. This shift can possibly go in parallel with the evolution of Western society, keeping in mind the social nature of TABP. Moreover, it is still an open question, what is more important from perspective of health – the TABP as an entity or certain components of it.
TABP as a Social Phenomenon: Role of Society
Type A can also be regarded as a social phenomenon. Eaker et al. (1989) found that men with higher education level had higher Type A scores, and the Type A was more prevalent among white-collar workers. The relevance of social factors was emphasized by Friedman and Rosenman (1974) who stated that “the most important reason, at least in the United States, is the transformation of nineteenth-century Yankee pragmatism into an unbridled drive to acquire more and more of the world’s material benefits” (p. 166). They continue (p. 167) that “When greed of this sort becomes indiscriminate, and cannot be sated by quality but only by numeration, the person involved has become a Type A.” Here it can be suggested that the evolution of Western society has a significant impact on manifestation and acceptance of TABP within society which later leads to better or worse health outcomes. Acceptance and demand for Type A traits could have led not only to higher prevalence of Type A but also to broader variability within Type A concept, increasing potential for protective health effects.
The relevance of environment for manifestation of behavior has often been overlooked in epidemiological studies of behavioral risk factors of CHD. One of the authors of the concept emphasized that Type A behavior “particularly emerges when relevant milieu conditions elicit Type A behavior in susceptible persons” (Rosenman 1990). It seems that the pattern is neither a personality trait nor a standard reaction to a challenging situation; instead it is the reaction of a psychologically predisposed person to a situation which challenges him or her (Jenkins and Zyzanski 1980).
Problems in TABP Research
It can be summarized that the associations between TABP and health outcomes depend on many factors. On the one hand, these are population-specific indicators, such as age group, gender, and prior or current diseases. On the other hand, there are different measurement techniques to evaluate the extent of TABP as a personality trait. Finally, certain dimensions of TABP can also play the role.
Another very important aspect is that there are many psychological factors that can trigger the negative effects on health. Some of them (such as hostility) could be in a causal chain between Type A and premature death and possibly can be regarded as components of TABP. Simultaneously, there exists a variety of personal features within every person at the same time which means that even a person with disease-prone aspect of personality can have or develop behaviors that lead to protective effects.
It can be noted that possible mechanisms for associations of TABP and health have been proposed, but the true mechanism is still under question. It can happen so that it is not the TABP which triggers negative physiologic reactions in individual, but some other related psychological factors – overt (such as hostility) or hidden (stress or dissonance between personal strivings and society’s expectations or sense of social desirability) ones.
In addition, the studies on TABP have omitted the cultural aspects – they had not provided epidemiological data on TABP across populations and subgroups and did not account for other psychological traits. All this can be relevant in the cultural perspective of the Type A phenomenon, which is a Western culture-bound syndrome. The TABP is embodying many of the cultural values of an industrial, capitalist society, where competition, ambition, materialism, and time urgency of rush hours and deadlines are all part of daily life (Helman 2000). Furthermore, this model of stressful behavior also encompasses some of the contradictions within cultural values of Western societies, and the Type A individual is the living embodiment of those contradictions. On the one hand, the individuals displaying Type A show marked aggressiveness, ambition, and competitive drive, which usually are not considered as very good features in personal relations. Such people are work oriented and “workaholic,” preoccupied with deadlines, and chronically impatient (Friedman and Rosenman 1959). On the other hand, modern Western industrial society encourages the development of TABP traits by rewarding them: those who exhibit them often become successful executives, professionals, politicians, managers, technocrats, and salesmen. However, these rewards often involve constant anxiety about failure, demotion, or loss of control. It can be argued that this paradox of values – that some forms of antisocial behavior are being constantly rewarded by the society – is symbolically resolved when the Type A individual is “punished” by suffering a heart attack and emerges from the hospital as a chastened, fragile, and less aggressive Type B (Helman 2000). Similarly, Carroll (1995) suggested that since it is not Type A individuals that have an increased risks but rather their environments that elicit the behavior pattern in them – this suggests that sociocultural aspects can have very important implications for the effects of TABP on health.
Regardless of all complexities and ambiguities related with Type A research, it can be stated that the Type A was a trigger of health research, related with psychological factors.
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