Type B Behavior Pattern
KeywordsCoronary Heart Disease Behavior Pattern Coronary Heart Disease Risk Academic Dishonesty Standardize Interview
A pattern of overt behavior that was traditionally felt to be associated with a decreased risk of coronary heart disease and which is characterized by a lack of urgency, decreased competitive drive, and unhurried movements and speech.
Type B behavior pattern was originally proposed as the natural antithesis of type A, a set of behaviors felt to predispose a person to coronary heart disease. A type B person is a relaxed, noncompetitive individual who is not driven by ambition or time urgency. There has been significant controversy as to the utility of type A and B in defining heart disease risk, and interest in the behavior pattern has waned considerably as a result, leading to a relative paucity of more recent investigations on the subject.
Type B behavior pattern was initially conceptualized by two cardiologists, Friedman and Rosenman (1959), after they identified a potential link between competitive, alert, and fast moving people and coronary heart disease. These people were felt to have type A behavior pattern. Those who exhibited opposite traits were labeled type B. They initially identified groups of men based on overt behavioral characteristics as well as self-reported traits. Patients classified as type B were those who had a relative absence of drive or ambition, denied a sense of urgency, and had limited desire for competition or for setting or meeting deadlines. During the intake interview, they were further observed to be those who were unhurried in speech and movement, who did not seem impatient, and who sat in a relaxed manner.
Friedman and Rosenman (1960) attempted to further study the behaviors associated with coronary heart disease by having participants listen to two monologues, with one designed to be slow and frustrating for those with a chronic sense of urgency. Once again, those in group B were considered the normal controls who did not exhibit the behaviors in question. They were found to have a gentle sinusoidal wave pattern of breathing, no propensity for hand clenching, and normal frequency of body movements (in several cases recorded as none). It is worth noting that within the group of patients classified as type B, there was some heterogeneity of behaviors, with some participants exhibiting a few type A behaviors and some exhibiting none.
The Western Collaborative Group Study (WCGS) was initiated in the early 1960s and was designed to determine the prospective diagnostic value of three potential coronary heart disease risk factors: serum lipoproteins, blood coagulation abnormalities, and behavior patterns (Rosenman et al. 1964). Within the behavioral component, the type B group was once again presented as a set of control patients who did not exhibit the coronary-prone type A behaviors, but this time the group was further subdivided into those whose behavior pattern was fully developed (B-4) or less developed (B-3). The majority of type B participants fell into the B-3 category; they exhibited some type A traits but overall fit the pattern of type B better. Those in the B-4 category were felt to be those who completely fit the profile of the easygoing, noncoronary-prone individual. Though these subdivisions were not used in the final reporting of results, it did normalize the idea that the behaviors were part of a continuum, rather than discreet categories.
Patients were interviewed and results published at various stages for the WCGS, with the study ultimately concluding after 9 years (Rosenman et al. 1975). Patients with type B behavior pattern were found to have significantly less coronary heart disease than those with type A, even when other risk factors such as smoking, parental history of CHD, and serum lipoproteins were taken into account. This study provided much of the interest in type A and B as predictive factors of coronary heart disease risk, and it was taken as evidence of a strong link between observable behavioral traits and the development of heart disease. This interest naturally translated into further studies by other researchers, and several followed on the heels of the WCGS.
In 1985 results from the MRFIT (Multiple Risk Factor Intervention Trial) were published which contradicted those of the WCGS (Shekelle et al. 1985). After classification of behavior pattern based on interview and a standardized self-report assessment, no association was found between type B behaviors and a decreased risk of first major coronary events (defined in the study as a confirmed heart attack, whether fatal or not). The Framingham study (Eaker et al. 1989) was another large-scale study of behavior and heart disease, conducted around the same time. Again, unlike the WCGS, the Framingham study did not find that type B denoted any decreased risk of a heart attack or fatal coronary artery disease. Interestingly though, it did suggest that there may be a perceptual difference in symptoms, as those with type B were less likely to suffer from uncomplicated angina pectoris, the intense chest discomfort associated with plaque in the coronary arteries that does not fully occlude them. Given that both groups were just as likely to experience coronary artery disease itself (as evidenced by their similar risk of heart attacks), it may be that those with type B either are less likely to be worried about, pay attention to, or bother to report chest discomfort.
As more and more studies failed to show the same strong associations between coronary heart disease and behavior that the WCGS had demonstrated, the hypothesis began to lose favor. A more recent cross-cultural undertaking was conducted in Finland, where researchers followed patients classified by behavior pattern over a period of 20 years (Šmigelskas et al. 2015). They ultimately concluded that there was no decreased risk for those with type B behaviors compared to their type A counterparts, another strong piece of evidence against the theory.
Type B Behavior Pattern
In the initial studies of behavior and coronary heart disease, much of the focus was on type A traits, and little effort was made to come up with a unique description of those traits central to type B behavior pattern. Despite this, early studies lend many clues to its manifestations. Those who are type B speak in a slower and more even manner (Jenkins et al. 1967). They may work steadily but it is without a sense of urgency. The type B subject is rarely impatient and takes the time to enjoy things outside of work; they can be very hardworking, but they do not worry about time or achievement. Similarly, they may still set goals but will pause to enjoy the completion of a task, rather than trying to immediately set another challenge (Friedman et al. 1975). They are also not prone to hostility or aggressiveness. They are described as easygoing and introspective. Their general demeanor is more pleasant than that of type As. For example, when asked to solve puzzles in competition for a bottle of wine, type B subjects appear relaxed and amused at the prospect and seem to enjoy themselves during the activity. Even when told the puzzle is unsolvable during debriefing, they do not appear annoyed or disgruntled at the news.
Given the initial hypothesis that type B meant a reduced risk of coronary heart disease, several studies examined possible physiological or social reasons for this difference. Friedman et al. (1975) found that type B behavior is associated with lower blood cholesterol and triglyceride levels. They also examined plasma catecholamines (hormones involved in the body’s stress response) and found that those with type B had lower basal levels of norepinephrine. During a challenge activity, the levels of the type B participants remained steady, despite frustrations, unlike the type A participants who experienced a spike in their norepinephrine levels during the task.
Those with type B are described as having less preoccupation with deadlines, but this may be due to them actually experiencing time differently. Warner and Block (1984) conducted a creative experiment in which they had participants attempt to shut off a light after a certain amount of time had passed, without allowing them to use any methods of marking time passage. Willing participants were asked to make sure they arrived on time for the experiment. Those with type B were just as likely to arrive on time and be wearing a watch, and they were better and more consistent judges of time than their type A counterparts.
An aspect that is central to type B behavior pattern is a lack of preoccupation with ambition or goal attainment. When it comes to achievement, type B people may once again see things differently. They endorse less motivation for achievement overall compared to those who are type A and are less focused on the impact, or outcome, of that achievement, instead being motivated by both the process and its impact in more equal measure (Davis et al. 1986).
Many comments made in early studies implied that type B behaviors were the more desirable ones for health – both physical and mental. Friedman and Rosenman (1959) made the observation that type B men were more content with their lives and were, on the whole, more involved with their families and recreational activities, rather than being preoccupied with goals and competitive activities. Type B traits are not necessarily positive in all situations though. Research from academic environments highlight some potential pitfalls of type B behavior. Type B is associated with academic dishonesty (Weiss et al. 1993), perhaps because their decreased worries about failure make them fear consequences less. In the same study, type B college students were also found to be more focused on grades rather than learning. Type B students also report feeling less confident in their scholastic competence, intellectual competence, morality, and global self-worth (McGregor et al. 1991).
In their original investigations, Friedman and Rosenman (1959) emphasized the importance of overt behavior in determining who exhibited a normal, or type B, pattern. After making numerous observations on hand clenching, breathing patterns, motion, and speech, they developed the standardized interview (SI) which relied on behaviors (or lack thereof) during a formatted interview to identify those who were type B.
Though the standardized interview was established as the gold standard for separating type A from B, it was not without issues, many of which were summarized by Jenkins, Rosenman, and Friedman in 1967 with their creation of the Jenkins Activity Survey (JAS). The standardized interview, which took 20–30 min, required training to conduct and score it and took time to interpret. The idea to create a standardized paper version of the assessment led to the creation of the JAS which was completed by patients from the WCGS (who had been previously categorized as type A or B by an SI). In its original form, the survey had 39 items and was scored on two scales for type A and type B. Given that it was self-administered by participants, much of the behavioral basis of the SI did not translate to the JAS, which could not rely on the manner in which participants answered questions the way the SI had.
One of the earliest standardized assessments to be developed, the Bortner scale was a 14-item self-report measure which had a number of contrasting adjectives representing type A or B behavior (Bortner 1969). A responder would then choose which one was more characteristic of their behavior. For example, a type B respondent would report being a good listener, able to wait patiently, caring only about satisfying themselves no matter what others think, and not particularly competitive and having many interests.
Another self-report scale, the Framingham type A behavior pattern scale, was developed specifically for the Framingham study (Haynes et al. 1978). The ten-item scale was one of several designed to assess different behavioral and personality traits which might be associated with coronary heart disease. Someone with type B behaviors would identify as not being competitive, pressed for time, or bossy, and they would deny having a need to excel, eating too quickly, or getting upset when forced to wait for something. With regard to work, type B would be suggested by someone who does not dwell on work after they leave or worry about their performance regularly.
Type B behavior pattern is displayed by a relaxed, easygoing approach without competitiveness, aggressiveness, or a strong sense of urgency and impatience. Numerous studies have examined its potential role in coronary heart disease, and almost all have failed to replicate the original results suggesting it was associated with decreased risk of coronary heart disease compared to type A. There is evidence that those classified as type B may be a distinct group that interprets the world around them differently, and this is related to both positive and negative outcomes, depending on the situation.
- Haynes, S.G., Levine, S., Scotch, N., Feinleib, M., & Kannel, W.B. (1978). The relationship of psychosocial factors to coronary heart disease in the Framingham study. I. Methods and risk factors. American Journal of Epidemiology, 107(5), 362–382. http://aje.oxfordjournals.org/.
- Rosenman, R. H., Brand, R. J., Jenkins, C. D., Friedman, M., Straus, R., & Wurm, M. (1975). Coronary heart disease in the western collaborative group study: Final follow-up experience of 8½ years. The Journal of the American Medical Association, 233(8), 872–877. doi:10.1001/jama.1975.03260080034016.CrossRefPubMedGoogle Scholar
- Shekelle, R. B., Hulley, S. B., Neaton, J. D., Billings, J. H., Borhani, N. O., Gerace, T. A., … Stamler, J. (1985). The MRFIT behavior pattern study. II. Type A behavior and incidence of coronary artery disease. American Journal of Epidemiology, 122(4), 559–570. http://aje.oxfordjournals.org/.