TYPE A BERAVIOUR PATTERN Relationship to Coronary Heart Disease, Personality and Life Adjustment* DAVID
L. KEEGAN, N. SINHA,
BHlROV JOHN
E.
M.D.' M.A.2
MERRIMAN, M.D.3
CAROL SHIPLEY, B.S.W. 4
pattern person is more easy going, less time urgent and work oriented. Rosenman and Friedman have found that in the age groups 39to 59, A behaviour subjects developed more coronary heart disease (CHD) than subjects rated B pattern (21). Although there has been research to better characterize and objectify the A behaviour concept, Lipowski emphasizes the need for still clearer definition and encourages research into personality dimensions and how the behaviour interacts with other life stressors (II, 15). It was to this end the present study was undertaken.
There has been a recurring theme that cardiac patients share common behavioural characteristics as long as physicians have been treating such patients (16). These include excessive striving and responsibility, need for achievement, punctuality and job dedication, and obsessiveness. Since the western technological society considers these features desirable, there is considerable controversy about the role they play in coronary heart disease and even greater disagreement on how to distinguish pathology from the sociocultural fabric. The best researched and validated theory is that of the A behaviour pattern. Rosenman describes this as an action/ emotion complex (Behaviour) exhibited by an individual in a lifelong struggle to obtain too much from the environment in too short a time against the opposing efforts of objects or people in that environment (20). Individuals are assessed for the presence of the pattern by a Stress Interview which includes careful observation of content and style. The A pattern is characterized by a hard driving, impatient, restless person under time pressure, striving for achievement while the non-A or B
Method Sixty male subjects, all under 60 years of age (mean 48.9 years) taken consecutively from a cardiologist's practice, were studied. Fifty of these patients had been referred for cardiovascular assessment by their family physicians, while ten were assessed as applicants to a coronary prevention exercise program. Only those who had suffered a myocardial infarction within three months of the evaluation were ruled out. All subjects underwent an intensive cardiovascular evaluation including a resting and exercise challenge EKG. Following diagnosis, they were separated into two major diagnostic groups for purposes of the study. The CHD group included individuals with either angina (A), myocardial infarction (MI), or both (A-MI), while the non-coronary heart disease (NCHD) group consisted of subjects with no evidence of illness (NI), non-cardiac chest wall pain (CP), or hypertension with no cardiac disease (HT). CP subjects had normal resting and exercise EKGs and the HT had pressures greater than 160mm Hgsystolicand 100mm Hg diastolic, respectively. All subjects were given the RosenmanFriedman Stress Interview which was video-
*Manuscript received May 1978; revised January 1979. I Associate Professor of Psychiatry, University of Saskatchewan, Saskatoon. 2psychologist, University Hospital, Saskatoon at time of study; now Psychologist at Alberta School Hospital, Red Deer, Alberta. 'Professor of Medicine, University of Saskatchewan at time of study; now in private practice in Tulsa, Oklahoma. 'Research Assistant, Departmentof Psychiatry, University Hospital, Saskatoon. Address reprint requests to: Dr. David Keegan, Department of Psychiatry, University Hospital, Saskatoon, Saskatchewan.
Can. J. Psychiatry Vol. 24 (1979)
724
December,
1979
TYPE
A
BEHAVIOUR PATTERN
taped and subsequently rated by Dr. Rosenman who was unaware of the cardiac diagnoses. They were rated on a continuum of A behaviour from most to least (AI, A2, X, B). For purposes of analysis, subjects rated AI or A2 were combined as an A group whilethose rated X or B formed a non-A group. A battery of psychosocial tests were administered to assess personality, temperament and life stress and strain. These included the Minnesota Multiphasic Personality Inventory (MMPI), Thurstone Temperament Schedule (TTS), Holmes and Rahe Schedule of Recent Experience (SRE), and the Rosenman Sociological Questionnaire (RSQ) (5, 10,26).Twenty-seven demographicquestions includingmarital status, occupation, education, family background, religion and social mobility were included. Analysis of variance, the F test, was used to assessstatistical differences between the groups on the variables measured (4). Results There were 47 subjects with A behaviour pattern, 10 with extreme A I characteristics and 37 with the moderate A2 pattern. Of the 13 non-A subjects, 8 were rated X, having few A characteristics and considered non-A behaviour, while 5 with no A characteristics were rated B. In terms of diagnosis there were significantly more A subjects in the CHD group, p< 0.0 I, in fact only 3 non-As appeared in the group of 47 subjects. On the other hand, the NCHD group had 10 non-A subjects (Table I). The A subjects were found in all diagnostic groups but the largest number was found in the MI group. The smallest number was in the HT and CP groups. Interestingly there were 9 A subjects in the NI group who had no symptoms or illness but were assessed for a coronary prevention exercise program (Table II). When compared, the A and the non-A groups were similar in age, occupation, education, religion, social mobility and were no different in number of life change events as measured by the SRE. On the other hand, the A subjects were significantly more dissatisfied with their marriages, p< 0.05 and life achievements, p
L. KEEGAN, N. SINHA,
BHlROV JOHN
E.
M.D.' M.A.2
MERRIMAN, M.D.3
CAROL SHIPLEY, B.S.W. 4
pattern person is more easy going, less time urgent and work oriented. Rosenman and Friedman have found that in the age groups 39to 59, A behaviour subjects developed more coronary heart disease (CHD) than subjects rated B pattern (21). Although there has been research to better characterize and objectify the A behaviour concept, Lipowski emphasizes the need for still clearer definition and encourages research into personality dimensions and how the behaviour interacts with other life stressors (II, 15). It was to this end the present study was undertaken.
There has been a recurring theme that cardiac patients share common behavioural characteristics as long as physicians have been treating such patients (16). These include excessive striving and responsibility, need for achievement, punctuality and job dedication, and obsessiveness. Since the western technological society considers these features desirable, there is considerable controversy about the role they play in coronary heart disease and even greater disagreement on how to distinguish pathology from the sociocultural fabric. The best researched and validated theory is that of the A behaviour pattern. Rosenman describes this as an action/ emotion complex (Behaviour) exhibited by an individual in a lifelong struggle to obtain too much from the environment in too short a time against the opposing efforts of objects or people in that environment (20). Individuals are assessed for the presence of the pattern by a Stress Interview which includes careful observation of content and style. The A pattern is characterized by a hard driving, impatient, restless person under time pressure, striving for achievement while the non-A or B
Method Sixty male subjects, all under 60 years of age (mean 48.9 years) taken consecutively from a cardiologist's practice, were studied. Fifty of these patients had been referred for cardiovascular assessment by their family physicians, while ten were assessed as applicants to a coronary prevention exercise program. Only those who had suffered a myocardial infarction within three months of the evaluation were ruled out. All subjects underwent an intensive cardiovascular evaluation including a resting and exercise challenge EKG. Following diagnosis, they were separated into two major diagnostic groups for purposes of the study. The CHD group included individuals with either angina (A), myocardial infarction (MI), or both (A-MI), while the non-coronary heart disease (NCHD) group consisted of subjects with no evidence of illness (NI), non-cardiac chest wall pain (CP), or hypertension with no cardiac disease (HT). CP subjects had normal resting and exercise EKGs and the HT had pressures greater than 160mm Hgsystolicand 100mm Hg diastolic, respectively. All subjects were given the RosenmanFriedman Stress Interview which was video-
*Manuscript received May 1978; revised January 1979. I Associate Professor of Psychiatry, University of Saskatchewan, Saskatoon. 2psychologist, University Hospital, Saskatoon at time of study; now Psychologist at Alberta School Hospital, Red Deer, Alberta. 'Professor of Medicine, University of Saskatchewan at time of study; now in private practice in Tulsa, Oklahoma. 'Research Assistant, Departmentof Psychiatry, University Hospital, Saskatoon. Address reprint requests to: Dr. David Keegan, Department of Psychiatry, University Hospital, Saskatoon, Saskatchewan.
Can. J. Psychiatry Vol. 24 (1979)
724
December,
1979
TYPE
A
BEHAVIOUR PATTERN
taped and subsequently rated by Dr. Rosenman who was unaware of the cardiac diagnoses. They were rated on a continuum of A behaviour from most to least (AI, A2, X, B). For purposes of analysis, subjects rated AI or A2 were combined as an A group whilethose rated X or B formed a non-A group. A battery of psychosocial tests were administered to assess personality, temperament and life stress and strain. These included the Minnesota Multiphasic Personality Inventory (MMPI), Thurstone Temperament Schedule (TTS), Holmes and Rahe Schedule of Recent Experience (SRE), and the Rosenman Sociological Questionnaire (RSQ) (5, 10,26).Twenty-seven demographicquestions includingmarital status, occupation, education, family background, religion and social mobility were included. Analysis of variance, the F test, was used to assessstatistical differences between the groups on the variables measured (4). Results There were 47 subjects with A behaviour pattern, 10 with extreme A I characteristics and 37 with the moderate A2 pattern. Of the 13 non-A subjects, 8 were rated X, having few A characteristics and considered non-A behaviour, while 5 with no A characteristics were rated B. In terms of diagnosis there were significantly more A subjects in the CHD group, p< 0.0 I, in fact only 3 non-As appeared in the group of 47 subjects. On the other hand, the NCHD group had 10 non-A subjects (Table I). The A subjects were found in all diagnostic groups but the largest number was found in the MI group. The smallest number was in the HT and CP groups. Interestingly there were 9 A subjects in the NI group who had no symptoms or illness but were assessed for a coronary prevention exercise program (Table II). When compared, the A and the non-A groups were similar in age, occupation, education, religion, social mobility and were no different in number of life change events as measured by the SRE. On the other hand, the A subjects were significantly more dissatisfied with their marriages, p< 0.05 and life achievements, p
