A type of behavior, or personality style, called the Type A pattern has received much attention. For many years, doctors have observed that victims of heart attacks are often hostile, aggressive, impatient people, too absorbed in their work. In the 50s, two cardiologists compiled a list of the Type A behaviors that characterize patients with coronary artery disease (Friedman & Rosenman, 1974). Type A people are too competitive and successful; they feel short of time, find it difficult to relax, and become impatient and angry when meeting time delays or people they consider incompetent. On the surface, they seem self-confident, but in fact they are constantly tormented by a feeling of self-doubt; they force themselves to do more and more in less and less time. Some of the behaviors related to the type «A» pattern are given in Table. 14.3.
Table 14.3. Types of behavior characteristic of the type «A» pattern
Type «B» pattern refers to people who do not exhibit type «A» characteristics. Type B people can relax without guilt and work without rush; they do not have a sense of lack of time and the impatience that accompanies it, they do not get angry over trifles.
To investigate the association between Type A behavior and coronary heart disease, more than 3000 healthy middle-aged men were surveyed using a structured interview. It was designed to be annoying. The interviewer made the subject wait without explanation and then asked a series of questions about competition, hostility, and lack of time. For example: «Do you ever feel like you’re in a hurry or don’t have enough time? Do you drive fast? Do you consider yourself ambitious and difficult to manage, or easy-going and carefree? Do you get offended when someone is late? The interviewer interrupted, asked defiant questions, and made inappropriate remarks. The subject was no longer evaluated by the answers themselves, but by the way he behaved when answering the questions. For example, men with extreme Type A behavior spoke loudly and passionately, spoke to the interviewer without interruption, looked tense and pursed their lips, and described situations of hostility with great emotional force. Type B men sat at ease, spoke slowly and softly, smiled often, and were easily interrupted.
Dividing the subjects into types «A» and «B», they were observed for 8,5 years. During this period, men with «A» behaviors had twice as many heart attacks or other types of coronary heart disease as men with «B» behaviors. These results did not change even after taking into account diet, age, smoking and other variables (Rosenman et al., 1975).
Other studies have confirmed this doubling of risk with Type A behavior in both men and women (Kornitzer et al., 1982; Haynes, Feinleib & Kannel, 1980). In addition, autopsy and X-ray examination of the internal walls of the coronary vessels revealed a correlation between type A behavior and the severity of arterial blockade (Williams et al., 1988; Friedman et al., 1968).
After reviewing these data, in 1981 the American Heart Association decided that Type A behavior should be considered a risk factor for coronary heart disease. However, two more recent studies failed to find an association between Type A behavior and heart disease (Case et al., 1985; Shekelle et al., 1983). Although some researchers attribute this negative result to the methods used to evaluate individuals in these studies, others feel that the definition of Type A behavior as originally formulated is too vague. They argue that time pressure, haste, and competitiveness are not the most important factors and that hostility is the decisive variable.
Several studies have confirmed that hostility carries more weight in predicting heart disease than a general characteristic of behavior as type A (Booth-Kewley & Friedman, 1987; Dembrosky et al., 1985; Thoresen, Telch & Eaglestone, 1981) . To explore the «angry» component of Type A behavior in more detail, several studies have used personality tests rather than interviews to measure hostility. For example, in a 25-year study of 118 male lawyers, those who scored high on a personality questionnaire in law school were found to be five times more likely to die before age 5 than their less hostile peers (Barefoot et al. ., 50). In a similar later study by physicians, medical school hostility scores were found to be predictive of coronary heart disease as well as all-cause mortality (Barefoot, Williams & Dahlstrom, 1989). Both studies took into account the effects of smoking, age and high blood pressure. There is some evidence that when a person suppresses anger, holding it in, it can be even more damaging to the heart than openly expressed anger (Wright, 1983; Spielberger et al., 1988).
A number of studies have shown that the level of hostility is a more significant indicator of the likelihood of illness than the overall level of manifestation of type «A» behavior.
Hardy individuals (i.e., those who do not get sick when stressed) are more active at work, more attuned to new challenges and changes, and more in control of their lives than people who succumb to the effects of stress.
How does type A behavior or hostility as a component of it lead to coronary heart disease? One possible biological mechanism is the nature of the response of the individual’s sympathetic nervous system to stress. When in an experimental stressful situation (for example, when threatened with failure, exhaustion, or conflicting demands), most subjects report feelings of anger, irritation, and tension. At the same time, in subjects with a high score of hostility as their personal characteristic, the increase in blood pressure, heart rate, and release of stress hormones is much higher than in subjects with a low score of hostility (Suarez & Williams, 1989). The same was found when comparing subjects with behavior types «A» and «B». Apparently, in hostile individuals and/or individuals with type A behavior, the sympathetic nervous system is hypersensitive to stressful situations.
All these physiological changes harm the heart and blood vessels.
Perhaps hostile and non-hostile people have fundamentally different nervous systems. In agitated and frustrated non-hostile individuals, the parasympathetic nervous system operates like an extinguishing switch and calms them down. On the contrary, it may be weak in hostile individuals. When they are angry, they constantly release adrenaline and are unpleasantly annoyed all the time. As a result, they interact differently with their environment (Williams, 1989).
Fortunately, the Type A behavior pattern is amenable to change through well-designed psychotherapy programs, and people who are able to moderate their Type A behavior have a reduced risk of coronary heart disease.
Type A Behavior Correction
The combination of cognitive and behavioral methods can significantly reduce type A behavior (Friedman et al., 1994). The subjects were 1000 people who had at least once had a heart attack. Treatment group subjects were helped to reduce their sense of time pressure by teaching them to wait by the phone (individuals with Type A behavior are particularly irritated by this situation), and take this opportunity to think about things they usually don’t have time to think about or watch. people, or start a conversation with a stranger. Treatment also included learning to express oneself without being irritated by people, and to change specific behaviors (such as interrupting others, eating or speaking in a hurry). Therapists helped these subjects re-evaluate the underlying beliefs (such as the notion that success is measured by the amount of work done) that drive many Type A individuals into hasty and hostile behavior. Finally, the subjects found a way to make their home and work environments less stressful (for example, reducing the amount of unnecessary social obligations).
In this study, the main dependent variable was the occurrence of new heart attacks. By the end of the study — 4,5 years later — their number in the experimental group was almost half that of control subjects who were not taught how to change their lifestyle. Clearly, Type A behavior modification was beneficial to the health of the subjects in the experimental group (Friedman et al., 1994).
Like other studies described in this chapter, this experiment was based on the assumption that mind and body interact. Simple models that describe the impact of stress on health have given way to complex models that explain how the biological, psychological, and social factors that determine health or disease are intertwined. As we have seen, the body produces specific physiological responses to stress. For people with a predisposition to heart disease, these physiological responses to stress can lead to poor health. At the same time, individual perception of stress is determined by the characteristics of events occurring in the environment of the individual, his personal history, assessment of events and style of coping. Thus, the degree to which an individual experiences psychological distress or health problems caused by potentially stressful situations is determined by the strong and weak differences in his biological and psychological constitution with which he enters the situations encountered in his life.
Stress Coping Skills
Emotions and physiological arousal caused by stressful situations are extremely unpleasant, and this discomfort motivates the individual to do something to reduce them. The process by which a person tries to cope with stressful demands is called coping and occurs in two main forms. See →