For some 40 years scientists have been studying Type A behavior, a behavior pattern which may place individuals at risk for coronary heart disease (CHD). In the mid 1950's , two cardiologists, Meyer Friedman and R.H. Rosenman remarked that the primary risk factors of CHD, i.e. hypertension, smoking, and elevated serum cholesterol, did not explain the vast increase of incidence of the disease occurring in the preceding 50 years. (1) Subsequent studies offered enough evidence for the National Heart, Lung, and Blood Institute in 1981 to conclude that Type A Behavior was associated with increased risk of CHD in middle aged United States citizens in industrialized geographical areas. (2) However, since then, further research has produced both contrary and inconsistent findings regarding this association. The following will explain the manifestations of Type A behavior, the ways to measure it, the evidence supporting and negating its inclusion as a risk factor for CHD.
The Type A behavior pattern (TABP) is defined as an action-emotion complex stimulated by certain environmental events. It is believed to be influenced by Western cultural values that reward those who can produce in any capacity with great amounts of speed, efficiency and aggressiveness. (3)
The TABP is characterized by traits such as impatience, aggressiveness, a sense of time urgency, and the desire to achieve recognition and advancement. People exhibiting Type A behavior have a hyper awareness of time and thus walk, eat and perform most activities rapidly and perfunctorily.
Successive tests based on interviews of TABP subjects also suggest that people with Type A behavior tend to present physical manifestations; i.e., facial tension, rapid speech, prolepsis (interruption of others' speech), tongue and teeth clicking, and the audible forced inspiration of air. (2)
These traits are considered the stable and consistent characteristics derived from observation of subjects with TABP. However, emotional and behavioral reaction patterns do not occur outside of contexts. As the above characteristics represent the traits of TABP, it is necessary to recognize that these same subjects often find themselves in states or conditions that elicit this kind of behavior. People with TABP seem to find themselves in various high-pressured scenarios, which is regarded often as a result or state of this construct rather than a trait. One example might be that subjects with Type A behavior find themselves in high-demand/low-achievement work settings, which tends to increase their impatient and agitated behavior.
Occupational stress researchers are particularly interested in the concept of Type A behavior and hostility because of: 1) the possibility that these personality characteristics may moderate the effects of job stressors, and 2) research indicating that Type A is rewarded and reinforced in organizations by income and prestige (4, 5).
For example, differing effects of a job stressor was found in a study (6) of machine-paced letter sorting machine workers compared to self-paced workers. Machine pacing was associated with higher anxiety, anger and depression, but only for non-Type A workers.
Type A Behavior may also contribute to increased job performance, which is rewarded in organizations (4, 5), although the evidence linking Type A to productivity is mixed (7, p. 228-9). Type A is viewed not as a fixed personality trait but "as the outcome of a set of predispositions interacting with specific types of eliciting situations" (8, p. 924). As Singer and colleagues (9, p. 178) point out, employees "would learn more relaxed styles if the demands and deadlines, job loss threats and speedups, were diminished to a more acceptable level."
It is also possible to describe organizations in terms similar to those used to describe Type A in individuals: hard driving/ competitive, time-urgent, hostile, aggressive, job centered (7, p. 229). A survey has been developed (10) which provides a total organization's Type A/B score and three subcomponent scores: hard driving/aggressive, time-urgent and job centered, along with an individual's Type A/B score, and a score indicating Type A/B person-environment fit (7, p. 230).
Several different tests have been utilized in studying Type A behavior, such as the Bortner Rating Scale Type (11), the Framingham Type A Scale (12), the Jenkins Activity Survey (JAS) (13) and the Structured Interview (SI) (14).
The JAS is a questionnaire, filled out by the patient, therefore performing a self-evaluation of his/her own behavior. It makes queries about speed and impulsivity, job involvement, and aggressive behavior. This self report is considered less conclusive in relating TABP to CHD than the SI because of incidental bias and/or distortion.
Since Type A behavior pattern marks a reaction to a certain situation, the Structured Interview is preferred over the others as it evaluates behavior directly and has the strongest association with CHD (Example of SI). This method, however, requires intensive interviewer training and recognize a margin of error due to the interviewer's behavior while interviewing subjects. (15)
There are several uncertainties concerning the possible causal association of TABP to CHD, most of those arising from the large body of inconsistent findings.
Initial population studies in the United States and Europe, such as the Western Collaborative Group Study (WCGS) (16) and the Framingham Heart Study established a correlation between Type A Behavior and the development of CHD in healthy middle-aged men. However a 22-year follow-up of results from the WCGS study found that Type A behavior was not predictive of disease progression. Furthermore, negative findings from other studies such as the Aspirin Myocardial Infarction Study, the Multiple Risk Factor Intervention Trial have and several others have led to skepticism. (17, 18)
The inconclusive evidence might be due in part to the complexity of measuring the behavioral construct and the physiological disease together. Emotional and behavioral reaction patterns are not mutually exclusive, and due to the human body's complexity, it is likely that a variety of influences affect the relationship between personality and health. (19) Furthermore, methodological difficulties such as biased subject selection, inconsistency in scoring methods to evaluate disease, and failure of studies to correlate with risk factors other than high cholesterol have discouraged conclusive results.
In efforts to reconcile these contradictory positive and negative results, researchers have broken down the Type A behavior construct in order to study its many subcomponents. What most studies found was that the recurrence of a "Anger/Hostility" dimension appeared most predictive of CHD. (20) This "Hostility" part of the subcomponent is characterized by a tendency to react to unpleasant situations with responses that reflect anger, frustration, irritation, and disgust. The Anger or "Anger-In" factor is the inability to express anger directly towards the respective recipient. (21) To date, these studies suggest that the Hostility factor, which itself is comprised of several subcomponents, is more reliable as a predictor of CHD than its Type A counterpart.
Although Type A behavior has been established in the past as a possible risk factor of Coronary Heart Disease, further study into its makeup and pathological effects have produced inconclusive evidence. Behavioral and psychosocial factors are demonstrably related to CHD, which has been coined "coronary-prone behavior". However, this behavior is not the same as Type A behavior. On the other hand, subcomponents of the Type A behavior construct, such as hostility, have offered a stronger and more consistent relationship with the development and progression of CHD. These factors may currently be considered psychosocial risk factors for CHD and further research is needed to extend results.
In addition, the organizational stress literature suggests that in order to reduce Type A behavior and/or hostility, factors such as job demands, time urgency, hostility, job insecurity, and a punitive climate in the work environment will need to be controlled.
1. Friedman, M., Rosenman, RH. Comparison of fat intake of American men and women: possible relationship to incidence of clinical coronary artery disease. Circulation 1957; 16:339-47.
2. Denollet, Johan. Biobehavioral Research on Coronary Heart Disease: Where is the Person? Journal of Behavioral Medicine, Vol. 16, No. 2, 1993; 115-137.
3. Lachar, Barbara L. Coronary Prone Behavior, Texas Heart Institute Journal 1993; 20: 143-51.
4. Ivancevich JM, Matteson MT. Type A behavior and the healthy individual.British J Med Psychol 1988;61:37-56.
5. Chesney MA, Rosenman RH. Type A behavior in the work setting. In CL Cooper, R Payne. (Eds.) Current Concerns in Occupational Stress. London: Wiley, 1980:187-212.
6. Hurrell JJ. Machine-paced work and the Type A behavior pattern. Journal of Occupational Psychology 1985;58:15-25.
7. Matteson MT, Ivanevich JM. Controlling work stress. San Francisco: Jossey-Bass, 1987.
8. Matthews KA, Haynes SG. Type A behavior pattern and coronary disease risk: Update and critical evaluation. Am J Epidemiol 1986;123:923-960.
9. Singer JA, Neale MS, Schwartz GE, Schwartz J. Conflicting perspectives on stress reduction in occupational settings: A systems approach to their resolution. In Health and Industry: A Behavioral Medicine Perspective, edited by M. F. Cataldo and T. Coates, pp. 162-192. Wiley, New York, 1986.
10. Ivancevich JM, Matteson MT. Behavior activity profile -- OE. Houston, Stress Research Systems, 1983.
11. Bortner RW, Rosenman RH. The measurement of Pattern A behavior. Journal of Chronic Disorders 1967; 20: 525-33.
12. Haynes SG, Feinleib M, Kannel WB. The relationship of psychosocial factors to coronary heart disease in the Framingham study: Eight year incidence of coronary heart disease. American Journal of Epidemiology 1980; 111:37-58.
13. Jenkins CD, Zysanski SJ, Rosenman RH. The Jenkins Activity Survey. New York: Psychological Corp., 1979.
14. Friedman, HS and BoothKewley, S. Personality, Type A behavior, and coronary heart disease: The role of emotional expression. Journal of Personal Social Psychology; 53: 783-792.
15. Rosenman, RH, Friedman, M, Straus R, et al. A predictive study of coronary heart disease: the Western Collaborative Group Study. JAMA 1964: 15-22.
16. Rosenman, RH, Brand JH, Jenkins CD, Friedman M, Straus R, Wurm M. Coronary heart disease in the Western Collaborative Group Study: final follow-up experience of 8.5 years. JAMA 1975; 233:872-7.
17. Shekelle RB, Gale M, Norusis M. Type A score (JAS) and risk of recurrent coronary heart disease in the Aspirin Myocardial Infarction Study. American Journal of Cardiology 1985; 56: 221-5.
18. Shekelle RB, Hulley SB, Neaton JD, et al. The MRFIT behavior pattern study. Type A behavior and incidence of coronary heart disease. American Journal of Epidemiology 1985; 122: 559-70.
19. Friedman, HS and DiMatteo, MR. Health Psychology, 1989; 192-219.
20. Schneiderman N, Chesney MA, Krantz, DS. Biobehavioral aspects of cardiovascular disease: progress and prospects. Health Psychology 1989; 8: 6349-76.
21. Smith TW, Frohm KD. What's so unhealthy about hostility? Construct validity and psychosocial correlates for the Cook and Medley Ho scale. Health Psychology 1985; 4: 503-20.