Which of the following characteristics of a Type A personality have been determined

Type A Behavior

The type A behavior pattern was originally described by cardiologists Friedman and Rosenman in the 1950s as a behavior pattern characterized by agitation, hostility, rapid speech, and an extremely competitive nature. The contrasting type B behavior pattern consists of a more laid-back style and a lack of the type A characteristics mentioned previously. A structured interview was developed to measure type A behavior based on behaviors such as speech characteristics and subjects' responses to various questions.

In the 1960s and 1970s, many studies were conducted to probe the relationship between type A behavior and heart disease. Most of the studies revealed a correlation between type A behavior and coronary heart disease in both men and women, which is comparable and independent of the effects of smoking and hypertension. For example, two major studies obtained results supporting the findings that type A behavior is a risk factor for heart disease. The Western Collaborative Group Study (WCGS) followed initially healthy men for 8.5 years. The men were given questionnaires and took part in interviews to determine their type A status at the outset of the study. Those individuals who were identified as type A were more likely to have developed heart disease over the course of the 8.5 years of the study than the type B group. The Framingham Heart Study also showed that type A behavior was a predictor of CHD among white-collar men and women who worked outside of the home.

Since the 1980s, however, most studies have not corroborated the relationship between type A behavior and heart disease. The Multiple Risk Factor Intervention Trial (MRFIT) assessed whether interventions to reduce coronary risk factors, such as high blood pressure, smoking, or high cholesterol levels, decreased the potential for coronary disease in high-risk men and women. After 7 years, the results did not show a relationship between these measures of type A behavior and the incidence of the first heart attack. Further, there were reports from research that indicated that, after a heart attack, type B patients were more likely to die than type A patients. This finding could be explained as the result of healthier type A patients being the ones who initially survived their first heart attack. Regardless, however, this result certainly presented doubts about type A behavior as a coronary risk factor.

It is unclear why these studies resulted in such inconsistent findings. Some have suggested that type A behavior may be a risk factor for younger individuals rather than for older or high-risk individuals, such as the ones tested in the MRFIT study. Still, it seems that there are certain aspects of type A behavior, particularly anger and hostility, that remain correlated with coronary disease, even in studies in which overall type A behavior was not related to CHD.

2.7 The Hysterical Personality

A personality type, first clearly described by Janet at a time when hysteria was still regarded as an almost exclusively feminine condition, which is assumed to be particularly susceptible to develop conversion and other hysterical symptoms. As described, the characteristic features are attention-seeking behavior, shallow, labile emotions, and self-centered, demanding, interpersonal behavior. A variety of tactics are used to attract and retain the attention of others, including striking or sexually provocative clothing, flirtatious behavior, flattery, dramatized accounts of their past lives or current circumstances, and extravagant gestures.

Despite the linkages between these seven meanings the inevitable consequence of this diversity of usage was confusion and serious ambiguity. The situation was summarized trenchantly by the American psychiatrist Chodoff (1974): ‘Entities that are clinically quite different are being held together artificially by little more than the authority of an ancient name’ he asserted; ‘the diagnosis (of hysteria) has become a balloon filled with air rather than substance … it is a fossil encrusted with and obscured by successive layers of meaning.’ For good measure he reminded his audience that the term ‘hysteric’ was used widely by young male psychiatrists to describe almost any attractive female patient.

“Type A” personality

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Type A behavior: extreme sense of time urgency, competitiveness, impatience, and aggressiveness.

Twofold increase in CHD risk.

Damaging to cardiovascular system is regular expression of anger.

Positive correlation exists between serum cholesterol level and aggression. The higher the aggression score, the higher the cholesterol level.

A negative correlation exists between ratio of LDL-C to HDL-C and controlled affect score—the greater the ability to control anger, the lower this ratio. Those who learn to control anger experience reduction in risk for heart disease, whereas an unfavorable lipid profile is linked with aggressive (hostile) anger coping style.

Anger expression plays a role in CRP levels. Greater anger and severity of depression, separately and in combination with hostility, are linked to elevations in CRP.

Other mechanisms linking emotions, personality, and CVD: increased cortisol secretion, endothelial dysfunction, hypertension, and increased platelet aggregation and fibrinogen.

Ten tips that help improve coping strategies:

Do not starve your emotional life. Foster meaningful relationships. Provide time to give and receive love in your life.

Learn to be a good listener. Allow the people in your life to really share their feelings and thoughts uninterruptedly. Empathize with them; put yourself in their shoes.

Do not try to talk over somebody. If you find yourself being interrupted, relax; do not try to outtalk the other person. If you are courteous and allow someone else to speak, eventually (unless he or she is extremely rude) he or she will respond likewise. If not, explain that he or she is interrupting the communication process. You can do this only if you have been a good listener.

Avoid aggressive or passive behavior. Be assertive, but express your thoughts and feelings in a kind way to help improve relationships at work and at home.

Avoid excessive stress in your life as best you can by avoiding excessive work hours, poor nutrition, and inadequate rest. Get as much sleep as you can.

Avoid stimulants such as caffeine and nicotine. Stimulants promote the fight-or-flight response and tend to make people more irritable in the process.

Take time to build long-term health and success by performing stress-reduction techniques and deep breathing exercises.

Accept gracefully those things over which you have no control. Save your energy for those things that you can do something about.

Accept yourself. Remember that you are human and will make mistakes from which you can learn along the way.

Be more patient and tolerant of other people. Follow the golden rule.

8.08.2.3.2 Anger and hostility

As noted above, type A behavior consists of several behaviors, including competitiveness, time urgency, and hostility, yet it is possible that not all these behaviors contribute equally to coronary risk. What have consistently emerged as correlates of CHD in these studies are characteristics relating to hostility, anger, and certain speech characteristics derived from the structured interview, as well as the characteristic of not expressing anger or irritation or “anger-in.” For example, a reanalysis of data from the WCGS described above showed that “potential-for-hostility,” vigorous speech, and reports of frequent anger and irritation were the strongest predictors of CHD (Matthews, Glass, Rosenman, & Bortner, 1977). Even in the MRFIT study, which was not able to relate type A behavior to CHD, hostility characteristics in MRFIT subjects were associated with increased CHD risk (Dembroski, MacDougall, Costa, & Grandits, 1989).

The Cook and Medley Hostility Inventory (Cook & Medley, 1954), a scale derived from the Minnesota Multiphasic Personality Inventory (MMPI), has been shown in two studies to be related to occurrence of coronary disease. This scale appears to measure attitudes such as cynicism and mistrust of others (Barefoot & Lipkus, 1994). In one study involving a 25-year follow-up of physicians who completed the MMPI while in medical school, high Cook-Medley scores measured in college students predicted incidence of CHD as well as mortality from all causes, and the relationship was independent of the individual effects of smoking, age, and presence of high blood pressure (Barefoot, Dahlstrom, & Williams, 1983) (Figure 5). There is also evidence that low hostility scores are associated with decreased death rates during a subsequent 20-year follow-up of nearly 1900 participants in the Western Electric Study (Shekelle, Gale, Ostfeld, & Paul, 1983). In other studies it was shown that traits of hostility (e.g. assessed in terms of behaviors and attitudes indicative of hostility derived from the type A behavior structured interview) were related to the development of CHD in initially healthy men and in high-risk participants in the MRFIT study (for a review see Helmers, Posluszny, & Krantz, 1994). Subsequent research has further suggested that hostility scores on the Cook and Medley (1954) scale are higher in low socioeconomic status groups, higher in men and non-whites in the USA, and also positively related to the prevalence of smoking (Siegler, 1994). Thus, it is possible to hypothesize that hostility may account for some of the socioeconomic and gender differences in death rates from cardiovascular diseases (Stoney & Engbretson, 1994).

In the late 1950s, the Type A behavior pattern was described as a contributing factor in the development of coronary heart disease (CHD). Comprised of impatience, achievement striving, competitiveness, and hostility, this pattern does predict the development of CHD. However, inconsistencies in the available research have led to the study of individual elements of the pattern. Hostility, and more recently dominance, have emrged in such studies as significant risk factors for CHD and premature mortality. Psychophysiological stress responses are a likely mechanism linking such behavioral traits with disease, and related interventions have been found effective in preventing recurrent coronary events.

History of the Concept

In the 1960s, the concept of the type A behavior pattern was introduced by cardiologists Meyer Friedman and Ray Rosenman to describe individuals who possessed excessive time urgency and free-floating hostility and who, by virtue of this behavior pattern, were believed to be coronary-prone. This conceptualization fostered hundreds of investigations in the 1970s and 1980s aimed at replicating early associations with coronary disease, refining its measurement, and understanding its physiological underpinnings. In 1980, a classic paper was published by Williams and his colleagues that suggested that the hostility component of the type A behavior pattern was its toxic core (Figure 1). Angiography patients were divided by gender, type A behavior, and hostility, and these classifications were related to occlusive disease. For both males and females, hostility was a better predictor of ≥75% occlusion than type A behavior. This seminal investigation was subsequently replicated in a large number of studies using a variety of subjects and study designs and resulted in a shift in thinking away from type A behavior toward hostility as a key coronary-prone behavior.

8.13.3.3.1 Modifying Hostility and Type A Behaviors

A variety of clinical intervention studies have attempted to decrease type A behavior either in persons with elevated CHD risk factors or in samples of coronary patients. Most of these early, small studies demonstrated that elements of type A behavior can be decreased to some extent in subjects who are motivated to change (Allan and Scheidt, 1996; Suinn, 1982). Accompanying changes in type A behavior, some studies also measured changes in traditional CHD risk factors such as serum cholesterol levels or blood pressure.

The Recurrent Coronary Prevention Project (RCPP; Friedman et al., 1986), is a large study of CHD patients conducted to determine whether modification of type A behaviors of anger, impatience, and irritability, lower the recurrence of heart attacks and deaths. Type A counseling included drills to change specific type A behaviors, focused discussions on beliefs and values underlying type A behavior, rearrangements of home and work demands, and relaxation training to decrease physiologic arousal. After 4.5 years, the rate of heart attack recurrence for the type A behavioral counseling group was significantly lower than for the cardiology counseling and control groups (Friedman et al., 1986). However, in light of the recent negative evidence regarding associations of type A behavior with CHD, it is possible that the beneficial effects of the RCPP study resulted from more general salutary effects of the interventions in reducing chronic distress and increasing coping skills and social support among patients.

Personality

The time-urgent, competitive, easily angered type A personality enjoyed a long vogue as a potential marker of cardiovascular risk, especially while white collar occupational groups continued to experience a high rate of coronary events. That epidemiological picture has since undergone a radical change, with people of lower socioeconomic position now being at greater risk of CVD in many developed countries. The focus on personality as a cardiovascular risk factor has also faded because of the difficulties in classifying individuals' personalities reliably. There is also only limited evidence that personalities can be changed, although new ways of responding to the stresses of everyday life can be learned, and the evidence that attempting to do so results in a meaningful reduction in cardiovascular events is scant indeed.

Type A Behavior

A stress- and work-related behavior pattern termed type A behavior has attracted a considerable amount of attention over the past decades. This attention was based, to a large extent, on findings from the prospective Western Collaborative Group Study, in which about 3000 middle-aged employed men were classified either as type A individuals or as their more relaxed type B counterparts on the basis of a standardized interview technique (the structured interview). At the 8.5-year follow-up, it was found that the prevalence of myocardial infarction was about twice as high among type A as among type B individuals, after controlling for traditional risk factors (blood pressure, blood lipids, cigarette smoking, etc.). This study initiated a great number of investigations and experiments aimed at revealing factors that contribute to the development of this behavior pattern and the psychophysiological mechanisms that could create a link to myocardial infarction. Work-related stress was found to play an important role in this context.

Type A behavior is defined in terms of an extreme sense of time urgency, impatience, competitiveness, and aggression/hostility. Work conditions in industrialized countries, emphasizing the importance of efficiency, productivity, a high work pace, and competitiveness, are considered to contribute to the development of this behavior pattern. In addition, individuals classified as type A have been found to be particularly responsive to challenges at work (obstacles to keeping up the pace of work, lack of control, competition, harassment, etc.) in terms of blood pressure, heart rate, blood lipids, and catecholamine output. Intensive, frequent, and/or sustained activation ofthese physiological stress responses contributes to the atherosclerotic process and to blood clotting and are, thus, likely to form a pathway between type A behavior and the elevated risk of myocardial infarction. Results for women are in general less consistent than they are for men, which could be explained by the fact that the structured interview was developed using male subjects.

The high work pace and competitiveness associated with the type A behavior pattern are usually reinforced at work by giving the individual a higher income, appreciation, and a successful occupational career (higher rank). Consequently, efforts to modify this behavior pattern in healthy individuals have not been particularly successful. However, after a myocardial infarction individuals tend to be more motivated to change their lifestyle, and, indeed, a prospective intervention study has shown a reduced risk of reinfarction among individuals who were able to modify their type A behavior.

Interest in the global type A behavior has diminished in favor of one specific component of this behavior pattern – the aggression-hostility component, which seems to be the most toxic factor in terms of myocardial risk. The important role played by hostility in cardiovascular disease was first demonstrated in a longitudinal study by Barefoot and colleagues, which found that medical students with high scores on the Cook-Medley hostility scale of the Minnesota Multiphasic Personality Inventory (MMPI) had a sixfold increase in mortality when followed up 25 years later, mainly due to coronary heart disease (CHD). Subsequent studies have consistently supported this finding by showing that individuals who are high in hostility have a significantly increased risk of myocardial infarction. As medication to prevent and treat cardiovascular disease has improved considerably during the past decades and the incidence rate of myocardial infarction has declined steadily since 1980, interest in performing large prospective studies on type A behavior and CHD has diminished accordingly.

Conceptualization and Assessment

Considerable conceptual confusion has surrounded the type A construct. Type A behavior has been variously described as a medical disorder, an inappropriate coping mechanism, a strong need for productivity, or a pattern of physiological reactivity. Although most research has presumed type A behavior constitutes an enduring personality trait, other studies have attributed type A behavior to specific cognitions that can be modified through therapeutic interventions. Much of the accumulated discrepancy in results between studies of type A may be attributable to poor agreement in construct definition and assessment.

Type A behavior was first assessed through clinical ratings applied to structured interviews or videotaped structured interviews, and these interview techniques have been further updated and expanded by Meyer Friedman and colleagues. The current technique combines both observations and subjective reporting of patients using eliciting remarks. The interview consists of multiple queries that are designed to elicit manifestation of time urgency and free-floating hostility that emerge for type A, but not for type B, individuals. Questions include “Do you mind very much waiting in grocery checkout, bank, or theater lines or waiting to be seated in a restaurant?” (time urgency) and “Do you often find it difficult to fall asleep or to continue to sleep because you are upset about something a person has done?” (hostility). Scoring is based on both endorsements of items and the presence of psychomotor signs. For time urgency, signs include aspects of facial tension, posture, speech, breathing, and perspiration. For free-floating hostility, these include facial expression, eyelid movement, vocal orientation, and hand clenching. For each item, scores are clinical ratings varying in assigned weights and ranges. Total scores range from 0 to 480, and a total score greater than 45 indicates the presence of type A traits.

As an alternative to the interview technique, self-report measures of type A were developed to simplify data collection for use in large-scale epidemiological studies of CHD. One of the earliest and most frequently used questionnaires is the Jenkins Activity Scale (JAS). Other pen-and-paper measures of type A behavior include the Framingham Type A Scale, the Bortner Scale, the MMPI-2 Type A Scale, the Gough Adjective Checklist, the Thurstone Activity Checklist, the Coronary Prone Attitudes Scale, and the Ketterer Stress Symptoms Frequency Checklist.

The content and emphasis of type A self-report measures vary substantially. The JAS includes subscales of hard-driving competitiveness, speed and impatience, and job involvement. The Framingham Type A Scale includes time urgency, competitive drive, and perceived job pressures, but does not include hostility. The Bortner scale contains 14 adjective pairs between which respondents mark the level of agreement with either type A or type B traits (e.g., “Never late” versus “Casual about appointments”). The MMPI-2 Type A Scale includes 19 items that assess the type A components of hostility, competitiveness, and time urgency; these were selected from the total pool of MMPI-2 questions by expert consensus and verified using empirical tests of item-to-type A group classification. The Ketterer Scale compares self-ratings of type A characteristics with parallel ratings of a friend or family member.

The reliability of the various interview and self-report measures is quite good. For example, interrater correspondence for discriminating type A and B individuals using the videotaped structured interview has ranged from 75 to 90%. For the MMPI-2 Type A Scale, test–retest reliability is high (r = 0.82), and internal consistency is moderately high (α = 0.72), at least for male respondents. Other self-report measures of type A show similar levels of reliability. Prevalence estimates of type A behavior have varied from 50 to 75% depending on the populations studied and assessment techniques employed.

The validity of self-report measures of type A were originally documented by comparing scores between type A and type B individuals already categorized using the gold-standard interview technique. Although both interview and self-report assessment techniques have good reliability, the two approaches are only modestly interrelated. For example, the JAS showed a 73% agreement with the type A interviews in a cross-validation sample of 419 men participating in the Western Collaborative Group Study. Similarly, the Bortner scale was shown to explain only 53% of the variability in type A clinical interview ratings. This has led to considerable debate as to whether self-report questionnaires of type A are a valid means of describing the same constellation of features identified by the structured interview. Studies using self-report measures have generally provided less association with cardiovascular health outcomes than have interview techniques. As a result, self-report measures of type A have been criticized for relying on the insight of respondents, restricting the range of type A traits, and being influenced by the social undesirability of many items. Because self-report measures do not involve a live interaction with the individual, these scales may not accurately assess the action–emotion complex described by the creators of the interview technique.