Investigation of a controversial issue

A slightly longer report on "Type A" and "Type B" behavior, appearing in Science85, also illustrates the key features of investigating and reporting. In this article, John Tierney examines how two studies have called into question a frequent presumption: aggressive, impatient, and inflexible "Type A" men are prime candidates for heart attacks.

Type A's: Maybe Now You Can Relax

A quick summary for the Type A reader who doesn't have time to read this whole article:

Two new studies find that someone with a Type A personality — impatient, competitive, aggressive, easily angered — does not have an abnormally high risk of suffering a heart attack. These results are surprising and controversial. Some researchers speculate that it's safe to be Type A as long as you're not hostile.

Now, for the leisurely Type B still reading, some background. In the-last several years, the Type A person has had plenty to worry about — not that this is unusual, of course. The Type A always has plenty to worry about. But only recently did the medical establishment add to his woes. Most researchers ignored the theory about A and B personality types long after it was proposed in 1959 by cardiologists Meyer Friedman and Ray Rosenman. The theory wasn't officially sanctioned until 1981, when the American Heart Association reviewed evidence of a disproportionate rate of heart disease among Type A's. It decided that Type A behav-' ior should be classified as a risk factor for heart disease.

Last year Friedman further convinced the establishment with a study in which victims of heart attacks were trained to relax. These men were told to drive in slow highway lanes, pick out the longest line at the bank, play a game to lose, set aside time for doing nothing. Compared with a control group, the men who modified their Type A behavior suffered only half as many nonfatal heart attacks. Friedman, concluding that Type A behavior is the primary cause of heart disease, wrote, "We know now beyond any doubt what we suspected before."

But this year new doubts have arisen. A team led by Robert B. Case, a cardiologist at St. Luke's-Roosevelt Hospital Center in New York, analyzed the personalities of 516 heart attack victims and then monitored their health for up to three years. " We fully expected that the people who scored highest in Type A traits would have more heart attacks and die sooner," says Case. "Then we analyzed the data and found no relationship at all." This study impresses many researchers, but it's also been faulted because of how it measured Type A personalities. The subjects were asked to fill out a questionnaire about their habits and traits — whether they found it difficult to make time for a haircut, for instance, or whether they were more hard driving than their colleagues at work. This same questionnaire has been used in the past to link Type A's and heart disease (and it's cited approvingly by the American Heart Association), but some insist that Type A traits can only be measured accurately in an interview. Friedman and Rosenman say that it's crucial for an interviewer to observe telltale signs of Type A behavior, such as speaking rapidly, interrupting often, jiggling knees, clenching a fist, or grimacing.

But another study, scheduled for publication this fall, used interviews and also produced negative results. Richard Shekelle, an epidemiologist at the University of Texas, and colleagues studied 3,110 middle-aged men who had not suffered a heart attack but were considered prime candidates because of their blood pressure, cholesterol level, or cigarette smoking. Interviewers rated the men as Type A or Type B. Within eight years of the interviews, 129 of the men had heart attacks, and 62 died. There was no pattern: Type B's were just as likely to be stricken as Type A's.

It's possible, as many critics claim, that the interviewers weren't skilled at identifying Type A behavior. "But the fact remains," says Shekelle, "that several investigators are not finding an association of Type A behavior and heart disease, and we have to reassess the conventional wisdom." Both he and Case suspect the problem may lie in the definition of Type A. "It's too diffuse," Case says. "We're indebted to Friedman and Rosenman for pointing the way, but the time has come to focus on specific characteristics of behavior that are dangerous."

On hostility, for instance. Duke University internist Redford Williams and University of Maryland psychologist Theodore Dembroski recently found that a person's level of hostility and cynicism is a better predictor of heart disease than his overall level of Type A behavior... "The kind of person at risk is someone who generally feels that other people are not to be trusted — that they'll lie and cheat if they can get away with it," says Williams. "It's the kind of person who, when an elevator doesn't come up from the floor below, immediately assumes people downstairs are holding up the elevator out of sheer inconsideration." This theory is gaining favor with scientists, although it does seem to provoke hostility in the fathers of Type A theory. "You can't dissect a human — you can't isolate hostility from other Type A traits," says Rosenman. Adds Friedman, "It's awfully hard to find a hostile man who isn't impatient. And an impatient man eventually gets hostile."

Any Type A who reads this far must be frustrated. Whom to believe? Is it really necessary to slow down? Perhaps the most soothing advice comes from Dembroski: "I suspect the danger is not a matter of being hard driving, hard working, quick to do things. It's how you go about it — whether or not you're hostile. Don't let things get to you."