(Accepted for publication in: J. Personality Assessment in 1989 but may not have appeared)
"A-B" MAY NOT PREDICT HEART DISEASE BUT MANY OTHER SCALES DO: IS IT TIME TO ABANDON "A-B"?
University of N.S.W., Australia
JAS or SI or neither?
Although the various measures of "A-B" have now been shown to be seriously problematical and as generally not predicting coronary heart disease (CHD) this matters little as there are a large number of scales measuring other constructs which do predict CHD. Future research should therefore abandon the failed "A-B" concept and investigate more fully the alternative measures.
Yarnold & Bryant (1988) are just one example of many authors who have recently commented on the now widely acknowledged failure (See e.g. Appels, Mulder & Van Houtem, 1985; Emara, El-Islam, Abu Dagga & Moussa, 1986; Ray, 1986; Jenkins, Rosenman & Zyzanski, 1974; Katz & Toben, 1986; Lelouch & Kornitzer, 1982; Linden, 1987; Matthews, 1982; Myrtek & Greenlee, 1984; Nanjundappa, Friis & Taladrid, 1987; Rosenman, 1978; Ruberman, Weinblatt, Goldberg & Chandbury, 1984; Shekelle, Hulley, Neaton et al, 1985; Young, Barboriak, Hoffman & Anderson, 1984) of the Jenkins Activity Survey or "JAS" (Jenkins, Zyzanski & Rosenman, 1979) to predict coronary heart disease (CHD) but who still, for all that, seem unable to let go of the "A-B" concept that the JAS claims to measure. Eysenck (1990) has a slightly different approach. He still uses "A-B" terminology to denote coronary-prone and non-coronary-prone personalities but gives a description of what those personalities are that is more in accord with the evidence than is the description
offered by the Jenkins group.
The JAS is not, of course the only measure of "A-B" in the sense intended by the Jenkins group. The other main measure of "A-B" is the structured interview (or "SI"). The SI appears in some studies to have some correlation with CHD incidence but, as Yarnold & Bryant rightly point out, has other problems: notably difficulty of training raters, subjectivity of scoring and poor score reliability in various senses of
that term. Yarnold & Bryant are particularly persuasive in noting that the SI can reasonably be administered only once to each subject because subjects tend to "wise up" after the first administration. This means that the reliability of the measure in what is arguably the most important sense of that term is in principle unknowable. From a psychometrician's point of view, therefore, it would be hard to imagine a worse measure of anything. Additionally, in view of its weak relationship with the JAS, the small predictive success of the SI could even be due its measuring things outside the "A-B" concept. In the circumstances, Yarnold & Bryant urge us not to "throw out the baby with the bathwater" and urge us to continue using the JAS but with extra precautions. It is my submission that there is no baby in the bathwater but that there are lots of interesting babies elsewhere.
The other "babies"
The measures that Yarnold & Bryant suggest to enable continued use of the JAS (such as using only extreme scores) are very limiting and, as such, have something of an air of the counsel of despair. Their comment that we need to develop better alternative measures to the JAS is also somewhat strange. The crucial fact that Yarnold & Bryant and many others seem oblivious of is that there are already many self- report personality scales in the literature which do predict CHD. The JAS is in fact unusual in not predicting CHD. This can perhaps most clearly be seen in Krug & Sherman (1977) -- who show that in two large studies ten out of the 16 scales in the 16PF differentiated CHD sufferers from non-sufferers. There is, therefore, no reason at all to persevere with any form of the failed "A-B" concept. As reviews of the literature made plain as long ago as 1982 (e.g. Diamond, 1982) various measures of aggression or hostility in particular are good predictors of CHD. Being aggressive or hostile takes its toll on the body in various ways and CHD is one of those ways. It may therefore be useful here to mention at least a small sample of the more recent findings to this effect. A brief look at predictive scales outside the
aggression/hostility area will also be attempted.
Scales of aggression and hostility
Katz & Toben (1986) found that the JAS did not predict CHD symptomatology but the Novacco (1975) Anger scale did.
Eysenck (1990) reported a large prospective study in which it was found that an apparently unpublished scale of anger and excitement predicted a variety of adverse cardiac events.
Ray (1984b & 1986) found that the Ray (1976) Directiveness scale (measuring aggressive dominance) was the strongest of several predictors of CHD and that partialling out Directiveness from the small correlation between the JAS and CHD reduced that correlation to non-significance. Ray (1984b) used a simplified scoring system to get A-B score but Ray (1984a) showed that this scoring system and the standard scoring system give results that are essentially identical.
Smith, Follick & Korr, 1984) found that the frequency of anginal pains was predicted only by trait anger.
Rime & Bonami (1979) used mainly scales constructed by themselves for the occasion and reported five different personality predictors of CHD including their own scales measuring self-assertiveness and ego-defensiveness.
Van Dijl (1982) lists a 9-item scale of aggressiveness/ hostility which was found on several occasions to predict CHD.
Scales of other constructs: Eysenck's variables
Eysenck's two major personality variables (neuroticism and introversion. See e.g. Eysenck & Eysenck, 1969) have been implicated with CHD in a number of studies. Lelouch & Kornitzer (1982) found anomalous results with the Bortner (1969) scale of A-B but also found that the Eysenck N scale was the best predictor of CHD. More anxious persons suffered more CHD.
Drummond (1982) found that introversion predicted CHD symptomatology.
Siltanen, Lauroma, Nirrko, Punsar, Pyorala, Tuominen & Vanhala (1975) reported a study done in Finland wherein the scales used were especially constructed in Finnish. Their two best predictors of CHD, however, were "inhibition" followed by Neuroticism. If we identify "inhibition" with "introversion", we again have an indication of the relevance of Eysenck's variables.
Eysenck himself (Eysenck, 1990) has also discussed the relationship between adverse cardiac events and extraversion/neuroticism.
Although most of the content of the JAS can be traced to familiar personality variables such as dominance and achievement motivation (Ray & Bozek, 1980; Hansson, Hogan, Johnson & Schroeder, 1983), there is a small residue of reasonably unique items which load on what Jenkins, Zyzanski & Rosenman (1979) call the "Speed and Impatience" or SI factor. It is, in fact, this aspect of "A-B" that seems to be most stressed in discussions of what constitutes "A-B". Regrettably, even
the JAS test manual (Jenkins et al, 1979) shows that this factor does not predict CHD. There is, however, another measure of SI which was in fact partly derived from the JAS. This scale (the Ray & Bozek, 1980, Freneticism scale) does predict CHD (Ray, 1986) when appropriate controls are applied. This tends to suggest that the Jenkins and Rosenman group had better clinical insights than scale -constructing skills. Their theory was partly right even if their measuring
instruments were inadequate.
It is hoped that sufficient has been said to indicate that there
are far more promising lines of enquiry to follow in investigating the
personality correlates of CHD than anything offered by the various
measures of A-B. Other readings that would give extra context to what
has been said here are: Linden (1987); Dembroski, MacDougal, Herd &
Shields (1979); Haynes & Matthews (1988); Wright (1985) and Booth-
Kewley & Friedman (1987).
Appels, A., Mulder, P. & Van Houtem, J. (1985) De validteit van de
Jenkins Activity Survey, een vragenlijst ter meting van het type
A gedrag. Nederlands Tijdschrift voor de Psychologie en haar
Grensgebieden 40, 474-487.
Booth-Kewley, S. & Friedman, H.S. (1987) Psychological predictors
of heart disease: A quantitative review. Psychological Bulletin
Dembroski, T.M., MacDougall, J.M., Herd, J.A. & Shields, J.L (1979)
Effect of level of challenge on pressor and heart rate responses
in Type A and B subjects. J. Applied Social Psychology 9, 209-
Diamond, E.L. (1982) The role of anger and hostility in essential
hypertension and coronary heart disease. Psychological
Bulletin 92, 410-433.
Drummond, P.D. (1982) Personality traits in young males at risk for
hypertension J. Psychosomatic Research 26, 585-589.
Emara, M.K., El-Islam, M.F, Abu Dagga, S.I. & Moussa, M.A. (1986)
Type A behaviour in Arab patients with myocardial infarction.
J. Psychosomatic Res. 30, 553-558.
Eysenck, H.J. & Eysenck, S.B.G. (1969) Personality structure and
measurement. London: Routledge.
Hansson, R.O., Hogan, R., Johnson, J.A. & Schroeder, D. (1983)
Disentangling Type A behavior: The roles of ambition,
insensitivity and anxiety. J. Res. Personality 17, 186-197.
Haynes, S.G. & Matthews, K.A. (1988) Area review: Coronary prone
behavior: Continuing evaluation of the concept.
Annals of Behavioral Medicine 10, 47-59.
Jenkins, C.D., Rosenman, R.H. & Zyzanski, S.J. (1974) Prediction of
clinical coronary heart disease by a test for the coronary prone
behavior pattern. New England J. Medicine 290, 1271-1275
Jenkins, C.D., Zyzanski, S.J. & Rosenman, R.H. (1979)
Jenkins Activity Survey manual N.Y.: Psychological Corp.
Katz, R.C. & Toben, T. (1986) The Novacco anger scale and Jenkins
Activity Survey as predictors of cardiovascular reactivity.
J. Psychopathology & Behavioral Assessment 8, 149-155
Krug, S.E. & Sherman, J.L. (1977) Psychological trait analysis in
preventive medicine. Journal of IAPM Winter, 48-56.
Lelouch, M. & Kornitzer, M. (1982) Ischemic heart disease and
psychological patterns. In: H. Denolin (Ed.) Psychological
problems before and after myocardial infarction Basel: S. Karger
Linden, W. (1987) On the impending death of the type A construct:
Or is there a phoenix rising from the ashes?
Canadian J. Behavioural Science 19, 177-190.
Matthews, K.A. (1982) Psychological perspectives on the Type A
behavior pattern. Psychological Bulletin 91, 293-323
Myrtek, M. & Greenlee, M.W. (1984) Psychophysiology of Type A
behavior pattern: A critical analysis. J. Psychosomatic Res.,
Nanjundappa, G., Friis, R. & Taladrid, B. (1987) Type A personality:
Hispanic and Anglo diabetes and cardiovascular disease.
International Migration Rev. 21, 643-655.
Ray, J.J. (1976) Do authoritarians hold authoritarian attitudes? Human Relations, 29, 307-325.
Ray, J.J. (1984a) Confusions in defining A-B personality type: A rejoinder to Jenkins & Zyzanski. British Journal of Medical Psychology 57, 385
Ray, J.J. (1984b) Authoritarianism, A-B personality and coronary heart disease: A correction. British Journal of Medical Psychology 57, 386.
Ray, J.J. (1986) Alternatives to the A-B personality concept in predicting coronary heart disease. Personality Study & Group Behaviour 6(2), 1-8.
Ray, J.J. & Bozek, R.S. (1980) Dissecting the A-B personality type. British Journal of Medical Psychology 53, 181-186.
Rime, B. & Bonami, M. (1979) Overt and covert personality traits
associated with coronary heart disease. British J. Medical
Psychology 52, 77-84
Rosenman, R.H. (1978) The interview method of assessment of the
coronary-prone behavior pattern. In T.M. Dembroski, S.M. Weiss,
J.L. Shields, S.G. Haynes & M. Feinleib (Eds.) Coronary-prone
behavior N.Y.: Springer.
Ruberman, W., Weinblatt, E., Goldberg, D.D. & Chandbury, B. (1984)
Psychosocial influence on mortality after myocardial infarction.
New England J. Medicine 311, 552-559.
Shekelle, R.B., Hulley, S.B., Neaton, J.D. et al (1985) The MRFIT
behavior pattern study III: Type A behavior and incidence of
coronary heart disease. American J. Epidemiology 122, 559-570.
Smith, T.W., Follick, M.J. & Korr, K.S. (1984) Anger, neuroticism,
Type A behaviour and the experience of angina.
British J. Medical Psychol. 57, 249-252.
Van Dijl, H. (1982) Myocardial infarction patients and heightened
aggressiveness/hostility. J. Psychosomatic Res. 26, 203-208.
Wright, L. (1985) The Type A behavior pattern and coronary artery
disease. American Psychologist 43, 1-12.
Yarnold, P.R. & Bryant, F.B. (1988) A note on measurement issues in
Type A research: Let's not throw out the baby with the bath water
J. Personality Assessment 52, 410-419.
Young, L.D., Barboriak, J.J., Hoffman, R.G. & Anderson, A.J. (1984)
Coronary-prone behavior attitudes in moderate to severe coronary
artery occlusion J. Behavioral Medicine 7, 205-215
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