The dark psychosomatic history of heart disease part I

This new blog series explores the problematic history of the Type A personality in two parts.

‘Type A’ referred to people who were ambitious, aggressive, and extremely competitive. They were always short of time and in constant pursuit of achievements. In the 1970s and 1980s, a stream of news articles and scientific reports stated that people with Type A behavior had an increased risk of coronary heart disease. Bestseller books explained to readers how they could “liberate” themselves of this risk if they were willing to recognize and change their personality flaws. An article in the New York Times advised Type A’s to “practice standing in lines doing nothing.”

Later scientific studies failed to replicate Type A behavior as a risk factor for heart disease. Eventually, it would become clear that much of the original research had been secretly funded by the tobacco industry. Today, in part I we look at the origin of Type A and how it entered popular culture.

The leading cause of death

At the turn of the 19^th century, a revolutionary change occurred in medicine. Mankind had always been plagued by infectious diseases such as smallpox, typhus, and cholera but improvements in sanitation, hygiene, and food supply changed how people died.

In western countries, people no longer succumbed to abrupt infections but to chronic diseases that developed slowly over time. Cancer is a prime example of this but there is one other slowly developing malady that surpasses all others in terms of mortality: coronary heart disease.

The illness took the best of iconic US presidents Woodrow Wilson, Franklin D. Roosevelt, and Dwight Eisenhower. Like many Americans, they fell victim to a silent epidemic of cardiovascular disease in the 20^th century. But while heart disease was on the rise, its causes remained obscure. Many thought it was just part of the aging process which little could be done about except for bed rest and taking things slower.

Soon after Roosevelt’s death in 1945, a prospective study was set up to learn more about the causes of coronary heart disease. The idea behind it was simple but had rarely been pursued. Scientists would measure as many things as they could in a large group of people and then follow them up over time. Eventually, some of these people would develop cardiovascular disease and die from it. The scientists could then trace back which factors, measured at the beginning of the study, were associated with these cardiovascular events.

The city of Framingham, Massachusetts was chosen for its proximity to Harvard Medical School, and because it was considered representative of the US population as a whole. The Framingham study, as it became known, introduced the term ‘risk factor’ and demonstrated that smoking, cholesterol levels, and hypertension increased the risk of coronary heart disease. When President Roosevelt, for example, suffered a cerebral hemorrhage at the age of 63, his blood pressure was reported to be as high as 300/190 mm. Such hypertension was not a cause of concern among his physicians even though lowering it could have postponed Roosevelt’s death.  

Armed with the newly acquired knowledge from Framingham, physicians tried to control an increasing number of heart attacks and strokes. Despite spectacular advances in cardiac surgery, however, success in dampening the rising tide of heart disease was limited. In most western countries approximately a third of all deaths are still due to cardiovascular disease. It remains the single largest cause of death today.

Some physicians argued that the risk factors identified in Framingham and other studies were insufficient. They claimed that scientists missed the single most important cause of heart disease. The answer, they said, lay in the personality features of the patient. It is here that our journey into the dark psychosomatic history of heart disease starts.

The disease of the ambitious businessman

Although today cardiovascular disease is more prevalent in lower socio-economic classes, in the early 20^th century it was the other way around. Heart disease was the illness of doctors and businessmen. One article even described it as “an occupational hazard of the medical profession.” The eminent Canadian physician William Osler speculated that cardiovascular disease was the result of working too vigorously. “It is not the delicate neurotic person who is prone to angina” he wrote, “but the robust, the vigorous in mind and body, and the keen and ambitious man, the indicator of whose engines is always at ‘full speed ahead’.”

Others elaborated on this stereotype. Helen Flanders Dunbar, a pioneer of the psychosomatic movement, noted that coronary heart disease is most often found in managers, proprietors, and officials. These were people who worked hard and had little interest in sports or other hobbies. They were ambitious, wanted to seize authority, and dominated their social relationships. “They would rather die than fail”, Dunbar wrote in her dramatic prose.

The descriptions of Osler and Dunbar were attractive but poorly supported by research. Scientists who tested the idea of a coronary-prone personality found that patients with the disease were actually very similar to control subjects. A review of the early psychosomatic literature soberingly concluded that “the opinion that psychological factors are etiologically related to coronary atherosclerosis is as yet devoid of factual documentation.” That would soon change.

Type A personality

The two scientists who managed a breakthrough came from outside the psychosomatic field. Meyer Friedman and Ray Rosenman were cardiologists who described their hypotheses in simple terms. Their papers were devoid of psychoanalytic vocabulary that would repel the interest of the medical profession.

During their years of treating cardiac patients, Friedman and Rosenman claimed to have discovered a behavior pattern, which they called ‘Type A’, that was associated with heart disease. Type A was very similar to what Osler and Dunbar had come up with before. It referred to people who were ambitious, aggressive, and extremely competitive. They were always short in time and in constant pursuit of achievements. Think of an ambitious businessman who has no time to spare for hobbies or social relationships but only wants to make more money.

Friedman and Rosenman also coined the term ‘hurry sickness’ to characterize Type A, describing it as follows:

“The type A person is invariably punctual and greatly annoyed if kept waiting; he rarely finds time to indulge in hobbies, and when he does, he makes them as competitive as his vocation. He dislikes helping at home in routine jobs because he feels that his time can be spent more profitably. He walks rapidly, eats rapidly, and rarely remains long at the dinner table.”

When someone remarked that the front edge of the chairs in their reception room wore out rather quickly, Friedman and Rosenman interpreted this as a result of Type A behavior. Their patients with heart disease must have sat stressed and impatiently on the top of the chair, they reasoned.

Friedman and Rosenman believed that Type A behavior was provoked by our modern way of living and that this was the true reason why coronary heart disease was on the rise.

People were driven in constant competition to achieve more and more in less and less time. Although Friedman and Rosenman admitted to displaying Type A behavior themselves sometimes, it was clear in their writing that it had a negative connotation. Friedman, for example, wrote that it was a “reaction of individuals who feel basically insecure and inadequate.” The real top managers did not have Type A behavior because they knew how important it was to sometimes take things slowly.

In everyday language ‘Type A’ is sometimes used for someone who is hard-working, well organized, and perfectionistic. An achiever who gets the job done or has good grades at school. In the framework of Friedman and Rosenman, however, Type A behavior mainly referred to severe competitiveness and time urgency. Those were the two main ingredients, and they were considered a bad thing. Type A behavior was seen as a ticking time bomb that would eventually burst.

The Western Collaborative Group Study

At the end of the 1950s, Friedman and Rosenman started publishing scientific papers that reported a link between Type A and cardiovascular disease. They claimed that those exhibiting Type A behavior succumbed to coronary artery disease six times more frequently than subjects in the control group who had a more relaxed way of living (which they called Type B behavior).

More importantly, the two cardiologists were able to set up a prospective study just like the one in Framingham. It was called the Western Collaborative Group Study. Starting in 1960, more than 3000 employees from 11 Californian businesses were enrolled and followed up over time. The results supported their hypothesis. Employees who displayed Type A behavior went on to develop more cardiovascular disease than the control group. Although the risk ratio decreased from 6 to 2, it was still a significant relationship. When an analysis of the Framingham cohort reported similar results, science seemed to have vindicated popular psychology. Type A became a household name for ambitious people who tried to live their life at double speed.

Liberate yourself

In 1974, Friedman and Rosenman published the book “Type A Behavior and Your Heart” which became a bestseller. The book explained “how to recognize the Type A pattern in your own personality and behavior.” It included an elaborated description and checklist so that readers could test if they were a Type A person and therefore at risk of coronary heart disease. Another section of the book explained how to change one’s Type A behavior. As is common in the psychosomatic literature, Friedman and Rosenman put responsibility fully in the hands of the patients. “It is you who must take the steps to liberate yourself” the book told its readers. This makes it the most appealing but at the same time, most toxic aspect of psychosomatic theory.

Treatment for Type A behavior consisted of simple (and frankly sometimes rather idiotic) advice: “visit a museum, browse in a bookstore, or just watch fellow human beings pass by.” Friedman and Rosenman also instructed their patients to walk, talk and eat slower. They advised reading the oeuvre of Marcel Proust because its complex prose made it impossible to skim the text. The most important part of treatment consisted of recognizing that you might have a problem with Type A behavior. “First and foremost,” the book stated, “you must recognize that you do harbor flaws in your personality, and that they are not virtues but defects.”

A series of news articles spread the same message with titles such as “Will Success Kill ‘Type A’ Man?” or “Stress No. 1 Coronary Factor? Type B Better Off in a Type A World”. Jane Brody, health correspondent for the New York Times devoted a large article to the topic titled “Rushing Your Life Away With ‘Type A’ Behavior.” Brody recognized herself in the descriptions of Type A behavior and decided to change her way of living using the book of Friedman and Rosenman. She presented a long list of tips that readers could adopt to reform their Type A lifestyle. It included advice such as: “spend some time alone”, “cultivate your esthetic side”, “leave your watch home for a week”, and “practice standing in lines doing nothing.”

We can only hope that few people took this advice at heart (no pun intended). Articles from that period, however, suggest otherwise. A 1986 review in the Medical Journal of Australia, for example, deplored that Type A behavior was taken so seriously. It stated:

“The result of this widespread belief that stress can cause heart disease has led some of the most productive people in the community to worry about their future and, in some cases, to retire from positions of responsibility.”

The Type A personality fad reached its zenith in 1981 when a consensus report was published. The National Heart, Lung, and Blood Institute (NHLBI) had sponsored two conferences for a panel of experts to evaluate the evidence on Type A behavior causing heart disease. “There was general agreement”, the final report read, “that a relationship between type A behavior and CHD [[coronary heart disease] was supported by the data.” The review panel added: “This risk is greater than that imposed by age, elevated values of systolic blood pressure and serum cholesterol, and smoking and appears to be of the same order of magnitude as the relative risk associated with the latter three of these other factors.” With the support of the prestigious NHLBI panel, the evidence for Type A behavior looked firmly established. But just as the theory reached its peak, it all started to crumble.

Failed replications

In the years that followed, a long series of prospective studies failed to find an association between Type A behavior and cardiovascular disease. The Multiple Risk Factor Intervention Trial, The Honolulu Heart Program, the Multicenter Post-Infarction Program, the Anglo-Scandinavian Study of Early Thrombolysis, the Cardiac Arrhythmia Pilot Study, and later the Kuopio Ischemic Heart Disease Risk Factor Study and Japan Public Health Center-based Prospective Study failed to replicate a connection between Type A and heart disease.

Most damaging were the reanalyses of the Framingham and Western Collaborative Group cohorts. Instead of studying the incidence of cardiovascular disease in all participants, as the original analyses had done, researchers now looked at cardiac mortality in those diagnosed with heart disease. In these new analyses, there was no link with Type A behavior. In fact, in the Western Collaborative Group Study, persons with Type B behavior were most likely to succumb to heart disease. Clearly, something was wrong with the theory. 

Another problem was the definition of Type A behavior. It was far from clear what Type A behavior was and what it wasn’t. One article rightly called it a “heterogeneous hodgepodge.” Rosenman and Friedman and their colleagues designed questionnaires to measure it in a standardized way, but these were soon considered unreliable when it became clear they did a poor job at predicting heart disease.

The ‘gold standard’ remained the structured interview as used by Friedman and Rosenman. They believed that it was not so much the response to questions that mattered, but the way in which participants responded. A person might, for example, answer that he was always calm and relaxed but if he answered in a stressed or aggressive way, he might still be labeled as Type A. Some of the questions in the structured interview were deliberately presented in such a way (e.g. by speaking slowly or tripping over words) that they would provoke a response. Typical signs of Type A behavior were interrupting the speaker, an abrupt staccato style of speech, accentuating keywords, or repeatedly saying “Uh-huh” or, “Yes, yes” while the interviewer was speaking. Friedman and Rosenman once called identifying type A traits “a more artful than scientific achievement.” They stressed that scientists must first be trained (by them) in order to do it accurately.

There was also the problem that in their Western Collaborative Group study, half of the participants were labeled as having the Type A behavior pattern. In other studies that used the structured interview, this percentage reached 70% or even 90%.  One review noted that “placing such large percentages of individuals in an at-risk category is inconsistent with sound epidemiological practice.”

Lastly, there was the problematic funding of Friedman and Rosenman’s studies. In the 21st century, it would become clear that crucial research on Type A behavior was funded secretly by the tobacco industry. More on this in part II of the series.