Type A behaviour: a reappraisal of its characteristics in cardiovascular disease
Disclosures Drs Sirri, Fava, Guidi, Porcelli, Rafanelli, Grandi, Grassi, Pasquini, Picardi, Quartesan, Rigatelli and Sonino have no conflict of interest to declare. Dr Bellomo has been sponsored as speaker at meetings and congresses by Ely-Lilly, Janssen-Cilag, AstraZeneca, Bristol Meyers Squibb, Lundbeck, Pfeizer and Glaxo-SmithKline in the last two years.
Giovanni A. Fava, M.D.,
Department of Psychology,
University of Bologna
viale Berti Pichat 5
40127 Bologna, Italy
Tel.: +39 051-2091339
Fax: +39 051 243086
Aims: The role of type A behaviour in cardiovascular disease is controversial and most of the research is based on self-rating scales. The aim of this study was to assess the prevalence of type A behaviour in cardiology and in other medical settings using reliable interview methods that reflect its original description.
Methods: A sample of 1398 consecutive medical patients (198 with heart transplantation, 153 with a myocardial infarction, 190 with functional gastrointestinal disorders, 104 with cancer, 545 with skin disorders and 208 referred for psychiatric consultation) was administered the Structured Clinical Interview for the DSM-IV and the Structured Interview for the Diagnostic Criteria for Psychosomatic Research (DCPR) which identifies 12 clusters, including type A behaviour.
Results: A cardiac condition was present in 366 patients. There was a significant difference in the prevalence of type A behaviour in cardiovascular disease (36.1%) compared with other medical disorders (10.8%). Type A behaviour frequently occurred together with psychiatric and psychosomatic disturbances, particularly irritable mood, even though in the majority of cases it was not associated with DSM-IV diagnoses. Among cardiac patients, those with type A behaviour were less depressed, demoralised and worried about their illness.
Conclusions: Type A behaviour was found to occur in about a third of cases of patients with cardiovascular disease. Only in a limited number of cases was it associated with depression. It has a lifestyle connotation that may have important clinical consequences as to stress vulnerability and illness behaviour.
- • Type A behaviour (TAB) is a set of psychological features, such as competitiveness and sense of time urgency, frequently observed in cardiac patients.
- • The role of TAB in cardiovascular disease is controversial because of contradictory findings which may result from the use of self-administered questionnaires for TAB.
- • The Diagnostic Criteria for Psychosomatic Research (DCPR) provides a set of criteria for the categorical and interviewer-based identification of TAB.
- • TAB is significantly more prevalent in cardiovascular disease (36.1%) compared with other medical disorders (10.8%).
- • Both in cardiac and non-cardiac patients, TAB frequently occurs together with DCPR irritable mood, even though they are not hierarchically related.
- • Among cardiac patients, TAB may lead to minimise both psychological impacts of a life-threatening disease and the vulnerability to its consequences, and thus to underestimate the need to modify unhealthy lifestyles.
The concept of type A behaviour was introduced by the cardiologists Meyer Friedman and Ray H. Rosenman in the late 1950s to describe a ‘specific emotion-action complex’ they frequently observed in their patients (1). Friedman and Rosenman identified six core features of type A behaviour: (i) an intense drive to achieve self-selected, but usually poorly defined goals, (ii) competitiveness, (iii) a persistent desire for recognition and advancement, (iv) involvement in several functions subjected to time restrictions, (v) an accelerated rate of execution of several physical and mental functions and (vi) an increased mental and physical alertness (1). Subsequently, Friedman (2) specified that type A behaviour includes both covert and overt characteristics. The former are insecurity and inadequate self-esteem, whereas the main overt components are sense of time urgency (impatience) and free-floating hostility. They result in several specific behavioural and psychomotor manifestations, such as speed in walking and eating, intense discomfort when waiting in lines, involvement in different activities simultaneously, extreme punctuality, rapid speech, tense posture, chronic facial tension, loss of temper while driving, sleeplessness because of anger or frustration, disbelief in altruism and excessive irritability or discomfort when facing trivial errors by others (2).
Type A behaviour predicted both onset and worse outcome of coronary heart disease (CHD) in longitudinal studies (3,4). In 1981, the evidence for a significant association between type A behaviour and cardiovascular diseases led the National Heart, Lung & Blood Institute to include type A behaviour among the independent risk factors for CHD (5). Beginning from the mid-1980s, the emergence of some contradictory findings resulted in a reappraisal of the predictive role of type A behaviour on the onset and course of CHD (6). Afterwards, it was suggested that only some components of type A behaviour, in particular hostility, yield an adverse effect on the cardiovascular system (7). A major difficulty in interpreting the results is the fact that most studies assessed type A behaviour with self-administered questionnaires, even though semi-structured interviews seem to be more reliable for the recognition of the motor-expressive characteristics of type A behaviour.
In 1995, a structured research interview for the determination of type A behaviour, following Friedman and Rosenman’s original characteristics, was developed and validated (8–11). It was included in the Diagnostic Criteria for Psychosomatic Research (DCPR) (8), a set of 12 psychosomatic syndromes, including also other psychological variables, such as irritable mood and demoralisation.
While the role of type A behaviour in cardiac diseases has been the object of a large body of literature, its occurrence in the setting of other medical conditions has been virtually neglected. Few preliminary data suggested a possible involvement of type A behaviour in some non-cardiac diseases (12–20). However, the lack of a systematic comparison between type A behaviour as observed in cardiology settings and in other medical environments does not allow to infer whether such characteristics are specific or not to cardiovascular diseases.
The aim of this investigation was to compare the prevalence and characteristics of type A behaviour, as assessed by a structured interview (DCPR), in a highly heterogeneous group of medical patients, encompassing both cardiological and non-cardiological illness.
Materials and methods
Procedures and subjects
Patients were recruited from different medical settings in an ongoing multicenter project concerned with the psychosocial dimensions of medical patients (21). Studies involved in the research project had different aims and sample sizes, but they had the same methodology in the assessment of psychiatric disorders and psychosomatic syndromes. Patients were recruited consecutively, with the intent of being representative of their respective clinical populations:
- • Consecutive outpatients with heart diseases (N = 351, 25.1% of the total sample) from three different sources: (i) 198 patients who underwent heart transplantation from the Heart Transplantation Unit of the Institute of Cardiology at the S. Orsola Hospital of Bologna, Italy; (ii) 61 consecutive patients with a recent (within 1 month) first myocardial infarction diagnosis from the Cardiac Rehabilitation Program of the Bellaria Hospital in Bologna, Italy; and (iii) 92 consecutive patients with a recent (within 1 month) first myocardial infarction diagnosis from the Institute of Cardiology of University Hospital in Modena, Italy. There were no medical exclusion criteria. The diagnosis of myocardial infarction required the presence of at least two of the following three criteria: (i) typical ischaemic symptoms (chest pain or shortness of breath) lasting for more than 10 min, (ii) CPK level more than two times the upper limit of normal, (iii) electrocardiographic evidence of ischaemic ST-segment depression, ST-segment elevation or new pathological Q waves.
- • Consecutive outpatients with functional gastrointestinal disorders (N = 190, 13.6%) from the Functional Gastrointestinal Disorders Outpatient Clinic of the Scientific Institute of Gastroenterology at Castellana Grotte, Italy. Patients with organic diseases were excluded.
- • Consecutive outpatients who had received a diagnosis of cancer within the past 18 months (N = 104, 7.4%) from the S. Anna University Hospital in Ferrara, Italy. Exclusion criterion was the presence of cognitive impairment, as defined by a score lower than 24 at the Mini Mental State Examination (22).
- • Consecutive outpatients with skin disorders (N = 545, 39%) from the Dermopathic Institute of the Immaculate (IDI-IRCCS) in Rome, Italy. Dermatological diagnoses encompassed psoriasis, urticaria, non-atopic dermatitis, connective tissue disease, skin tumours, bullous disease, skin ulcers and atopic dermatitis.
- • Consecutive inpatients referred for psychiatric consultation in two large university-based general hospitals (N = 208, 14.9%) from the University of Perugia and University of Foggia, Italy. Exclusion criteria were the presence of cognitive impairment, as defined by a score lower than 24 at the Mini Mental State Examination (22), or acute psychotic symptoms or presence of acute pain.
The patients who were approached were 1557; 159 (10.2%) declined to participate. The most common reason for refusal was lack of time. The total sample included 1398 patients (676 men, 48.4% and 722 women, 51.6%), with a mean age of 45.7 (SD = 15.16) years and a mean of 10.6 (SD = 3.85) years of education. There were no significant differences in terms of sociodemographic variables between the patients who accepted and those who refused. The study protocol was approved by institutional review boards and local ethics committees, and written informed consent was obtained from all patients.
All patients underwent two detailed structured interviews by clinical psychologists or psychiatrists with extensive experience in psychosomatic research and specific training.
Psychiatric disorders were investigated with the Structured Clinical Interview for DSM-IV (SCID-IV) (23). Diagnoses were grouped according to diagnostic categories: mood disorders, anxiety disorders, somatoform disorders, adjustment disorders and other disorders (including psychotic disorders, eating disorders, sexual dysfunctions and substance use related disorders). Psychosomatic syndromes were diagnosed with the Structured Interview for the DCPR (21). The DCPR consist of 12 psychosomatic syndromes: health anxiety, disease phobia, thanatophobia, illness denial, functional somatic symptoms secondary to a psychiatric disorder, persistent somatisation, conversion symptoms, anniversary reaction, type A behaviour, irritable mood, demoralisation and alexithymia. The four syndromes related to somatisation (functional somatic symptoms secondary to a psychiatric disorder, persistent somatisation, conversion symptoms and anniversary reaction) were grouped into one diagnostic cluster. The three syndromes concerning hypochondriacal fears and beliefs (disease phobia, health anxiety and thanatophobia) were clustered into a single category named ‘DCPR illness-affirming’.
According to the DCPR criteria, type A behaviour refers to the presence of at least five of nine characteristics: (i) excessive degree of involvement in work and other activities subject to deadlines; (ii) steady and pervasive sense of time urgency; (iii) display of motor-expressive features (rapid and explosive speech, abrupt body movements, tensing of facial muscles, hand gestures) indicating sense of being under the pressure of time; (iv) hostility and cynicism; (v) irritable mood; (vi) tendency to speed up physical activities; (vii) tendency to speed up mental activities; (viii) high intensity of desire for achievement and recognition and (ix) high competitiveness. The Structured Interview has shown excellent inter-rater reliability, construct validity and predictive validity for psychosocial functioning and treatment outcome (9–11).
Data were entered in spss (SPSS Inc., Chicago, IL, USA), after which descriptive statistics were calculated. A series of χ2 was performed to compare the frequencies of DSM-IV psychiatric disorders and DCPR psychosomatic syndromes between groups. Chi squared tests and independent sample t-tests were used to compare the groups according to categorical (gender) and continuous (age, years of education) demographic variables, respectively. The relationship between type A behaviour and setting of recruitment, DSM-IV and DCPR comorbidity was also examined by means of multivariate analyses. A logistic regression analysis was performed to evaluate whether type A behaviour was independently predicted by the setting in which patients were recruited (cardiology, gastroenterology, oncology, dermatology, consultation-liaison psychiatry). Then, point biserial correlation between type A behaviour and ‘at least one DSM-IV diagnosis’ and ‘at least one DCPR diagnosis (other than type A behaviour)’ as dependent variables was conducted. For all tests performed, the significance level was set at .05, two-tailed.
A cardiac condition was found in 366 patients (72.7% males), with a mean age of 57.2 (SD = 11.90) years, and a mean of 10.2 (SD = 4.25) years of education. This sample included the 351 consecutive outpatients recruited in the three cardiac units plus 15 of the inpatients referred for psychiatric consultation. The remaining 1032 patients with other medical conditions formed the non-cardiac group (39.7% males), with a mean age of 41.7 (SD = 14.09) years, and a mean of 10.6 (SD = 3.80) years of education.
A total of 243 patients (17.4% of the total sample; 60.5% males) received a diagnosis of type A behaviour, with a mean age of 50.7 (SD = 13.80) years, and a mean of 11.1 (SD = 4.15) years of education. Of these 243 subjects, 132 (54.3%) were diagnosed with a cardiac condition: 129 (97.7%) were found among the outpatient cardiology practice settings and 3 (2.3%) among the consecutive inpatients referred for psychiatric consultation. The other 111 (45.7%) type A patients, who did not have a cardiac diagnosis, included patients with skin diseases (N = 65; 58.6%), followed by inpatients from psychiatric consultation services (N = 19; 17.1%), outpatients with functional gastrointestinal disorders (N = 16; 14.4%) and those who had received a diagnosis of cancer within the past 18 months (N = 11; 9.9%). Type A behaviour was thus found in 36.1% (132 of 366 subjects) of patients with cardiac conditions and 10.8% (111 of 1032 subjects) of non-cardiac patients (χ2 = 120.519; p < .001).
The 1155 patients (82.6% of the total sample) who did not satisfy the DCPR criteria for type A behaviour included 529 males (45.8%), had a mean age of 44.6 (SD = 15.22) years, and a mean of 10.5 (SD = 3.79) years of education. Of these, 234 (20.3%) had a cardiac disease: 222 (94.9%) were recruited within the outpatient cardiology practice settings and 12 (5.1%) within the consecutive inpatients referred for psychiatric consultation. The remaining 921 (79.7%) non-type A patients had a non-cardiac diagnosis: 174 (18.9%) subjects were recruited in gastroenterology, 93 (10.1%) in oncology, 480 (52.1%) in dermatology and 174 (18.9%) in consultation-liaison psychiatry.
Table 1 depicts the comparison between type A subjects with and without a cardiac diagnosis according to the frequencies of both psychiatric disorders and psychosomatic syndromes. Type A behaviour patients who presented with a cardiac condition were less likely to be diagnosed with a psychiatric disorder according to the DSM-IV than those who did not (χ21 = 5.965; p < .05). They showed significantly higher rates of anxiety disorders compared with their non-cardiac counterparts (χ21 = 5.455; p < .05), but lower percentages of somatoform and adjustment disorders (χ21 = 16.333; p < .001 and χ21 = 17.789; p < .001, respectively). There were no significant differences in mood disorders that were concerned mainly with unipolar depression (there were only seven patients with bipolar disorder). With regard to the DCPR syndromes, cardiac patients with type A behaviour were more likely to display irritable mood (χ21 = 17.493; p < .001) than non-cardiac patients, but they showed significantly lower rates of somatisation syndromes and alexithymia (χ21 = 35.707; p < .001 and χ21 = 6.142; p < .05, respectively).
Table 1. Frequencies of psychiatric disorders and psychosomatic syndromes in type A patients with and without a cardiac condition
|DSM mood disorders||25 (10.3)||9 (6.8)||16 (14.4)||3.770||n.s.|
|DSM anxiety disorders||61 (25.1)||41 (31.1)||20 (18)||5.455||< .05|
|DSM somatoform disorders||13 (5.3)||0 (0)||13 (11.7)||16.333||< .001|
|DSM adjustment disorders||26 (10.7)||4 (3)||22 (19.8)||17.789||< .001|
|Other DSM disorders||4 (1.6)||1 (0.8)||3 (2.7)||.701||n.s.|
|No DSM diagnoses||128 (52.7)||79 (59.8)||49 (44.1)||5.965||< .05|
|DCPR illness-affirming||59 (24.3)||26 (19.7)||33 (29.7)||3.183||n.s.|
|DCPR illness denial||18 (7.4)||9 (6.8)||9 (8.1)||0.134||n.s.|
|DCPR somatisation||49 (20.2)||8 (6.1)||41 (36.9)||35.707||< .001|
|DCPR irritable mood||103 (42.4)||72 (54.5)||31 (27.9)||17.493||< .001|
|DCPR demoralisation||60 (24.7)||30 (22.7)||30 (27)||.599||n.s.|
|DCPR alexithymia||21 (8.6)||6 (4.5)||15 (13.5)||6.142||< .05|
Table 2 shows the comparison between cardiac patients with and without type A behaviour according to both psychiatric disorders and psychosomatic syndromes. Type A subjects had significantly lower rates of DSM-IV mood disorders (χ21 = 4.841; p < .05) and of several DCPR syndromes: the cluster concerning hypochondriacal fears and beliefs (χ21 = 7.497; p < .01), the cluster related to somatisation (χ21 = 11.243; p < .001), demoralisation (χ21 = 7.241; p < .01) and alexithymia (χ21 = 5.031; p < .05). However, irritable mood was significantly more frequent among type A patients (χ21 = 39.361; p < .001).
Table 2. Frequencies of psychiatric disorders and psychosomatic syndromes in cardiac patients with and without type A behaviour
|DSM mood disorders||43 (11.7)||9 (6.8)||34 (14.5)||4.841||< .05|
|DSM anxiety disorders||94 (25.7)||41 (31.1)||53 (22.6)||3.128||n.s.|
|DSM somatoform disorders||3 (.8)||0 (0)||3 (1.3)||1.707||n.s.|
|DSM adjustment disorders||10 (2.7)||4 (3)||6 (2.6)||.069||n.s.|
|Other DSM disorders||6 (1.6)||3 (2.3)||3 (1.3)||.514||n.s.|
|No DSM diagnoses||222 (60.7)||79 (59.8)||143 (61.1)||.056||n.s.|
|DCPR illness-affirming||104 (28.4)||26 (19.7)||78 (33.3)||7.497||< .01|
|DCPR illness denial||23 (6.3)||9 (6.8)||14 (6)||.105||n.s.|
|DCPR somatisation||52 (14.2)||8 (6.1)||44 (18.8)||11.243||.001|
|DCPR irritable mood||124 (33.9)||72 (54.5)||52 (22.2)||39.361||< .001|
|DCPR demoralisation||115 (31.4)||30 (22.7)||85 (36.3)||7.241||< .01|
|DCPR alexithymia||33 (9)||6 (4.5)||27 (11.5)||5.031||< .05|
The logistic regression analysis found that type A behaviour was independently predicted by belonging to the cardiology setting [β = 1.592 (SE .251); Wald statistic 40.166 (df = 1), p < .001; Exp(β) = .204; (CI 95%: 0.124–0.333)]. Point biserial correlation showed that type A behaviour was weakly albeit significantly associated with DCPR comorbidity (at least one diagnosis) (r = .10; p < .001), whereas no significant association was found with DSM-IV comorbidity.
Our study found that type A behaviour is significantly more prevalent in cardiovascular disease compared with other medical disorders and it was found to frequently occur together with some psychosomatic syndromes. Some limitations might affect the interpretation of the results. First, the cross-sectional design did not allow to examine the stability of psychiatric and psychosomatic diagnoses over time. We also used a sample of convenience and not a random sample and our definition of ‘cardiac patient’ was based on current findings and did not include past history of cardiac diseases. However, our study has the merit to assess type A behaviour in a large sample size with subjects coming from different settings. Furthermore, type A behaviour was identified by means of a structured research interview that displayed excellent inter-rater reliability and reflected the original description of the syndrome (1), and was not based on self-rating scales. The Review Panel on Coronary-Prone Behavior and Coronary Heart Disease suggested that type A behaviour could be associated not only with coronary endpoints but also with non-cardiovascular conditions (5), but a direct comparison was missing from the literature. Furthermore, the studies examining type A behaviour in non-cardiac diseases relied mostly on self-rating instruments and were characterised by small sample sizes (12–20).
In the present study, the prevalence of type A behaviour in our population of patients with cardiovascular disease was 36.1%. This means that the expectation of finding it in every patient with cardiovascular disease is unrealistic, whereas it may mark a subtype of illness. The difference in prevalence between cardiovascular and non-cardiovascular disease was significant and the multivariate analysis confirmed the association between type A behaviour and the cardiac setting.
Mood disorders occurred in conjunction with type A behaviour in only about 7% of patients with cardiovascular disease. Demoralisation, a subclinical form of mood disorder according to the DCPR, was more common, as it occurred in a quarter of patients. It derives from the convergence of psychological distress and subjective sense of incompetence (the idea that one is not able to deal with a stressful situation) (24), with particular reference to feelings of hopelessness and helplessness (25). The DCPR showed that demoralisation and major depressive disorder are distinct and not hierarchically related phenomena (26). Demoralisation frequently precedes the onset of serious diseases, such as myocardial infarction, and it is significantly associated with both a worse clinical outcome and a diminished quality of life (24,27,28). In a previous study (29), DCPR demoralisation was found to characterise one third of patients with DSM-IV adjustment disorder. In our study, demoralisation was far more frequent than DSM-IV adjustment disorder probably because the former sensitively identifies subsyndromal psychosocial distress.
The most distinctive characteristic significantly associated with type A behaviour was irritable mood according to the DCPR. This finding seems to confirm the strong relationship between irritability and cardiovascular diseases (7). Since the 1980s, hostility emerged as one of the components of type A behaviour most associated with increased cardiac risk. The predictive role of clinical phenomena linked to irritability (i.e. cynical hostility and trait anger) on the onset and course of cardiovascular diseases has been indicated by many studies (30–32). Increased levels of irritability also independently predicted mortality among heart transplanted patients (33).
The relationship between type A behaviour and irritable mood was significant both in cardiac and non-cardiac patients. This suggests that irritability is one of the core features of type A behaviour, regardless of the setting of occurrence. However, irritable mood did not occur in almost half (45.5%) of type A subjects with a cardiac condition and in two of three (72.1%) of those with another medical diagnosis. Although type A behaviour and irritable mood are significantly associated, they are not hierarchically related: the latter may occur even outside the type A behavioural pattern and not all the type A subjects satisfy the DCPR criteria for irritable mood.
Furthermore, cardiac patients with type A behaviour were significantly more likely to have a DSM-IV anxiety disorder than non-cardiac patients. Most of the literature on the link between psychiatric disorders and increased cardiovascular risk concerned mood disorders; yet, in recent years several studies are pointing to a detrimental effect of anxiety on the cardiovascular system. Both physiological (e.g. sympathetic activation) and behavioural (i.e. unhealthy health habits) mechanisms have been proposed to explain how high levels of anxiety may increase the risk of onset and progression of CHD (7,34,35).
Type A behaviour may share some features with hypomania (36,37), which frequently results in an over-optimistic view of one’s own ability to cope with a stressful situation (as a life-threatening disease is) and in the minimisation of vulnerability to future difficulties (e.g. medical complications). According to Barrick (36), type A behaviour also overlaps with cyclothymia and hyperthymic temperament. Two investigations seem to confirm this hypothesis. In a study by Oedegaard and colleagues (38), bipolar II patients had higher speed and impatience than those with unipolar depression. The same component of type A behaviour was significantly associated with cyclothymic temperament. Wang and colleagues (37) found a significant relationship between type A behaviour and hyperthymic temperament, which may characterise a subtype of bipolar disorder named ‘bipolar IV’ (depression in subjects with hyperthymic temperament) (39). As suggested by Wang et al. (37), the close association between type A behaviour and the bipolar spectrum, especially its subsyndromal manifestations, may explain the increased risk of cardiovascular mortality in patients with bipolar disorders (40). It is conceivable, even though yet to be tested, that type A behaviour may be part of an atypical form of the bipolar disorder. An innovative characterisation of cyclothymia, essentially based on abnormal reactivity to social environment (41), could shed some light on this intriguing relationship.
Type A behaviour may have important clinical consequences as to both the awareness of allostatic load and illness behaviour, which may adversely affect the rehabilitation process. Allostatic load reflects the cumulative effects of long-standing stressful experiences in daily life (42). It may result from both the frequent and/or prolonged activation of the stress response system and the inability to shut off allostatic responses after a stress is terminated (42). The toxic effects of both allostatic load and stress in general on the cardiovascular system have been documented (7,42–44) and type A behaviour may mediate the relationship between stress and cardiovascular morbidity. Subjects with type A behaviour respond to laboratory mental tasks with a greater activation of the sympathetic nervous system than type B subjects (45). A chronic activation of both the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis in type A subjects was also outlined (46). Type A features (e.g. excessive work involvement even during weekends, lack of leisure activities, competitiveness even in recreational activities) may expose subjects to daily stressful events, but also decrease their ability to interrupt the stress response.
As to illness behaviour, in our study, cardiac patients with type A behaviour had fewer DCPR syndromes concerning worries about one’s own health than non-type A patients. Type A behaviour may be associated with a tendency to minimise both the psychological impact of a life-threatening medical illness and the vulnerability to its possible consequences. This may lead patients to underestimate the need to modify unhealthy lifestyles.
Point biserial correlation allowed to further examine whether type A behaviour was modestly but significantly associated with DSM-IV and DCPR comorbidity. We found that only the presence of DCPR comorbidity was significantly related to type A behaviour. This result seems to extend to the total sample the lack of significant associations between type A behaviour and DSM-IV psychiatric diagnoses, except for a significant lower prevalence of mood disorders, found among cardiac patients. Furthermore, the low correlation with DCPR comorbidity suggests that type A behaviour may be clinically relevant in cardiology regardless of the extent to which it is influenced by other psychosomatic syndromes (see Table 2).
In the past decade, studies on the psychosocial aspects of cardiovascular diseases emphasised the role of depression (7,47–49) and hostility/irritability (7,30–32), neglecting other psychosocial variables, such as type A behaviour. The presence of comorbidity (especially anxiety disorders and irritable mood) and of detrimental lifestyle attitudes in conjunction with a major depressive disorder were found to have considerable clinical implications (50–52). Resolution of the depressive episode is unlikely to entail solution to the complex clinical configuration (53). Not surprisingly successful treatment of depression in cardiovascular diseases was not associated with cardiovascular benefits (54). In psychiatric settings, a sequential approach (pharmacotherapy of depression followed by psychotherapy addressed to the comorbid symptomatology) was found to entail significant benefits in terms of relapse rate (51). Similar considerations and strategies may potentially apply to cardiovascular illness, when type A behaviour is found to accompany the depressive symptoms. Its lifestyle connotations (55) may be important also when type A behaviour is not accompanied by depressed and irritable mood. Indeed, targeting lifestyle modification was found to entail significant benefits in prognosis of coronary artery disease (56–60).
This study was supported in part by a grant from Compagnia di San Paolo, Torino, Italy, to Dr Rafanelli. Compagnia di San Paolo had no further role in the study design; in the collection, analysis and interpretation of data; in the writing of the report and in the decision to submit the manuscript for publication.
Drs Sirri, Fava and Sonino designed the study. Drs Sirri, Guidi, Porcelli, Rafanelli, Bellomo, Grandi, Grassi, Pasquini, Picardi, Quartesan and Rigatelli collected the data. Dr Guidi performed the statistical analysis. Drs Sirri, Fava and Sonino drafted the article, with the subsequent input and approval of all authors.