THE LETHAL TYPE A BEHAVIOR PATTERN
Heart disease is the single greatest killer of Americans—and men in their middle years are especially vulnerable: One American male in five dies of a heart attack before the age of sixty.
Relatively rare in the United States until the 1920s, heart disease is a distinctly “modern” affliction that has increased dramatically in recent years. During the past two decades the coronary death rate for men has risen alarmingly. But at the same time the coronary death rate for women, much lower to begin with, declined.
Nutrition experts have virtually convinced the nation that a diet high in cholesterol is responsible for this epidemic. But now this theory has been seriously challenged by two California cardiologists, Drs. Meyer Friedman and Ray Rosenman, who have developed a revolutionary new concept which suggests that how a man lives is more important than what he eats in determining whether or not he will die of a coronary.
Until 1957 Friedman and Rosenman were conventional cardiologists studying the standard risk factors. But they have now built an impressive case for the concept that stress, personality, and behavior account for the high incidence of heart attacks among middle-aged American men.
How did this dramatic transformation in their views evolve? Puzzled by the enormous increase in heart disease in recent years, they first began to suspect that a fatty diet was not the answer when they investigated whether the relative immunity of the American woman to coronaries could be explained by dietary differences.
Although their suspicion was confirmed by cross-cultural studies showing that some groups of people who eat the most fats have little heart disease—the Irish, for example—they decided to test for themselves. Enlisting the help of a Junior League club in San Francisco, they studied what these women ate and also what their husbands ate. Their diets were essentially the same.
What then was protecting the women? these researchers wondered. For years their medical colleagues had argued, and many still do, that female sex hormones are the answer. Not so, Friedman and Rosenman found. Black women in America get even more heart attacks than their husbands. And in other countries, like Italy and Mexico, women and men are equally susceptible to heart disease.
So much for sex hormones, and fatty diets too. Since the experts had not yet come up with satisfying solutions, these Cardiologists decided to solicit other opinions. They sent a questionnaire listing ten possible causes of heart attacks to a group of businessmen and a group of physicians with coronary patients. The majority in both groups picked “excessive competition and the stress of meeting deadlines” as the primary culprits.
Coming from business types this reply didn’t seem startling, but coming from doctors it did. Since the medical literature was filled with studies implicating high-fat diets, their response was clearly at odds with most scientific investigators. And that was news.
Popular folklore had long suggested that people died of heart attacks because of too much stress and strain, but like most of the medical profession, Friedman and Rosenman had always ignored such common wisdom. Now, however, they began to take it seriously.
Aware that the pace of our lives has accelerated rapidly during the years that heart disease proliferated, they began to wonder about the impact of this new stress. Perhaps men were suffering its effects more than women because men were more regularly exposed to such pressure at work. The speculation needed to be tested.
The first indisputable evidence for their thesis that stress— more specifically, an acute sense of time urgency—plays a role in heart disease came from a study of tax accountants. Accountants were selected because the intensity of their workload varies between routine periods and times of pressure when tax deadlines must be met. In this study diet, exercise, and other factors were controlled, and cholesterol levels were measured regularly over a period of several months.
The result: As the April 15 deadline approached, there was a significant jump in cholesterol level for all these men— which fell again in subsequent months when their routine became more placid. Not every man reacted to the tension to the same extent, but the overall peaking of cholesterol level in the blood during a time of great emotional stress meant that these two factors were decisively correlated.
This was the first controlled experiment proving that the amount of cholesterol in the blood can be altered by the brain—and not just by the consumption of fat by mouth. Other researchers have since duplicated these results.
The next step was to analyze more precisely the individual differences in how people handle stress. Friedman and Rosenman developed an interview technique for behavorial typing that focuses on work and leisure habits, as well as on attitudes toward time. But it is analyzed more for the intensity and emotional overtones of the responses than for verbal answers.
These interviews led them to define two main behavior patterns, which they called Type A and Type B. (Since most people are mixtures of the two types, the interview techniques were eventually refined to include four subdivisions in each group.) They found that the Type B man, comparatively relaxed and unhurried, at ease with himself and other people, rarely suffers from heart disease before the age of sixty—regardless of whether he smokes, eats fatty foods, or fails to exercise.
By contrast, the Type A man is three times more likely to be stricken by a heart attack; and if he is under fifty, the risk is ten times greater. What is the Type A man like?
The general picture is as follows: Ambitious, competitive, and aggressive, he is involved in a continual struggle against time and/or other people. His sense of time urgency is accute. Almost always punctual, he is greatly annoyed if kept waiting. Delays in restaurants, at airports, or in traffic irritate him; and he is impatient with people who don’t come quickly to the point. He tends to talk rapidly and eat rapidly, but usually feels way behind in doing everything he thinks he should—and worries inordinately about meeting deadlines.
Not inclined to spare time for hobbies, Type A likes to do several things simultaneously (reading while eating or shaving, for example), and often engages in two lines of thought at once (polyphasic thinking). He is likely to be an inattentive listener, especially when he considers the conversation insignificant.
Type A regards his home primarily as a place to dress for work, and often his family plays only a small role in his life.
He dislikes doing chores, or getting involved in household matters, and usually goes to bed early. Getting a good night’s rest for the next day’s work interests him more than family activities, says Dr. Friedman, because, “He values achievement time—and nothing about his home is achievement.”
As part of the same pattern, he rarely takes a vacation. When he does, he is likely to combine it with business or choose a competitive activity like gambling or hunting. Seldom away from work because of sickness, he rarely goes to a doctor and almost never to a psychiatrist. He doesn’t feel he needs either.
Type A often becomes so mechanized in his responses, so obsessed by numbers, that his life becomes a race in which he is competing against time, against other people—and, ultimately, against himself.
No matter what he buys, only numbers count: how many suits, how many cars, how many cases of wine. It is the same at work: He is concerned about how many clients he has; how many insurance policies he sold; how many articles he published. Likewise during his leisure time: What matters if he travels to Europe is how many cities he visited; in tennis, how many sets he played; in hunting, the number of ducks he shot.
A sense of insecurity about himself and his status usually underlies Type A’s tendency to push and strive incessantly. Almost incapable of dealing with people except by setting up a competitive struggle, he often has difficulty in his personal relationships. But because he is always measuring his own value by the number of his achievements, and feels that others are judging him by this yardstick too, he is never content. The numbers must always rise—and when they don’t, he feels like a failure.
Despite their drive to achieve, however, Type A’s are not necessarily most successful. In fact, they often lose out to B’s for the top jobs, because the A’s are too competitive, too driven. Also, being intensely goal-directed, they are apt to be less creative than B’s. With an eye always on the clock, A’s are unwilling to consider matters they regard as time-wasting; as a result, their decisions tend to be hasty—and often mistaken in the long run.
Though Type A behavior doesn’t necessarily lead to success, it bears a startling resemblance to the American ideal, the style that ambitious parents urge upon their sons, the style that most mid-life men have been trained to emulate. Driving and agressive, the Type A man likes to get a lot of things done, all as quickly as possible. He gives the impression of iron self-control. He has machismo. He is a composite of many of our society’s most admired male traits.
The tragedy is that Type A behavior is also lethal: This living embodiment of masculine ideals is the typical coronary candidate.
Although many questions about coronary fatalities remain unanswered, Friedman and Rosenman have clearly documented that Type A behavior by itself generates certain biochemical changes that cause heart disease: Blood cholesterol rises, adrenalinelike substances flood the body, and the normal reserve of life-sustaining hormones is depleted.
Their statistics are coldly convincing because in addition to studying the personalities of coronary victims, they have also studied a large group of healthy men—and successfully predicted which ones would have heart attacks.
Begun in 1960, this study involves 3,500 men, aged 35 to 59, with no known history of heart disease when the program began. They were interviewed and classified according to behavior type, as well as all other standard risk factors. Regardless of whether these men smoked or not, had high blood pressure or not, or exercised or not, those who got heart attacks ten years later were overwhelmingly Type A’s. (By 1970, 257 men had been stricken—70 per cent of them A’s. And among the younger men 39 to 49, the figure is even higher: Seventy-nine per cent have been A’s.)
About half of all American males are confirmed Type A’s, say Friedman and Rosenman, compared to relatively few females. But as women become more aggressive, and move into the marketplace on higher levels, they expect this to change—and the heart attack rate to rise. (Heart disease rose sharply among Japanese women after World War II, when they were liberated from wholly domestic duties.) The Type A pattern is common among hard-driving executives, but it also occurs in many other occupations—everything from factory workers to truck drivers to psychiatrists.
Says Rosenman about this Type A condition: “It is a sickness, although it is not yet recognized as such.”
*11\93\2*
