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Behavior therapy for type a patients
LETTERS TO THE EDITOR
BEHAVIOR THERAPY
FOR TYPE A PATIENTS
This letter briefly introduces a new approach to psychological treatment of the type A cardiac patient; fuller details will be reported later as further analyses are completed. However, some preliminary results show this approach to be promising. The type A personality was identified by Friedman and Rosenman’-” in a series of well designed studies demonstrating the association of this behavioral pattern with high risk for heart disease. They also reported3*4 that the type A traits were more predictive, with less error, of heart disease than predictions based solely upon examination of lipid data such as the beta/alpha lipoprotein level. The type A behavioral pattern consists of: a high drive toward poorly defined goals, persistence of work toward recognition and advancement, eagerness to compete, continuous involvement in activities with self-imposed deadlines, working at such activities at a high rate, and a heightened mental and physical alertness. The pilot program of psychological treatment was a combination of two behavior modification programs developed by Suinn”: anxiety management training and visuo-motor behavior rehearsal.6 The former trains patients in identification of the physical/physiologic signs of stress and elimination of these reactions from the behavior pattern. It has been successful in patients with diffuse anxieties.7*s Visuomotor behavior rehearsal is a method that enables a patient to acquire new adaptive habit patterns through practicing these patterns under controlled imagery conditions. This procedure has been applied to the retraining of executives, concert musicians and members of the United States National Ski Team.g The program for cardiac patients is a 5 hour treatment program called Cardiac Stress Management Training (CSMT). Patients are trained in the methods for coping with stress situations and stress arousal, and in the means for altering their lifestyles to reduce stress. It is assumed that the type A patient is particularly susceptible to stress because his behavior places him in situations of stress, for instance, from deadlines. It is also assumed that the type A patient needs to alter his activities significantly in order to avoid further stress. All patients underwent rehabilitation in the Spalding Rehabilitation Center, Cardiac Reconditioning Unit, Denver, Colorado. This rehabilitation program is comprehensive, involving medical resources, physical exercise and dietary assistance, all individualized for each patient. Patients are introduced into the program within 2 to 4 weeks after infarction, and typically are followed up in an outpatient treatment program three times a week for 8 weeks. Blood lipid measurements are obtained at the beginning and at the end of the program through the laboratory facilities in the hospital attached to the Center. An experimental group of 10 type A patients was selected for Cardiac Stress Management Training, with a control group of 10 who did not receive this training. All patients had been undergoing the comprehensive medical rehabilitation treatment previously indicated, that is, exercise, dietary assistance and medical supervision. A questionnaire on the patients’ reactions to the stress training program indicated that 83 percent believed it led to substantial improvements in their reactions to stress,
and 83 percent believed there were major changes in their behavior patterns or lifestyles. The median cholesterol and triglyceride levels showed, respectively, a decrease from 215 to 194 mg/lOO ml and a decrease from 143 to 104 mg/lOO ml in those patients who underwent the stress training. The control group showed no change in cholesterol level from the median of 214 mg/ 100 ml, and a decrease in triglyceride level from 146 to 130 mg/lOO ml. The mean decrease in body weight in the group trained in stress management was 3.0 lb as compared with 1.3 lb for the patients in the control group. The only way in which the two groups differed was in the participation or nonparticipation in the stress management program. Further detailed statistical analyses are being conducted on the data. At this point the stress management training program seems promising since 8 of 10 patients who participated had a decrease in cholesterol level and 9 of 10 a decrease in triglyceride level, as compared with 5 of 10 patients in the control group who had a decrease in either measurement. Since the program was developed as a sbortterm treatment program that can be completed in 2 weeks, it may prove to be the first meaningful approach to reducing the psychological risk factors associated with heart disease. Richard M. Suinn, PhD Loring Brock, MD Cecil A. Edie, PhD Colorado State University Fort Collins, Colorado References 1. FrIedman M, Roseman R: Association of specific overt behavior pattern with bled and cardiovascular findings. JAMA 169:1286. 1959 2. Rosenman R, Frfedman M: Association of specific behavior pattern in women with blood and cardiovascukr findings. Circulation 24:173, 1961 3. Rosenmsn R, Friedman M, Straw R. et al: A predictive study of coronary heart disease. JAMA, 189:15. 1964 4. Rosenman R, Friedman M. Straus R, et al: Coronary heart disease in the Western Collaborative Group study: a follow-up experience of two years. JAMA 19566. 1966 5. Sulnn R: Anxiety management training for general anxiety. In. The Innovative Therapies: Critical and Creative Contributions @inn R. Weigel R, %I). New York, Harper a Row. 1973 Sulnn R: Visuo-motor behavior rehearsal for adaptive behavior. Unpublished mawscript, 1973 Edfe C: Uses of AMT in treating trait anxiety. Unpublished doctoral dissertation. Colarado State University, 1972 Nlcofetil J: Anxiety management training. Unpublished doctoral dissertation. Colorado State University, 1972 Sulnn R: Visuo-motor behavior rehearsal for athletes. Sports Med J 6: 1, 1973
COMMENT The usual approach to management of a patient after myocardial infarction is alteration of the primary risk factors for infarction by such methods as changing diet, stopping smoking, normalizing weight, reducing serum lipids by diet and medication and enhancing physical activity, and, more recently, by purposeful programs of physical conditioning. Unfortunately, it is clear from published data that such approaches have not been associated with a significant decrease in the rate of recurring coronary events. The association of type A behavior with the incidence of both primary and recurring coronary events seems clear from our own published data as well as the relevant data from many other investigators. The letter from Suinn et al. strongly indicates that alteration of the patient’s behavior
August 1975
The American Journal of CARDIOLOGY
Volume 36
269
BEHAVIOR THERAPY
FOR TYPE A PATIENTS
This letter briefly introduces a new approach to psychological treatment of the type A cardiac patient; fuller details will be reported later as further analyses are completed. However, some preliminary results show this approach to be promising. The type A personality was identified by Friedman and Rosenman’-” in a series of well designed studies demonstrating the association of this behavioral pattern with high risk for heart disease. They also reported3*4 that the type A traits were more predictive, with less error, of heart disease than predictions based solely upon examination of lipid data such as the beta/alpha lipoprotein level. The type A behavioral pattern consists of: a high drive toward poorly defined goals, persistence of work toward recognition and advancement, eagerness to compete, continuous involvement in activities with self-imposed deadlines, working at such activities at a high rate, and a heightened mental and physical alertness. The pilot program of psychological treatment was a combination of two behavior modification programs developed by Suinn”: anxiety management training and visuo-motor behavior rehearsal.6 The former trains patients in identification of the physical/physiologic signs of stress and elimination of these reactions from the behavior pattern. It has been successful in patients with diffuse anxieties.7*s Visuomotor behavior rehearsal is a method that enables a patient to acquire new adaptive habit patterns through practicing these patterns under controlled imagery conditions. This procedure has been applied to the retraining of executives, concert musicians and members of the United States National Ski Team.g The program for cardiac patients is a 5 hour treatment program called Cardiac Stress Management Training (CSMT). Patients are trained in the methods for coping with stress situations and stress arousal, and in the means for altering their lifestyles to reduce stress. It is assumed that the type A patient is particularly susceptible to stress because his behavior places him in situations of stress, for instance, from deadlines. It is also assumed that the type A patient needs to alter his activities significantly in order to avoid further stress. All patients underwent rehabilitation in the Spalding Rehabilitation Center, Cardiac Reconditioning Unit, Denver, Colorado. This rehabilitation program is comprehensive, involving medical resources, physical exercise and dietary assistance, all individualized for each patient. Patients are introduced into the program within 2 to 4 weeks after infarction, and typically are followed up in an outpatient treatment program three times a week for 8 weeks. Blood lipid measurements are obtained at the beginning and at the end of the program through the laboratory facilities in the hospital attached to the Center. An experimental group of 10 type A patients was selected for Cardiac Stress Management Training, with a control group of 10 who did not receive this training. All patients had been undergoing the comprehensive medical rehabilitation treatment previously indicated, that is, exercise, dietary assistance and medical supervision. A questionnaire on the patients’ reactions to the stress training program indicated that 83 percent believed it led to substantial improvements in their reactions to stress,
and 83 percent believed there were major changes in their behavior patterns or lifestyles. The median cholesterol and triglyceride levels showed, respectively, a decrease from 215 to 194 mg/lOO ml and a decrease from 143 to 104 mg/lOO ml in those patients who underwent the stress training. The control group showed no change in cholesterol level from the median of 214 mg/ 100 ml, and a decrease in triglyceride level from 146 to 130 mg/lOO ml. The mean decrease in body weight in the group trained in stress management was 3.0 lb as compared with 1.3 lb for the patients in the control group. The only way in which the two groups differed was in the participation or nonparticipation in the stress management program. Further detailed statistical analyses are being conducted on the data. At this point the stress management training program seems promising since 8 of 10 patients who participated had a decrease in cholesterol level and 9 of 10 a decrease in triglyceride level, as compared with 5 of 10 patients in the control group who had a decrease in either measurement. Since the program was developed as a sbortterm treatment program that can be completed in 2 weeks, it may prove to be the first meaningful approach to reducing the psychological risk factors associated with heart disease. Richard M. Suinn, PhD Loring Brock, MD Cecil A. Edie, PhD Colorado State University Fort Collins, Colorado References 1. FrIedman M, Roseman R: Association of specific overt behavior pattern with bled and cardiovascular findings. JAMA 169:1286. 1959 2. Rosenman R, Frfedman M: Association of specific behavior pattern in women with blood and cardiovascukr findings. Circulation 24:173, 1961 3. Rosenmsn R, Friedman M, Straw R. et al: A predictive study of coronary heart disease. JAMA, 189:15. 1964 4. Rosenman R, Friedman M. Straus R, et al: Coronary heart disease in the Western Collaborative Group study: a follow-up experience of two years. JAMA 19566. 1966 5. Sulnn R: Anxiety management training for general anxiety. In. The Innovative Therapies: Critical and Creative Contributions @inn R. Weigel R, %I). New York, Harper a Row. 1973 Sulnn R: Visuo-motor behavior rehearsal for adaptive behavior. Unpublished mawscript, 1973 Edfe C: Uses of AMT in treating trait anxiety. Unpublished doctoral dissertation. Colarado State University, 1972 Nlcofetil J: Anxiety management training. Unpublished doctoral dissertation. Colorado State University, 1972 Sulnn R: Visuo-motor behavior rehearsal for athletes. Sports Med J 6: 1, 1973
COMMENT The usual approach to management of a patient after myocardial infarction is alteration of the primary risk factors for infarction by such methods as changing diet, stopping smoking, normalizing weight, reducing serum lipids by diet and medication and enhancing physical activity, and, more recently, by purposeful programs of physical conditioning. Unfortunately, it is clear from published data that such approaches have not been associated with a significant decrease in the rate of recurring coronary events. The association of type A behavior with the incidence of both primary and recurring coronary events seems clear from our own published data as well as the relevant data from many other investigators. The letter from Suinn et al. strongly indicates that alteration of the patient’s behavior
August 1975
The American Journal of CARDIOLOGY
Volume 36
269