- Email: [email protected]
Type A Behavior Reduction Program for Healthy Middle-Aged Army Officers
Psychological and Behavioral Benefits of a Stress/ Type A Behavior Reduction Program for Healthy Middle-Aged Anny Officers MAURIZIO FAvA, M.D., ANDREW LI1TMAN, M.D., PETER HALPERIN, M.D. EILEEN PRAlT, B.A., COL FREDERICK
R.
DREWS, MSC, PE.D.
LTC MARVIN OLESHANSKY, MC, M.D., CPT JOSEPH KNAPIK, MSC, Sc.D. CPT CARA THOMPSON, ANC, CHRIS BIELENDA, M.S.
Twenty army officers who participated in a stress/type A behavior reduction program and a comparison group of J 7 officer nonparticipants I"Olunteered to undergo a battery ofpsychological and behavioral tests before and after the program. Following the program, participants displayed a significantly greater reduction in average daily caloric intake and levels ofperceived stress, anxiety. hostility, depression. psychological distress. and type A behavior as compared to the officers who did not participate in it. Given the fact that most ofthese psychological and behavioral factors have been found in previous studies to be related to an increased risk for coronary artery disease, it seems that the changes reported by the participants in the program are potentially healthful.
T
he impact of stress on the heart has been fairly extensively evaluated. Although life events such as loss of a spouse. loss of a job. retirement. or other disruptions of life do not seem to be risk factors per se for coronary heart disease (CHD).' such events or even everyday minor events can elicit in predisposed individuals psychophysiological responses leading to heart disease. The importance of behavior in determining an individual's predisposition to developing CHD has been confirmed by numerous epidemiological studies that have found an association between type A behavior and an increased incidence of CHD in population-based studies of men. 2 Type A behavior (TAB). first described by Friedman and Rosenman. 3 is a behavioral pattern characterized by a continuously harrying sense of time urgency and by easily aroused free-floating hostility.
Although the relationship between TAB. stress. and CHD is considered by some investigators to be somewhat controversial.4 over the past few years a variety of programs have been created to modify TAB and/or to reduce stress levels with the intent to lower the risk of heart disease. The most ambitious program is represented by the Recurrent Coronary Prevention Project. in which 1.013 patients with a history of heart attacks were divided into two intervention groups. Patients who received only cardiac group Received March 9. 1990; revised October 9. 1990; accepted October 31. 1990. From the Departments of Psychiatry and Preventive Medicine. Massachusells General Hospital. Boston; and the U.S. Army War College. Carlisle Barracks. Pennsylvania. Address reprint requests to Dr. Fava. Depanment of Psychiatry ACC-SIS. Massachusells General Hospital. Boston. MA 02114. Copyright © 1991 The Academy of Psychosomatic Medicine. 337
VOLUME 32· NUMBER 3· SUMMER 1991
•
I
Stress / Type A Reduction Program
counseling. consisting mostly of a discussion of traditional risk factors for CHD. had a significantly higher cardiac event recurrence rate than patients who received TAB reduction group counseling in addition to cardiac group counseling.~
Healthy middle-aged army officers at the U.S. Army War College in Carlisle. Pennsylvania. underwent a randomized. controlled trial of a stress/type A behavior reduction program conducted by U. Gill and F.R. Drews. A marked decrease in TAB as measured by the Videotaped Structured Interview (VSI). participant questionnaires. and spouse questionnaires was observed in 41.9% of 61 volunteer participants in the program and in only 8.9% of 56 control group officers who did not participate in it.1> Since Colonel Drews. in collaboration with Dr. Gill. has continued over the past few years to conduct this stressrrAB reduction program at the U.S. Army War College. we decided to investigate in more detail the possible psychological and behavioral benefits of participation in this program by using outcome measurements of TAB. dietary intake. leisure-time physical activity. anxiety. depression. somatic symptoms. and hostility. METHODS The U.S. Army War College is the U.S. Army's senior educational institution aimed to prepare carefully selected senior officer-students (lieutenant colonels and colonels) for future duty as commanders or staff officers at the highest levels of the army. During their stay at the War College. officer-students are exposed to several stressors: marked changes in their responsibility. expectations to give frequent oral and written reports. relocation. comparison on a daily basis to peers of equally outstanding qualifications. and. finally. a marked degree of uncertainty about their next assignment. The stressrrAB reduction program at the Army War College consisted of a total of 13 sessions of approximately 90 minutes each occurring over a period of7 months. The counseling sessions were designed according to the basic guidelines used in the Recurrent Coronary Pre338
TABLE I. Outline of the basic elements of the
stress/type A behavior reduction program I) Introduction to the concept of group intervention. its rules. and organization. 2) Discussion of anger. impatience. aggravation. and irritation; their relationship to stress hormones. 3) Explanation of the type A behavior pallem model. 4) Development of stress self-monitoring techniques. 5) Use of dri lis and relaxation techniques. 6) Training in cognitive control of anger and its components. 7) Introduction to methods of coping with stress. 8) Constructing drills for specific stressful situations. 9) Enhancing self-esteem. 10) Discussion of the imponance of exercise and nutrition. II) Training in the use of anxiety-reduction techniques. 12) Review of training.
vention Project and described earlier. 7 (The basic elements of this program are summarized in Table I.) In September 1987. at the beginning of the academic year. 40 of 275 male senior army officers attending classes at the Army War College volunteered to participate in the study. and their written consent was obtained. Study subjects were divided into two groups. Group I (n=22) consisted of male officer-students who had agreed to participate and who then completed the stressrrAB reduction program (age=43.1±1.9 years. mean±SD). Group C (n= 18) consisted of male officer-students not participating in the program and functioning as a comparison group (age 43.6±2.6 years). Of these 40 subjects. 37 completed the study: 20 of group I and 17 of group C. This study was conducted in two phases. In the pre-treatment phase (phase I). study subjects (n=37) were assessed in September 1987 with instruments measuring "behavioral" (TAB. diet. and leisure-time physical activity) and "psychological" (perceived stress. anxiety. depression. and hostility) correlates of risk for cardiovascular disease. The post-treatment phase (phase 2) took place in May 1988 after stressrrAB reduction classes ended; it involved the assessment of the officers (n=37) with these same instruments. During the few weeks prior to data collection PSYCHOSOMATICS
Fava et al.
TABLE 2. Comparisons between groop I and group C scores on Global Assessment of Recent Stress Scale and Kellner's Symptom Questionnaire (SQ) Mean±SD Group I Global Assessment of Recent Stress Scale Pre-treatmem Post-treatment Pre-post difference SQ Anxiety Pre-treatment Post-treatment Pre-post difference SQ Depression Pre-treatment Post-treatmem Pre-post difference SQ Somatic Symptoms Pre-treatment Post-treatmem Pre-post difference SQ Hostility Pre-treatmem Post-treatmem Pre-post difference SQ Total Score Pre-treatment Post-treatment Pre-post difference
(n=20)
GroupC (n=l7)
19.6tI2.4 16.5tI0.3 3.ltI4.5
FTest
p
12.4±6.3 13.8tlO -1.4t7.6
4.6 0.7
0.04
1.3
NS NS
5.4t4.8 3.4t3.4 2.0±4.7
2.8±2.6 3.9±4.2 -l.lt3.8
3.9 0.2 4.9
NS NS 0.04
5.2±5.1 2.6±3.0 2.6±5.0
I.O±I.I 1.5±2.7 -o.5±2.2
10.7
0.05
1.3 5.5
0.03
5.4t3.2 3.8t3.3 1.6t3.5
2.8t2.7 3.1±2.6 -o.3±2.9
7.2 0.6 3.1
0.D2
7.5t4.9 3.8t3.9 3.7t4.0
3.lt3.1 3.8t3.5 -o.6t2.5
10.0 0.0 14.7
0.004
23.4tI5.4 13.6tll.3 9.8tI2.9
9.7±6.2 11.6tlO.5 -1.9±8.5
11.8 0.3 10.2
NS
NS NS
NS 0.0005 0.002
NS 0.003
Note: NS=not significam.
both in phases I and 2, all participants underwent a VSI in accordance with the Friedman and Powell method to measure TAB. 8 A trained interviewer who was blind to the I vs. C group status of each subject conducted and scored the VSI. On the day of the data collection, each participant was administered the Kellner's Symptom Questionnaire (SQ), a 92-item self-rating scale containing four subscales based on factor analysis of symptoms: anxiety, depression, somatic symptoms, and hostility.9 Each subject was also administered the Global Assessment of Recent Stress Scale, a 7-item scale that evaluates the current status of pressure and stress in several areas of one's life,to and the Perceived Stress Scale, a 14-item scale that measures the degree to which situations are perceived as stressfuL ' ! In addition, the investigators devised a scale, the Physical Exercise Attitude Scale, a 9-item scale designed to assess the degree of "unVOLUME 32· NUMBER 3· SUMMER 1991
healthy," excessively competitive, impatient, and hostile attitudes toward exercising. The degree of self-selected leisure-time physical activity during the week prior to the day of the data collection was assessed with a modified version of the Seven-Day Physical Activity Recall,'2 which is designed to evaluate and estimate the energy expenditure (kcal/week) in leisure-time physical activities. The daily dietary food intake (cal/day) during the 3 days prior to the data collection was assessed with a 3-Day Recall Questionnaire (a computerized dietary assessment form, "The Food Processor," by ESHA Research, Salem, Oregon). The differences between the two groups during phase I and phase 2 (pre- and post-treatment) were evaluated using a factorial analysis of variance (ANOVA), and the differences between phase I and 2 in the two groups were evaluated using a repeated measures ANOVA. 339
Stress / Type A Reduction Program
TABLE 3. Comparisons between group I and group C scores on the Videotaped Structured Interview (VSI), Perceived Stress Scale, Physical Exercise Attitude Scale, and Seven-Day Physical Activity Recall Mean±SD Group I
GroupC
(n=20)
(n=l7)
FTest
23.3±6.7 16.5±3.8 6.9±7.6
17.1±5.1 J7.2±7.7 -{).2±6.8
10.0 0.2 8.7
0.004 NS 0.006
24.7±4.7 22.6±3.3 2.1±4.2
20.8±4.3 20.9±4.7 -{).I±5.4
6.6 1.5 2.0
0.02 NS NS
Pre-treatment Post-trealment Pre-post difference
3064±2139 3296±2370 -232±1535
3584±1726 3875±2800 -291±2783
0.6 0.5 0.0
NS NS NS
VSI - Time Urgency
(n=21) 28.6±5.7 15.3±7.0 13.2±6.4
21.2±6.8 17.1±9.1 4.1±7.3
11.1 0.4 14.1
0.003 NS 0.0007
9.0±4.3 3.9±3.9 5.1±3.6
6.1±4.1 5.6±4.4 0.5±5.0
3.6 1.3 9.4
NS NS 0.005
37.6±8.5 19.2±1O.2 18.4±8.8
27.3±9.9 21.5±13.5 5.8±11.5
10.0 0.3 12.6
0.004 NS 0.002
p
Perceived Stress Scale Pre-treatment Post-treatment Pre-post difference
Physical Exercise Attitude Scale Pre-treatment Post-treatment Pre-post difference
Seven·Day Physical Activity Recall (kcal/wk)
Pre-treatment Post-treatment Pre-post difference
(n=l2)
VSI- Hostility Pre-treatment Post-treatment Pre-post difference
VSI - Total Score Pre-treatment Post-treatment Pre-post difference Note: NS=not significant.
RESULTS The results of our study are summarized in Tables 2 and 3. As pointed out in Table 2, in phase I, group I subjects (n=20), consisting of the officerstudents participating in the stressrrAB reduction program, reported significantly higher scores of global stress, depression, hostility, somatic symptoms, and psychological distress (the latter measured by the total score of the Kellner's SQ) than group C subjects (n= 17), consisting of officer-students not participating in the program. In phase 2, following completion of the stressrrAB reduction program, the two groups did not differ significantly from each other in self-reported global stress, anxiety, depression, somatic symptoms, hostility, and psychological distress. However, the reduction in the scores of anxiety, depression, hostility, and psychological distress reported by group I subjects after the 340
program was significant when compared to the slight increase in these symptoms reported by group C during the same time period. As shown in Table 3, in phase I, group I subjects reported significantly more perceived stress as well as a more negative and more excessively competitive attitude toward exercise than group C subjects (n= 17). In addition, prior to treatment, group I subjects were found to display higher degrees of global TAB (represented by the VSI total score) along with a greater sense of time urgency, a TAB subcomponent. In phase 2, following completion of the stressrrAB reduction program, the two groups did not differ significantly from each other in self-reported perceived stress and attitude toward exercise or in TAB and its subcomponents. The reduction in perceived stress and hostility, time urgency, and TAB global scores observed in group I following the program was significant in comparison to that PSYCHOSOMATICS
Fava et al.
among group C subjects during the same time period. The average total dietary intake during phase I was significantly greater (F test =5.4. p
L
to-the-mean" phenomenon. If the hypothesis that these psychological and behavioral changes in group I subjects were related to their participation in the stress(fAB program is in fact true. one might wonder whether such changes are indeed positive and healthful. An increased risk for CHD has been associated in epidemiological studies with elevated levels of stress. 13 TAB.2 hostility;4 and depression. '5 The officer-students who participated in the stress(fAB reduction program (group I) displayed a significant reduction in comparison to nonparticipants in all the test scores concerning the above-mentioned behavioral and psychological factors. Given the crosssectional nature of our study. however. one cannot draw any conclusion regarding the potential role of this psychological and behavioral intervention in reducing the overall risk for CHD in these subjects. In any case. the seeming healthfulness of this stress(fAB reduction program is confirmed by the participants' significant decrease in their total daily caloric food intake. In conclusion. the stress(fAB reduction program in healthy middle-aged army officers appears to be followed by marked. potentially healthful psychological and behavioral changes. These changes include a marked decrease in perceived stress. hostility. anxiety. depression. psychological distress. TAB. and total caloric dietary intake. and they seem favorable to the individuals involved. A larger study on the effects of this program. utilizing a random allocation strategy. is necessary.
The \'iews. opinions, and/or findinp,s contained in this report are those oftheauthor(s)and should not be construed as an official Department of the Army position, policy. or decision, unless so designated by other official documentation.
References I. Reich P: How much does slress contribute 10 cardiovascular disease'? Journal of CardiOl'ascular Medicine 8:825--83 \, 1983 2. Matthews KA. Haynes SG: Reviews and commentary:
:WI
Stress / Type A Reduction Program
3. 4.
5.
6.
7. 8.
342
type A behavior pallem and coronary disease risk. update and clinical evaluation. Am J Epidemiol 123:923-960. 1986 Friedman M. Rosenman R: Type A Behavior and Your Heart. New York. Knopf. 1974 Williams RB: Psychological factors in coronary artery disease: epidemiological evidence. Circulation 76 (suppll):117-123.1987 Friedman M. Thoresen CEo Gill JJ. et al: Aheralion of type A behavior and its effect on cardiac recurrences in post myocardial infarction patienls: summary resuhs of the recurrent coronary prevenlion project Am Heart J 112:653-665.1986 Gill JJ. Price VA. Friedman M. et al: Reduction in type A behavior in heahhy middle-aged American military officers. Am Heart J 110:503-514. 1985 Drews FR: A Healthy Life: Exercise. Behal'ior. Nutrition. Indianapolis. Benchmark Press Inc. 1986 Friedman M. Powell LH: Diagnosis and quanlilative assessmenl of type A behavior: introduction and description of the videotaped structured interview. Integrative Psychiatry 2:123-129.1984
9. Kellner R: A Symptom Questionnaire. J Clin Psychiatry 48:268-274. 1987 10. Linn MW: A Global Assessment of Recenl Stress (GARS) Scale. 1m J Psychiatry in Med 15:47-59. 19851986 II. Cohen S. Kamark T. Mermelstein R: A global measure of perceived stress. J Health Soc Behav 24:385-396. 1983 12. Wilson PWF. Paffenberger RS. MorrisJN. et al: Assessmenl methods for physical activity and physical fitness in population studies: repon of a NHLBI workshop. Am Heart J III :1177-1192. 1986 13. Lacroix AZ: Occupational exposure to high demand/low cOnlrol work and coronary hean disease incidence in the Fmmingham cohon. Unpublished doctoml dissertation. Universily of Nonh Carolina. Chapel Hill. 1984 14. Manuck SB. Kaplan JR. Mallhews KA: Behavioral antecedenls of coronary hean disease and atherosclerosis. Arteriosclerosis 6:2-14. 1986 15. Murphy JM. Monson RR. Olivier DC. et al: Affective disorder and monality. Arch Gen Psychiatry 44:473480. 1987
PSYCHOSOMATICS
R.
DREWS, MSC, PE.D.
LTC MARVIN OLESHANSKY, MC, M.D., CPT JOSEPH KNAPIK, MSC, Sc.D. CPT CARA THOMPSON, ANC, CHRIS BIELENDA, M.S.
Twenty army officers who participated in a stress/type A behavior reduction program and a comparison group of J 7 officer nonparticipants I"Olunteered to undergo a battery ofpsychological and behavioral tests before and after the program. Following the program, participants displayed a significantly greater reduction in average daily caloric intake and levels ofperceived stress, anxiety. hostility, depression. psychological distress. and type A behavior as compared to the officers who did not participate in it. Given the fact that most ofthese psychological and behavioral factors have been found in previous studies to be related to an increased risk for coronary artery disease, it seems that the changes reported by the participants in the program are potentially healthful.
T
he impact of stress on the heart has been fairly extensively evaluated. Although life events such as loss of a spouse. loss of a job. retirement. or other disruptions of life do not seem to be risk factors per se for coronary heart disease (CHD).' such events or even everyday minor events can elicit in predisposed individuals psychophysiological responses leading to heart disease. The importance of behavior in determining an individual's predisposition to developing CHD has been confirmed by numerous epidemiological studies that have found an association between type A behavior and an increased incidence of CHD in population-based studies of men. 2 Type A behavior (TAB). first described by Friedman and Rosenman. 3 is a behavioral pattern characterized by a continuously harrying sense of time urgency and by easily aroused free-floating hostility.
Although the relationship between TAB. stress. and CHD is considered by some investigators to be somewhat controversial.4 over the past few years a variety of programs have been created to modify TAB and/or to reduce stress levels with the intent to lower the risk of heart disease. The most ambitious program is represented by the Recurrent Coronary Prevention Project. in which 1.013 patients with a history of heart attacks were divided into two intervention groups. Patients who received only cardiac group Received March 9. 1990; revised October 9. 1990; accepted October 31. 1990. From the Departments of Psychiatry and Preventive Medicine. Massachusells General Hospital. Boston; and the U.S. Army War College. Carlisle Barracks. Pennsylvania. Address reprint requests to Dr. Fava. Depanment of Psychiatry ACC-SIS. Massachusells General Hospital. Boston. MA 02114. Copyright © 1991 The Academy of Psychosomatic Medicine. 337
VOLUME 32· NUMBER 3· SUMMER 1991
•
I
Stress / Type A Reduction Program
counseling. consisting mostly of a discussion of traditional risk factors for CHD. had a significantly higher cardiac event recurrence rate than patients who received TAB reduction group counseling in addition to cardiac group counseling.~
Healthy middle-aged army officers at the U.S. Army War College in Carlisle. Pennsylvania. underwent a randomized. controlled trial of a stress/type A behavior reduction program conducted by U. Gill and F.R. Drews. A marked decrease in TAB as measured by the Videotaped Structured Interview (VSI). participant questionnaires. and spouse questionnaires was observed in 41.9% of 61 volunteer participants in the program and in only 8.9% of 56 control group officers who did not participate in it.1> Since Colonel Drews. in collaboration with Dr. Gill. has continued over the past few years to conduct this stressrrAB reduction program at the U.S. Army War College. we decided to investigate in more detail the possible psychological and behavioral benefits of participation in this program by using outcome measurements of TAB. dietary intake. leisure-time physical activity. anxiety. depression. somatic symptoms. and hostility. METHODS The U.S. Army War College is the U.S. Army's senior educational institution aimed to prepare carefully selected senior officer-students (lieutenant colonels and colonels) for future duty as commanders or staff officers at the highest levels of the army. During their stay at the War College. officer-students are exposed to several stressors: marked changes in their responsibility. expectations to give frequent oral and written reports. relocation. comparison on a daily basis to peers of equally outstanding qualifications. and. finally. a marked degree of uncertainty about their next assignment. The stressrrAB reduction program at the Army War College consisted of a total of 13 sessions of approximately 90 minutes each occurring over a period of7 months. The counseling sessions were designed according to the basic guidelines used in the Recurrent Coronary Pre338
TABLE I. Outline of the basic elements of the
stress/type A behavior reduction program I) Introduction to the concept of group intervention. its rules. and organization. 2) Discussion of anger. impatience. aggravation. and irritation; their relationship to stress hormones. 3) Explanation of the type A behavior pallem model. 4) Development of stress self-monitoring techniques. 5) Use of dri lis and relaxation techniques. 6) Training in cognitive control of anger and its components. 7) Introduction to methods of coping with stress. 8) Constructing drills for specific stressful situations. 9) Enhancing self-esteem. 10) Discussion of the imponance of exercise and nutrition. II) Training in the use of anxiety-reduction techniques. 12) Review of training.
vention Project and described earlier. 7 (The basic elements of this program are summarized in Table I.) In September 1987. at the beginning of the academic year. 40 of 275 male senior army officers attending classes at the Army War College volunteered to participate in the study. and their written consent was obtained. Study subjects were divided into two groups. Group I (n=22) consisted of male officer-students who had agreed to participate and who then completed the stressrrAB reduction program (age=43.1±1.9 years. mean±SD). Group C (n= 18) consisted of male officer-students not participating in the program and functioning as a comparison group (age 43.6±2.6 years). Of these 40 subjects. 37 completed the study: 20 of group I and 17 of group C. This study was conducted in two phases. In the pre-treatment phase (phase I). study subjects (n=37) were assessed in September 1987 with instruments measuring "behavioral" (TAB. diet. and leisure-time physical activity) and "psychological" (perceived stress. anxiety. depression. and hostility) correlates of risk for cardiovascular disease. The post-treatment phase (phase 2) took place in May 1988 after stressrrAB reduction classes ended; it involved the assessment of the officers (n=37) with these same instruments. During the few weeks prior to data collection PSYCHOSOMATICS
Fava et al.
TABLE 2. Comparisons between groop I and group C scores on Global Assessment of Recent Stress Scale and Kellner's Symptom Questionnaire (SQ) Mean±SD Group I Global Assessment of Recent Stress Scale Pre-treatmem Post-treatment Pre-post difference SQ Anxiety Pre-treatment Post-treatment Pre-post difference SQ Depression Pre-treatment Post-treatmem Pre-post difference SQ Somatic Symptoms Pre-treatment Post-treatmem Pre-post difference SQ Hostility Pre-treatmem Post-treatmem Pre-post difference SQ Total Score Pre-treatment Post-treatment Pre-post difference
(n=20)
GroupC (n=l7)
19.6tI2.4 16.5tI0.3 3.ltI4.5
FTest
p
12.4±6.3 13.8tlO -1.4t7.6
4.6 0.7
0.04
1.3
NS NS
5.4t4.8 3.4t3.4 2.0±4.7
2.8±2.6 3.9±4.2 -l.lt3.8
3.9 0.2 4.9
NS NS 0.04
5.2±5.1 2.6±3.0 2.6±5.0
I.O±I.I 1.5±2.7 -o.5±2.2
10.7
0.05
1.3 5.5
0.03
5.4t3.2 3.8t3.3 1.6t3.5
2.8t2.7 3.1±2.6 -o.3±2.9
7.2 0.6 3.1
0.D2
7.5t4.9 3.8t3.9 3.7t4.0
3.lt3.1 3.8t3.5 -o.6t2.5
10.0 0.0 14.7
0.004
23.4tI5.4 13.6tll.3 9.8tI2.9
9.7±6.2 11.6tlO.5 -1.9±8.5
11.8 0.3 10.2
NS
NS NS
NS 0.0005 0.002
NS 0.003
Note: NS=not significam.
both in phases I and 2, all participants underwent a VSI in accordance with the Friedman and Powell method to measure TAB. 8 A trained interviewer who was blind to the I vs. C group status of each subject conducted and scored the VSI. On the day of the data collection, each participant was administered the Kellner's Symptom Questionnaire (SQ), a 92-item self-rating scale containing four subscales based on factor analysis of symptoms: anxiety, depression, somatic symptoms, and hostility.9 Each subject was also administered the Global Assessment of Recent Stress Scale, a 7-item scale that evaluates the current status of pressure and stress in several areas of one's life,to and the Perceived Stress Scale, a 14-item scale that measures the degree to which situations are perceived as stressfuL ' ! In addition, the investigators devised a scale, the Physical Exercise Attitude Scale, a 9-item scale designed to assess the degree of "unVOLUME 32· NUMBER 3· SUMMER 1991
healthy," excessively competitive, impatient, and hostile attitudes toward exercising. The degree of self-selected leisure-time physical activity during the week prior to the day of the data collection was assessed with a modified version of the Seven-Day Physical Activity Recall,'2 which is designed to evaluate and estimate the energy expenditure (kcal/week) in leisure-time physical activities. The daily dietary food intake (cal/day) during the 3 days prior to the data collection was assessed with a 3-Day Recall Questionnaire (a computerized dietary assessment form, "The Food Processor," by ESHA Research, Salem, Oregon). The differences between the two groups during phase I and phase 2 (pre- and post-treatment) were evaluated using a factorial analysis of variance (ANOVA), and the differences between phase I and 2 in the two groups were evaluated using a repeated measures ANOVA. 339
Stress / Type A Reduction Program
TABLE 3. Comparisons between group I and group C scores on the Videotaped Structured Interview (VSI), Perceived Stress Scale, Physical Exercise Attitude Scale, and Seven-Day Physical Activity Recall Mean±SD Group I
GroupC
(n=20)
(n=l7)
FTest
23.3±6.7 16.5±3.8 6.9±7.6
17.1±5.1 J7.2±7.7 -{).2±6.8
10.0 0.2 8.7
0.004 NS 0.006
24.7±4.7 22.6±3.3 2.1±4.2
20.8±4.3 20.9±4.7 -{).I±5.4
6.6 1.5 2.0
0.02 NS NS
Pre-treatment Post-trealment Pre-post difference
3064±2139 3296±2370 -232±1535
3584±1726 3875±2800 -291±2783
0.6 0.5 0.0
NS NS NS
VSI - Time Urgency
(n=21) 28.6±5.7 15.3±7.0 13.2±6.4
21.2±6.8 17.1±9.1 4.1±7.3
11.1 0.4 14.1
0.003 NS 0.0007
9.0±4.3 3.9±3.9 5.1±3.6
6.1±4.1 5.6±4.4 0.5±5.0
3.6 1.3 9.4
NS NS 0.005
37.6±8.5 19.2±1O.2 18.4±8.8
27.3±9.9 21.5±13.5 5.8±11.5
10.0 0.3 12.6
0.004 NS 0.002
p
Perceived Stress Scale Pre-treatment Post-treatment Pre-post difference
Physical Exercise Attitude Scale Pre-treatment Post-treatment Pre-post difference
Seven·Day Physical Activity Recall (kcal/wk)
Pre-treatment Post-treatment Pre-post difference
(n=l2)
VSI- Hostility Pre-treatment Post-treatment Pre-post difference
VSI - Total Score Pre-treatment Post-treatment Pre-post difference Note: NS=not significant.
RESULTS The results of our study are summarized in Tables 2 and 3. As pointed out in Table 2, in phase I, group I subjects (n=20), consisting of the officerstudents participating in the stressrrAB reduction program, reported significantly higher scores of global stress, depression, hostility, somatic symptoms, and psychological distress (the latter measured by the total score of the Kellner's SQ) than group C subjects (n= 17), consisting of officer-students not participating in the program. In phase 2, following completion of the stressrrAB reduction program, the two groups did not differ significantly from each other in self-reported global stress, anxiety, depression, somatic symptoms, hostility, and psychological distress. However, the reduction in the scores of anxiety, depression, hostility, and psychological distress reported by group I subjects after the 340
program was significant when compared to the slight increase in these symptoms reported by group C during the same time period. As shown in Table 3, in phase I, group I subjects reported significantly more perceived stress as well as a more negative and more excessively competitive attitude toward exercise than group C subjects (n= 17). In addition, prior to treatment, group I subjects were found to display higher degrees of global TAB (represented by the VSI total score) along with a greater sense of time urgency, a TAB subcomponent. In phase 2, following completion of the stressrrAB reduction program, the two groups did not differ significantly from each other in self-reported perceived stress and attitude toward exercise or in TAB and its subcomponents. The reduction in perceived stress and hostility, time urgency, and TAB global scores observed in group I following the program was significant in comparison to that PSYCHOSOMATICS
Fava et al.
among group C subjects during the same time period. The average total dietary intake during phase I was significantly greater (F test =5.4. p
L
to-the-mean" phenomenon. If the hypothesis that these psychological and behavioral changes in group I subjects were related to their participation in the stress(fAB program is in fact true. one might wonder whether such changes are indeed positive and healthful. An increased risk for CHD has been associated in epidemiological studies with elevated levels of stress. 13 TAB.2 hostility;4 and depression. '5 The officer-students who participated in the stress(fAB reduction program (group I) displayed a significant reduction in comparison to nonparticipants in all the test scores concerning the above-mentioned behavioral and psychological factors. Given the crosssectional nature of our study. however. one cannot draw any conclusion regarding the potential role of this psychological and behavioral intervention in reducing the overall risk for CHD in these subjects. In any case. the seeming healthfulness of this stress(fAB reduction program is confirmed by the participants' significant decrease in their total daily caloric food intake. In conclusion. the stress(fAB reduction program in healthy middle-aged army officers appears to be followed by marked. potentially healthful psychological and behavioral changes. These changes include a marked decrease in perceived stress. hostility. anxiety. depression. psychological distress. TAB. and total caloric dietary intake. and they seem favorable to the individuals involved. A larger study on the effects of this program. utilizing a random allocation strategy. is necessary.
The \'iews. opinions, and/or findinp,s contained in this report are those oftheauthor(s)and should not be construed as an official Department of the Army position, policy. or decision, unless so designated by other official documentation.
References I. Reich P: How much does slress contribute 10 cardiovascular disease'? Journal of CardiOl'ascular Medicine 8:825--83 \, 1983 2. Matthews KA. Haynes SG: Reviews and commentary:
:WI
Stress / Type A Reduction Program
3. 4.
5.
6.
7. 8.
342
type A behavior pallem and coronary disease risk. update and clinical evaluation. Am J Epidemiol 123:923-960. 1986 Friedman M. Rosenman R: Type A Behavior and Your Heart. New York. Knopf. 1974 Williams RB: Psychological factors in coronary artery disease: epidemiological evidence. Circulation 76 (suppll):117-123.1987 Friedman M. Thoresen CEo Gill JJ. et al: Aheralion of type A behavior and its effect on cardiac recurrences in post myocardial infarction patienls: summary resuhs of the recurrent coronary prevenlion project Am Heart J 112:653-665.1986 Gill JJ. Price VA. Friedman M. et al: Reduction in type A behavior in heahhy middle-aged American military officers. Am Heart J 110:503-514. 1985 Drews FR: A Healthy Life: Exercise. Behal'ior. Nutrition. Indianapolis. Benchmark Press Inc. 1986 Friedman M. Powell LH: Diagnosis and quanlilative assessmenl of type A behavior: introduction and description of the videotaped structured interview. Integrative Psychiatry 2:123-129.1984
9. Kellner R: A Symptom Questionnaire. J Clin Psychiatry 48:268-274. 1987 10. Linn MW: A Global Assessment of Recenl Stress (GARS) Scale. 1m J Psychiatry in Med 15:47-59. 19851986 II. Cohen S. Kamark T. Mermelstein R: A global measure of perceived stress. J Health Soc Behav 24:385-396. 1983 12. Wilson PWF. Paffenberger RS. MorrisJN. et al: Assessmenl methods for physical activity and physical fitness in population studies: repon of a NHLBI workshop. Am Heart J III :1177-1192. 1986 13. Lacroix AZ: Occupational exposure to high demand/low cOnlrol work and coronary hean disease incidence in the Fmmingham cohon. Unpublished doctoml dissertation. Universily of Nonh Carolina. Chapel Hill. 1984 14. Manuck SB. Kaplan JR. Mallhews KA: Behavioral antecedenls of coronary hean disease and atherosclerosis. Arteriosclerosis 6:2-14. 1986 15. Murphy JM. Monson RR. Olivier DC. et al: Affective disorder and monality. Arch Gen Psychiatry 44:473480. 1987
PSYCHOSOMATICS