- Email: [email protected]
The Type A behavior pattern and coronary heart disease: a critical and personal look at the Type A behavior pattern at the turn of the century
International Congress Series 1241 (2002) 99 – 104
The Type A behavior pattern and coronary heart disease: a critical and personal look at the Type A behavior pattern at the turn of the century Geir Arild Espnes* Department of Social Work and Health Science and Section for Sport Sciences, Norwegian University of Science and Technology, 7094 Trondheim, Norway
Abstract The Type A behavior pattern (TABP) was a great success in predicting coronary heart disease (CHD) incidence for 20 – 30 years, and was considered a strong and independent risk factor for CHD development. The TABP, or behavior classifications closely related to this pattern, are still used both in practice and in research settings for this purpose. But, due to a number of negative findings of the relation between Type A behavior pattern and CHD from the middle of the 1980s and onward, and few positive findings in the same period of time, researchers and practitioners have questioned whether the TAPBP’s predictability of future CHD development has vanished. Is that the case, or what has happened that could have caused this change in trend of results and belief in the Type A behavior pattern? This article describes the TABP development, present status and alternative psychological explanations to CHD development. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Type A behavior pattern; Coronary heart disease; Personality; Trait; Social support
1. Introduction One of the first modern attempts to scrutinize the impact of psychological factors on heart incidences was the British author and scientist, Sir William Osler [1]. His lectures on personality correlates to angina pectoris [2] drew a great deal of attention to the problem area. After that, several scientists became interested in doing research in the area [3 –5], but it was not before the 1950s that the link between general behavior and coronary heart disease (CHD) were thoroughly investigated. *
Corresponding author. Fax: +47-7359-1770. E-mail address: [email protected] (G.A. Espnes).
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 6 3 5 - 0
100
G.A. Espnes / International Congress Series 1241 (2002) 99–104
The Type A behavior pattern (TABP) concept was launched by the cardiologists Rosenman and Friedman from the Western Collaborative Group Study and appeared in journal articles during 1959 –1964 [6,7]. There was a growing interest in the concept in the 1960s and 1970s. The pattern was, via research, found to be an independent risk factor for CHD development, as strong as the rest of the known risk factors combined. The original definition of the TABP was that the pathologic behaviour was ‘‘composed primarily of competitiveness, excessive drive and an enhanced sense of time urgency’’ [7], but it was later developed to ‘‘. . .TABP refers broadly to any person who is involved in an aggressive and incessant struggle to achieve more and more in less and less time’’ [8]. The first and original method of assessing Type A was the Structured Interview (SI). The instrument portfolio was later extended to comprise a scale developed for the purpose, the Jenkins Activity Survey (JAS) [9]. Rosenman [10], however, has since argued that this, and especially other, self-report measures ‘‘poorly assess TAB and have few interrelationships. Their ongoing use in many studies unfortunately continues to confuse.’’ That was also part of the conclusions in a metaanalysis by Booth-Kewley and Friedman [11]. The personal structured interview is far better than other assessment techniques. The SI takes in much more information about the individuals’ behaviour than does the selfreport scales. It also takes in information on how the person behaves in the interview situation, the phrases he uses and so on. After 20 years of continuing success, dark clouds gathered over the TABP. During the 1970s and 1980s, several findings reported little or no relationship between CHD and TABP. The earlier mentioned metaanalysis by Booth-Kewley and Friedman [11] concluded that the Type A behavior is only modestly related to CHD (and other occlusive diseases). Practitioners and researchers around the world started to consider TABP as an obsolete concept.
2. Developments and alternatives 2.1. Definition and model developments During the 1970s, different research on psychological impact on CHD development had shown that aggression, frustration and anger have a great influence on CHD development [11]. This had already been shown in the first research on Type A, and especially in the follow-ups and is also shown in the later definitions of the Type A behavior (Ref. [12], p. 2): . . .an action emotion complex involving behavioral predispositions such as aggressiveness, competitiveness, and impatience; specific behaviors such as muscle tenseness, alertness, rapid and empathic vocal stylists and accelerated pace of activities; and emotional responses such as irritation, hostility and increased potential of anger. The 1974 definition clearly put more emphasis on the results of the competitiveness and excessive drive than did the 1964 definition. The 1990 definition has developed this side. The picture that is drawn of the Type A person is far more negative when it comes to
G.A. Espnes / International Congress Series 1241 (2002) 99–104
101
emotions than it seemed to be in 1964. The frustration of not getting the expected results seems to have become important. This is probably an influence from the developments in the related areas. Byrne [13] included this in the following model (Fig. 1). This model postulates that manifest Type A behaviours arising from the underlying existence of competitiveness achieve their greatest pathophysiological toxicity if they are frustrated in their expression and realization (Ref. [13], p. 1). 2.2. Changeability of TABP It has been asked whether it is possible to change a TABP toward a healthier behaviour pattern. There is a large body of evidence that underlines the difficulty in changing the Type A behaviour. Rozanski et al. [14], for example, pointed to the problems with lifestyle behaviour changes. Carroll [15], however, reported positive modifications of Type A behaviour by the use of stress management training. We have in the literature and in our own research seen some success in using moderate physical activity as a potent procedure to change toward a healthier behaviour pattern. It is unclear though what exactly is causing the changes [16,17]. 2.3. The psychopathological alternatives to explain the psychopathological impacts in CHD development The first and most obvious alternative to explain the psychopathological impacts in CHD development are the personality traits and their connection to CHD development originally stemming from the observations of Menninger and Menninger [3], Kemple [4] and Gildea [5]. The personality trait explanations include characteristics which also have been connected to CHD development via Type A behaviour. In the Type A definition [8], CHD risk is explained as a result of the stress due to frustrations encountered when
Fig. 1. A model showing the pathways from competitiveness via Type A behaviour to frustration and CHD toxicity (adopted from Ref. [13], p. 1).
102
G.A. Espnes / International Congress Series 1241 (2002) 99–104
accomplishing what they set out to do. These characteristics comprise aggression, anger and hostility [11,18]. As a part of the hostility, suspiciousness has also been connected to CHD development. Of a later date is knowledge of the impact of depression/melancholia on CHD development [14,19]. The depression –CHD linkage is probably the topic that has been most present in everyday conversations in recent years. The reason is that several studies that have attracted considerable attention have especially focused on this connection. Anxiety and neuroticism has also, for a number of years, been connected to CHD development [11,13]. Based on their metaanalysis, Booth-Kewley and Friedman [11] concluded that a cluster of negative thoughts and feelings, which they named ‘‘negative emotions,’’ could have an effect on CHD development. As one can see, this is a combination of the previous characteristics. This has been given some attention by researchers in recent years, although conclusions could not be drawn as to whether negative emotion plays a crucial role in CHD development. The Hemingway and Marmot [20] review states that lack of social support is connected to CHD development. Large parts of the empirical research here is that of Gerdi Weidner. Her studies have shown that men who lack social support from their families, or more often do not have a family, suffer more often from cardiac incidents than do those who have support. Rozanski et al. [14] underline the effect of social isolation on CHD development. Based on what we now know, Rozanskiet al. (Ref. [14], p. 2210) suggested the following: Psychosocial factors may contribute in the development and promotion of coronary artery diseases in three ways: (1) they directly promote pathogenesis of atheroschlerosis; (2) they contribute to maintenance of unhealthy lifestyle behaviors (such as smoking and a poor diet); and after development of clinical disease, when targeted reduction of all unhealthy lifestyle behaviors becomes increasingly paramount, coexisting psychological stresses form an important barrier to successful modification of these lifestyle behaviours.
3. Present status and near future 3.1. What is the status of the TABP in 2001? When TABP was found to be an inadequate predictor of CHD in several research findings in the 1970s, 1980s and 1990s, one should think that the whole idea was banned. But that is not the case. In 2001, several researchers around the world still work with the TABP in different settings. Why is that? What is the reason for the continuing belief in TABP in spite of findings in the 1970s. The reason is that researchers in the field have come across several shortcomings in the research from the 1970s and 1980s, e.g., that there are few prospective studies in this research portfolio, and that inadequate measures were used (‘‘self-report measures poorly assess TAB and have few interrelationships, their ongoing use in many studies unfortu-
G.A. Espnes / International Congress Series 1241 (2002) 99–104
103
nately continues to confuse’’) [10]. In addition, there were possible changes in journal publication policy during the 1970s/1980s, and, lastly, there is a will and ability to update, clarify and reconceptualize the TABP by the scientists working with the concept. 3.2. The near future First, there is need for new metaanalyses in this research area. The Booth-Kewley and Friedman metaanalyses were authored during a period of negative feelings for the TABP. We all know that even metaanalyses are influenced by the researcher’s views and by the dominant ‘‘winds’’ that are blowing at the time of writing. Second, there is need for a new large prospective study where the most successful of the new theoretical possibilities are challenged. During the last 2 years, a lady with the Type A characteristics has become an iconperson of today. She appears both on screen and as a PC-play personality. She is competitive, she is impatient, always alert, she gets aggressive when frustrated, she tries to accomplish more and more in less and less time. Her name is Lara Croft.
References [1] W. Osler, Lectures on Angina Pectoris and Allied States, D. Appelton, New York, 1892. [2] W. Osler, Lectures on angina pectoris, Lancet 1 (1910) 839 – 844. [3] K.A. Menninger, W.C. Menninger, Psychoanalytic observations in cardiac disorders, Am. Heart J. 11 (1936) 10 – 26. [4] C. Kemple, Rorschach method and psychosomatic diagnosis: personality traits of patients with rheumatic disease, hypertension, cardiovascular disease, coronary occlusion and fracture, Psychosom. Med. 7 (1945) 85 – 89. [5] E. Gildea, Special features of personality which are common to certain psychosomatic disorders, Psychosom. Med. 11 (1949) 273 – 277. [6] M. Friedman, R.H. Rosenman, Association of a specific overt behavior pattern with increases in blood cholesterol, blood clotting time, incidence of arcus senilis and clinical coronary artery disease, JAMA, J. Am. Med. Assoc. 169 (1959) 1286 – 1296. [7] R.H. Rosenman, M. Friedman, R. Straus, M. Wurm, R. Kositchek, W. Hahn, N.T. Werthessen, A predictive study of coronary heart disease: the western collaborative group study, JAMA, J. Am. Med. Assoc. 189 (1) (1964) 103 – 110. [8] M. Friedman, R.H. Rosenman, Type A Behaviour and Your Heart, Knopf, New York, 1974. [9] C.D. Jenkins, S.J. Zyzanski, R.H. Rosenman, Jenkins Activity Survey Manual, The Psychological, New York, 1979. [10] R.H. Rosenman, Proceedings from the 14th World Congress on Psychosomatic Medicine. Psychosomatic Medicine: Towards the years 2000. Cairns, Australia, 31st August – 5th September 1997. [11] S. Booth-Kewley, H.S. Friedman, Psychological predictors of heart disease: a quantitative review, Psychol. Bull. 101 (3) (1987) 343 – 362. [12] R.H. Rosenman, Type A behavior pattern: a personal overview, J. Soc. Behav. 5 (1990) 1 – 24. [13] D.G. Byrne, Type A behaviour, anxiety and neuroticism: reconceptualizing the paths and boundaries of coronary-prone behaviour, Stress Med. 12 (1996) 227 – 238. [14] A. Rozanski, J.A. Blumenthal, J. Kaplan, Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy, Circulation 99 (1999) 2192 – 2217. [15] D. Carroll, Health Psychology: Stress, Behaviour and Disease, The Falmer Press, London, 1992. [16] L. Schmied, H. Steinber, T. Moss, E. Sykes, Aerobic exercise and Type A behaviour, J. Sports Sci. 12 (1994) 433 – 445.
104
G.A. Espnes / International Congress Series 1241 (2002) 99–104
[17] G.A. Espnes, K. Johnsen, E. Arntsberg, Type A behaviour pattern (TABP), Type 2 personality and the effect of moderate endurance training, Conference Proceedings from 12th Conference of the European Health Psychology Society, Vienna 31 August – 02 September 1998. [18] F.G. Fowkes, G.C. Leng, P.T. Donnan, I.J. Deary, R.A. Kiemersma, E. Housley, Serum cholesterol, triglycerides, and aggression in the general population, Lancet 340 (1992) 995 – 998. [19] I. Sihm, G. Dehlholm, E.S. Hansen, L.U. Gerdes, Psychic vulnerability and Type A among young Danish male survivors of acute myocardial infarction, Nordisk Psykiatrisk Tidsskrift 45 (1991) 451 – 456. [20] H. Hemingway, M. Marmot, Clinical review. Evidence based cardiology. Psychological factors in the aetiology and prognosis of coronary heart disease; systematic review of prospective cohort studies, BMJ [Br. Med. J.] 318 (1999) 1460 – 1467.
The Type A behavior pattern and coronary heart disease: a critical and personal look at the Type A behavior pattern at the turn of the century Geir Arild Espnes* Department of Social Work and Health Science and Section for Sport Sciences, Norwegian University of Science and Technology, 7094 Trondheim, Norway
Abstract The Type A behavior pattern (TABP) was a great success in predicting coronary heart disease (CHD) incidence for 20 – 30 years, and was considered a strong and independent risk factor for CHD development. The TABP, or behavior classifications closely related to this pattern, are still used both in practice and in research settings for this purpose. But, due to a number of negative findings of the relation between Type A behavior pattern and CHD from the middle of the 1980s and onward, and few positive findings in the same period of time, researchers and practitioners have questioned whether the TAPBP’s predictability of future CHD development has vanished. Is that the case, or what has happened that could have caused this change in trend of results and belief in the Type A behavior pattern? This article describes the TABP development, present status and alternative psychological explanations to CHD development. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Type A behavior pattern; Coronary heart disease; Personality; Trait; Social support
1. Introduction One of the first modern attempts to scrutinize the impact of psychological factors on heart incidences was the British author and scientist, Sir William Osler [1]. His lectures on personality correlates to angina pectoris [2] drew a great deal of attention to the problem area. After that, several scientists became interested in doing research in the area [3 –5], but it was not before the 1950s that the link between general behavior and coronary heart disease (CHD) were thoroughly investigated. *
Corresponding author. Fax: +47-7359-1770. E-mail address: [email protected] (G.A. Espnes).
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 6 3 5 - 0
100
G.A. Espnes / International Congress Series 1241 (2002) 99–104
The Type A behavior pattern (TABP) concept was launched by the cardiologists Rosenman and Friedman from the Western Collaborative Group Study and appeared in journal articles during 1959 –1964 [6,7]. There was a growing interest in the concept in the 1960s and 1970s. The pattern was, via research, found to be an independent risk factor for CHD development, as strong as the rest of the known risk factors combined. The original definition of the TABP was that the pathologic behaviour was ‘‘composed primarily of competitiveness, excessive drive and an enhanced sense of time urgency’’ [7], but it was later developed to ‘‘. . .TABP refers broadly to any person who is involved in an aggressive and incessant struggle to achieve more and more in less and less time’’ [8]. The first and original method of assessing Type A was the Structured Interview (SI). The instrument portfolio was later extended to comprise a scale developed for the purpose, the Jenkins Activity Survey (JAS) [9]. Rosenman [10], however, has since argued that this, and especially other, self-report measures ‘‘poorly assess TAB and have few interrelationships. Their ongoing use in many studies unfortunately continues to confuse.’’ That was also part of the conclusions in a metaanalysis by Booth-Kewley and Friedman [11]. The personal structured interview is far better than other assessment techniques. The SI takes in much more information about the individuals’ behaviour than does the selfreport scales. It also takes in information on how the person behaves in the interview situation, the phrases he uses and so on. After 20 years of continuing success, dark clouds gathered over the TABP. During the 1970s and 1980s, several findings reported little or no relationship between CHD and TABP. The earlier mentioned metaanalysis by Booth-Kewley and Friedman [11] concluded that the Type A behavior is only modestly related to CHD (and other occlusive diseases). Practitioners and researchers around the world started to consider TABP as an obsolete concept.
2. Developments and alternatives 2.1. Definition and model developments During the 1970s, different research on psychological impact on CHD development had shown that aggression, frustration and anger have a great influence on CHD development [11]. This had already been shown in the first research on Type A, and especially in the follow-ups and is also shown in the later definitions of the Type A behavior (Ref. [12], p. 2): . . .an action emotion complex involving behavioral predispositions such as aggressiveness, competitiveness, and impatience; specific behaviors such as muscle tenseness, alertness, rapid and empathic vocal stylists and accelerated pace of activities; and emotional responses such as irritation, hostility and increased potential of anger. The 1974 definition clearly put more emphasis on the results of the competitiveness and excessive drive than did the 1964 definition. The 1990 definition has developed this side. The picture that is drawn of the Type A person is far more negative when it comes to
G.A. Espnes / International Congress Series 1241 (2002) 99–104
101
emotions than it seemed to be in 1964. The frustration of not getting the expected results seems to have become important. This is probably an influence from the developments in the related areas. Byrne [13] included this in the following model (Fig. 1). This model postulates that manifest Type A behaviours arising from the underlying existence of competitiveness achieve their greatest pathophysiological toxicity if they are frustrated in their expression and realization (Ref. [13], p. 1). 2.2. Changeability of TABP It has been asked whether it is possible to change a TABP toward a healthier behaviour pattern. There is a large body of evidence that underlines the difficulty in changing the Type A behaviour. Rozanski et al. [14], for example, pointed to the problems with lifestyle behaviour changes. Carroll [15], however, reported positive modifications of Type A behaviour by the use of stress management training. We have in the literature and in our own research seen some success in using moderate physical activity as a potent procedure to change toward a healthier behaviour pattern. It is unclear though what exactly is causing the changes [16,17]. 2.3. The psychopathological alternatives to explain the psychopathological impacts in CHD development The first and most obvious alternative to explain the psychopathological impacts in CHD development are the personality traits and their connection to CHD development originally stemming from the observations of Menninger and Menninger [3], Kemple [4] and Gildea [5]. The personality trait explanations include characteristics which also have been connected to CHD development via Type A behaviour. In the Type A definition [8], CHD risk is explained as a result of the stress due to frustrations encountered when
Fig. 1. A model showing the pathways from competitiveness via Type A behaviour to frustration and CHD toxicity (adopted from Ref. [13], p. 1).
102
G.A. Espnes / International Congress Series 1241 (2002) 99–104
accomplishing what they set out to do. These characteristics comprise aggression, anger and hostility [11,18]. As a part of the hostility, suspiciousness has also been connected to CHD development. Of a later date is knowledge of the impact of depression/melancholia on CHD development [14,19]. The depression –CHD linkage is probably the topic that has been most present in everyday conversations in recent years. The reason is that several studies that have attracted considerable attention have especially focused on this connection. Anxiety and neuroticism has also, for a number of years, been connected to CHD development [11,13]. Based on their metaanalysis, Booth-Kewley and Friedman [11] concluded that a cluster of negative thoughts and feelings, which they named ‘‘negative emotions,’’ could have an effect on CHD development. As one can see, this is a combination of the previous characteristics. This has been given some attention by researchers in recent years, although conclusions could not be drawn as to whether negative emotion plays a crucial role in CHD development. The Hemingway and Marmot [20] review states that lack of social support is connected to CHD development. Large parts of the empirical research here is that of Gerdi Weidner. Her studies have shown that men who lack social support from their families, or more often do not have a family, suffer more often from cardiac incidents than do those who have support. Rozanski et al. [14] underline the effect of social isolation on CHD development. Based on what we now know, Rozanskiet al. (Ref. [14], p. 2210) suggested the following: Psychosocial factors may contribute in the development and promotion of coronary artery diseases in three ways: (1) they directly promote pathogenesis of atheroschlerosis; (2) they contribute to maintenance of unhealthy lifestyle behaviors (such as smoking and a poor diet); and after development of clinical disease, when targeted reduction of all unhealthy lifestyle behaviors becomes increasingly paramount, coexisting psychological stresses form an important barrier to successful modification of these lifestyle behaviours.
3. Present status and near future 3.1. What is the status of the TABP in 2001? When TABP was found to be an inadequate predictor of CHD in several research findings in the 1970s, 1980s and 1990s, one should think that the whole idea was banned. But that is not the case. In 2001, several researchers around the world still work with the TABP in different settings. Why is that? What is the reason for the continuing belief in TABP in spite of findings in the 1970s. The reason is that researchers in the field have come across several shortcomings in the research from the 1970s and 1980s, e.g., that there are few prospective studies in this research portfolio, and that inadequate measures were used (‘‘self-report measures poorly assess TAB and have few interrelationships, their ongoing use in many studies unfortu-
G.A. Espnes / International Congress Series 1241 (2002) 99–104
103
nately continues to confuse’’) [10]. In addition, there were possible changes in journal publication policy during the 1970s/1980s, and, lastly, there is a will and ability to update, clarify and reconceptualize the TABP by the scientists working with the concept. 3.2. The near future First, there is need for new metaanalyses in this research area. The Booth-Kewley and Friedman metaanalyses were authored during a period of negative feelings for the TABP. We all know that even metaanalyses are influenced by the researcher’s views and by the dominant ‘‘winds’’ that are blowing at the time of writing. Second, there is need for a new large prospective study where the most successful of the new theoretical possibilities are challenged. During the last 2 years, a lady with the Type A characteristics has become an iconperson of today. She appears both on screen and as a PC-play personality. She is competitive, she is impatient, always alert, she gets aggressive when frustrated, she tries to accomplish more and more in less and less time. Her name is Lara Croft.
References [1] W. Osler, Lectures on Angina Pectoris and Allied States, D. Appelton, New York, 1892. [2] W. Osler, Lectures on angina pectoris, Lancet 1 (1910) 839 – 844. [3] K.A. Menninger, W.C. Menninger, Psychoanalytic observations in cardiac disorders, Am. Heart J. 11 (1936) 10 – 26. [4] C. Kemple, Rorschach method and psychosomatic diagnosis: personality traits of patients with rheumatic disease, hypertension, cardiovascular disease, coronary occlusion and fracture, Psychosom. Med. 7 (1945) 85 – 89. [5] E. Gildea, Special features of personality which are common to certain psychosomatic disorders, Psychosom. Med. 11 (1949) 273 – 277. [6] M. Friedman, R.H. Rosenman, Association of a specific overt behavior pattern with increases in blood cholesterol, blood clotting time, incidence of arcus senilis and clinical coronary artery disease, JAMA, J. Am. Med. Assoc. 169 (1959) 1286 – 1296. [7] R.H. Rosenman, M. Friedman, R. Straus, M. Wurm, R. Kositchek, W. Hahn, N.T. Werthessen, A predictive study of coronary heart disease: the western collaborative group study, JAMA, J. Am. Med. Assoc. 189 (1) (1964) 103 – 110. [8] M. Friedman, R.H. Rosenman, Type A Behaviour and Your Heart, Knopf, New York, 1974. [9] C.D. Jenkins, S.J. Zyzanski, R.H. Rosenman, Jenkins Activity Survey Manual, The Psychological, New York, 1979. [10] R.H. Rosenman, Proceedings from the 14th World Congress on Psychosomatic Medicine. Psychosomatic Medicine: Towards the years 2000. Cairns, Australia, 31st August – 5th September 1997. [11] S. Booth-Kewley, H.S. Friedman, Psychological predictors of heart disease: a quantitative review, Psychol. Bull. 101 (3) (1987) 343 – 362. [12] R.H. Rosenman, Type A behavior pattern: a personal overview, J. Soc. Behav. 5 (1990) 1 – 24. [13] D.G. Byrne, Type A behaviour, anxiety and neuroticism: reconceptualizing the paths and boundaries of coronary-prone behaviour, Stress Med. 12 (1996) 227 – 238. [14] A. Rozanski, J.A. Blumenthal, J. Kaplan, Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy, Circulation 99 (1999) 2192 – 2217. [15] D. Carroll, Health Psychology: Stress, Behaviour and Disease, The Falmer Press, London, 1992. [16] L. Schmied, H. Steinber, T. Moss, E. Sykes, Aerobic exercise and Type A behaviour, J. Sports Sci. 12 (1994) 433 – 445.
104
G.A. Espnes / International Congress Series 1241 (2002) 99–104
[17] G.A. Espnes, K. Johnsen, E. Arntsberg, Type A behaviour pattern (TABP), Type 2 personality and the effect of moderate endurance training, Conference Proceedings from 12th Conference of the European Health Psychology Society, Vienna 31 August – 02 September 1998. [18] F.G. Fowkes, G.C. Leng, P.T. Donnan, I.J. Deary, R.A. Kiemersma, E. Housley, Serum cholesterol, triglycerides, and aggression in the general population, Lancet 340 (1992) 995 – 998. [19] I. Sihm, G. Dehlholm, E.S. Hansen, L.U. Gerdes, Psychic vulnerability and Type A among young Danish male survivors of acute myocardial infarction, Nordisk Psykiatrisk Tidsskrift 45 (1991) 451 – 456. [20] H. Hemingway, M. Marmot, Clinical review. Evidence based cardiology. Psychological factors in the aetiology and prognosis of coronary heart disease; systematic review of prospective cohort studies, BMJ [Br. Med. J.] 318 (1999) 1460 – 1467.