How two cardiologists discovered Type A

Taken from the desk of a patient who suffered a fatal heart attack while rushing to catch the 5:43 pm train*

by Carolyn Thomas   ♥   @HeartSisters

Back in 1959, cardiologists Drs. Meyer Friedman and Ray Rosenman submitted a research paper to the Journal of the American Medical Association. Their study was accepted and published; it suggested a correlation between coronary artery disease and those living with “overt behavior pattern A” – a link the co-authors claimed was as significant as smoking, cholesterol and high blood pressure.(1)  Their subsequent best selling book Type A Behavior And Your Heart in 1974 prompted further studies by other researchers, and soon “Type A personality” became a popular term in our everyday conversations. The name described people who exhibit personality traits like hostility, impatience, competitiveness, drive, perfectionism and an unhealthy dependence on external rewards.

But it turns out it was a sharp-eyed secretary in their medical practice who first brought this potential link to their attention.

In an interview with The American Institute of Stress for their Health and Stress publication*, the late Dr. Rosenman explained:

“A discerning secretary in our office practice told us that in contrast to our other patients, those with coronary artery disease were rarely late for appointments and preferred to sit in hard-upholstered chairs rather than softer ones or sofas.

“These chairs also had to be reupholstered far more often than others because the front edges quickly became worn out.

“They looked at their watches frequently and acted impatient when they had to wait, usually sat on the edges of waiting room chairs and tended to leap up when called to be examined. Her astute observations significantly reinforced our own awareness of similar behaviors.”

Over the years since their early research and book launch, the initial support and enthusiasm for their Type A/coronary heart disease theory has waned. Their conclusions were further questioned after it was discovered that the tobacco industry had been a major funder of Type A behavior pattern research from the late 1950s until the late 1990s.

In fact, tobacco giant Philip Morris provided most of the funding to the Meyer Friedman Institute (a research center at the University of California, San Francisco named after one of the “Type A” cardiologists, dedicated to studying the relationship between cardiovascular disease and stress) to a total of nearly $11 million up to 1997.(2)

Big Tobacco’s substantial funding to important Type A researchers in the field included – ironically! – supporting a university research chair in preventive medicine at the same university.

This corporate strategy helped the industry counter both public concerns and growing expert opinions that blamed cigarette smoking for several serious health problems.  In other words, “it’s not smoking that caused your cancer or heart disease, it’s your stressed-out personality!”

Tobacco companies hoped that research on many forms of individual health risks such as genetics or “addictive personalities” could suggest alternative and legitimate explanations for the relationship between smoking, cancer, and coronary heart disease. This even included research on the “curative” aspects of smoking to relieve stress.

A Philip Morris vice-president disclosed in a memo at the time that Yale University had also received similar research funding that was indirectly channeled through the Meyer Friedman Institute to circumvent Yale’s ban on accepting tobacco industry funding. (2) The memo concluded:

“From such research, there is a really large potential for shifting blame away from smoking.”

But unfortunately for Philip Morris and other major tobacco companies, later studies failed to confirm the opinion of a National Institutes of Health expert panel that had initially endorsed the early theory that Type A was a “significant risk factor for coronary disease in middle-aged U.S. workers”. 

As study after study disputed the original Friedman and Rosenman theories, only one Type A personality characteristic, the “toxic component” of hostility, was generally considered to be linked with coronary heart disease.

But guess who funded this research into hostility ?

With most other Type A personality traits discredited, Philip Morris provided its “largest funding to date” to Dr. Redford Williams of Duke University, totaling $5 million from 1985 to 1989, in order to examine the effects of hostility on coronary artery disease.(3)

Dr. Williams’ past research suggested that hostile people are more likely to develop irregular heart rhythms, and to die before reaching their 50s. Another tobacco company, RJ Reynolds, had previously funded his studies to reach the same conclusion on the same subject at Duke in 1983, along with Dr. Rosenman and others. Dr. Williams is also the author, with his wife Virginia Williams, of the book Anger Kills: Seventeen Strategies for Controlling Hostility That Can Harm Your Health.

Although his Type A theory is largely discredited by now, Dr. Rosenman’s description of those early days of cardiac research still offer a compelling glimpse into the work of these two cardiologists as they tried to unravel the medical mysteries of heart disease, as he explained in the The American Institute of Stress interview:

”    Mike (Dr. Meyer Friedman) and I were partners in our San Francisco clinical practice across the street from Mount Zion Hospital and Medical Center. Our Harold Brunn Institute for Cardiovascular Research building adjoined the hospital, and following early hospital rounds we spent full mornings in the research lab and afternoons in the office with our patients.

“By 1950, although fat and cholesterol had long been fed to lab rabbits to produce vascular lesions, little was known about where plasma cholesterol came from or how it was metabolized. We also noted that this type of vascular damage was quite different from that seen in patients with coronary artery disease.

“We obtained grants to begin animal studies and Mike was able to solve many fundamental aspects of cholesterol metabolism. Around 1952, because of our growing interest in cholesterol, we obtained blood samples from our private patients at every visit for (no-cost) accurate analyses at our research lab.”

The medical duo also observed that the cluster of behaviours that emerged from their research subjects was far more common in males than females, and they also claimed that the increased incidence of coronary disease had occurred mainly in men without any significant changes of diet or diagnoses of diabetes, hypertension or other risk factors. Nor could the latter explain large geographic differences in coronary disease across North vs. South Europe and elsewhere. NOTE FROM CAROLYN: One wonders, of course, how many female patients were even considered/invited to participate in those early studies given the prevalent gender gap in cardiology research in the mid 20th century – a gap that continues to this day. 

Another reason that the Type A/coronary heart disease link theory gradually fell out of favour was that, like the word “stress”, Type A meant different things to different people. In response to the question “Is stress the same as Type A?”, Dr. Rosenman explained during his American Institute of Stress interview:

”    Type A behavior pattern and stress are quite different.

“I am amazed at how many books and vast numbers of publications use the word stress so glibly and entirely without definition. I think that what most people call stress actually refers to anxiety or feelings of mental and emotional strain.

“Type A’s rarely perceive stress or admit to being stressed. It’s often stated that Type A’s cause stress in others, but rarely personally feel stressed.

“However, it is probably true that some factors in what we call stress do contribute to coronary heart disease.”

 

Q: What do you make of Type A personality as a risk for coronary heart disease?

(1) Friedman M, Rosenman RH. Association of Specific Overt Behavior Pattern With Blood and Cardiovascular Findings: Blood Cholesterol Level, Blood Clotting Time, Incidince of Arcus Senilis, and Clinical Coronary Artery Disease. JAMA. 1959; 169(12):1286-1296. doi:10.1001/jama.1960.03000290012005.

(2) Petticrew MP, Lee K, McKee M. Type A Behavior Pattern and Coronary Heart Disease: Philip Morris’s “Crown Jewel.” American Journal of Public Health. 2012;102(11):2018-2025. doi:10.2105/AJPH.2012.300816.

(3) Wall C.  – Letter to Murray H Bring. April 1, 1992. Bates no. 2023137226/7230. Available at: http://legacy.library.ucsf.edu/tid/hxn87e00.

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NOTE FROM CAROLYN:  I wrote more about identifying cardiac risk factors in my book  “A Woman’s Guide to Living with Heart Disease“.  You can ask for it at bookstores (please support your local independent bookseller!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher Johns Hopkins University Press (use their code HTWN to save 30% off the list price).

See also:

Forget Type A: a woman’s heart disease risk is higher for Type D personalities

A ‘crazy-making vicious cycle of stress and discontent”

Stressed: Who, me?

Why “NO” is a complete sentence

Is family stress hurting your heart?

Poor marriage = poor heart health for women

A heart patient’s guide to the three stages of chronic stress

“Stress creep”: are you like the frog in the pot of boiling water?

How runaway stress hurts your heart – and your brain

How our girlfriends can help us get through the toughest times

Four ingredients in the heart patient’s recipe for stress

Six personality coping patterns that influence how you handle heart disease