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1、(Circulation. 1998;98:405.) 1998 American Heart Association, Inc.Clinical Investigation and ReportsProspective Study of a Self-Report Type A Scale and Risk of Coronary Heart DiseaseAbstractBackgroundSeveral methods exist by which to assess type A behavior (TAB).Although the videotaped clinical inter
2、view is regarded as the gold standard, self-report measures have also proved useful in assessing TAB in large population studies. The purpose of this study was to examine prospectively the relationship of TAB to risk of coronary heart disease (CHD) incidence with the use of the revised Minnesota Mul
3、tiphasic Personality Inventory (MMPI-2) Type A Scale. To the best of our knowledge,this is the first test of this scale in the context of predicting CHD incidence. Methods and ResultsThe study was performed in the VA Normative Aging Study, an ongoing cohort of older (mean age, 61 years) community-dw
4、elling men. A total of 1305 men who were free of diagnosed CHD in 1986 completed the MMPI-2 Type A Scale. During an average 7.0 years of follow-up, 110cases of incident CHD occurred. Compared with men in the lowest quartile of type A scores, men in the highest quartile had multivariate adjusted rela
5、tive risks of 2.86 (95% CI, 1.19 to 6.89; P for trend=0.016) for combined CHD death and nonfatal myocardial infarction (MI) and 2.30 (95% CI, 1.32 to 4.01; P for trend=0.001) for combined CHD death/nonfatal MI plus angina pectoris. The relationship of TAB to CHD was independent of measures of anger
6、and cynicism. ConclusionsThe MMPI-2 Type A Scale predicts CHD incidence. Further research is warranted to examine the correlation, if any, between this scale and the videotaped clinical interview.Key Words: coronary disease type A personality hostility angerIntroductionResearch on TAB peaked during
7、the 1980s, accompanied by high levels of enthusiasm for the screening and diagnosis of this behavior pattern and psychosocial interventions aimed at modifying the risk of CHD.1 However,conflicting evidence on the relationship between TAB and CHD in epidemiological studies2 3 4 has led some observers
8、 to question the clinical utility of identifying this behavior pattern.57Part of the reason for the conflicting evidence linking TAB to coronary risk may be the differences in methods used by researchers to identify this behavior pattern. Broadly, 2 approaches exist for diagnosing the type A pattern
9、: the structured interview approach (also known as VCE8,9) and various self-report questionnaire based approaches, such as the JAS,10 the Framingham Type A Scale,11 and the Bortner Scale.12 The advantage of the VCE approach is that it provides a situation in which TAB may be directly observed. As fo
10、rmulated by Friedman,13 TAB is an action-emotion complex that requires an environmental challenge to serve as the trigger forexpression. The overt manifestations of the behavior pattern includ afree-floating but well-rationalized hostility, hyperaggressiveness, and a sense of time urgency. Visual cu
11、es to TAB, such as hurried speech and hostile facial expressions, are most likely to be caught during the VCE. By contrast, self-report assessments of TAB are unlikely to capture these aspects of behavior, which are often beyond a subjects awareness. It is notable, therefore, that epidemiological st
12、udies reporting no association between TAB and CHD2 3 4 have tended to use questionnaire based approaches, whereas interview-based approaches have continued to reportan association.The conflicting results of studies based on self-reported assessment of TAB may occur in part because existing question
13、naires inquire about some but not all of the components of this action-emotion complex.19 For example,the JAS (a commonly used self-report instrument in previous US studies2,3) includes subscales for hard-driving competitiveness, speed and impatience, and job involvement. However, the instrument doe
14、s not contain many items regarding hostility or aggressiveness. Another commonly used questionnaire, the Framingham Type A Scale,11 assesses an individuals sense of time urgency, competitive drive, and perceptions of job pressures but not the level of hostility (which is measured by a separate scale
15、). Thus, different questionnaires have tended to emphasize different components of the TAB pattern. In contrast to earlier scales such as the JAS, the MMPI-2 Type A Scale incorporates a broader set of components that have been identified as being potentially toxic: hostility, competitiveness, and ti
16、me urgency. It is possible that it is the combination of the above components, rather than any one in isolation,20 that increases coronary risk, so a globalassessment of TAB (such as provided by the MMPI-2 scale) might provide a better prediction of CHD. Therefore, the purpose of the present study w
17、as to examine prospectively the ability of the MMPI-2 Type A Scale to predict CHD incidence. To the best of our knowledge, this is the first report of the use of the MMPI-2 Type A Scale in the context of predicting CHD incidence in a cohort of disease-free individuals.MethodsThe study was carried ou
18、t in the Normative Aging Study, which is a longitudinal study of aging established by the Veterans Administration in 1961.21 The study cohort consists of 2280 community-dwelling men from the greater Boston area who were 21 to 80 years of age at the time of entry. Volunteers were screened at entry ac
19、cording to health criteria20 and were free of known chronic medical conditions (including diabetes mellitus) at the start of follow-up.Assessment of TABIn 1986, the MMPI-222 was administered by mail to all active cohort members (n=1881). Of the 1550 men who responded (82.4% response rate), complete
20、and valid questionnaire data were available for 94% (n=1459). We excluded 154 men with preexisting CHD (angina pectoris or history of MI), resulting in a study population of 1305 men. The mean age of the study population was 61.8 years (SD, 8.3 years; range, 40 to 90 years). TAB was assessed prospec
21、tively, ie, before the onset of coronary heart disease. The MMPI-2 Type A Scale is made up of 19 items that require true or false responses to questions about time urgency, competitiveness, andhostile attitudes (see the Appendix). High scorers on the type A scale are described as hard-driving, fast-
22、moving, and work-oriented individuals who frequently become impatient, irritable, and annoyed. The scale was developed from the MMPI Restandardization Project involving a national, representative sample of 2600 subjects (1138 men and 1462 women).23 Butcher et al23 developed the scale from a multiste
23、p process involving the rational identification of content areas (independent rater selection of items from the total MMPI pool and expert consensus on selection of items) and statistical verification of item-to-scale membership. The type A scale has excellent 9-day test-retest reliability (r=0.82)
24、and internal consistency reliability (Cronbachs =0.72) in men.23 Responses to the scale have been validated against spousal ratings of behavior. Specific behaviors described by spouses of high-TAB men include having temper tantrums; acting bossy; arguing over minor things; and being irritable, angry
25、, and tense.23 Responses to the type A scale were categorized a priori into 4 approximately equally sized groups on the basis of the distribution of scores in this population: 0 to 4 (24.5%),5 to 7 (29.1%), 8 to 10 (23.8%), and 11 (22.7%). Assessment of Anger, Cynicism, and Hostility From the MMPI-2
26、, we also assessed levels of anger and cynicism, both of which have been reported previously to be correlated with TAB, to predictthe risk of CHD.24 25 26 27 The MMPI-2 Anger Content Scale is made up of 16 items that require true or false responses to questions about expression or control of anger.
27、It has high test-retest reliability (r=0.85) and internal consistency reliability (Cronbachs =0.76) in men.23 This scale has been shown previously to predict a 2- to 3-fold increased risk of CHD incidence in this cohort.25 High scores on the scale suggest anger-control problems. These individuals re
28、port being irritable andhotheaded and sometimes feeling like swearing or smashing things. Individual items on the MMPI-2 anger scale are quite similar to those of other scales, like the Spielberger Anger Expression Scale,28 which measures aspects of anger such as frequency of the expression of anger
29、 directed at other people or objects (Anger-Out Subscale) and the extent to which a person works to control the experience and expression of anger (Anger-Control Subscale). Responses to the anger subscale werecategorized a priori into 3 levels on the basis of the distribution of scores in this popul
30、ation: 0 or 1, 2 to 4, and 5 to 14. The MMPI-2 Cynicism Scale comprises 23 items that inquire about misanthropic beliefs. The scale also has excellent test-retest reliability (r=0.80) and internal consistency reliability (Cronbachs =0.86).23 Individuals who score high on this scale expect hidden, ne
31、gativemotives behind the acts of others, eg. believing that most people are honest simply because they fear being caught. These individuals are likely to hold negative attitudes toward those close to them, including fellow workers, family, and friends.22 Items on the cynicism scale overlap with many
32、 of the questions that make up the 50-item Ho Scale,29 which some have suggested measures cynical hostility.30 Because the Ho Scale has been linked to CHD incidence in some studies, some researchers have claimed that it taps into the toxic core of TAB.31 32 33 Finally, we examined 3 additional subsc
33、ales in the original MMPI related to hostility and aggression.27 These subscaleshostile affect (5 items), hostile attribution (12 items), and aggressive responding (9 items)were developed by Barefoot et al27 from a subset of the Ho Scale items and have been demonstrated to predict CHD incidence and
34、all-cause mortality.27 Hostile affect measures the negative emotions associated with social relationships, and high scores reflect anger, impatience, and loathing when dealing with others. Hostile attribution measures the tendency to interpret the behavior of others as intended to harm the responden
35、t, and high scores reflect suspicion, paranoia, and fear of threat to the self. Aggressive responding measures the respondents tendency to use anger and aggression as instrumental responses to problems or to endorse these behaviors as reasonable and justified.27 Measurement of Other Cardiovascular R
36、isk Factors Every 3 to 5 years, participants in the Normative Aging Study are assessed by physical examination, updating of medical history, and measurement of a variety of biochemical values, including serum cholesterol. Cigarette smoking status (current, former, or never) is ascertained by a train
37、ed interviewer. Current smokers are defined as men who smoke 1 cigarette per day. Weight and height are measured with the participants wearing only socks and underpants. Body mass index (weight/height2) is then calculated. Blood pressure is measured by an examining physician with a standard mercury
38、sphygmomanometer with a 14-cm cuff. With the subject seated, systolic blood pressure and fifth-phase diastolic blood pressures are measured in each arm to the nearest 2 mm Hg. The average systolic and diastolic blood pressures in both arms were used in analyses. Only 8 individuals in the study popul
39、ation were receiving oral hypoglycemic agents or insulin. Assessment of Morbidity and MortalityThe average length of follow-up in the present study was 7.0 years (SD, 2.3 years). The present study includes all confirmed CHD end points (angina pectoris, myocardial infarction, fatal CHD) that occurred
40、 during the average 7 years of follow-up. Individuals were censored either at the time of developing a coronary end point (or death) or from the time of their most recent follow-up visit.A medical history was obtained from each participant at his regular follow-up visit every 3 to 5 years. The hospi
41、tal records were obtained for every report of a possible CHD event and reviewed by a board-certified cardiologist (P.S.V.). The criteria for myocardial infarction and angina pectoris were those used in the Framingham Heart Study.34 MI was diagnosed only when documented by unequivocal ECG changes (ie
42、, pathological Q waves), by a diagnostic elevation of serum enzymes (serum glutamicoxalacetic transaminase and lactic dehydrogenase) together with chest discomfort consistent with MI, or by autopsy. Angina pectoris was diagnosed when the subject reported recurrent chest discomfort lasting up to 15 m
43、inutes, which was distinctly related to exertion and relieved by rest or nitroglycerin. Death from CHD was designated when a death certificate (coded according to the eighth revision of the International Classification of Diseases35) indicated an underlying cause of death coded to rubric 410 through
44、 414. The medical records in each instance of CHD death were reviewed by a board-certified cardiologist (P.S.V.) to ensure accurate coding. Most deaths occurring in this cohort are notified through next of kin or postal authorities. Every year, birthday cards have been mailed to participants in the
45、cohort, at which point news of a participants death is likelyto be reported to the investigators by the next of kin. Additional opportunities to ascertain the vital status of participants occur when supplemental questionnaires are mailed to participants approximately annually. Finally, we routinely
46、search the state vital records and the records of the Department of Veterans Affairs to find deaths that may have gone unreported. Thus, our ascertainment of fatal events is both systematic and comprehensive.Data AnalysisWe ran proportional hazards models using SAS36 to estimate the relative risks o
47、f CHD according to different levels of type A score, controlling for a range of potential confounding variables ascertained in 1986, including age (years), body mass index (kg/m2), smoking status (never, former, current), systolic and diastolic blood pressure (mm Hg), serum cholesterol level (mg/dL)
48、, family history of heart disease (yes/no), and whether the participant drank 2 drinks of alcohol per day (yes/no). The multivariate probability value for linear trend in the relative risk was estimated by entering the type A score as a continuous variable in theregression models.DiscussionThe first
49、 large-scale prospective epidemiological demonstration of the link between TAB and CHD incidence emerged from the Western Collaborative Group Study in 1975.38 Two other confirmatory studies of CHD incidence followed: the Framingham Heart Study11 and the French-Belgian Cooperative Group Study.39 On the basis of the evidence available at the time, a National Institutes of Health panel concluded in 1981 that TAB was an independent risk factor for CHD.40 In studies published before 1985, the most co
