Circulation. 1999;100:685-688
(Circulation. 1999;100:685-688.)
© 1999 American Heart Association, Inc.
Prospective Study of a Self-Report Type A Scale and Risk of Coronary Heart Disease: Test of the MMPI-2 Type A Scale
Mark W. Ketterer, PhD
Henry Ford Health Sciences Center Detroit, Mich
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Introduction
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To the Editor:
Kawachi et al1 report that type A behavior, as measured by
the Minnesota Multiphasic Personality Inventory (revised) (MMPI-2), is
an independent predictor of coronary heart disease death,
nonfatal myocardial infarction, and angina, even after controlling for
anger and cynicism, also measured by the MMPI-2. This is the first
study to validate the predictive validity of the MMPI-2 for cardiac end
points. The risk ratios observed were moderately strong, although not
as strong as those previously observed for other measures of emotional
distress (eg, the Beck Depression Inventory and the Crown-Crisp Phobic
Anxiety Inventory). Because measures of different types of emotional
distress are always confounded, the independence of the type A behavior
scale above and beyond these other scales remains unclear. More
importantly, the claim that this scale is independent of anger is
dubious given that a dose-response relationship exists between severity
of coronary artery disease and denial of anger2 3
as measured by discrepancies between frequency ratings from patients
and a person they select as "someone who knows you well." For males
at least, the more severe a person's coronary artery disease,
the more likely the patient is to deny anger relative to a significant
other's rating of anger frequency.4 Approximately 40% of
males from a catheterization laboratory sample display
denial of anger, and denial predicts a 4.4-fold increased relative risk
for death over 5 years.5
Thus, any study that uses only self-reported anger provides little in
the way of valid understanding. Apart from randomly assigned,
controlled intervention trials, perhaps the most pressing need in
clinical care of stress in the ischemic heart disease patient
is a test of the relative power and independence of these various
scales. Once a scale (or scales) emerges as the strongest and most
independent predictor(s) of outcomes, it will be possible to make
authoritative recommendations for clinical screening.
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References
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Kawachi I, Sparrow D, Kubzansky LD, Spiro A III,
Vokonas PS, Weiss ST. Prospective study of a self-report type A scale
and risk of coronary heart disease: test of the MMPI-2 Type A
Scale. Circulation. 1998;98:405412.[Abstract/Free Full Text]
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Ketterer MW. Denial specific to Friedman's pathogenic
emotions in Jenkins activity type A and angiographically-referred
males. Psychosomatics. 1992;33:7280.[Abstract/Free Full Text]
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Ketterer MW, Lovallo WR, Lumley MA. Quantifying the
density of Friedman's pathogenic emotions (AIAI). Int J
Psychosom. 1993;40:2228.[Medline]
[Order article via Infotrieve]
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Ketterer MW, Kenyon LM, Foley BA, Brymer J, Rhoads K,
Kraft P, Lovallo WR. Denial of depression as an independent correlate
of coronary artery disease. J Health Psychol. 1996;1:93105.[Abstract]
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Ketterer MW, Huffman J, Lumley MA, Wassef S, Gray L,
Kenyon L, Kraft P, Brymer J, Rhoads K, Lovallo WR, Goldberg AD. Five
year followup for adverse outcomes in males with at least minimally
positive angiograms: the importance of "denial" in assessing
psychosocial risk factors. J Psychosom Res. 1998;44:241250.[Medline]
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Response
Ichiro Kawachi, MD, PhD;
Laura D. Kubzansky, PhD
Department of Health and Social Behavior,
Harvard School of Public Health,
Channing Laboratory,
Harvard Medical School,
Boston, Mass
David Sparrow, PhD;
Avron Spiro, III, PhD;
Pantel S. Vokonas, MD
Normative Aging Study,
Department of Veterans Affairs Outpatient Clinic,
Boston, Mass
Scott T. Weiss, MD
Pulmonary and Critical Care Division Beth Israel Hospital
and Harvard Medical School,
Boston, Mass
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Introduction
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We thank Dr Ketterer for drawing our attention to the finding
that a dose-response relationship exists between severity of
coronary artery disease and denial of anger. We would point
out, however, that in both our recent study linking type A behavior to
risk of coronary disease1 and our earlier report
of an association between anger and coronary
disease,2 assessments of anger were made prospectively
before the onset of coronary disease. Participants in the
Normative Aging Study are examined every 3 to 5 years by a physician
for any signs and symptoms of coronary disease. Anyone with
diagnosed coronary disease at the time of personality
assessment was excluded from our analyses. Thus, although we
cannot completely exclude subclinical disease, the type of bias
described by Dr Ketterer is unlikely to have been a major factor in our
studies. On the other hand, we strongly agree with Dr Ketterer that
better studies are needed to establish the differential predictive
power and independence of various states of emotional distress (eg,
depression, anxiety, and anger) in relation to coronary disease
risk.3
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References
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Kawachi I, Sparrow D, Kubzansky LD, Spiro A III,
Vokonas PS, Weiss ST. Prospective study of a self-report type A scale
and risk of coronary heart disease: test of the MMPI-2 Type A
Scale. Circulation. 1998;98:405412.
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Kawachi I, Sparrow D, Spiro A III, Vokonas P, Weiss
ST. A prospective study of anger and coronary heart disease:
the Normative Aging Study. Circulation. 1996;94:20902095.[Abstract/Free Full Text]
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Kubzansky LD, Kawachi I, Weiss ST, Sparrow D. Anxiety
and coronary heart disease: a synthesis of epidemiological,
psychological, and experimental evidence. Ann Behav Med. 1998;20:4758.[Medline]
[Order article via Infotrieve]