(Circulation. 1999;100:685-688.)
© 1999 American Heart Association, Inc.
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Prospective Study of a Self-Report Type A Scale and Risk of Coronary Heart Disease: Test of the MMPI-2 Type A Scale
Henry Ford Health Sciences Center Detroit, Mich
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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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1. 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;98:405–412.
2.
Ketterer MW. Denial specific to Friedman's pathogenic
emotions in Jenkins activity type A and angiographically-referred
males. Psychosomatics. 1992;33:72–80.
3. Ketterer MW, Lovallo WR, Lumley MA. Quantifying the density of Friedman's pathogenic emotions (AIAI). Int J Psychosom. 1993;40:22–28.[Medline] [Order article via Infotrieve]
4. 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;1:93–105.[Abstract]
5. 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;44:241–250.[Medline] [Order article via Infotrieve]
Response
Department of Health and Social Behavior, Harvard School of Public Health, Channing Laboratory, Harvard Medical School, Boston, Mass
Normative Aging Study, Department of Veterans Affairs Outpatient Clinic, Boston, Mass
Pulmonary and Critical Care Division Beth Israel Hospital and Harvard Medical School, Boston, Mass
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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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TopIntroductionReferencesIntroduction References |
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1. 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;98:405–412.
2.
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;94:2090–2095.
3. 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;20:47–58.[Medline] [Order article via Infotrieve]
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