patients, even though patients tended to sit on the edge of waiting room chairs to the
extent that an upholsterer commented that the front edges of the waiting room chairs
were unusually worn (Friedman and Rosenman, 1974). Eventually, however, they sent
out a questionnaire asking 150 businessmen what they believed had precipitated a heart
attack in a friend. Few thought it was due to diet or smoking and most felt it was due
to ‘excessive competitive drive and meeting deadlines’ (Rosenman et al., 1964: 73).
A subsequent study suggested that physicians agreed even though this was not a
recognized cause in the medical literature of the time. This and subsequent research
ultimately led to the identification of the constellation of characteristics described above
and its long-term investigation in a large prospective study known as the Western
Collaborative Group Study. This examined risk factors for coronary heart disease
(CHD) in a sample of over 3,000 healthy middle-aged men. The study started in 1960
and followed participants for more than 27 years. Rosenman and colleagues assessed
the participants in the study using a structured interview, in which the interviewer
asked questions in a confrontational manner (including interrupting the participant)
with the aim of provoking the participant in order to assess aggression and time urgency
(Chesney, Eagleston and Rosenman, 1980). The men were then followed up at 8.5
and 22 years. The researchers found after 8.5 years that those men who were classified
as type A had around twice the risk of developing CHD as those who were type B,
even after controlling for other risk factors. At this stage it appeared that type A was
a risk factor that was as important as smoking or high blood pressure for the
development of CHD. However, on follow-up after 22 years, the researchers found
that type A behaviour no longer showed a significant relationship with CHD (Ragland
and Brand, 1985). Thus, after the initial enthusiasm about the importance of this risk
factor, doubts were raised.
Many other research teams around the world were also conducting studies of type
A behaviour during the 1960s and 1970s and in the early years (pre-1978) these tended
to support the idea that type A was linked to CHD (Miller et al., 1991). However,
after this time, the majority of subsequent studies, like that of the Western Collaborative
Group itself, failed to support the original findings. As a result the role of type A in
heart disease became a controversial issue. A number of meta-analyses have been
conducted over the years (e.g. Booth-Kewley and Friedman, 1987; Miller et al., 1996;
Myrtek, 2001). For example, Miller et al. (1996) suggested that the null findings were
due to a range of methodological differences between the early studies and those
conducted later. First, the more recent studies often looked at samples that were already
at high risk of heart disease. Second, over time, questionnaire measures (e.g. the Jenkins
Activity Survey; Jenkins, Zyzanski and Rosenman, 1971) have been used rather than
the structured interview, which allows assessment of behaviour in interaction.
Compared to the interview, questionnaire items have limitations in terms of assessing
behaviour and tend to be less effective in predicting CHD. Overall, Miller et al. (1996)
concluded that type A behaviour was a risk factor for heart disease as, across studies
based on structured interviews, about 70 per cent of middle-aged males with CHD
were type As, as opposed to 46 per cent of healthy males.
Myrtek (2001) reviewed all prospective studies (a total of 25) published up to 1998
investigating coronary heart disease and type A behaviour. They concluded that taking
all studies together there was no significant association between type A behaviour and
PERSONALITY AND HEALTH 121