To Be B or Not to Be B—Is That the Question?

The good doctor, whether general practitioner or specialist, … studies the patient's personality as well as his disease. ¹

— Sir Hugh Cairns (1896–1952)

The eminent Scottish surgeon, John Hunter (1728–1793), suffered from angina pectoris. He also suffered from a short fuse. One day, immediately after an intensely heated board meeting, Hunter stormed out of the room, collapsed, and died in the arms of a colleague. ² His case brought to light the powerful influence of emotions on the heart.

Hunter very likely had what modern physicians would call a Type A personality, which is characterized by intense ambition, strong competitiveness, and a constant preoccupation with deadlines. Persons lacking these traits are said to have a Type B personality. From the cardiac standpoint, the difference between the 2 types may be important—or it may not.

More than 40 years ago, Friedman and Rosenman ³ reported that people with a Type A personality had a 7-fold greater incidence of clinical coronary artery disease than did those with a Type B personality. Since then, many conflicting reports have appeared concerning the relationship between Type A personality and the development and progression of coronary artery disease. ^4–7

A panel sponsored by the National Institutes of Health in 1981 concluded that Type A behavior constituted an independent risk factor for coronary artery disease. ⁵ The risk was similar in magnitude to that created by smoking, hypercholesterolemia, or elevated blood pressure. Four years later, however, members of the Multicenter Post-Infarction Research Group ⁶ argued that there was “no uniform evidence to substantiate either a close relation between the characteristic behavior of the Type A personality and coronary disease or the protective effects of the Type B personality.”

The controversy escalated in 1993, when Lachar ⁸ suggested that coronary-prone behavior and Type A behavior are not synonymous, and that the coronary-prone patient should not be envisaged as the “achievement-oriented, overburdened workaholic. Instead, coronary-prone behavior appears to include physiologic and emotional reactivity to challenging situations,” especially those triggering anger, cynicism, mistrust, and hostility. ⁸

Subsequent investigations further complicated this issue. A case-control study of 340 patients by O'Connor and coworkers ⁹ in 1995 raised the possibility that decreased levels of HDL cholesterol account for the increased risk of nonfatal myocardial infarction in persons with the Type A personality. Unfortunately, most other studies on psychosocial risk factors for myocardial infarction have not included data on HDL cholesterol. Consequently, the nature of the association between the Type A personality and serum HDL concentration remains problematic.

In 1996, Denollet's group ¹⁰ introduced the Type D personality as a strong coronary risk factor. (Type C relates to coping with cancer. ^11,12) The D stands for a “distressed” personality type—one that has a tendency to experience negative emotions and to inhibit self-expression. ^13,14 Patients with coronary artery disease and a Type D personality have a 4-fold risk of death compared with non-Type D patients. ¹⁵

Recently, Rozanski and associates ¹⁶ extensively reviewed the impact of psychological factors on the pathogenesis of cardiovascular disease. They concluded that psychosocial stressors mediate cardiovascular disease through sympathetic hyperreactivity, increased arrhythmogenesis, procoagulant activity, and accelerated atherosclerosis.

How, then, can practitioners use these various findings to help their patients? The answer depends on the medical and psychosocial biases of the individual physician. Friedman and colleagues, for example, helped alter Type A behavior in patients who had sustained a myocardial infarction, contending that such alteration substantially reduces the recurrence of myocardial infarction as well as episodes of silent ischemia. ^4,17,18 But is that approach necessarily good? According to a 1981 editorial in The Lancet, ¹⁹ making a substantial change in Type A behavior could result in a “demotion in status, in job function, in the regard of colleagues and possibly in personal income.”

Despite myriad studies during the past 5 decades, the precise role of personality types in producing or preventing coronary artery disease awaits clarification. Meanwhile, current evidence suggests that Type D has displaced Type A as the dominant personality risk factor for coronary artery disease. Therefore, to be B or not to be B is no longer a fitting question. Today, a more appropriate question might be, “Is there any merit in converting Type A personality to Type B, Type B to A, or Type D to A or B?” All things considered, our answer is an unequivocal … perhaps.