Medical diamosis of type A behavior

The objective of this investigation was to develop a medically oriented examination (including a
search for physical signs in addition to elicitation of symptoms) for the ,accurate diagnosis of
type, A and type B behaviors,. Comprising the study were 99 post-myocardial. infarction patients,
15 clinically well,persons./n whom clinical coronary heart disease subsequently developed, and
23 healthy type Bsubjects. All participants were subjected to a videotaped clinical exqmi,nation
during which, in addition to elfciting responses to questions, 14 possible physical or psychomotor
signs (many of which,are newly discovered) of type A behavior were also observed. Each
physical sign and symptom was given an arbitrarily weighted score (according to, its observed
frequency of occurrence in previously studied and authenticated type A behavior). These total
scores were then statistically analyzed to obtain a critical diagnostic score for the presence of
type A behavior. The medically oriented videotaped clinical examinationdetected the presence
of type A behavior in 97 of 99 (98%) successively examined postinfarction patientsand in 14 of
15 (93%) subjects who were clinically well at thetime. of their videotaped.clinical examination but
who subsequently had clinical coronary heart disease. Conversely type A behavior was
diagnosed by videotaped clinical examination in only 1 of 23 (4%) healthy men who .previously
had been found to exhibit type B behavior by prior diagnostic procedures. (AM HEART J
1993;128:807-818.)

Meyer Friedman, MD, and Ghassan Ghandour, PhD Sun Francisco, Calif.

We first observed in 1959i a significantly greater studies13-17in which no correlation was found be-
prevalence of clinical coronary heart disease (CHD) tween TAB and CHD. The reports of Ragland and
in persons who exhibited time urgency (TU) and BrandiGs i7 will be discussed first, because they at-
free-floating hostility (FFH)-a disorder we labeled tempted a postcard-telephone interview follow-up of
type A behavior (TAB). Subsequent studie& 3 re- type A and type B participants in the Western Col-
vealed that otherwise healthy persons with this dis- laborative Group Study, who were initially recruited
order later had clinical CHD significantly more fre- in 1960 and 19612t3 by one of us (M.F.). The clinical,
quently than those (type B) who did not exhibit analytic, and statistical shortcomings of these two
symptoms and signs of TAB. More recently, in a ran- studies have already been pointed out by a number
domized clinical trial of more than 990 postinfarction of investigators.rs2i Suffice it to state here that in
patients,4-6 an attempt was made to modify the addition to the clinical flawsi in the studies by
intensity of TAB in two thirds of them. The recur- Ragland and Brand, 161l7 their statistical conclusions
rence rate of another cardiac incident (i.e., infarction are contradicted by the data they present. Their data
or instantaneous cardiac death) was 45 % lower in the indicate that both at the end of 9 years and 22 years,
treated group than in the remaining 300 control sub- the coronary mortality rate in type A subjects was
jects. This close relationship between TAB and CHD significantly higher than that in type B subjects (i.e.,
has been confirmed not only by individual studies 100 % higher at the end of 9 years and 25 % higher at
conducted by a number of investigators7-lo but also the end of 22 years). There are two additional inter-
by two recent meta-analyse& i2 of all literature per- esting facts: (1) One of the authors (R. Brand) in an
taining to this relationship. earlier report3 pointed out the higher type A mortal-
However, there have also been epidemiologic ity rate at the end of 9 years, and (2) the investigator
responsible for collecting the clinical data described
in these reports isnot listed as a coauthor,
From the Meyer Friedman Institute, Mount Zion Medical Center of the In the remaining negative epidemiologic
University of California, San Francisco.
studies,13-15the investigators apparently were un-
Received for publication Jan. 14, 1993; accepted March 1, 1993.
aware of our earlier reports,1-3y22-26which pointed out
Reprint requests: Meyer Friedman, MD, Meyer Friedman Institute, Mount
Zion Medical Center of UCSF, P.O. Box 7921, San Francisco, CA 94120.
that a correct diagnosis of TAB cannot be made un-
Copyright @ 1993 by Mosby-Year Book, Inc. less,as in any other medical disorder, an examination
0002~8703/93/$1.00 + .lO 4/l/47687 is performed in which both the physical and psych-

607

608 Friedman and Ghandour
Fig. 1. Arrow points to indentation in anterolateral por-
tion of tongue of young womanwith severetype A behav-
ior pattern. Depressedarea is due to chronic pressureof
this area of the tongue againstback of upper incisor tooth.
omotor signs are observed (Figs. 1 to 6), as well as
the traits and/or symptoms elicited. Unfortunately
all of these studies depend on the subjective re-
sponses of the participants to stereotyped questions
presented to them in writing or verbally by nonpro-
fessional clerks. Repeatedly we have observed that
because of either their reluctance to admit it or their
lack of awareness of the presence of impatience or
easily aroused hostility, type A subjects deny having
either of these two components of TAB and would
have been designated type B persons were it not
for their exhibiting the physical signs of TAB (Figs.
1 to 6).
Because this lack of awareness of many of the
physical signs and more arcane traits and symptoms
of TAB may be chiefly responsible for the otherwise
unnecessary controversy concerning the relationship
between TAB and the pathogenesis of CBD, we will
describe in this report the symptoms/traits, and psy-
chomotor signs we presently look for when diagnos-
ing TAB. In addition, we present a quantitative
scoring method for assessingthe relative severity of
TAB in individual subjects.
METHODS
Identification of type A manifestations of time urgency rarely exhibit any episodesof TU or FFH. None had ever
and free-flo&ting hostility. Three groupsof men were sub-
jected to the newly designedvideotaped clinical examina-
tion (VCE) for the diagnosisand quantitative assessment ageagewas56 years (range47 to 63); one wasblack and 22
September 1993
American Heart Journal
Fig. 2. Arrow points to translucent benign growth at tip
of tongue of 4%year-old man whoseVCE score exceeded
200. He habitually pressedhis tongue into a gap between
two upper incisor teeth.
of TAB. The characteristics of these three groups are as
follows.
Group 1. This group included the first 99ambulatory and
recovered patients with myocardial infarction successively
recruited for the Recurrent Coronary Prevention Project
(RCPP).4,5Their averageagewas55 years (range44 to 65).
Three of the 99 patients were black, and the remainder
were white.
Group 2. Included in this group were 23 healthy male
type B subjects,the majority of whom (18) had beendiag-
nosed.ashaving type B behavior in 1960 and 1961 by the
Western Collaborative Group Study,2,3 which used an in-
terview that wassubsequentlydesignatedthe TAB struc-
tured interview by other investigators.g,l4 (The five addi-
tional type B subjectswere selectedfrom a large group of
businessexecutives. They had been observedfor a number
of years by three or more of their businessassociatesto
had any clinical evidence of CHD, and their electrocardio-
gramsobtained in 1989and l.990were normal. Their aver-
Volume 126, Number 3, Part 1
American Heart Journal Friedman and Ghandour 609

Fig. 3. Shading of lower eyelid depicts bilateral deposition of melanin-like pigmentation observed in
varying degreesof intensity in approximately 27% of personswith type A behavior. Pigmentation often
involves upper eyelid and may also involve upper area of cheeks.

Fig. 4 Ticlike exposureof scleraaround iris is causedby retraction of upper and lower eyelids. Most of-
ten on5y upper eyelid retracts exposing sclera above upper portion of iris.

Fig. 5. Ticlike retraction of bilateral portions of lips toward earsis shownleading to partial opening of
mouth, sometimessufficient to exposedistal endsof teeth. Sometimesretraction is extensive and may last
several seconds.
 September 1993
610 Frie&mn and Ghandour American Heart Journal

Table I. The 33 type A manifestations of time urgency and free-floating hostility*

I. Manifestations of the presence of time urgency
A. Symptoms/Traits
1. Self-awareness of time urgency (20)
a. Eliciting query: Do you believe more often than not that you are in a hurry to get things done?
2. Warning by others to slow down (15)
a. Eliciting query: Does your spouse or any close friend ever tell you to slow down, take it easier, or become less tense?
3. Haste in walking (5), eating (5), and leaving the table (5) (5-15)
a. Eliciting queries:
1) Do you walk fast? (5)
2) Do you eat fast? (5)
3) After you finish your dinner, do you sit and chat with your family or do you leave the table immediately? (5)
4. Indulgence in polyphasic activities (5-15)
a. Eliciting queries:
1) Do you like to look at television, read a magazine or newspaper, and eat at the same time? (5)
2) Do you like to look at your mail or do other things while listening to someone on the phone? (5)
3) Do you regularly think of other matters while listening to your spouse or others? (5)
5. Intense dislike of waiting in lines (10)
a) Eliciting query: DO you mind very much waiting in grocery checkout, bank, or theater lines or waiting to be seated
in a restaurant? (an emphatically expressed dislike is considered a scoring response)
6. Fetishistic punctuality (10)
a) Eliciting query: If you make an appointment with someone, say at 2 PM, will you be there? (a scoring response to this
query is one of the following statements emphatically expressed: Im always on time, Ill be there on the button
or even before 2 PM, or Ill be there and I resent it if the other person keeps me waiting; the type B person calmly
responds, usually or Ill try to be there)
7. Infrequent recall of memories, observation of natural phenomena, or daydreaming (10)
a) Eliciting query: DO you find you have time just to sit and daydream, to meditate or recall old memories, or to carefully
scrutinize flowers, trees, birds, or animals? (a scoring response is failure of examinee to do any of these things)
B. Psychomotor signs
Unlike elicitation of symptoms/traits of either time urgency or free-floating hostility, detection of psychomotor or physical
signs of type A behavior may take many hours of training and instruction. Just as it takes many hours of listening to heart
murmurs for a medical student to acquire the acoustic skills to differentiate one valvular murmur from another, so it may
take a long time for a person to diagnose some of the more subtle physical signs indicative of the presence of impatience or
hostility.
1. Chronic facial tension (20)
This sign springs from tautness of the maxillomasseter muscle complex and is often accompanied by moderate contrac-
tion of the frontalis muscle; the eyelids are often narrowed
2. Ticlike elevation of eyebrows (5)
If present at all, it appears 3 to 10 times during the 15- to 20-minute examination period
3. Ticlike elevation or retraction of one or both shoulders (5) This usually appears with similar frequency as eyebrow el-
evation
4. Tense posture-abrupt, rapid, jerky movements (5)
Examinee sits tensely and/or movements are hurried and abrupt
5. Rapid speech (10)
Examinee speaks at 140 or more words per minute, sometimes making total comprehension difficult
6. Hastening speech of others (20)
Examinee frequently utters rapidly, uh huh, uh huh or mmh, mmh, to hasten unconsciously the rate of speech of
others
7. Prolepsis (20)
Three questions are asked of the examinee by the examiner, after he or she first relates in a tedious, pleonastic manner
a mundane circumstance, which probably enhances the impatierme of the person being questioned. Having done this, the
examiner then tediously poses the question, but before finishing it he or she begins to stutter. The examiner notes whether
the examinee, aware of the context of the question, becomes proleptic. An example of this presentation follows: The ex-
aminer begins by saying, Most working people usually arise before 8 AM during the week-the examiner then purposely
becomes pleonastic by adding, that is, Monday through Friday. Of course, on Saturday and Sunday, they may sleep lat-
er. Having said this, the examiner then begins to ask the experimental question: Now in your own case, Mr. Jones, on
weekdays what time do you usually-and then he or she begins to stumble saying uh-uh-uh. The test is positive if
the examinee interrupts the stuttering by answering the question before it has been completely presented. This ques-
tioning procedure is performed at three different times during the examination and uses a different question for each
exercise. If the examinee interrupts the examiners questioning sentence two out of three times, the test is considered
a scoring response.

*Numbers in parentheses represent videotaped clinical examination scere values.

Volume 126, Number 3, Part 1
American Heart Journal Friedman and Ghandour 611

Table I. contd

8. Tongue-teeth clicking (5-20)

This clicking sound is created by abrupt separation of the front part of the tongue from its prior adhesion to the back of
the upper incisors when the mouth is opened to speak. This tongue pressure against these upper teeth reflexly occurs when
the maxillomasseter muscle complex becomes tense. If this latter tension becomes habitual and prolonged, tongue to teeth
pressure occurs, not infrequently but permanently causing indentations (Fig. 1) or extrusions (Fig. 2) of the tongue. (Note:
If just clicking is heard the score is 5, but if there is also tongue disfiguration the score is 15)
9. Audible, forced inspiration of air (10)
The examinee is observed at times, particularly when he is speaking rapidly, to suck in a breath of air as he continues to
speak
10. Expiratory sighs (5-20)
Although type B subjects sometimes emit an expiratory sigh, if an exammee is observed to sigh more than once during
the examination period, a score of 5 is given; if more than 5 times, a score of 20 is given
11. Excessive facial perspiration (40)
Chronic extrusion of beads of perspiration from the skin of the forehead and upper lip at normal room temperature, in
an otherwise apparently healthy person is not observed frequently; when it is observed it should be considered an ominous
sign of a hyperactive sympathetic nervous system (Note: Whether this manifestation results from the presence of time
urgency or free-floating hostility or both remains to be determined, it is not to be confused with the cold facial perspi-
ration that sometimes accompanies angina pectoris)
12. Frequent eyelid blinking (5)
A positive response is 25 or more eye blinks per minute
II. Manifestations of free-floating hostility
A. Symptoms or traits
1. Frequent loss of temper while driving (10)
Eliciting query: Do you get upset when driving, particularly while commuting? Does your spouse ever have to tell you to
cool or calm down when driving with you? Do you swear at other drivers? (an affirmative response to any of these ques-
tions is a scoring response)
2. Disbelief in altruism (5)
Eliciting query: Do you believe that most people are not basically honest and are not eager to help others? (an afhrmative
answer is a scoring response)
3. Sleeplessness because of anger/frustration (10)
Eliciting query: Do you often find it difficult to fall asleep or to continue to sleap because you are upset about something
a person has done? (a scoring response is one in which the examinee relates that this phenomenon is a common event)
4. Chronic difficulty in filial relationships (10)
Eliciting query: Do you find (or have you found) it difficult to deal with your children? (Almost every parent may encoun-
ter some difficulties in dealing with their children particularly when the latter are adolescents. Therefore the examiner
should not be content with asking a single question but should ask a sufficient number to get a clear idea of the filial re-
lationships. Also, careful note should be made of the possible emergence of psychomotor signs in the examinee as he re-
sponds to this question. For example, if the voice of the examinee becomes strident or his face clouds up as he discusses
this question, a scoring response is indicated regardless of the content of his discussion.)
5. Intramarital tension or competition (15)
Eliciting query: Do you have any feelings that your spouse is competing against you or is too critical of your faults? (A
scoring response is made only if the examinee states that he has these feelings often or if his voice becomes bitter and his
face becomes perturbed as he answers the query.)
6. Teeth grinding (25)
Eliciting query: Do you grind your teeth? Has your dentist ever told you that you do so?
7. Easily provoked irritability or discomfort on encountering trivial errors of commission or omission by others (15)
Eliciting query: Can you tell me what things annoy or upset you? (A quick answer by the examinee in which he lists, fre-
quently in an unpleasant voice, several or more trivial events [e.g., the car driving errors of others, the indifference of store
clerks, or the tardiness of the mail is a scoring response.)
B. Psychomotor signs
Psychomotor signs suggestive of the presence of free-floating hostility, such as those suggestive of time urgency or impatience,
must be searched for from the beginning until the very end of the videotaped clinical examination and regardless of what
query has been presented to the examinee.
1. Facial hostility (25)
The physiognomy indicative of hostility is created by a combination of subtle but definite contractions of the orbital mus-
cles, the muscles surrounding the mouth, and the masseter muscles (for illustration and further facial details, see Fig. 6
and its accompanying legend)
2. Periorbital pigmentation (25)
A diffuse and permanent deposit of of melanin usually involving the skin of the lower eyelid, although not infrequently
a deposit also occurs in the upper eyelid (Fig. 3)
 September 1993
612 Friedman and Ghandour American Heart Journal

Table I. contd
3. Ticlike retraction of upper (and sometimes lower) eyelid (25)
A quick, abrupt, partial retraction of the upper eyelid (sometimes accompanied by a similar retraction of the lower eyelid)
that briefly exposes the sclera above the iris (Fig. 4)
4. Hostile vocal qualities (25)
A speaking voice that is grating, harsh, irritating, or generally unpleasant or excessively loud warrants a positive score
5. Ticlike bilateral retraction of buccinator and orbicularis oris muscles (25)
Quick, short drawing back of the sides of the mouth, sometimes sufficient to expose the teeth (Fig. 5)
6. Clenched hand in casual conversation (5)
This physical sign although frequently observed in coronary patients is also occasionally observed in healthy type B sub-
jects
7. Hostile laugh (10)
A very loud, explosive, unpleasant, quasihumorous, jarring outburst of sound

were white.) These type B subjects had also been recruited type B subjects. For example, the TAB manifestation,
for the RCPP to eliminate possible bias because the exam- chronic facial tension, which was observed in more than
iners were unaware that these healthy type B subjects had half of the coronary patients (Table IIA) but in none of the
been interspersed with postinfarction patients. type B subjects was consequently assigned a score of 20. On
Group 3. To test the possible predictive validity of the the other hand, although hand clenching was noted in the
VCE, the scores of 15 men who were free of all clinical majority of coronary patients, it also was observed in 8 of
symptoms and ECG signs of CHD at the time of their the 23 type B subjects. Therefore it was given a score of only
VCEs, but who subsequently (2 to 12 months) had symp- 5.
toms and signs of clinical CHD, were collected and com- This weighting of scores provides the following absolute
pared with the VCE scores of persons in groups 1 and 2. ranges: total VCE, 0 to 480; TU; 0 to 225; and FFH, 0 to 255.
Seven of the 15 had angina, showed angiographic evidence Prevalence of each type A manifestation in coronary
of severe coronary artery obstruction, and had undergone patients and type B subjects. The percentage prevalence
angioplasty. The remaining eight had a documented myo- of each of the 33 type A manifestations in the total group
cardial infarction. The average age of the 15 men was 56 of coronary patients and type B men was determined (Ta-
years (range 42 to 62). All 15 were white. Henceforth in this bles IIA and IIB).
report this group will be designated as pre-CHD-examined Average number of type A manifestations observed in
subjects. coronary patients and type B subjects. The average
Each man in the three groups was subjected to a VCE, number of TU and FFH manifestations present in coronary
an updated revision of the videotaped structured interview patients and type B subjects was also determined (Table
(VSI) used earlier for detection of TAB in the RCPP.4 A III).
comparison of the diagnostic type A manifestations Determination of total VCE score and its two compo-
searched for in the VSI and in the VCE (compare Table III nents. The total VCE scores in the 99 coronary patients
in the RCPP report4 with Table I in the present report) in- and 23 type B subjects (Table IV) were obtained by com-
dicates that eight new possible type A manifestations have bining the scores of their TU and FFH manifestations. The
been added and five VSI manifestations have been omitted symptoms/traits and psychomotor signs making up these
in the currently used VCE. manifestations are listed in Table I.
Nineteen of the 33 type A manifestations searched for in Determination of the optimal diagnostic Cutoff score
the VCE (seven symptoms/traits and 12 psychomotor values of total VCE and its Component scores. The most
signs) suggest the presence of the TU component of TAB. valid type A diagnostic procedure is one that will be most
The remaining manifestations (seven symptoms/traits and efficient in discriminating a coronary patient or coronary-
seven psychomotor signs) suggest the presence of FFH. prone subject from a person who is relatively immune to
These manifestations are listed and described in Table I. this disorder (i.e., a type B subject). With this goal in mind
Table I also describes the general nature of the queries used we used the receiver operating characteristic methodolo-
to elicit these manifestations. gyz7, 28 to determine which of the cutoff values of the
We also changed the numeric weights (scores) that we three scores .(total, TU, and FFH) would provide us with
had previously assigned to many of the same manifesta- thegreatestdiagnosticsensitiuity(theproportionofpostin-
tions that we searched for and scored in the VSI procedure farction subjects correctly identified as type A), specijicity
used in the RCPP.4 First, we arbitrarily increased the nu- (the proportion of type B subjects correctly identified as
meric values of all TAB manifestations. Second, we type B), and efficiency (the proportion of the total group
weighted the scores of each of the 33 TAB manifestations of both type A and B persons correctly identified). Table
observed in groups 1 and 2 (Tables IIA and IIB) to reflect V presents the classified data and the sensitivity, specific-
the frequency of their occurrence in patients with heart ity, and efficiency indexes for the optimal cutoff values
disease and conversely the rarity of their appearance in for each of the three VCE scores (i.e., total, TU, and FFH).
Volume 126, Number 3, Part 1
American Heart Journal Friedman and Ghandour 613

Comparison of VCE and VSI scores. As already noted

the VCE differs from the earlier employed VS14not only in
its different scoring system but also (1) in its inclusion of
eight new diagnostic manifestations,which have been rec-
ognized sincethe formulation of the VSI, and (2) its elim-
ination of five manifestationsusedin the VSI becausethey
are too infrequently observed in the 20 minutes required
for the VCE (e.g.,humming, minimal useof metaphors,and
continuous horizontal movement of the eyeballs).
The total VCE scores,aswell asthose of its two compo-
nents (TU and FFH), were compared with the VSI coun-
terpart scoresof the coronary patients and type B subjects
by determining the Pearson product-moment correlation
coefficients between the corresponding scoresof the total
VCE and VSI scores and their respective components
scores(Table VI).
The VCEs of the coronary and type B groupswere per-
formed by two examinerswho were unawareof the status
of the participants. Correspondencefor independently as-
sessedVCEs was 0.81 for the two examiners. Retest
reliabilities of the two examinersassessing the sameVCEs
after a lapse of 4 weekswere 0.91 and 0.93, respectively.
The VCEs of the 15 pre-CHD men were performed by
two different examinerswho were unawareof the later on-
set of clinical CHD in thesemen. Their correspondencefor Fig. 6. Hostility portrayed in this drawing is created by
independently assessed VCEs was0.86. The retest reliabil- combination of subtle but definite contractions of orbital
ities of these examinerswere 0.93 and 0.95, respectively. muscles,musclessurrounding mouth, and massetermus-
cles.Glaring of eyesis created by retraction of upper eye-
RESULTS lids through action of levator palpebrae muscles; this
results in exposureof a larger portion of iris. In addition,
Detection and scoring of the manifestations of time lacrimal segmentof orbicularis oculi musclesappearsto
urgency and free-floating hostility in coronary patients raise medial third of lower lid slightly, thereby increasing
and healthy type B subjects intensity of stare. Corrugator portion of orbicularis oculi
Manifestations of. time urgency. As shown in Ta- muscleslowerseyebrowsto achieve furtheraccentuation of
ble IIA, one or more of the 19 TU manifestations (7 perceived glare. Tightness or pursing of lips is achieved
through tension in orbicularis oris muscle.Combinedwith
symptoms/traits and 12 psychomotor signs) were de- bilateral pulling of risorius muscles,thinning ofvermillion
tected in all 99 coronary patients. Six of the seven surface of lips occurs,and pseudosmile appears.Glare of
symptoms/traits of TU manifestations and 5 of the 12 eyes, pseudosmile and slight bulge of. tensed masseter
TU psychomotor signs were detected in 50 % or more musclesof jaw create a look of anger under thin veneer of
of the coronary patients. The most frequently ob- civility. Slight deposit of melanin is present on lower eye-
lids.
served manifestation was the psychomotor sign of
prolepsis (97 % ).
Nine of the 19 TU manifestations, however, were
not detected in any of the 23 type B subjects (seeTa- tension or competition, and (4) irritation on encoun-
ble IIA). Moreover, the other 10 TU manifestations tering trivial errors of omission or commission of
were infrequently detected in the remaining type B other persons. Eight of the 14 manifestations of FFH
subjects. Their most frequently detected manifesta- could not be detected in any of the 23 type B subjects
tion (34%) was the symptom/trait, indulgence in (Table IIB). One or more of the remaining manifes-
polyphasic activities. tations could be detected in 2 of the 23 type B sub-
Manifestations of free-floating hostility. One or jects.
more of the 14 manifestations of FFH (seven symp- The numeric value given to each manifestation, as
toms/traits and .seven psychomotor signs) were de- already described, was weighted according to its
tected in all 99 coronary patients. Four of the seven prevalence in coronary patients and its rarity in type
symptoms/traits were detected (Table IIB) in more B subjects, with the exception of the very high value
than 50 % of the coronary patients. These four man- ascribed to excessive facial perspiration (Table IIA)
ifestations were (1) frequent loss of temper while despite its infrequent detection in coronary patients.
driving, (2) disbelief in altruism, (3) intramarital This exception was made because in the 54-year car-
614 Friedman and Ghpdour

Table IIA. Prevalence of 19 manifestations of time urgency in coronary patients and type B subjects

Prevalence (%) of manifestations

99 Coronary 23 Type B
Time urgency patients subjects Score values

Symptoms/Traits
Self-awareness of time urgency 80 2 10
Warning by others to slow down 88 17 15
Haste in walking, eating, leaving table 89 13 5-15
Indulgence in polyphasic activities 88 34 5-15
Intense dislike of waiting in lines 50 0 10
Fetishistic punctuality 79 9 10
Infrequent recall of memories, 22 9 10
observations of natural phenomena,
or daydreaming
Psychomotor signs
Chronic facial tension 51 0 20
Ticlike elevation of eyebrow(s) 16 0 20
Ticlike elevation or retraction 16 3 5
of one or both shoulder(s)
Abrupt, jerky body movements- 9 0 5
tense posture
Rapid speech 52 0 10
Hastening speech of others 42 0 20
Prolepsis 97 6 5-15
Tongue-teeth clicking and possible 79 1 5-20
tongue indentation
Audible forced inspiration of air 9 0 10
Expiratory sighs 68 9 5-20
Expiratory perspiration 3 0 40
Frequent eyelid blinking 7 0 5

Table IIB. Prevalence of 14 manifestations of free-floating hostility in coronary patients and type B subjects
Prevalence (%) of
manifestations

99 Coronary 23 Type B Score

Free-floating hostility patients subjects values

Symptoms/Traits
Frequent loss of temper while driving 80 3 10
Disbelief in altruism 52 7 5
Sleeplessness because of anger/frustration 37 2 10
Chronic difficulty in filial relationships 39 2 10
Intramarital tension or competition 70 8 15
Teeth grinding 11 0 25
Irritation on encountering trivial errors 60 9 15
of omission or commission by others
Psychomotor signs
Facial hostility 14 0 25
Periorbital pigmentation 27 0 25
Ticlike retraction of upper eyelid 4 0 25
Hostile vocal qualities 14 0 25
Ticlike retraction of buccinator 6 0 23
and orbicularis oris muscles
Clenched hand in casual conversation 63 8 5
Hostile laugh 5 0 10
Volume 126, Number 3, Part 1
American Heart Journal Friedman and Ghandour 615

Table III. Average number of time urgency and free-floating hostility manifestations in coronary patients and type B
subjects
Average number
of TU and FFH Average number of Average number of
manifestations TU manifestations FFH manifestations
Subjects per subject per subject per subject

Coronary patients (n = 99) 11.0 (5-18) 9.5 (5-15) 1.50 (O-5)

Type B subjects (n = 23) 2.5 (O-5) 1.8 (O-5) 0.65 (O-l)

TU, Time urgency; FFH, free-floating hostility.

Numbers in parentheses indicate range of values.

Table IV. Average scores of total VCE and its components

Coronary patients (n = 99) Type B subjects (n = 23)
Scores Average score (SD) Average score (SD)

Total VCE score (combined TU and FFH scores)

Symptoms/traits score 54.53 (21.5) 6.96 (10.9)
Psychomotor signs scores 46.9 (25.6) 9.3 (10.7)
Symptoms/signs score 101.43 (35.5) 16.3 (15.3)
TU component
Symptoms/traits score 42.81 (16.4) 6.9 (10.9)
Psychomotor signs score 35.25 (18.5) 8.65 (10.9)
Symptoms/signs score 78.06 (26.0) 15.6 (15.5)
FFH component
Symptoms/traits score 11.72 (9.9) 0 (0)
Psychomotor signs score 11.65 (13.23) 0.65 (2.9)
Symptoms/signs score 23.37 (13.25) 0.65 (2.9)

VCE, Videotaped clinical examination; TU, time urgency; FFH, free floating hostility; SD, standard deviation.

diology career of one of us (M.F.), it was observed combined TU and %FH .scores) of the 99 coronary
that any patient who exhibited this sign had an patients was 101.43 (-I- 35.5), with individual scores
infarction before the agle of 60 years. varying from 10 to 260. The average TU and FFH
Average number of time urgency and free-floating scores of these coronary patients were 78.06 ( +- 26.0)
hostility manifestations detected in each coronary pa- and 23.36 (+ 16.3), respectively. The average total
tient and type B subject. The average number of TU VCE score of the 23 type B subjects was 16.3 (+ 15.3).
and FFH manifestations detected in these 99 coro- The individual scores varied from 5 to 32. The aver-
nary patients was 11 per subject (Table III). Each age TU and FFH scores were 15.6 ( + 15.5) and 0.65
coronary patient possessed at least five TU and FFH (+2.3), respectively (Table IV).
manifestations, 18 being the maximum observed in As already described the total VCE scores of these
one of the coronary patients. coronary patients and type B subjects were consider-
The average number of TU and FFH manifesta- ably higher than the total VSI scores of these same
tions detected in the 23 type B subjects was 2.5 (Ta- coronary patients and type B subjects, which were
ble III). Five of the 23 type B subjects possessed none 22.04 and,4.5, respectively. As indicated in Table IV,
of the total 33 TU and1 FFH manifestations. The almost three fourths of the tot& VCE score is
maximum number of TU and FFH manifestations contributed by the TU component. This is because 19
observed in any of the remaining 18 subjects was five of the 33 detectable type A manifestations were con-
(Table III). No FFH manifestations weredetected cerned with TU.
(Table III) in 21 of the 23#type B subjects. Each of the bptimal ;VCE coronary diagnostic Cutoff scores. As
remaining two subjects exhibited one FFH manifes- determined by the earlier described receiver operat-
tation. ing characteristic methodology, t,otaZ VCE cutoff
Average VCE scores of 1:hecoronary patients and type scores of 45 or above were found (Table V) to be the
B subjects. The average total VCE score (i.e., the optimal numeric value to differentiate between the
 September 1993
616 Friedman and Ghandour American Heart Journal

Table V. Optimal diagnostic VCE coronary Cutoff scores

Total VCE score >45 TU score >43 FFH score >5

No. Me A Type B Type A Type B Type A Type B

Coronary patients 99 97 2 90 9 81 18
Type B subjects 23 1 22 2 21 2 21
Coronary patients 122 98 24 92 30 83 39
and type
B subjects

Sensitivity 97 Diagnosed type A = g8 ~ 90 Diagnosed type A = g1 ~ 81 Diagnosed type A = 82%

99 Coronary patients 99 Coronary patients 99 Coronary patients

Specificity 22 Diagnosed type B = g6% 21 Diagnosed type B = gl% 21 Diagnosed type B = gl%
23 Type B patients 23 Type B patients 23 Type B patients

Efficiency 119 Accurately diagnosed = g8% 111 Accurately diagnosed = g1 % 102 Accurately diagnosed = 84 y
122 Coronary patients 122 Coronary patients 122 Coronary patients
and type B subjects and type B subjects and type B subjects

VCE, Videotaped clinical examination; TU, time urgency; FFH, free-floating hostility.

Table VI. Correlations between average VCE and VSI patients. Thus, by use of only the optimal cutoff
scores of coronary patients and type B subjects score obtained from the FFH symptom/trait and
VCE TU VCE FFH
psychomotor signs for diagnostic discrimination, 18
Total VCE
scores us component us component of the 99 coronary patients (18%) would have been
total VSI VSI TU us VSI FFH diagnosed as having type B behavior (Table V). Even
scores component scores component scores poorer diagnostic discrimination would have been
achieved if only the optimal cutoff score of the
WE 85.55 66.37 19.18
(46.52) (17.10) (17.10) FFH symptoms/traits was employed in that 44 of the
VSI 18.22 14.50 3.72 99 coronary patients (44%) would have been diag-
( 9.20) ( 7.02) ( 2.82) nosed as having type B behavior.
r 0.921 01918 0.727 As might be expected from the preceding results,
P 0.0001 0.0001 0.0001
the cutoff score (45) of the total VCE (i.e., the score
VCE, Videotaped clinical examination; VSI, videotaped structured inter- obtained from all detected manifestations of both the
view; TU, time urgency; FFH, free-floating hostility. TU and FFH components) proved to be the most
Numbers in parentheses are standard deviations.
sensitive (98%), specific (96% ), and efficient (98%)
(Table V).
coronary and the type B men. As indicated
patients Comparison of VCE and VSI diagnostic procedures.
in Table V, 97 of the 99 coronary patients (98%) but The coefficients of correlation (Table VI) between
only 1 of the 23 type B men (4 % ) had a total VCE the total VCE and VSI scores or between the scores
score of 45 or above. of the TU and FFH components of the two examina-
Searching and scoring the symptoms/traits and tions were very high. This indicates the close rela-
psychomotor signs of the TU component of the total tionship that exists between the two diagnostic pro-
VCE proved more efficient (Table V) than seeking cedures.
only the FFH manifestations. But scoring only TU However, despite the high correlation between
manifestations failed to diagnose TAB in 9 of the 99 these two scores, the cutoff value (45) of the total
coronary patients and conversely ascribed TAB to 2 VCE proved more sensitive than the critical VSI
of the 23 type B subjects. Moreover, if only the TU score in that (Table V) it diagnosed 97 of the 99 cor-
symptoms/traits were searched for and scored but onary patie~nts as having TAB, and the cutoff value
the TU psychomotor signs were overlooked, 17 of the (13.4) of the VSI diagnosed 89 of the 99 coronary pa-
99 .coronary patients would have been diagnosed as tients (90%) as having TAB.
possessing type B behavior, Also, increasing the VCE scores of all manifesta-
Use of the optimal cutoff scores obtained from tions increased the numeric difference between the
the detection of only the FFH manifestations of the total VCE diagnostic cutoP value for TAB and the
VCE did not appear to be an efficient diagnostic tool other scores. Although when 13.4 was used as the VSI
for the detection of type A behavior in the coronary diagnostic cutoff value, in addition to the 10 coro-
Volume 126, Number 3, Part 1
American Heart Journal
nary patients this score classified as type B, scores in
eight other patients were only 0.5 to 1.5 above the
critical cutoff score of 13.4. The smallness of this
difference in the VSI procedure makes a diagnostic
misclassification more likely than in the VCE proce-
dure.
VCE and time urgency and free-floating hostility com-
ponent scores in group 3 before the onset of clinical
coronary heart disease in these subjects. Fourteen of
the 15 healthy men in group 3 (93%), before their
onset of documented CHD, exhibited a VCE score
above the TAB diagnostic cutoff value of 45. Their
average total VCE score was 133 (range 38 to 207; SD
50). Their average TU score was 83 (range 23 to 130;
SD 32), and their average FFH score was 49 (range 15
to 109; SD 29).
When these scores were compared with their coun-
terparts in the 99 postinfarction patients in group 1
(Table IV), no significant statistical difference was
found. In short, up to 12 months before their docu-
mented occurrence of clinical CHD, 93% of these
men exhibited a TAB score that was determined
when they were negative for the presence of CHD,
both clinically and by ECG.
DISCUSSION
We have attempted to improve the sensitivity,
specificity, and efficiency of an examination for the
detection of TAB ever since we first introduced the
so-called structured interview in 1959.l This pro-
cedure searched for 17 symptoms/traits and psycho-
motor signs suggestive of the presence of TU and
FFH, the two components comprising the TAB dis-
order.ssy 24 In succeeding years we discovered addi-
tional diagnostic TAB symptoms/traits and psycho-
motor signs, and in 1979 we developed the VSI for
diagnostic use in the RCPP.4> 5 This diagnostic pro-
cedure sought to detect the presence of 28 manifes-
tations of TAB. As already mentioned, videotaping
was added not to increase the efficiency of the exam-
ination but to permit the feasibility of further diag-
nostic scrutiny and also to obtain a permanent
record, thus allowing a means of documenting possi-
ble future changes in the intensity of TAB by com-
parison of later and initial videotaped examinations.
The presently described examination, the VCE,
has been renamed because our earlier diagnostic
procedures from the very beginning actually were
neither structured nor an interview, because we
never confined ourselves to a rigidly prescribed set of
questions but often varied the questions we asked.
More important, we also sought to detect physical or
psychomotor signs of TAB as carefully as we sought
symptoms and traits.
The VCE differs from our previously employed
VSI, as already described, in its scoring system and
Friedman and Ghandour 617
its search for five additional symptoms and psycho-
motor signs of TAB. We believe its superiority to the
VSI is demonstrated in that it diagnosed TAB in 97
of 99 coronary patients but in only 1 of 23 type B
subjects. When these same 122 coronary patients and
type B subjects were given the VSI, however, the re-
sult was an incorrect diagnosis of type B behavior in
10 coronary patients.
It was of interest that the cutoff diagnostic score
of the TU component of the VCE was almost as ef-
ficient (Table V) as the total VCE cutoff score in
diagnosing the coronary patients as having TAB and
the known type B men as having type B behavior.
However, use of the optimal diagnostic cutoff) score
of just the FFH component was found to be a
relatively poor diagnostic tool in that it diagnosed 18
of the 99 coronary patients (18%) as having type B
behavior (Table V). When the psychomotor signs of
the FFH component were disregarded, the diagnos-
tic cutoff score of the FFH component did even
more poorly, yielding a false diagnosis in 44 (44 % ) of
the 99 coronary patients of type B behavior.
These latter findings agree with those of McCramie
et a1.,2gLeon et al.,3o and Hearn et a1.,31who by means
of the same questionnaire (the Cook-Medley hostil-
ity questionnaire) as that used by Shekelle et al.,32
Williams et a1.,33and Barefoot et a1.34found no causal
relevance of hostility to either the prevalence or the
incidence of CHD.
These latter discordant conclusions by no means
rule out the probability that hostility, as we have long
insisted,l> 22,24plays a significant role in the enhance-
ment of the course of CHD. What these inconsisten-
cies do demonstrate, however, as suggested by Hearn
et al.,31is the basic fallibility of attempting to detect
the presence of TAB or any other medical disorder
without ascertaining the physical signs and the
symptoms/traits of a disorder.
It is also important for accuracy in the diagnosis of
TAB that the examiner have sufficient training and
intrinsic capabilities (1) to elicit the correct responses
to his or her interrogation of and (2) to detect the of-
ten subtle psychomotor signs exhibited by the type A
person.
In short, we believe in the veracity of the following
statement with which we concluded our report pub-
lished in 1964.2
Certainly, it cannot be stressed too greatly that the cor-
rect classification of a subject depended far more upon
the motor and emotional qualities accompanying his re-
sponses to specific questions than the actual content of
his answers. To minimize or to misunderstand this last
differential is to fail in the correct behavioral assess-
ment of a subject.
If these words were heeded much of the present
confusion concerning the relationship between TAB
 September 1993
618 Friedman and Ghandour American Heart Journal

and CHD would not occur. We also believe that this Heart Disease. A critical review. Circulation 1981;63:1199-
1215.
confusion will disappear when qualified examiners 11. Booth-Kewley S, Friedman HS. Psychological predictors of
search as diligently for the psychomotor signs of heart diseases. A quantitative review. Psycho1 Bull 1987;
TAB as for the symptoms and traits of this behavior. 101:340-62.
12. Mathews KA. Coronary heart disease and type A behavior:
Also, when this occurs a sense of time urgency (or update on and alternatives to the Booth-Kewley and Fried-
impatience) will be recognized to be equally or even man quantitative review. Psycho1 Bull 1988;104:373-80.
more involved than hostility in the pathogenesis of 13. Case RB, Heller SS, Case NB, Moss AJ. Type A behavior and
survival after acute myocardial infarction. N Engl J Med
clinical CHD. After all, contemporary historians and 1985;313:737-41.
philosophers are as impressed with our increasing 14. Shekelle RB, Hulley SB, Neaton JD, Billings JH, Borhani NO,
sense of time urgency or impatience as with our in- Gerace TA, Jacobs DR, Lasser NL, Millemark MB, Stander J.
The MRFIT behavior pattern study. II. Type A behavior and
creasing hostility. incidence of coronary heart disease. Am J Epidemiol 1985;
A final caveat is in order! A high VCE score (i.e., 45 122:559-70.
or above) indicates the presence of TAB but not nec- 15. Ruberman W, Weinblatt E, Goldberg JD, Chandhary BS.
Psychosocial influences on mortality after myocardial infarc-
essarily CHD. But a low score (i.e., below 45) not only tion. N Engl J Med 198%311:552-g.
indicates the absence of TAB, but it also suggests a 16. Ragland DR, Brand RJ. Type A behavior and mortality from
relative protection against the future incidence of coronary heart disease. N Engl J Med 1988;318:65-9.
17. Ragland DR, Brand RJ. Coronary heart disease mortality in
CHD. We state this last because of the rarity, in our the Western Collaborative Group Study. Am J Epidemiol
clinical experience, of ever finding a low VCE score in 1988;127:462-75.
a patient with CHD. 18. Powell LH, Dennis CA, Thoresen CE. Type A behavior and
mortality from coronary heart disease [Letter]. N Engl J Med
We thank Jennifer Joss, AB, for her invaluable aid in assembling 1988;319:114-5.
much of the clinical data described in this article. We also thank 19. Lacy CR, Robbins ML, Kostis JB. Type A behavior and mor-
Marc Goldyne, MD, Department of Dermatology, University of tality from coronary heart disease [Letter]. N Engl J Med
1988;319:114-5.
California, San Francisco, who did the drawing and accompanying
20. Chesney MA, Black GW. Type A behavior and mortality from
legend in Fig. 6.
coronary heart disease [Letter]. N Engl J Med 1988;319:116-7.
21. Friedman M. Type A behavior: a frequently misdiagnosed and
rarely treated disorder. AM HEART J 1988;115:930-6.
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