BOSTON — The image is part of American lore: A graying executive, overworked and overwhelmed, drops face down in the sidewalk surge of expensive shoes and pin-striped suits, dead of a heart attack.
Such things happen far too often. But should the man's personality be blamed for his passing? Is he a victim of "Type A" behavior?
The idea that aggressive, impatient people work themselves into heart attacks has long been accepted by the public. But it's never been universally endorsed by heart specialists. Now, nearly three decades after the Type A theory was proposed by Drs. Meyer W. Friedman and Ray H. Rosenman, an abundance of new research is raising fresh doubts.
Some say that hostility and anger, not anxiety and competitiveness, are the key personality traits in heart disease. Others contend that the entire notion is nonsense.
"It's certainly premature to say there's nothing to Type A," says Dr. Elaine Eaker of the National Institutes of Health. "We're entering an era of confusion on it, mostly because some recent studies have not shown a strong relationship."
One of those studies was conducted by Drs. Robert B. Case and Arthur J. Ross. They found that Type A's live just as long after heart attacks as do their easy-going counterparts, the Type B's. About the Type A theory, Ross says: "I think, personally, it's a myth."
A major underpinning for the Type A concept was the "Western Collaborative Group Study," conducted by Rosenman and Friedman in the 1960s. It found that men with Type A personalities were two or three times more likely to die of heart attacks. Only one large, carefully conducted study has ever attempted to duplicate those results--and it was unable to do so.
This massive study re-examined the Type A theory. After assessing the personalities of more than 3,000 men and watching them for seven years, researchers found no link between behavior and heart trouble. Type A's and Type B's were equally beset by heart attacks.
"We came out with zero results no matter how we looked at it," said Dr. Richard B. Shekelle of the University of Texas, Houston.
Dr. William P. Castelli, director of the long-running Framingham Heart Study, said that any increase in heart attacks among Type A's can be explained by their tendency to smoke cigarettes and have high blood pressure and high blood cholesterol levels.
"If you have your traditional risk factors under control, it doesn't matter whether you're Type A," Castelli said. "You're not going to get a heart attack."
'Trash, Not Science'
Friedman bristles at doubts over Type A's importance. He calls the research by Case and Ross "trash, not science." Other scientists miss the link, he says, because they don't know how to diagnose Type A behavior.
For Friedman, the emblems of Type A personality are aggravation, impatience, irritability and anger. Type A's are aggressive and often insecure. They talk a mile a minute. They are always in a hurry, trying to fit more and more work into less and less time. Friedman estimates that more than half of all American men in cities are Type A's.
Their mirror images are Type B's. They are more self-secure and less likely to be contemptuous of others. They can get angry, but they don't let little things, like rude drivers, make them boil.
In Friedman's opinion, Presidents Lyndon B. Johnson and John F. Kennedy were Type A's, while Ronald Reagan and Gerald Ford are Type B's.
Can Be Changed
Friedman believes it's possible to transform Type A's into Type B's and make them live longer. He set up a counseling program to help people overcome their Type A impulses and concluded that he cut their heart attack rate in half.
However, another researcher, Dr. Redford B. Williams of Duke University, believes that hostility is the only personality trait that's clearly linked to heart trouble. He says hostile people are more likely to have hardening of the arteries and to die at an early age.
Hostile people are filled with cynical distrust. "They don't feel they can depend on other people to be nice," he said. "They are concerned that others will be selfish and mean." And, as a result of this attitude, they are often angry.
Williams says heart diseases in Type A's probably result from a chronic overproduction of certain hormones. But it's not clear whether the hostility causes these hormones, or the hormones cause the hostility.
Either way, he says, it may someday be possible to prevent heart damage in Type A's by giving them drugs that control their secretion of hormones.
Friedman agrees that hostility is very important, but he said: "To say that impatience or time urgency is not part of this disease is a tragedy. Nothing makes a hostile person angrier than to get impatient."