In 1988, the New England Journal of Medicine published an editorial commentary by Joel Dimsdale,1 who commented on the topsy-turvy career of the putative psychosocial risk factor for coronary heart disease (CHD) originally known as the Type A behaviour pattern (TAB), an action-emotion complex observed in people who are aggressively involved in a chronic struggle with life to achieve more and more in less and less time. Since its inception in the 1950s, the quest to legitimize TAB as a genuine risk factor for CHD has indeed been turbulent, suffering numerous setbacks. Most of the controversy came from epidemiological uncertainty generated by mixed results linking TAB to CHD outcomes. At the beginning of the new millennium, the vast majority of contemporary researchers would agree that the simple model linking TAB to CHD is clearly inadequate.
Does this inadequacy necessarily mean that the Type A construct has no validity, and that the entire area of investigation should be abandoned altogether? Some people agree, while others beg to differ. The article by Cole and his colleagues2 in this issue of the International Journal of Epidemiology entitled Time urgency and risk of non-fatal myocardial infarction represents the latest in a growing chain of evidence suggesting we might be able to salvage something useful from the chequered career of the Type A concept. The Cole et al.2 paper supports the more general conclusion that researchers should not rush to abandon the use of the paper-and-pencil measures for assessing components of Type A behaviour. Briefly, Cole et al.2 culled four items from the Framingham Type A scale to examine the relationship between subjective ratings of Time Urgency & Impatience (TUI) and non-fatal myocardial infarction (MI) in 240 cases and an equal number of matched controls. Their results showed time urgency and impatience was associated with a dose-response increase in risk of MI, independent of other risk factors. Importantly, the association remained significant after controlling for global Type A scores.
This brief commentary seeks to provide a broader context within which to interpret findings published by Cole et al. With regard to the historical backdrop, research on TAB has evolved to a point where most researchers now recognise that the construct is multidimensional in nature, and that different components have differential relevance for health, illness and medical problems resulting from a variety of causes.3 Increased recognition that we are dealing with a family of related constructs has even caused researchers to examine cousin constructs. In particular, the field has witnessed a dramatic shift away from (global) Type A research toward research on cynical hostility (see 4 for a meta-analysis). The unravelling of the Type A construct has left another legacy. As I have noted in a previous review article,5 this consists of the growth of an interesting and potentially fruitful body of literature relating the Time Urgency & Irritability (TUI) subcomponent of the Type A construct to a variety of measures of general ill health. In general, this emerging literature supports the view that not all Type A behaviours are necessarily coronary-prone or even health-relevant. Evidence now suggests that some Type A components are irrelevant to health and illness, but might still predict occupational performance. Moreover, this fledgling knowledge base suggests the TUI subcomponent may be uniquely associated with a variety of health outcomes and a negative risk profile which increases susceptibility to general ill health. This risk profile consists of the presence of vulnerability factors and the absence of health protective factors. Just to take one example, there is evidence to suggest that individuals are vulnerable to health problems resulting from (car) accidents by virtue of their TUI scores and not their global Type A scores.6 When considered in the aggregate, this growing data-base underscores the more general theme that subcomponent measures of Type A-related constructs are superior to global undifferentiated measures with respect to understanding vulnerability to different types of medical problems.
It seems appropriate at this time to take stock and evaluate the state of theory and assessment in this area. A cluster of interrelated measurement scales can readily be identified, starting with Cole et al,2 who culled four items from the Framingham Type A scale to develop a scale they believe measures Time Urgency & Impatience (TUI). Wright et al7 have developed a 42-item scale to assess a construct they labelled Time Urgency & Perpetual Activation, (TUPA), and have provided preliminary evidence for construct validity in research that pitted the TUPA against other measures that ostensibly measure the same construct. Spence et al8 factor analysed the student version of the Jenkins Activity Survey (JAS-Form T) to develop a five-item subscale they labelled the Impatience-Irritability (II) scale, finding the scale was uniquely related to physical health. Landy et al.9 have also studied the construct of time urgency in relation to health outcomes by developing a new multidimensional scale called the Behaviourally Anchored Rating Scale (BARS), which ostensibly measures seven dimensions of time urgency. Menon et al.10 have recent factor analysed the BARS, finding two separate interpretable subscales, which they labelled strategic time urgency, and obsessive time urgency. Furthermore, they reported a differential pattern of correlations to physical/ medical symptoms implicating obsessional time urgency as the sole health risk. By far the most widely used scale in this area is the 21-item Speed & Impatience (SI) subscale of the Jenkins Activity Survey (JAS) measure of the TAB. Hart5 has reviewed evidence to suggest the SI subscale from the JAS is uniquely predictive (relative to global A-B scores) of generalized health problems and health-risk processes. Clearly, work in this area seems to be growing at a healthy pace. But, a word of caution is in order, lest history repeat itself.
Ironically, one of the potential pitfalls in the burgeoning area of Type A subcomponent research is the very rapid proliferation of these different measurement scales. Because research to adequately support the reliability or validity of the various scales (i.e. TUI, TUPA, II, Strategic & Obsessional Time Urgency, SI) has yet to be conducted, it cannot be assumed they are all measuring the same theoretical construct. Also, we still do not know if this ambiguously defined construct is sufficiently stable over time to make it a viable CHD risk factor. Thus, generalizability of findings across different measurement scales might be quite limited. Clearly, in order to extrapolate from the operational level of analysis to the theoretical and conceptual level (and thereby move the field ahead), we need to quickly develop a programme of studies to evaluate the construct validity and reliability of the available assessment instruments. Without independent evidence of construct validity, empirical associations to health indicators derived from epidemiological research remain sterile, telling us little about the nature of the putative causal agent. Also, in order for us to develop conceptual models of the mediating mechanisms that might explain how this poorly understood personality construct (time urgency & impatience?) confers increased health risk, we need to have a much richer theoretical understanding of the attributes of the trait(s). Finally, efficient and effective therapeutic and preventative interventions would also depend on more precise theoretical specification of the nature of the causal agent.
Thus, future studies that seek to extend and refine work by Cole2 and others might wish to address the question Is there any validity to the Time Urgency & Irritability concept? Developmentally, the Time Urgency & Irritability concept is now beginning to metamorphose from infancy to early childhood. I sincerely hope it can avoid following in the topsy-turvy footsteps of its Type A predecessor, which left in its wake a rather dubious career trajectory. Something seems to be emerging from the literature, but whatpreciselyis it?
Notes
School of Psychology, University of Leeds, Leeds, UK. E-mail: kenh{at}psyc.leeds.ac.uk
References
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2
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