There is ample research to show that behavioural risk factors play an important role in the development and progression of heart disease. In fact many researchers including Dr Dean Ornish consider them to be as or more important than the physical ones described in the previous chapter. This is because a certain percentage of people with high risk factors go on to have a heart attack. In addition, in certain populations, the risk of heart attack is low for cultural reasons as will be described later. More important, the research shows that by modifying these behavioural patterns it is obviously possible to reduce the risk of having a second heart attack.
The link between psychological health and well being has been recognised for many years but it was the pioneering research of Dr Caroline Thomas who, in 1948 with the psychiatrist Dr Barbara Betz, scientifically proved this. They studied a few hundred students at the Johns Hopkins School of Medicine and classified them as: ‘Alpha’ (cautious, steady, self-reliant and non-adventurous), ‘Beta’ (spontaneous, clever and flexible), and ‘Gamma’ (brilliant, confused and complicated). Thirty years later they found that the Gamma had the most medical problems with 77.3% having some serious illness as compared to 25% of Alpha and Beta. In another sample of 127 medical students they found that 13 deaths among those originally classified as Gamma compared to none in the other groups after 30 years.
Dr George Vaillant, a famous psychiatrist at Harvard University, studied 185 medical students in the early forties. He followed their lives for over 40 years and found that of the 59 men with the best mental health, only 2 became chronically ill or died before the age of 53. In a similar group with the worst mental health, 18 became chronically ill or died. He identified the ability to respond flexibly to change as a key trait that protected one from chronic illness and disease.
Many other recent studies have explored the connection between psychological disorders and heart disease. Depression, for example, increases the risk of having a second heart attack by around 50%. This makes it imperative to deal uncompromisingly with the depression that many patients experience after they have had a heart attack or bypass surgery.
From his early hunting days man has lived in a tribe and has an inherent need to be a part of a group. To be liked by others is a powerful motive for most people, especially those with a strong need for affiliation. Isolation is one of the most difficult punishments for most people. In fact the isolation cell is used as punishment for the most hardened criminals. People who are socially isolated are under chronic stress. Recent research shows that people who are isolated or feel lonely have a much higher risk of developing heart disease.
Dr Kristina Orth-Gomer at The National Institute of Psycho-Social Health in Stockholm has found that social isolation in middle-aged Swedish males is a risk factor comparable to smoking in the causation of myocardial infarction.
She found that in heart patients attachment behaviour was lower. By ‘attachment’ she means having someone very close, who one can confide in, share feelings with, hold and comfort. High attachment scores are protective and prevented heart disease even in the presence of high cholesterol levels in the blood.
Dr Orth-Gomer found another dimension of social behaviour that also predicted heart disease — this was social integration or the size and quality of the person’s social network. The risk was multiplied in those with low social integration, especially those who smoked, had hypertension or diabetes.
Other researchers have found that people who are married have a lower incidence of illness than unmarried or divorced people. Those men who reported that their wives were supportive were far less likely to have severe blockages of their arteries. In another study in Cleveland married men with multiple risk factors were studied and those who said that their wives showed them their love were much less likely to develop angina despite high risk levels.
Even the emotional closeness one derives from a pet can have a healing effect. Men with pets have been found to have a 4 to 6 times lower risk of dying in the first year after a heart attack.
Studies of Japanese men who have migrated to America show that those, who have maintained a traditional lifestyle with an emphasis on close social connections with their friends and relations, have a much lower incidence of heart disease than those who adopted an isolated western lifestyle. This is after allowing corrections for differences in cholesterol levels and dietary fat intake. What emerged was that the stable culture with family and social ties somehow protected the Japanese men from heart disease.
Dr Dean Ornish considers loneliness to be one of the most important risk factors for developing heart disease and has written a book Love and Survival on the importance of the power of connection, community and intimacy on health. Group therapy is a core facet of the Ornish programme and one of the major aims of his programme is to foster a strong sense of connection with others in the group and help people break the bonds of isolation. The healing effects of human connection are increasingly being recognised in the treatment of trauma and other psychological disorders. If you have heart disease it is important that you work on becoming aware of and changing, if you have a tendency to be isolated or feel lonely. In fact it is a good idea to learn how to open up to others.
For most people, fear is the root cause of isolation. Some people are afraid of being hurt or being taken advantage of and isolate themselves to prevent this. Such people may have many acquaintances but do not get close to them.
Dr Alexander Lowen M.D., the founder of Bioenergetics and the author of the book Love, Sex and Your Heart, feels that many patients with coronary artery disease are afraid of expressing love, “The problem that most of us face is that the defences we erected to protect the heart have become its prison and are now unconscious&. Most people believe that they would be fully capable of loving if only they were loved. They confuse the longing for love with loving itself. They sense the loving in their heart but can’t get to it, cut off as they are from their heart by the barriers they erected to save it.”
Opening up to others and learning to trust others more, is one way of breaking out of your isolation cell. Talking to another about your feelings, secret hopes and dreams is a first step. More important is to learn how to listen to another and share in that person’s joys and disappointments. One must also be willing to create time and give of oneself to others.
A few years ago I met a rich businessman at a party. He had inherited substantial wealth but said that his life was empty and lacked meaning. In a very offhand manner I asked him if he had ever considered the ultimate high: helping others. Two years later I met him again and he walked across the room and thanked me. I was surprised as I could not even remember his name. He explained that he had taken my suggestion seriously and had started doing voluntary work with poor people on weekends and this had changed his life. He said he had learned how to treat them as equals and had learned a lot from them about what is really important in life. He had made many new friends in the sector and was now considering handing over his businesses to professional managers so as to be able to dedicate more of his time to voluntary work.
The link between one’s personality and the heart has been recognised from time immemorial. Terms like ‘warmhearted’, ‘hard-hearted’ and ‘cold-hearted’ have become a part of one’s common everyday language. The truth of this folk wisdom has been confirmed by research and shows that cynical, cold-hearted people are more likely to die of heart disease.
Links have been found between a number of psychosomatic diseases like asthma, rheumatoid arthritis, ulcerative colitis and migraine, but nowhere is the link as clear as in the case of heart disease. Certain personality traits, especially hostility and cynicism, predispose one to die of heart disease. In addition, persons with these traits have a much higher risk of developing a second heart attack once they have developed coronary artery disease.
In the early 1970s, Dr Meyer Friedman and Dr Ray Rossman published a book called Type A Behaviour and Your Heart. In this book they revealed the results of a study of three thousand people in San Francisco. They identified certain personality traits that they labelled Type A; patients with these traits had a four times greater risk of developing heart disease. This increased risk was over and above that caused by other risk factors such as cholesterol, high blood-pressure and diet. The increased risk for a Type A person is the same as that of someone who smokes two packets of cigarettes a day. In fact, the risk is higher (about seven times) because the Type A person is also much more likely to smoke cigarettes and to have hypertension.
They identified another personality type which they called Type B people, with this personality type rarely developing Coronary Artery Disease before the age of sixty-five. In his book Treating Type A Behaviour and Your Heart, Dr Meyer Friedman described the results of educational classes for hundreds of patients who had already suffered a heart attack. The results of modifying Type A behaviour was that the risk of a second heart attack was reduced by 48% in the first and second years and there was a 372% decrease in mortality in the third year. This proved that it was possible to modify Type A behaviour and that this personality trait was responsible for progression of the disease.
Further research by other researchers has shown hostility to be the most toxic component of the Type A risk factor. Cynicism, a tendency to ascribe negative intentions to others, is a mental attitude that predisposes one to react to others and to situations with hostility.
Dr Paul Falger of the S.L. University School of Medicine in the Netherlands found that the coronary prone individual has a habitual manner of acting alert, with an utterly competitive involvement and an exaggerated need for personal recognition through work. He has observed that these competitive and aggressive people often have a habit of getting over-involved in things and are prone to unprecedented explosions.
Gen Kapoor is an example of a Type A person. He retired early from the army, following a heart attack and took to social work, to help the poor. He started a small charitable organisation, which soon expanded into a large enterprise. All the General could talk about was his organisation and his achievements.
His colleagues noticed that he had a terrible temper. If someone contradicted him, he would fume for days and use foul and abusive language to criticise the person behind his back. To the external world, he was a saintly person concerned with the welfare of the poor. To those who worked with him, the General seemed more concerned with his own status and publicity. He was preoccupied with the faults of others, and had declared ‘war’ on another voluntary organisation, which he considered corrupt.
Petty things would trigger off attacks of rage. The staff turnover in the General’s agency was phenomenal. Everyone recognised that the General’s hostility was creating many difficulties as some of the trustees had resigned.
Dr Ram, a trustee of the organisation, had tried to point out to the General the effect his hostility was having on those working with him and on his own health. He told the General about the famous English surgeon Dr John Hunter (1729-93), who suffered from angina and had noticed the link between emotions and heart disease. Dr Hunter was often said to comment, “My life is in the hand of any rascal who chooses to annoy me.” Dr Ram lost no opportunity to remind the General that Dr Hunter’s words were prophetic and he died after a heated argument with members of the Board of his hospital.
None of this seemed to have any effect until Dr Ram wrote to the General pointing out that he was destroying the culture of the organisation and that unless he changed, the trustees would move to have him removed from the Board. Dr Ram also sent the General a copy of Treating Type A Behaviour and Your Heart by Dr Meyer Friedman.
After reading the book, Gen Kapoor grudgingly accepted that he was a classical Type A personality and that it might have ruined his health. He decided to change and in his usual manner decided to wage war on his Type A behaviour rather than the world at large. On introspection, he realised that he was angry most of the time and that his ‘hostility’ had created major problems for him at work and with his family and friends.
It took a few months to change but people could not believe the transformation in his behaviour. He was surprised at how things were much better at work and at home. A few months later he gracefully thanked Dr Ram for saving his life telling him, “For the first in my life I know what it is to feel happy!”
The irritable, executive with his cellular phone, scurrying from one appointment to another is the archetypal Type A person. With globalisation, the Type A personality like a virus seems to becoming much more common. In rural cultures Type A behaviour was rarely known.
In addition to hostility many coronary prone individuals tend to be cynical and over-involved in themselves. They can be selfish, lack empathy and find it difficult to see another’s point of view. Many coronary prone people have a lack of basic trust and this makes them suspicious of other people, sometimes to the point of paranoia.
The Type A person is also characterised by a driving sense of time urgency, an intense struggle for status and has high levels of free floating hostility. Such people live for the deal or the job and evaluate everything numerically. The only important thing for them is to make it. Everything else: family, children, friends and even ethics are often secondary.
Hostility is the most harmful personality trait that predisposes one to develop heart disease. In response to stress, the hostile person feels irritated or very angry and in some cases this is expressed explosively. Often the person keeps simmering and does not express this anger or hostility directly. Many of them express it in indirect ways such as criticism and constant fault finding.
Teja Singh, a rich businessman, who suffered from angina is a typical example. At parties he would somehow manage to turn the topic to various social ills such as corrupt politicians, the exploitative school system, or the ungrateful poor. He would then get worked up and upset, use crude language and not allow others to have their say. If someone did not agree with him, he would get angry and have an angina attack.
Retired because of his angina, he spent his time clipping and collecting newspaper articles and writing letters to the editor. His wife Tina was gregarious and well liked by her friends but she noticed that friends had stopped inviting them over and this troubled her. A close friend finally told her that her husband was the problem and that his behaviour was offending others. At a loss as to what to do she talked to her doctor who suggested that she take her husband to consult Dr Nishant, a Behavioural Medicine Specialist, as Teja Singh’s behaviour was dangerous for his health.
Hostility has been found to be the most harmful aspect of Type A behaviour. Numerous studies have shown that the person who high levels of free floating hostility is at a much higher risk of having narrowed arteries due to atherosclerosis.
Free floating hostility is often manifested as criticism, cynicism, passive aggressive behaviour and irritability, the use of abusive and crude language and a harsh jarring voice. If the Type A person is engaged in a task which is interfered with, he will often explode in a manner totally out of proportion to the situation.
Driving is one area where the Type A person manifests his hostility and this often leads to trouble. The Type A driver often gets angry when anyone overtakes him. He will abuse the other driver or try to overtake and punish the other driver by flashing his lights, or trying to run him off the road or blocking his way.
Being made to wait is another situation to which the Type A person reacts with irritability. Typically, if someone else is late or has missed an appointment and made the Type A person wait he will be very angry.
Dr Venkat, a skin specialist, had returned to India from America after he developed angina at the age of 36. He felt that with his American qualifications, patients would flock to him and he would have a relaxed practice in India. At first he found that he was fairly busy but gradually his practice dwindled. After a lot of soul searching during therapy for his Type A behaviour, he finally accepted the harsh reality that he was his own worst enemy. A friend from his medical college days, told him that patients were getting upset at the way in which he ticked them off for not following instructions or being late and did not want to go back to see him.
He learned how this aspect of his Type A behaviour was self-defeating and recognised that he got worked up and had chest pains when someone was late and kept him waiting. Dr Venkat learned to deal with the situation by developing a flexible system to suit his patients and the local culture. In addition he started using the free time between patients to practise an advanced form of self-hypnosis, to heal his mind at an unconscious level.
A few months later, he was gratified to find that he was getting calmer and could now even be amused about his earlier impatience. It took Dr Venkat a long time to get back to his practice, but this experience concretely helped him realise that his impatience and hostility were unhealthy and self-destructive and this motivated him to change.
Six months after starting his programme of Type A counselling and dietary modification, Dr Venkat was pleasantly surprised to find that his exercise stress test showed marked improvement, and two years later his stress test was normal. While this did not mean that his arteries were no longer blocked, it did show that his arteries had opened up enough so that his heart now received enough blood for him to be able to exercise vigorously.
The Type A person is usually very good at hiding these traits from others and finding rational arguments to support their hostility. I remember talking to Mr Kini, who came in ranting about his son-in-law and how he would teach him a lesson. All his arguments were very logically thought out, but over a very short time it became evident that Mr Kini was typical of the Type A person.
Mr Kini was angry because his daughter had not consulted him before she agreed to marry her sweetheart. She knew her father well enough to realise that he would always raise objections or find something wrong and had therefore gone ahead and consented.
Despite his wife and others warning him that his behaviour would damage his relationship with his daughter Mr Kini kept up his tirades. It was only when his wife told him that she would leave him to get away from his obsessive preoccupation with ‘teaching their son-in-law a lesson’ that he agreed to seek help. Therapy not only helped him get over his obsession with his son-in-law but built bridges in his relationship with both his daughter and the earlier much despised son-in-law.
The Type A person is very alert to all forms of deceit and hypocrisy in others. It often appears that he has his radar tuned into the hypocrisy of politicians, businessmen and priests. As the Type A person is extremely mistrustful of the intentions of others he is the first to notice what is wrong in a situation. Such people find it difficult to trust or be close to others.
Dr Redford Williams, of Duke University, considers cynicism and mistrust to be the central core of Type A behaviour. He has noticed that increasing cynicism and mistrust is associated earlier death from heart attacks.
Dr Larry Sherwitz of the University of California and his team noticed that the patients who frequently used self-referent words and phrases such as ‘I’ ‘me’ ‘mine’ in their speech had more severe heart disease. In fact, researchers have been able to correlate the amount of coronary blockage to the number of times the person refers to himself in an interview. The higher the number self referent statements the patients used, the greater the blockage and more severe the disease. He also noticed that patients with CAD have a tendency to use numbers rather than metaphors and analogies in their speech.
Patients with coronary artery disease often claim that before their attack they felt that they were struggling all the time. Some say they were tired of life and felt they were on a treadmill, which they could not get off.
The reason for feeling that one is struggling constantly, is often due to the fact that many Type A people try to fit in as many things as possible into a short period of time. Others try to do a number of things at the same time. This leads them to feel pressured all the time.
For instance, some Type A persons will try to read a book or newspaper while watching television. It is not unusual to see this trait (polyphasic behaviour) during leisure activities. For example, an acquaintance who died at 42 from a coronary was trying to learn German using tapes while he played golf.
The constant activity means that the person is alert all the time and cannot relax for a few minutes. This is very stressful. A patient whom I was treating told me after a heart attack, “I feel guilty if I do not work or keep myself busy, I feel that I am wasting time. Even when playing with my children I feel I could be doing something more useful. Holidays are sheer hell, I keep wondering about the office. I’ve forgotten how to have fun.”
Exploration under hypnosis revealed that he had incorporated a belief, as a child, that he was worthwhile only as long as he achieved things, since his father only paid him attention when he did well at school and was critical if he did not come first in class. He thus needed to keep on achieving all the time to feel worthwhile.
He finally understood why his expectations always seemed to expand and he kept finding new and more difficult goals to work towards. It required hard work to help him unlink his self-esteem from the need to achieve in order to give himself the internal permission to relax and enjoy himself, without having to achieve things all the time.
Many people with coronary artery disease have an exaggerated need for status, especially through work. This makes them very competitive, so much so that some will not even let a child win a game while playing with them. Many patients find this constant need for status can be quite a struggle and this adds to the stress they experience.
Mr Surve, a senior advertising executive, discovered during a routine medical check up that he had coronary artery disease. He had no symptoms but his doctor warned him that he would have to cut down on work. This upset him very much and he got severely depressed. Mr Surve had always believed that he was special and was chosen to rise to the top of his company. Now, like a bolt out of the blue, this heart problem had come in the way.
Lying in bed after an angiography, he realised that he had a real problem as he did not have any friends. Apart from a few juniors, no one had come to see him. Even his children visited him for a few minutes and left the hospital.
Later during family therapy, he saw how he had alienated his children by comparing their achievements with his own at a younger age. He realised that his constant boasting about his own achievements had driven others away from him (an example of self-involvement).
One of the characteristic signs of a Type A person is that he lacks a sense of humour, especially the ability to laugh at himself. The Type A person’s humour is likely to be sarcastic and have an edge of hostility and envy. He will often ridicule weaker people or those unable to fight back. He may also have the unpleasant habit of making fun of people behind their backs and using obnoxious or vulgar language.
Dr Meyer Friedman, the author of Treating Type A Behaviour and Your Heart, has noticed a tendency towards self-destruction. The Type A person will often do things that will get him into trouble, such as taking undue risks in business, cheating on his taxes or getting into fights and quarrels.
Take the earlier mentioned case of Dr Venkat. At the early stages of his setting up practice in India, he began to have an affair with his secretary and would give her expensive presents and take her out to expensive eating places. He realised in therapy, that he was bound to be noticed by his patients and friends, and it was only a matter of time before his wife got to know.
Hostility, cynicism and mistrust lead people to keep a distance from others and this turns into a deep sense of alienation and loneliness. One way to avoid these painful feelings is by filling up one’s life with ceaseless activity. This puts the person under chronic stress which can causes heart disease.
The most harmful traits are the hostility, cynicism and self-involvement followed by the constant struggle to achieve things and to be in control.
Most people will find it difficult to accept that their behaviour is responsible for their illness. If confronted by others, they usually have some rational justification for their behaviour. For example, they might maintain that unless one is pushy and aggressive, one will be left behind or that others will gobble them up.
Those with coronary disease have learned to camouflage their feelings from others. While they may be feeling murderous, to the outside observer they appear to be totally calm. It was because of this that Dr Meyer Friedman’s team, while studying Type A behaviour, intentionally designed a stressful and irritating interview to bring out the Type A traits. Patients were made to wait without an explanation for long periods and the interviewers often asked them difficult questions and contradicted them frequently. Most of the diagnosis of Type A behaviour was done on the basis of non-verbal cues.
When made to wait, the Type A person would fidget restlessly and be ready to shoot out of his chair at a moment’s notice. He usually spoke rapidly and would often complete another’s sentences.
The intense hostility of the Type A person which is often bottled up can frequently be noticed in a jarring laugh, a tense, hostile facial expression and a tendency to use obscenities and critical or derogatory terms such as idiot, rascal, teach him a lesson etc. The Type A person often starts getting worked up when talking about past annoying experiences. Owing to his high levels of psychological denial, he may not be aware of these traits or may try to explain them away. Personality questionnaires are not an effective way of discovering these traits. The best way is to discuss them with close friends and family.
With rapid westernisation, coronary heart disease is becoming increasingly prevalent among Indian women. One reason for this rise is the fact that many more women have started smoking. In addition, many women, especially working women, have started developing Type A traits.
Women are better at hiding the intense sense of free floating hostility and a need to be in control. Such a woman is likely to have a deep underlying sense of insecurity, which is compensated for through achievements, especially at work. Type A women who do not work may be involved in social activities. Like coronary prone men, the Type A woman is likely to have a lot of bottled up hostility and a sense of impatience.
Some women with heart disease will often admit to a deep sense of insecurity and envy of others, who appear free to get on with work or are doing well. Many feel a sense of frustration at not being or doing enough. The Type A woman is likely to be under tremendous and chronic internal stress if she is unable to achieve her dreams. In his book, Dr Friedman reports that Dr Suzanne Haynes of the Framingham study found that Type A working women had four times as many heart attacks as compared to Type B working women.
The Type B person is the polar opposite of the Type A person. They have a more leisurely, relaxed and contemplative attitude towards life and they take things in their stride. In addition, the Type B person usually has a mature well-developed sense of humour. They can laugh at themselves and lack the hostility or crudeness of the Type A person’s humour.
The Type B person has a more relaxed long-term view of things. He rarely over-commits and is able to hand over and delegate without getting anxious about it. In contrast, the Type A person finds it difficult to give up control and even if he delegates, it is reluctantly and with close supervision.
Another major difference is the hostility. The fully developed Type A person gets angry and irritated by all manner of things — even reading the newspaper can trigger an attack of rage. In comparison, the Type B person has a much more balanced and calm view of life. As a mature person, he sees that the good and the bad often go together and are both a part of life. While he may be willing to fight injustice, he will not get overly upset to the extent that it becomes his only preoccupation. Similarly, when talking about or recalling an injustice, unlike the Type A person, he will have a more philosophical view.
The Type B person is also more likely to enjoy the simple pleasures of life — talking to friends, reading a novel or playing with their children. When the Type B person is doing something, he is usually fully absorbed in that experience, unlike the Type A person who is preoccupied with many things such as planning his other activities.
Dr Venkat, a Type A person described his experience of attending a concert after many years. He said that instead of enjoying the concert his mind kept jumping to hospital politics. Later he found himself getting restless as he wanted to go out and make a telephone call. Waiting for the concert to finish became an intolerable experience. In order to humour his wife he sat through the concert. During this period he noticed that hostility towards his wife built up and he later found himself criticising her for delaying him by talking with friends outside the theatre.
It is useful to recognise the effect that Type A behaviour has on all areas of your life. The realisation that it not only harms your health but may poison the rest of your life can be a strong motivation to change.
Since the Type A person is highly competitive, he usually finds it difficult to co-operate with his co-workers and is rarely liked by them. They therefore are unlikely to co-operate with him in his time of need.
The Type A person’s constant criticism and hostility induces tension in his subordinates and this can often lead to the Type A person being actively disliked. I have seen cases where subordinates will take any opportunity to sabotage their boss. The Type A person’s superiors often recognise his inability to delegate and get along with people. Due to this, they often choose someone with better interpersonal skills over a Type A person for promotion.
A study by Dr Meyer Friedman of leaders in business and society showed that the percentage of leaders with Type B traits was much higher than their percentage in the general population. Dr Friedman also observed that he has “yet to come across a single top Type B corporate executive who has had a heart attack before his 65th birthday.”
The Type A person is usually perceived by his wife and children to be a tyrant or bully and is often disliked by them. After their husbands have died of coronary disease, many wives say that it is a relief. I have also observed that children from families with one or two Type A parents have a much higher incidence of psychiatric illness, drug addiction and behavioural disturbances.
Mr Suri was an ageing retired politician who had been a minister. His son was severely addicted to heroin and Suri blamed his wife for this insisting, saying that she had not been a good mother. During therapy he once said, “She used to keep asking me to help with his homework and attend his school events. Did she not realise that I am a man of action and had much more important things to do like raising funds for the Party.” Mr Suri maintained that different rules applied to men of action like him.
It took him a long time to understand why his wife finally left him with her son and moved to her brother’s house. When he realised what he had done he suffered a severe attack of depression which had precipitated his heart attack.
The Type A person is much more likely to develop high blood pressure than his Type B counterpart. He is also more likely to smoke and suffer from smoking-related illnesses such as bronchitis and cancer. I have found that the Type A person is much more likely than the Type B person, to develop psychiatric disorders such as anxiety and depression.