Reliability of interview-assessed hostility ratings across mode of assessment and time.

These studies addressed 2 questions concerning interview-based hostility assessments: whether they are affected if the interview is conducted face-to-face versus telephone and whether they are stable across an extended time period. In Study 1A, 54 students were interviewed face-to-face and by telephone in a laboratory setting. Half the sample was reinterviewed in the laboratory 6 weeks later. The other half was reinterviewed by telephone at home. With 1 exception, all intraclass correlation coefficients (ICCs) comparing interview modes were above .62. In Study 1B, 48 adults were interviewed face-to-face in a laboratory and by telephone in their homes with a 2-week intervening interval. The ICC comparing interview modes was .78. In Study 2, 100 adults were interviewed face-to-face in a laboratory and approximately 4 years later by telephone in their homes. The ICC across interviews was .69. Thus, support was found for the stability of interview-based hostility assessments across interview methods and extended periods of time.

Hostility predicts magnitude and duration of blood pressure response to anger.

The hypothesis that hostile and nonhostile individuals would differ in both magnitude and duration of cardiovascular reactivity to relived anger was tested. Participants were 66 older adults (mean age, 62; 38 women and 28 men; 70% Caucasian American, 30% African American). Each took part in a structured interview scored using the Interpersonal Hostility Assessment Technique. Later each relived a self-chosen anger memory while heart rate and systolic and diastolic blood pressures were measured continuously using an Ohmeda Finapres monitor. Hostile participants had larger and longer-lasting blood pressure responses to anger. African Americans also showed longer-lasting blood pressure reactivity to anger. Health and measurement implications are discussed.

Ambulatory cardiovascular activity in Vietnam combat veterans with and without posttraumatic stress disorder.

The present study investigated the relationship between daily diary affect ratings and ambulatory cardiovascular activity in 117 male Vietnam combat veterans (61 with posttraumatic stress disorder [PTSD] and 56 without PTSD). Participants completed 12-14 hr of ambulatory monitoring and daily diary affect ratings. Compared with veterans without PTSD, veterans with PTSD reported higher negative affect and lower positive affect in daily diary ratings. No differences were detected for mean laboratory initial recordings or mean ambulatory heart rate (HR), systolic blood pressure (SBP), or diastolic blood pressure (DBP). However, compared with veterans without PTSD, veterans with PTSD demonstrated higher SBP and DBP variability and a higher proportion of HR activity (compared with initial recording values) during daily activity. There was a significant Time of Day x Group interaction for mean HR, with a trend for PTSD participants to maintain HR levels during evening hours.

Measures of hostility as predictors of facial affect during social interaction: evidence for construct validity.

We assessed the construct validity of several self-report measures and an interview-based measure of hostility (Interpersonal Hostility Assessment Technique [IHAT]) by evaluating their associations with a behavioral indicator of hostile emotions (facial expressions during social interaction). Participants in the study were 123 volunteers (44% males and 56% females) who were recruited from local community organizations. Self-report measures (Cook-Medley Hostility Scale, Rotter Interpersonal Trust Scale, Buss-Durkee Hostility Inventory, and Spielberger Anger Expression Scale) were represented by factor scores reflecting Overt Hostility, Covert Hostility, and Hostile Beliefs. A canonical correlation analysis identified significant associations between a set of facial affect scores reflecting animosity and various measures of hostility. Specifically, increases in anger and disgust expressions and decreases in happy facial expressions were associated with high IHAT scores and high scores on self-report measures of Hostile Beliefs and Covert Hostility. Women were more expressive than men, especially concerning positive affect, and women had lower scores on self-report measures of Hostile Beliefs and Overt Hostility. IHAT scores were uncorrelated with any of the self-report factors which suggests the two assessment techniques are tapping different aspects of the hostility construct.

Surrogate assessment of coronary artery disease patients' functional capacity.

An investigation of the surrogate assessment of coronary artery disease (CAD) patients' functional capacity was conducted using 193 patient and surrogate rater dyads. Mean age of patients and surrogate raters were 60.4 and 54.4 years, respectively. Patients and surrogates independently completed a brief questionnaire that assessed health and psychosocial factors. The Duke Activity Status Index (DASI) was contained in the patients' questionnaire, while a similar form modified to assess patients' functional capacity was imbedded in the surrogates' questionnaire. Results indicated similar psychometric characteristics and clinical validity for patients' self-report and surrogates' ratings, suggesting that the Surrogate Rating Form of the Duke Activity Status Index (DASI-SRF) is a reliable and valid proxy method of assessing patient's functional capacity when this information may not be obtained directly from the patient. Further, while there were no effects of surrogates' health and psychological characteristics on their ratings of patients' functional capacity, in comparison with other surrogates, spouses were more likely to rate patients higher in functional capacity. Exploration of the patient/care provider relationship via concurrent use of the DASI and DASI-SRF is discussed.

Depression and long-term mortality risk in patients with coronary artery disease.

Previous research has established that patients with coronary artery disease (CAD) have an increased risk of death if they are depressed at the time of hospitalization. Follow-up periods have been short in these studies; therefore, the present investigation examined this phenomenon over an extended period of time. Patients with established CAD (n = 1,250) were assessed for depression with the Zung Self-Rating Depression Scale (SDS) and followed for subsequent mortality. Follow-up ranged up to 19.4 years. SDS scores were associated with increased risk of subsequent cardiac death (p = 0.002) and total mortality (p < 0.001) after controlling for initial disease severity and treatment. Patients with moderate to severe depression had a 69% greater odds of cardiac death and a 78% greater odds of mortality from all causes than nondepressed patients. Increased risk was not confined to the initial months after hospitalization. Patients with high SDS scores at baseline still had a higher risk of cardiac death > 5 years later (p < 0.005). Compared with the nondepressed, patients with moderate to severe depression had an 84% greater risk 5 to 10 years later and a 72% greater risk after > 10 years. Patients with mild depression had intermediate levels of risk in all models. The heightened long-term risk of depressed patients suggests that depression may be persistent or frequently recurrent in CAD patients and is associated with CAD progression, triggering of acute events, or both.

Interpersonal Hostility Assessment Technique: description and validation against the criterion of coronary artery disease.

High levels of hostility are associated with adverse health outcomes. The Interpersonal Hostility Assessment Technique (IHAT; Barefoot, 1992) measures hostility from verbal behavior during a standardized interview. Four types of behaviors are scored as hostility: evading the question, irritation, and indirect and direct challenges to the interviewer. The sum of the frequencies of these acts is a Hostile Behavior Index (HBI), which is divided into two components: verbal, scored with speech content in mind, and paraverbal, based on vocal stylistics. This study examined characteristics of IHAT assessments in 129 male coronary patients. Satisfactory interrater reliabilities were obtained. The HBI correlated highly (.58) with coronary artery disease severity after controlling for traditional risk factors. This relation was not affected by question topic or by differential weighting of the four hostile behaviors. Both HBI components were significantly correlated with disease. Results are discussed in terms of their implications for hostility assessment.

Interpersonal and self-reported hostility among combat veterans with and without posttraumatic stress disorder.

The present study investigated self-reported and interpersonal hostility in 70 Vietnam combat veterans with and without posttraumatic stress disorder (PTSD) and 60 comparison community volunteer subjects. Veterans were 50 help-seeking, male Vietnam combat veterans with PTSD and 20 non-help-seeking male combat veterans without PTSD. Vietnam veterans with PTSD not only reported more hostility than non-PTSD veterans and healthy community volunteers, but also reacted behaviorally with more hostility during an interpersonal interaction. Compared to veterans without PTSD, veterans with PTSD reported significantly higher levels of hostility and demonstrated significantly greater non-verbal expressions of hostility during an interpersonal task. These results suggest that the level of hostility in PTSD combat veterans may be high as compared to comparison groups. The implications of these results and possible research directions are presented.

Hostility in asymptomatic men with angiographically confirmed coronary artery disease.

The association of hostility and coronary artery disease was evaluated in a case-control study of aircrew members who had been referred for coronary angiography on the basis of noninvasive tests or risk factor status. The asymptomatic status of the sample and the structured nature of the referral process minimize the methodologic problems normally associated with studies of patients undergoing angiography. Cases (n = 24) had some angiographic evidence of coronary artery disease, whereas controls (n = 25) were found to have no evidence of occlusion. An interaction was observed between smoking history and a measurement of hostility based on observations of the respondent's behavior during a standard interview. Among nonsmokers, cases had higher hostility scores than did controls (p = 0.004). This association was not present among smokers. Self-reported hostility did not discriminate cases from controls. These findings support the notion that hostility plays a role in the pathogenesis of coronary atherosclerosis and point to the potential importance of interactions between hostility and other risk factors.

Age differences in hostility among middle-aged and older adults.

Multiple measures of hostility were administered to middle-aged and older volunteers. There was a positive association between age and self-report measures reflecting hostile beliefs about others, including cynicism and suspiciousness. There was a weak inverse relationship between age and self-report measures of the overt expression of anger and aggression, but no association between age and measures of covert hostility was found. There was a positive relationship between age and an assessment of hostile behavior that was based on the respondent's interaction style during an interview. The magnitude of these age trends did not differ between men (n = 50) and women (n = 75). These findings illustrate the multidimensional nature of hostility. They also have practical implications for older people because hostility is associated with psychological well-being and has been shown to have consequences for health and longevity.

Measures of neuroticism and disease status in coronary angiography patients.

A high percentage of patients who undergo diagnostic angiography because they have chest pain are found to be free of significant coronary artery disease. To examine the psychological characteristics of these patients, we used several Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943) measures to assess the relationships between different aspects of neuroticism and coronary artery disease severity (CADSEV) in a sample of 1,462 angiography patients. The Conversion V profile was inversely and most strongly related to CADSEV. Single high scores on hypochondriasis or hysteria were also inversely related to CADSEV, but psychasthenia and Taylor Manifest Anxiety Scale (TMA; Taylor, 1953) scores were not. Using measures derived by a factor analysis of the MMPI, items relating somatic complaints were inversely related to CADSEV, but a measure of general neuroticism was not. These results support the hypothesis that the association between neuroticism and angiographic findings may be specific to a particular aspect of neuroticism, somatic preoccupation. The implications for neuroticism measurement and clinical practice are discussed.

Prognostic importance of social and economic resources among medically treated patients with angiographically documented coronary artery disease.

OBJECTIVE: To evaluate the hypothesis that diminished social and economic resources impact adversely on cardiovascular mortality in patients with coronary artery disease. DESIGN: Inception cohort study of patients undergoing cardiac catheterization from 1974 through 1980 and followed up through 1989. SETTING: Tertiary care university medical center. PATIENTS: Consecutive sample of 1965 medically treated patients with stenosis 75% or greater of at least one major coronary artery. Five hundred patients were not enrolled due to logistic problems; 33 refused; 64 had missing data on key medical variables. The final study population included 1368 patients, 82% male, with a median age of 52 years. MAIN OUTCOME MEASURE: Survival time until cardiovascular death. RESULTS: Independent of all known baseline invasive and noninvasive medical prognostic factors, patients with annual household incomes of $40,000 or more had an unadjusted 5-year survival of 0.91, compared with 0.76 in patients with incomes of $10,000 or less (Cox model adjusted hazard ratio, 1.9; 95% confidence interval, 1.57 to 2.32; P = .002). Similarly, unmarried patients without a confidant had an unadjusted 5-year survival rate of 0.50, compared with 0.82 in patients who were married, had a confidant, or both (adjusted hazard ratio, 3.34; 95% confidence interval, 1.84 to 6.20; P less than .0001). CONCLUSIONS: Low levels of social and economic resources identify an important high-risk group among medically treated patients with coronary artery disease, independent of important medical prognostic factors. Additional study will be required to see if interventions to increase these resources improve prognosis.

Subscapular elastofibroma in a young pitcher. A case report.

Subscapular elastofibromas and scapulothoracic bursitis can cause symptomatic masses in baseball pitchers. Both processes appear to represent reactive soft tissue responses to repetitive stress at the inferior border of the scapula. It is assumed that most masses in the subscapular area represent scapulothoracic bursitis rather than an elastofibroma. However, it is possible that some of the masses treated conservatively as scapulothoracic bursitis may be elastofibromas. A study is currently under way to evaluate the incidence of subscapular masses in college and professional pitchers in the United States. A follow-up report is anticipated when the study has been completed. The author requests information concerning any confirmed cases of elastofibroma in baseball pitchers.

Type A behavior and survival: a follow-up study of 1,467 patients with coronary artery disease.

Patients with documented coronary artery disease, admitted to Duke Medical Center between 1974 and 1980, were assessed for type A behavior pattern and were followed until 1984. The relation of type A behavior to survival was tested using data from coronary angiography to control for disease severity. Cox model regression analyses demonstrated an interaction (p less than 0.01) between type A behavior and an index of disease severity in the prediction of cardiovascular death. Among those with relatively poor left ventricular function, type A patients had better survival than type B. This difference was not present among patients with better prognoses. Type A behavior did not predict the subsequent incidence of nonfatal myocardial infarctions. Differential risk modification and differential selection into postinfarction status are possible explanations for the findings. These results need not conflict with the proposition that type A behavior plays a role in the pathogenesis of coronary artery disease.

Risk factors for myocardial infarction: the importance of relaxation.

Several risk factors for acute myocardial infarction (AMI) were examined, including history of smoking and hypercholesterolemia, income, education, coronary-prone behaviour by Structured Interview (SI) and the type and quality of stress-reducing relaxing activities, in a case-control study. Our sample included 100 AMI patients (80 males and 20 females, with mean ages 57.3 and 64.1 years, respectively), as well as 100 age- and sex-matched controls. Univariate differences between cases and controls were significant for history of smoking, income level, SI-defined hostility, SI-defined suppression of hostility, amount and type of relaxing activities and history of hypercholesterolemia. Multivariable analyses demonstrated that AMI patients reported significantly lower levels of relaxation and income, but higher levels of suppressed hostility and a higher incidence of hypercholesterolemia. Our findings confirm the significance of hostility and particularly suppressed hostility as AMI risk factors; furthermore, inadequate relaxation was identified as an independent risk factor associated with AMI.

Type A behavior and angiographically documented coronary atherosclerosis in a sample of 2,289 patients.

To determine the relationship between Type A behavior pattern and angiographically documented coronary atherosclerosis (CAD), we analyzed risk factor, behavioral, and angiographic data collected on 2,289 patients undergoing diagnostic coronary angiography at Duke University Medical Center between 1974 and 1980. Multivariable analyses using ordinal logistic regression techniques showed that Type A behavior as assessed by the structured interview (SI) is significantly associated with CAD severity after age, sex, hyperlipidemia, smoking, hypertension, and their various significant interactions were controlled for. This relationship, however, is dependent upon age. Among patients aged 45 or younger, Type A's had more severe CAD than did Type B's; among patients aged 46-54, CAD severity was similar between Type A's and B's; and among patients 55 and older, there was a trend toward more severe CAD among Type B's than among Type A's. These Type A-CAD relationships did not appear to be the result of various factors relating to the selection of patients for angiography. Type A behavior as assessed by the Jenkins Activity Survey was unrelated to CAD severity. These findings suggest that SI-determined Type A behavior is associated with more severe CAD among younger patients referred for diagnostic coronary angiography. The reversal of the Type A-CAD relationship among older patients may be due to survival effects. Inadequate sample sizes, use of assessment tools other than the SI, and failure to consider the Type A by age interaction could account for failures to find a Type A-CAD relationship in other studies. We conclude that the present findings are consistent with the hypothesis that Type A behavior is involved in the pathogenesis of CAD, but only in younger age groups. The Type A effect in the present data is small relative to that of both smoking and hyperlipidemia, however, and future research should focus more specifically on the hostility and anger components of Type A behavior, particularly in younger samples.

Suspiciousness, health, and mortality: a follow-up study of 500 older adults.

Scores on Factor L of the 16 PF, a measure of suspiciousness that is closely related to the Cook and Medley hostility scale, predicted survival in a sample of 500 older men and women during a follow-up of approximately 15 years. Those individuals with scores indicating higher levels of suspiciousness had greater mortality risk. This association remained significant after controlling for age, sex, physician's ratings of functional health, smoking, cholesterol, and alcohol intake. In addition, Factor L was associated with physician's ratings of health at the initiation of follow-up. These findings add to the weight of evidence that implicates a set of negative interpersonal attitudes in the domain of hostility, anger, cynicism, and mistrust as a prospective marker of individuals at risk for adverse health outcomes.

Social support, type A behavior, and coronary artery disease.

The interaction of Type A behavior and social support in relation to the degree of coronary artery disease (CAD) severity was investigated. One hundred thirteen patients undergoing diagnostic coronary angiography received the Type A structured interview (SI) and completed a battery of psychometric tests, including the Perceived Social Support Scale (PSSS). Statistical analyses revealed a Type by social support interaction, such that the probability of significant CAD was inversely related to the level of social support for Type As but not Type Bs. Type As with low levels of social support had more severe CAD than Type As with high levels of social support. On the other hand, this relationship was not present for Type Bs. These results are consistent with the hypothesis that social support moderates the long-term health consequences of the Type A behavior pattern.

Medical, psychological and social correlates of work disability among men with coronary artery disease.

This study identifies the medical, psychologic and social factors that independently affect employment in patients with coronary artery disease (CAD). At coronary angiography, extensive clinical, psychological and social profiles were collected on 814 men younger than 60 years with documented CAD. Clinical factors studied included measures of symptom severity, prior myocardial infarction, coronary anatomy and left ventricular function. Psychosocial factors studied included the Minnesota Multiphasic Personality Inventory (MMPI), Zung Depression and Anxiety Scales, a type A structured interview, Jenkins Activity Survey and measures of education and social support. Multiple logistic regression analyses were used to assess the relative strength of the relation between these different factors and the patients' employment status. Many single factors differed between the 204 men (25%) who were disabled and the 610 (75%) who were not. Disabled men were less educated but no different in age, marital status or number of dependents. Disabled men had lower ejection fractions and higher indexes of angina, previous myocardial infarction and coexisting vascular disease. Disabled men also were more depressed and anxious and had lower ego strength and higher hypochondriasis scores on the MMPI, but were no different in type A behavior. By multivariable analysis, the most significant (p less than 0.01) independent predictors of work disability were, in decreasing order of importance, low education level, history of myocardial infarction, high levels of depression and high levels of hypochondriasis. It is concluded that psychological and social factors are strongly related to work status in patients with CAD, and may be more important than medical factors.