Bizarre images and beta-adrenergic blocking agents: a unique case report.

Vivid imagery and hallucinations are occasionally reported by patients on beta-adrenergic blocking agents. The authors document this side effect with drawings by a well-known commercial artist.

Do environmental effects on human emotions cause cardiovascular disorders?

Environmental influences on human health include the effects of toxic materials and adverse ecological factors. Natural milieu stressors also affect emotions that may adversely affect cardiovascular function and precipitate or otherwise contribute to complications of cardiovascular diseases. However, although variously hypothesized, there is inadequate evidence that they directly contribute to the pathogenesis of sustained hypertension or coronary atherosclerosis.

The independent roles of diet and serum lipids in the 20th-century rise and decline of coronary heart disease mortality.

Risk factors are causally related to coronary heart disease (CHD), but in widely varying historic, geographic, socioeconomic, and individual relationships. Serum cholesterol is only one of many risk factors that, even when considered together in prospective studies, account for well under half of the CHD incidence. It is neither primarily regulated by the diet nor significantly related to it. Many findings discordant with widespread beliefs about a causal role of the diet in CHD are reviewed. It may be concluded that dietary fats are largely not responsible for relationships of serum cholesterol to CHD, or for its 20th-century rise and decline.

The Rationality/Emotional Defensiveness Scale--II. Convergent and discriminant correlational analysis in males and females with and without cancer.

The psychological correlates of the Rationality/Emotional Defensiveness Scale and its two subscales were examined in 1236 males and 863 females from the Western Collaborative Group Study. An additional 157 males and 164 females with some form of cancer other than of the skin were also included in this analysis. Characteristics measured included self-reported emotional control, anger expression, trait personality, depressive and neurotic symptomatology, Type A behavior, hostility, and social desirability. Results indicate that the Rationality/Emotional Defensiveness Scale is most strongly related to the suppression and control of emotions, especially anger. Scores on this scale also tend to be associated with less Type A behavior and hostility and with more social conformity. Analysis of the component subscale suggests that Antiemotionality, i.e. the extent to which an individual uses reason and logic to avoid interpersonally related emotions, is most strongly marked by the control of anger, while Rationality, i.e. the extent to which an individual uses reason and logic as a general approach to coping with the environment, is related to the control of anxiety and a higher level of trait curiosity. The psychological interpretation of the scale appears to be largely invariant across gender, unaffected by residualization of the total scale score for its association with Social Desirability, and, except for a few minor instances, unrelated to the diagnosis of cancer.

Does anxiety or cardiovascular reactivity have a causal role in hypertension?

Anxiety, stress, and cardiovascular reactivity (CVR) are variously believed to play a role in sustained hypertension. Although acute anxiety or stress elicits acute pressor responses, there is little support for their significant role in sustained hypertension. Anxiety correlates poorly with CVR, and blood pressure levels and anxiolytics do not sustain blood pressure lowering in subjects with hypertension-associated anxiety. Chronic anxiety disorders tend to be characterized by relatively low blood pressure and prevalence of sustained hypertension. Blood Pressure Regulation in hypertension is normal, and normo- and hypertensives have similar ambulatory blood pressure variability. Laboratory CVR fails to predict variability in natural environments, hyperreactors do not exhibit increased variability in natural environments, and the increased variability and ambulatory reactivity that is "accounted for" by laboratory responses is small. These findings do not support the belief that hypertension is related to a summation of heightened pressor responses over time. Antihypertensives normalize elevated blood pressures but do not alter CVR in the laboratory or variability in natural environments, probably because of a dual central regulation of resting and reactive blood pressures. Psychological stress responses result from selective neuronal activation rather than from generalized sympathetic neural responses or dysregulation. Differences in blood pressure responses during various emotions are only quantitative, with no specificity of sympathoadrenal or emotional responses to stressors. It may be time to regard reactive cardiovascular responses as physiological, rather than as psychological, and to require much stronger evidence to confirm causal roles of anxiety, stress, and reactivity in sustained hypertension.

Longitudinal changes in fat distribution in the Western Collaborative Group Study: a 23-year follow-up.

Anthropometric measurements for a total of 1,150 surviving subjects aged 65-86 and examined twice 23 years apart were analyzed with the following objectives: (1) to determine longitudinal changes on a large battery of anthropometric measures, (2) to examine the persistence of individual differences in the distribution of fat and relative weight, and (3) to investigate the relationship between changes in weight and changes in fat distribution. Significant changes toward an increase in size with age were observed in younger subjects below the age of 50 when first examined. In older subjects, age greater than or equal to 50, we observed a decrease in stature of 1.2 cm per decade, an overall decrease in weight of 1.6 kg, and no significant changes in trunk skinfold thickness. Longitudinal changes were most pronounced in the redistribution of fat and were also independent of weight changes. The relationships between measures of abdominal fat and overall obesity were stronger at follow-up than 23 years earlier.

Effects of placentation on selected Type A behaviors in adult males in the National Heart, Lung, and Blood Institute (NHLBI) twin study.

A dermatoglyphic index derived from monozygotic (MZ) twins of known placental type was used to estimate placentation retrospectively in a sample of adult male MZ twins. Examination of behavioral test scores with respect to placentation showed that the within-pair difference of most measures of type A behavior was smaller in presumed monochorionic than presumed dichorionic pairs. Measures of cognitive function and hostility were not related to placental type. Intraclass correlations in the monochorionic subgroup of MZ twins were greater than the correlations reported for the full sample of MZ twins. The trends were strongest for the Adjective Check List scales taken at two different exams 5 years apart and, to a lesser extent, for the Framingham type A scale. Our results are most consistent with greater intrauterine environmental covariance in monochorionic MZ twins as an explanation for inflation of the MZ twin correlation relative to dizygotic (DZ) correlation reported for some type A measures.

The Rationality/Emotional Defensiveness Scale--I. Internal structure and stability.

In a 10-year prospective study, Grossarth-Maticek and colleagues reported that the tendency to repress and/or deny emotions was strongly predictive of cancer mortality. The method used to assess repression/denial was modified recently by Spielberger to form the Rationality/Emotional Defensiveness (R/ED) Scale. The present study investigates the psychometric properties of the R/ED Scale in 1236 male (mean age = 71.8 yr) and 863 female (mean age = 68.5 yr) participants in a 27-year follow-up of the Western Collaborative Group Study. Analyses revealed high interitem consistency (Cronbach's alpha = 0.77 and 0.78 for men and women, respectively) and two independent and stable factors that we labeled 'Anti-emotionality' (27% of total variance) and 'Rationality' (21% of total variance). Excluding cancer subjects, significant gender differences were observed for individual items, total R/ED score, and the two subscales. Comparisons of the 159 male cancer patients and the 175 female cancer patients with the corresponding noncancer subjects suggest possible gender x cancer status and age x cancer status interactions. These results challenge Grossarth-Maticek's assertion that rationality/anti-emotionality is a unidimensional construct and indicate the need to take into account the effect of age and gender on the presence of these psychological constructs.

27-year mortality in the Western Collaborative Group Study: construction of risk groups by recursive partitioning.

The relationship of selected biological and behavioral characteristics measured at baseline examination to 27-year mortality due to coronary heart disease (CHD), cancers of all sites, and total mortality in the 3154 men that form the Western Collaborative Group Study was investigated using tree-structured survival analysis or recursive partitioning (RP). Intake (1960-61) characteristics included in the present analyses were age, serum cholesterol, systolic blood pressure (SBP), cigarette smoking, body mass index (BMI), Type A/B behavior, and behavioral hostility. Tree-structured survival analysis for CHD mortality partitioned the cohort into six groups and identified five groups with distinct survival experience. Exceptionally high CHD mortality rates (17.3 and 14.6 per thousand) were experienced by 89 older men with elevated hostility ratings and SBP less than or equal to 150, and 238 men whose initial SBP was greater than 150 mmHg. Younger men (age less than or equal to 48) with SBP less than or equal to 150 and with serum cholesterol levels greater than 227 had a death rate of 4.8 per thousand, compared with a rate of 1.7 in similar men with lower cholesterol levels. Applied to 27-year cancer mortality, the RP algorithm partitioned the cohort into four distinct survival groups. Younger (age less than 45) Type B men had superior survival compared with Type A men of similar ages, and the proportion of ever cigarette smokers in these two groups was not statistically different. The results obtained by tree-structured survival analyses were compared with results obtained by Cox regression survival analyses.

Smoking and alcohol consumption in adult male twins: genetic heritability and shared environmental influences.

This paper examines the heritability of cigarette smoking and alcohol consumption in 360 adult, male twin pair participants (176 monozygotic and 184 dizygotic pairs) in the second exam of the National Heart, Lung, and Blood Institute's Twin Study. Heritability estimates for smoking and alcohol use were calculated both before and after adjustment for shared variance between these behaviors and other characteristics, including coffee consumption, contact between twins, and two psychological traits: anger and activity. The purpose of the analysis was to determine the impact of adjustment for covariates on heritability estimates of smoking and alcohol use. Before adjustment, heritability of both smoking and alcohol use was highly significant and accounted for 52% and 60% of the variance, respectively. After adjustment for covariates, the heritability of smoking remained at 52% while that for alcohol use decreased to 43%. The fact that these estimates remained significant after adjustment for covariates leads to increased confidence about the role of genetics in both smoking and alcohol consumption.

Results of the multicenter antihypertensive treatment trials. Therapeutic implications and the role of the sympathetic nervous system.

The results of 19 antihypertensive treatment trials spanning some 20 years of research showed that treatment had significant benefits for pressure-related complications of hypertension but generally did not prevent coronary artery disease morbidity or mortality. As possible reasons for this relative failure were explored, new emphasis was placed on the role of the sympathetic nervous system in the vascular complications of hypertension. Most risk factors for coronary artery disease strongly involve the sympathetic nervous system, which may be the final common pathway for their adverse effects. The antihypertensive drugs used in most of the large clinical trials were associated with enhanced sympathetic activity. Moreover, excessive sodium depletion caused by large doses of diuretics and dietary low-sodium intake may have contributed to the treatment's ineffectiveness in preventing primary coronary disease. The implications of the research for antihypertensive treatment are discussed, with an emphasis on the physiologically appropriate role of clonidine therapy.

Psychological correlates of two measures of coronary-prone hostility.

The psychological correlates of the Cook and Medley Hostility (Ho) Scale and independent behavioral ratings of hostility were compared in a sample of adult, middle-aged male participants from the National Heart, Lung and Blood Institute Twin Study. Although the Ho Scale and behavioral ratings of hostility purport to measure the same construct, the underlying correlational pattern for each was quite different. Scores on the Ho Scale were associated positively with anxiety, neuroticism, and the tendency to "fake good"; behavioral hostility was related to measures of dominance, vigor, and self-confidence. Some correlates, such as the hard-driving and speed and impatience subscales from the Jenkins Activity Survey, represent a core set of correlates common to both. The meaning of hostility must be clarified before this construct's link to coronary heart disease can be defined.

The Cook and Medley HO scale: a heritability analysis in adult male twins.

Thirty-seven pairs of monozygotic (MZ) and 60 pairs of dizygotic (DZ) middle-aged, male, American twins were studied to determine the heritability of the Cook and Medley Hostility (HO) scale and its two subscales, Cynicism and Paranoid Alienation. No clear evidence for a significant genetic component was indicated for the full HO scale and the Paranoid Alienation subscale. Scores on these scales were found to be associated with age, socioeconomic status, the twinning condition, and the Minnesota Multiphasic Personality Inventory (MMPI) K scale. DZ twins scored higher than MZ on HO and Cynicism, and lower on the MMPI K scale. Statistical adjustments for age and socioeconomic status removed twin mean differences and weakened MZ intrapair correlations on the HO scale but did not change overall conclusions regarding heritability. After the association with K was partialled out from these scales and retested for heritability, both HO and Paranoid Alienation showed a weaker twin pair similarity than that observed in the unadjusted scales. However, Cynicism, the scale with the greatest item overlap with the K scale, was not affected by the adjustment. Since no genetic component was evident for the K scale in this sample it was concluded that if a genetic influence in these MMPI scales is present, it is mostly in the Cynicism subscale of HO.

Psychological characteristics in twins discordant for smoking behavior: a matched-twin-pair analysis.

The matched-twin-pair methodology was used to investigate the pattern of interactions between twinning and personality in 127 monozygotic and 140 dizygotic adult male twin pairs. Eighteen standard and three research scales from the California Psychological Inventory were used to identify differences in personality between twins discordant for smoking and in nonsmoking and ever-smoking twins treated as individuals. Although no evidence was obtained for a significant heritability component in the smoking habit, numerous interactions between the twinning condition (e.g., monozygotic or dizygotic) and personality were identified. As expected, monozygotic twins discordant for smoking show fewer personality differences than do individuals discordant for smoking. Discordant dizygotic twins show more disparity than unrelated individuals. The only personality scale showing a consistent discriminating effect regardless of the twinning condition was that measuring socialization. Results are discussed in terms of the environmental conditions that may contribute differentially to the smoking behavior in related and unrelated individuals.

Risk factors for late relapse in male and female ex-smokers.

Three hundred twenty-nine ex-smokers (149 males and 180 females) who had maintained abstinence for at least 3 months prior to intake were followed for a period of 1 year to ascertain individual characteristics from cognitive, behavioral, environmental, and health domains that were predictive of later relapse. Multiple logistic regression analysis revealed significant associations between relapse, family history, and stress variables in males and between relapse, family history, stress, pre- and postcessation smoking characteristics, work-related variables, and physical activity in females. Within the predictor sets, both risk and protective factors were identified. The male and female models are discussed separately, compared, and related to previous research. Implications for further model development are specified; most notably, the utility of conceptualizing relapse independent of gender is questioned. Future research efforts could focus on the role played by family smoking history in adult relapse behavior. Smoking cessation interventions may need to tailor their efforts specifically to men and to women. Along with techniques to manage stress both during and after cessation, women may benefit especially from interventions that provide nicotine replacement and counseling for work-related difficulties.

Stability of the type A structured interview and related questionnaires in a 10-year follow-up of an adult cohort of twins.

Associations between initial and 10-year follow-up assessment of the Type A behavior pattern (TABP) were examined in a sample of adult male twins using a broad range of instruments. When assessment is made by the Structured Interview and limited to the dichotomous Types A and B rating, 67% of the subjects received the same rating on both occasions. Spearman rank correlations between repeated self-report measures of TABP ranged from .55 to .70. Overall the stability among the self-report measures was greater than between the self-reports and the Structured Interview. Utilizing the twin design the relationship of genetic and environmental factors to tracking of TABP was examined and compared between monozygotic and dizygotic twin pairs. The implication of these results to the TABP construct is discussed.

Type A behavior and cancer mortality. Theoretical considerations and preliminary data.

If stress and cancer are related by coping failure, that connection presumably involves the immune system. This involvement has already been shown in animals. It can be hypothesized that Type A personalities (driving, impatient, sometimes hostile) go through states of repeated frustration because of unachieved goals. From that point of view, Type A individuals are alternately able to cope and unable to cope. Such a pattern would theoretically tend toward repeated episodes of suppression and recovery of the immune system, with increased probability of growth of transformed cells. An opposing hypothesis, derived from human survival studies, suggests that a subgroup of Type B individuals (termed "Type C"--accepting, giving-up) are more likely to suffer a poor prognosis. A preliminary study relating Type A/B behavior pattern to cancer mortality was done in a cohort of 3154 men from the Western Collaborative Group Study (WCGS). The cancer mortality rate for the period 1960-1977 was 0.037 for Type A subjects (58 cancer deaths/1589 Type A subjects), and 0.025 for Type B subjects, yielding an odds ratio of 1.55. The odds ratio dropped to 1.29 (95% confidence interval = 0.84-1.96) when controlled for age, cigarette smoking, serum cholesterol, systolic blood pressure, and education. Preliminary analysis from a follow-up to mid-1983 shows a similar association. The findings suggest that, if anything, Type A subjects are more likely to die of cancer than Type B subjects. Although the finding is not strongly suggestive of a clinically or theoretically significant association between Type A/B behavior pattern and cancer mortality, it is sufficiently interesting to warrant further investigation.

Cross-family correlates of blood pressure in the Western Collaborative Group Study.

The present study examined the association between one spouse's characteristics and his/her partner's blood pressure (BP) and the combined effect of parental characteristics on the BP levels of offspring in a subgroup of families recruited from the Western Collaborative Group Study (WCGS). Among the individual personality characteristics examined were pace of activity, reflectiveness, dominance, and emotional stability as assessed by the Thurstone Temperament Schedule (TTS). The confounding effects of age, weight, and father's disease status were controlled for by multiple-regression techniques. The results indicate a differential pattern of cross-spouse and cross-family associations for parents and offspring in these families. Higher scores on the TTS activity scale were associated with increased levels of BP in males and decreased levels of BP in females. The observed associations were of the same magnitude as those of more traditional correlates such as age and weight. The findings from the cross-family association analyses are contrasted with the separate patterns of familial correlation of BP and personality characteristics.