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Tipi Comportamentali e fattori di rischio psico-sociali

Prof. Plinio Fabiani17/11/2008

Facoltà di Psicologia

Corso di Medicina Sociale

TABP e TBBP• Competitività cronica per ottenere

sempre di più in minor tempo• Ambizione, Aggressività,

Impazienza• Stato di allerta, tensione

muscolare, eloquio rapido edempatico.

• Irritazione, manifestazioni di ira• Fronteggia eventi stressanti con

cui ingaggia sfide• Il tutto al di là della coscienza del

soggetto

• Piuttosto rilassato, deferente,soddisfatto, non affrettato.

• Raramente combatte perportare a termine più eventinel più breve tempo

• Risponde meno agli stessilivelli di sfida del tipo A

• E’ attivato da situazionipiacevoli ed intriganti

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TABP e Coronaropaie

• Studi iniziali di popolazione in USA ed Europa, comeWestern Collaborative Group Study (WCGS) ed ilFramingham Heart Study evidenziarono correlazione fraTABP e lo sviluppo di CHD in uomini sani di età media.

• Tuttavia un follow-up di 22 anni del WCGS trovò che ilTABP non era predittivo di progressione di malattia.Inoltre, rilievi negativi dal “Aspirin MyocardialInfarction Study”, “Multiple Risk Factor InterventionTrial” e molti altri hanno portato a scetticismo.

Come misurare TABP

• Diversi test sono stati utilizzati per lo studiodel Type A behavior, quali– Bortner Rating Scale Type,– Framingham Type A Scale,– Jenkins Activity Survey (JAS),– Structured Interview (SI).

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• The JAS is a questionnaire, filled out by thepatient, therefore performing a self-evaluation ofhis/her own behavior. It makes queries aboutspeed and impulsivity, job involvement, andaggressive behavior. This self report is consideredless conclusive in relating TABP to CHD than theSI because of incidental bias and/or distortion.

•Since Type A behavior pattern marks areaction to a certain situation, the StructuredInterview is preferred over the others as itevaluates behavior directly and has thestrongest association with CHD (Example ofSI). This method, however, requires intensiveinterviewer training and recognize a marginof error due to the interviewer's behaviorwhile interviewing subjects.

The Video Structured Interview• The current controversy on the predictive value of the Type A

Behavior Pattern (TABP) as a coronary risk factor brought into areconsideration of the assessment methods of this pattern. The VideoStructured Interview (VSI) is a scoring method of TABP by a trainedinvestigator, consisting of a rating scale based both on the content ofthe answers and on the psychomotor signs, with regard to the two maincomponents of the TABP: sense of time urgency and hostility. The VSIappears a more objective instrument than self-assessmentquestionnaires, avoiding the bias of denial, a coping mechanismwidely used by type A subjects. The VSI proved more sensitive andmore specific than the self-assessment methods or the structuredinterview (SI), the initial instrument aimed to assess TABP amongcoronary risk patients in american populations.

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Reasons for the trend toward nullfindings in research on Type A behavior.

1) a type of range restriction bias, disease-based spectrum(DBS) bias, produced many null findings. A study isvulnerable to DBS bias when researchers select onlyhigh-risk or diseased Ss for study.

2) self-report measures of TAB were often associated withnull findings.

3) null results were found for all studies that used fatalmyocardial infarction as a disease criterion.

4) TAB, as assessed by the structured interview, isassociated with CHD. More Type As (70%) were foundin diseased populations of middle-aged men than inhealthy populations of middle-aged men (46%).

Psychol Bull 1991 Nov;110(3):469-85

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A meta-analytic review of research onhostility and physical health.

A new meta-analysis of research on hostility andphysical health was conducted that includes 15studies used in previous meta-analytic reviews and30 new independent studies. Overall, the resultssuggest that hostility is an independent riskfactor for coronary heart disease (CHD). …Similar to other areas of research, the increaseduse of high-risk studies in recent years producedan increase in null findings.

Psychol Bull 1996 Mar;119(2):322-48

Ostilità: la subcomponente“tossica” di TABP

• Reazione a situazionispiacevoli con:– Rabbia– Frustrazione– Irritazione– Disgusto

• Più affidabile comepredittore di CHD

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Hostility, Anger, Expression andCVD

• HOSTILITY- a generally negative attitude toward othersof some extended duration and scope.– Cynical hostility (“think the worst of people and their

intentions”)- a strong predictor of arterial blockage andcoronary mortality.

• Cook-Medley Scale (MMPI) or Buss-Durkee Scale• Also related to risk factor profile (behavioral &

psychosocial)– Obesity, alcohol consumption, smoking, blood pressure, negative

life events, social support levels.– When these are controlled statistically relationship betw. HO and

CVD disappears. Therefore it is a “secondary factor”-- notindependently related.

– May also affect physiology through “Anger Expression”

Anger, Physiology & Health• Anger- unpleasant emotion accompanied by physiological

arousal usually of short duration– expressions- Anger-In and Anger-Out

• Anger-Out related to CAD severity--– maybe a matter of type of expression (outburst or controlled)

• CV Reactivity• angry outbursts---> large rate and BP increase• controlled expression--> smaller HR and BP response

– Provoked response (“buttons pushed”)- men their more physiologically(key point) reactive than wives

• Suppression Okay then?• No.. Also related to increase CAD severity

• Key appears to be controlled expression and communication!!

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Type D = NA + SI

Negative Affectivitytendency to experience negativeemotions across time/situations(14,15). High-NA individualsexperience more feelings ofdysphoria, anxiety, andirritability; have a negative viewof self; and scan the world forsigns of impending trouble(14).

Social Isolationtendency to inhibit the expressionof emotions/behaviors in socialinteractions to avoid disapprovalby others (16). High-SI individualstend to feel inhibited, tense, andinsecure when with others (17,18).

Type D personality as a long-term predictor ofdeath and cardiac events in patients with

coronary heart disease

European Journal of Cardiovascular Prevention and Rehabilitation 2003, 10:241–248

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(J Am Coll Cardiol 2004;44:997–1001)

Type D personality has beenshown to independently predictadverse clinical outcome in IHD,and the prognostic power of theType D personality equals that ofleft ventricular dysfunction.

Tipe D ed associazioni

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Coping:strategie negative e positive

• Evitamento della situazione– Evitare di studiare un esame

perché la materia è difficile– Darsi al bere perché lasciati dal

partner• Accessi d’ira o altro comportamento

aggressivo• Bere ed usare droghe• Impulsività

– Guida pericolosa– Mancate precauzioni sessuali.

• Adeguare la reazione all’eventostressante– Tecniche di rilassamento e

meditazione– Esercizio fisico (riduce stress,

ansia e depressione).– Riservare del tempo a hobbies

e ricreazione– Attenzioni dietetiche– Socializzazione

Controllo sul lavoro• Di recente i risultati dello studio Whitehall hanno mostrato che la mancanza di

controllo sul lavoro è un determinante significativo delle malattie coronariche– “Contribution of job control and other risk factors to social variations in coronary heart disease

incidence” M G Marmot et al; The Lancet July 26, 1997 p235-239

• Strutture di supporto sociale• Uno studio su uomini finlandesi suggerisce che la mancanza di speranza

(hopelessness) sia più strettamente correlata con l’insorgenza di aterosclerosi,di fumo alcol e nutrizione.– “Hopelessness and Risk of Mortality and Incidence of Myocardial Infarction and Cancer”;

Susan A Everson et al. Psychosomatic Medicine 58:113-121 (1996)

Stato socioeconomico e stress

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Teorie sulla correlazione fra SESe salute

• Teoria della deriva sociale• Cure mediche inadeguate• Aumento dei fattori di rischio• Maggiore stress

Stato socioeconomico e stress

In ogni cultura (stabile o instabile), esistonoClassi sociali; queste differiscono per molti fattori, uncostante comune denominatore della diversità è loSTRESS

Vs...

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Vs…..

Stato socioeconomico e stress

In ogni cultura (stabile o instabile), esistonoClassi sociali; queste differiscono per molti fattori, uncostante comune denominatore della diversità è loSTRESS

Stato socioeconomico e stressL’associazione fra SES e salute inizia nelle prime fasi della vita

Più basso è lo SES deigenitori, più elevata è lapressione arteriosa in età scolare

Disordini dell’apprendimentoe problemi emotivi simanifestano in maggiorfrequenza nei bambini dibasso SES

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• Tra la malattiacardiovascolare e lapsiche da sempre sipone un legamestretto anche se suquesto pesa anchel’antica credenza chevuole il cuore sededelle emozioni

William Harvey (1628)

• “qualsiasi sollecitazione dellamente sperimentata come doloreo piacere, come attesa o paura, ècausa di squilibriopsicosomatico, la cui influenzasi estende al cuore”

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John Hunter• the eighteenth-century

cardiovascular surgeon John Hunter,who once exclaimed; “My life is inthe hands of any rascal who choosesto put me in passion.” Hunter soonproved those words prophetic whenhe died from a violent coronaryartery spasm during a heatedexchange at a faculty meeting at theRoyal College of Physicians inGlasgow, Scotland.

• “It is more important to know whatsort of patient has the disease thanto know what sort of disease hasthe patient.”

Sir William Osler

Considered the father ofpsychosomatic medicine,acknowledging the role ofpsychology in the patient’s overallhealth.

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Stress Psicosociali(es.: depressione, isolamento)

Recidiva di eventicardiaci

ATEROSCLEROSI

EVENTI CLINICI

Fattori di rischioComportamentali(es.:fumo, cattiva dieta)

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(Circulation. 1999;99:2192-2217.)