The Type A personality – outdated concept of a vulnerable personality trait or still alive?

The concept of Type A personality – or Type A behaviour pattern (TABP), as it is nowadays conceptualized – originated in the 1950s as part of Friedman’s and Rosenman’s research into the relationship between behaviour and coronary heart disease. Type A individuals were characterised as competitive, ambitious, impatient, and hostile, in contrast to the more relaxed and less aggressive Type B personalities. While the construct gained significant attention in psychology and medicine for decades, its validity and utility have been increasingly questioned in contemporary research. This paper provides a narrative review of the rise and fall of the concept of Type A behaviour pattern and evaluates its subdomains.

Historical context

The genesis of Type A personality was serendipitous, and – as rumoured – originating from an upholsterer’s observation of unusual wear patterns on chairs in a cardiology practice. This anecdote, reported by Friedman and Rosenman, highlighted a behavioural peculiarity among patients – an inclination to sit at the edge of their seats, metaphorically and literally. Such behaviours inspired the pioneering studies linking Type A personality to cardiovascular outcomes.^1,2 These early studies suggested a robust association between Type A personality and coronary heart disease (CHD), propelling the concept into mainstream psychological and medical discourse.

Measures of Type A personality

The operationalisation of Type A personality relied on three primary instruments, each with unique characteristics and limitations:

• Jenkins Activity Survey (JAS) Developed in 1967, the JAS was designed to assess behavioural patterns linked to CHD.³ Its reliability coefficients ranged widely from 0.24 to 0.85, reflecting variability in consistency across different studies and samples.^3,4 JAS focused on dimensions such as time urgency, competitiveness, and job involvement. However, concerns about its construct validity arose due to inconsistencies in predicting health outcomes.

• Bortner Scale Introduced in 1969, the Bortner Scale is a self-report questionnaire that uses a continuum to evaluate traits associated with Type A behaviour pattern.⁵ Reliability coefficients for this scale ranged between 0.50 and 0.68.^5,6 While it offered simplicity and ease of use, the scale’s moderate reliability and low intercorrelation with other Type A behaviour pattern measures raised questions about its efficacy in capturing the full spectrum of Type A behaviours.

• Framingham Type A Scale Developed as part of the Framingham Heart Study in the 1970s, this scale focused on identifying personality traits predictive of CHD.⁷ Reliability coefficients for the Framingham Scale ranged from 0.54 to 0.71.^7,8 Despite its foundational role in psychocardiology, the scale faced challenges due to low intercorrelations with other instruments, suggesting that it might measure distinct aspects of Type A behaviour pattern rather than the overarching construct.

Across these measures, a recurring issue was the lack of convergent validity, as intercorrelations among the JAS, Bortner Scale, and Framingham Scale rarely exceeded 0.60.⁶ This discrepancy indicated that each tool might capture different facets of Type A personality, complicating efforts to generalise findings.⁹

Besides methodological issues, the course over the lifetime deserves consideration. A study examining whether Type A behaviour contributes to CHD events included 2,394 men aged 50 to 64 years revealed clear vulnerable time windows over the course of lifetime¹⁰ Type A behaviour was assessed using the three established measures: JAS, Bortner Scale, and Framingham Scale. Follow-up examinations were conducted at 5 and 9 years to identify incident CHD cases. After 9 years, there was no increased risk of CHD associated with any of the three scores, but within a shorter observation period of 5 years, high Bortner scores were associated with increased risk of CHD events. However, over the course of 5 to 9 years the impact reversed: High JAS and Bortner scores were associated with a decreased CHD risk. Further analysis of Type A scores with regard to the time until the first CHD event found strong inverse associations for all type A scores (JAS=205: –0.49 months to first event; 95% CI:–0.20 to –0.78; p=0.001; Bortner=176: –0.27 months; 95% CI: –0.10 to –0.44; p=0.002; Framingham=0.44: –0.0011 months; 95% CI: –0.0002 to –0.0019; p=0.01).

Rise and decline of the Type A behaviour pattern

Initial studies identified Type A personality as a significant predictor of CHD and other adverse health outcomes. However, as the field matured, these findings were strongly questioned. For instance, a study measuring Type A behaviour using JAS in 516 male patients with a follow-up period of one to three years, did not find a relation between Type A behaviour and the long-term outcome of acute myocardial infarction.¹¹ Another study examined the survival of 257 male CHD patients from the 8.5-year Western Collaborative Group Study.¹² Surprisingly, over a follow-up period of 12.7 and 11.5 years, respectively, among the 231 surviving patients, Type A individuals (n=160) had a lower CHD mortality rate (19.1 per 1000 person years) than Type B individuals (n=71; 31.7 per 1000 person years; p=0,04). The survival advantage for Type A behaviour was observed across age groups and was more pronounced in those with symptomatic myocardial infarction. These findings suggest that Type A behaviour does not increase the risk of CHD mortality and may even confer some survival benefit. A large-scale meta-analysis including over 74,000 participants showed no consistent link between Type A personality and CHD,¹³ further challenging its status as a risk factor. Subsequent research highlighted that Type A personality’s predictive value might reside in specific subdomains, such as hostility and time urgency, rather than the broader construct.

Subdomains

Breaking down the Type A personality into its subdomains, i.e. anger/hostility, time urgency, competitiveness, speed, led to mixed results. Anger and hostility were associated with CHD outcomes both in healthy and CHD populations;¹⁴ the risk of cardiovascular events was higher in the two hours following outbursts of anger, compared to other times.¹⁵

Competitiveness and time urgency demonstrated more nuanced relationships. In the Swiss National Cohort study (n=9921) the Bortner Scale was used to collect mortality information.¹⁶ During follow-up, 3469 deaths were observed (1118 CVD deaths). The whole Bortner Scale was not associated with mortality, just the subscales competitiveness and speed: In women, competitiveness was positively associated with all-cause mortality (highest category vs. lowest: HR 1.25 [95% CI: 1.08–1.44]), CVD mortality (1.39 [1.07–1.81]), and ischemic heart disease mortality (intermediate category vs. the lowest: 1.46 [1.02–2.10]). In men, CVD mortality was inversely associated with speed (highest category vs. lowest: 0.74 [0.59–0.93]).

Population studied

In the early studies of Type A personality, the populations under investigation were predominantly male. For instance, the initial cohorts of the Framingham Heart Study, a seminal investigation in this field, included primarily male participants. This gender imbalance limited the generalisability of findings and raised questions about the applicability of Type A personality of female populations. Subsequent research sought to address this gap, but early biases in the study design have left a lasting impact on the interpretation of Type A personality-related outcomes.

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Tab. 1: Key characteristics of Type A personality

Conclusion

As proposed by Rosenman and Friedman, Western society probably encourages Type A behaviour by valuing people who excel under time pressure. Consequently, Type A individuals are described as competitive, aggressive, hostile, chronically time-urgent, work-focused, and deadline-driven.

While early studies suggested that Type A behaviour pattern predicted CVD onset and progression, later research and meta-analyses failed to confirm these associations. Subsequent investigations shifted to examining TABP subdomains, such as time urgency, competitiveness, hostility, and speed, yielding partially promising findings.