Spirituality and health: is there a relationship?

The role of spiritual and religious factors in health, viewed from a scientific perspective, has been yielding interesting if not intriguing results. In general, studies have reported fairly consistent positive relationships with physical health, mental health, and substance abuse outcomes, mostly using cross-sectional or prospective designs. Some spiritual or religious factors, however, have failed in some studies to demonstrate significant outcomes. Empirical relationships have been commonly based on only a few questionnaire items. Adequate controls for possible moderating or confounding factors that could explain health outcomes have often been missing. A healthy skepticism seems called for, given the need to clarify and refine concepts, such as spirituality; to develop comprehensive assessments; and to conduct experimentally designed studies. Although the overall evidence is promising enough to warrant careful and expanded study, the need for a methodological pluralism in research and for cultural sensitivity is recommended.

Volunteerism and Mortality among the Community-dwelling Elderly.

Older residents (N 5 1972) in California were investigated prospectively for association of volunteering service to others and all-cause mortality. Potential confounding factors were studied: demographics, health status, physical functioning, health habits, social support, religious involvement, and emotional states. Possible interaction effects of volunteering with religious involvement and social support were also explored. Results showed that 31 percent (n 5 630) of respondents volunteered, about half (n5289) for more than one organization. High volunteers ([.greaterequal]2 organizations) had 63 percent lower mortality than nonvolunteers (age and sex-adjusted) with relative hazard (RH) 5 0.37, confidence interval (CI) 5 0.24, 0.58. Multivariate adjustment moderately reduced difference to 44 percent (RH 5 0.56, CI 5 0.35, 0.89), mostly due to physical functioning, health habits, and social support. Unexpectedly, volunteering was slightly more protective for those with high religious involvement and perceived social support. After multivariate adjustment, any level of volunteering reduced mortality by 60 percent among weekly attenders at religious services (RH 5 0.40; CI 5 0.21,0.74). Lower mortality rates for community service volunteers were only partly explained by health habits, physical functioning, religious attendance, and social support.

Spiritually and religiously oriented health interventions.

Controlled intervention studies offer considerable promise to better understand relationships and possible mechanisms between spiritual and religious factors and health. Studies examining spiritually augmented cognitive-behavioral therapies, forgiveness interventions, different meditation approaches, 12-step fellowships, and prayer have provided some evidence, albeit modest, of efficacy in improving health under specific conditions. Researchers need to describe spiritual and religious factors more clearly and precisely, as well as demonstrate that such factors independently influence treatment efficacy. Inclusion of potential moderating and mediating variables (e.g. extent of religious commitment, intrinsic religiousness, specific religious coping strategy) in intervention designs could help explain relationships and outcomes. Using a variety of research designs (e.g. randomized clinical trials, single-subject experimental designs) and assessment methods (e.g. daily self-monitoring, ambulatory physiological measures, in-depth structured interviews) would avoid current limitations of short-term studies using only questionnaires.

Anxiety, depression, and heart disease in women.

This is an extension of previous research that has reported on psychosocial risk factors in women participants in the Recurrent Coronary Prevention Project (RCPP). The RCPP women (N = 83) were under 65 years of age, non-diabetic, non-smoking and had experienced a myocardial infarction (MI) at least 6 months prior to the study. Baseline data was available on 80 RCPP subjects. Seventy three non-smoking, coronary disease-free women participants in the Stanford-Sunnyvale Health Improvement Project (SSHIP) served as a control-comparison group. Women with coronary heart disease had higher serum cholesterol than controls. There were no case-control differences in marital status, occupation, or number of children. RCPP women had Videotaped Structured Interview (VSI) Type A scores comparable to those of the SSHIP women, but had significantly higher VSI-hostility scores (p < .01). In addition. the post-MI women were rated more anxious and depressed, and had more avoidance symptoms than controls ( p < .01). Additional analyses involved the 65 RCPP women located at 8.5-year follow-up. In these women, univariate predictors of coronary recurrence (N = 13) were body mass index (kg/m)2. Peel Index, low time urgency (VSI) and high anxiety ( p < .05). Employment status, marital status, and education were not associated with subsequent cardiac events. These exploratory analyses suggest that the relations between heart disease and hostility, anxiety, and depression in women deserve further investigation.

Causal attributions and coronary heart disease in women.

The relationship between coronary heart-disease endpoints and attributional style in women has been previously unexamined. This study examined the attributions of 73 postmyocardial infarction (MI) women about their heart disease and explored the relationship between attributions and nonfatal coronary recurrence. Women's primary causal attributions included personal behavior (9.6%), blaming others (19.3%), stress (28.8%), luck (12.3%), and family history (13.7%). The largest proportion of recurrences occurred in women attributing their infarcts to marital problems. Of the attributional ratings, ascriptions involving spouses were the only attributions that met entry criteria for logistic regression (p = .019) after controlling for severity of first infarction.

Psychosocial predictors of mortality in 83 women with premature acute myocardial infarction.

This was an exploratory investigation of psychosocial risk factors for mortality in women with premature acute myocardial infarction (AMI). Subjects were 83 female participants in the Recurrent Coronary Prevention Project, who were between the ages of 30 and 63 in 1978, nonsmoking, nondiabetic, and at least 6 months beyond their index AMI. Follow-up ranged from 8 to 10 years, with an average of 8.5 years. Six deaths occurred in the 83 women over the follow-up. Univariate predictors of these deaths were arrhythmias on ECG (RR = 7.83, p = .003), being divorced (RR = 6.9, p = .003), being employed without a college degree (RR = 6.8, p = .03), and the inverse of Type A behavior, time urgency, and emotional arousability (p = .03; .005; .006, respectively). Multivariate stepwise logistic regression analysis produced a solution that included as independent predictors: arrhythmias on ECG (RR = 4.01, p = .004), being divorced (RR = 3.43, p = .01), and the inverse of time urgency (RR = 0.35, p = .02). In the multivariate model, "divorced" was interchangeable with "employed without a college degree" and "time urgency" was interchangeable with "emotional arousability." This small sample precludes firm conclusions, but provides a basis for hypothesis development.

Type A behavior pattern: new perspectives on theory, assessment, and intervention.

Research on the Type A behavior pattern (TA) has been plagued by inadequate theory, insensitive assessment, and insufficient interventions. These problems (e.g., using global dichotomous ratings of TA) have contributed to several failures of TA to predict cardiovascular outcomes prompting concern for new approaches. Conceptual models are discussed, such as a transactional model of TA, social cognitive theories (e.g., self-evaluative processes), and associative network theory (e.g., how emotions distort information). The view of hostility as the only pathogenic feature of TA is questioned. The ethnographic gap in TA research is described, and detailed descriptive and experimental case studies are recommended. Profile measures that assess all dimensions of TA are urged along with contextually sensitive multimodal assessments. Unlike results of some correlational studies, controlled TA interventions, although few, have consistently yielded positive results. Study of TA within an expanded conceptual perspective is encouraged, especially controlled experiments and interventions.

Effects of type A behavioral counseling and severity of prior acute myocardial infarction on survival.

The hypothesis under investigation was that the beneficial effect of type A behavioral counseling on survival after acute myocardial infarction (AMI) was conditional on the functioning of the cardiovascular system, as determined by the severity of the prior AMI. Subjects were 862 nonsmoking coronary patients in the San Francisco Bay Area, randomized in 1978 to receive, over 4.5 years, cardiac counseling or cardiac counseling plus type A behavioral counseling. Sixteen baseline factors plus an interaction term (severity of AMI X behavioral counseling) were evaluated for their prognostic significance. Behavioral counseling was not a significant predictor of coronary death in the total cohort, but the interaction between counseling and severity of the prior AMI was (p less than 0.05). Thus, the total cohort was divided into 2 subgroups of mild or serious prior AMI, and independent predictors of survival were isolated within each subgroup. In the subgroup with mild prior AMI, independent predictors were anterior AMI (p = 0.02), plasma cholesterol (p = 0.02) and behavioral counseling (p = 0.05). In the subgroup with serious prior AMI, none of the factors evaluated made a significant independent contribution. These findings suggest that a reduction in type A behavior may exert the greatest protection against coronary death in that subgroup of patients for whom the biologic aspects of coronary artery disease are not advanced. They also demonstrate the importance of considering the level of cardiac functioning before determining predictors of survival or optimum postcoronary care.

Emotional and temperamental correlates of Type A in children and adolescents.

Emotional and behavioral correlates of Type A behavior in children and adolescents were examined in 184 fifth-, seventh-, and ninth-grade students, classified as high or low Type A, using self-report, teacher ratings (fifth grade only), and structured interview procedures. Measures included the Hunter-Wolf A-B Rating Scale, Behavioral Symptoms of Stress Inventory, Dimensions of Temperament Survey, Desire for Control Scale, Eysenck Personality Inventory, and the Multiple Affect Adjective Checklist. High Type A children reported significantly more stressed-related behaviors, higher levels of depression, anger, anxiety, and cognitive disorganization, and greater reactivity than Low Type A. No differences were found on measures of temperament (activity level, attention span, adaptibility, and rhythmicity), desire for control, or introversion-extroversion. Females, in general, reported significantly more behavioral stress symptoms. However, no other gender differences were found. Possible reasons for reported differences between Type A children and adults are discussed, along with gender differences in behavioral symptoms. Need for multiple measures of Type A across situation is considered along with need for controlled longitudinal studies of Type A components and the influence of contexts.

Effect of discontinuance of type A behavioral counseling on type A behavior and cardiac recurrence rate of post myocardial infarction patients.

Three hundred post infarction participants who had received type A behavioral counseling in the Recurrent Coronary Prevention Project, (RCPP) agreed to be followed for 1 additional year after stopping 4.5 years of continuous type A behavioral counseling. One hundred fourteen participants who had served for 4.5 years as controls in the RCPP Study, thus receiving no type A behavioral counseling, volunteered to receive such counseling for 1 year. Eleven of the 300 previously type A counseled RCPP participants were lost to follow-up at the end of the additional year. The remaining 289 subjects at risk were found to have maintained their previously reduced intensity of type A behavior. Their previously observed relatively low cardiac recurrence rate during the additional year also did not significantly change. Ten of the 114 previous control RCPP participants were lost to follow-up at the end of the additional year. The remaining 104 subjects who had received a year's type A behavioral counseling showed a significantly reduced intensity of type A behavior and a similar significant decrease in both the cardiac mortality and morbidity rate. These results suggest that the decline in the intensity of type A behavior and also in the cardiac recurrence rate previously observed in post infarction subjects exposed to type A behavioral counseling persists for at least 1 year after cessation of such counseling.

Developing measures of type A behavior in children and adolescents.

Development of measures of Type A behavior in children and adolescents is described and the results of two studies to validate these measures are given. Children in the fifth, seventh, and ninth grades (n = 120 in Study I; n = 652 in Study II) were given five measures of the Type A Behavior Pattern (TABP): the Student Type A Behavior Scale (STABS); Student Structured Interviews (SSI), scored separately for content and behavior; Matthews Youth Test for Health (MYTH); and Parent Observation Checklist, as well as measures of state anxiety, trait anxiety, and depression. Descriptive statistics from the two samples were very similar and indicated that boys scored significantly higher than girls on the MYTH, while seventh and ninth grade girls scored significantly higher than fifth grade girls or boys of any grade on Structured Interview Behavior (SSI-Behavior). Correlations suggested separate self-reported perceptual and behavioral components of Type A behavior in children. In both studies, STABS and SSI-Content correlated moderately well (.48 to .49) but had little relationship with SI-Behavior and the MYTH. Measures of anxiety and depression included to assess discriminant validity were correlated with the self-report measures of TABP (.22 to .56), but showed little relationship with the behavioral measures, especially in the larger cross-validation study. Parallels between these results and those of adult studies are discussed, and the use of multiple measures in classifying subjects is suggested.

Type A behavior pattern and alcohol intake in middle-aged men.

Eighty-one sedentary but healthy, middle-aged men were studied. Type A behavior pattern (TABP) was determined by "structured interview", and dietary intake was assessed by alcohol questionnaire and 3-day diet record. Type A men reported drinking approximately twice as much alcohol as their non-Type A counterparts (mean +/- SD: 21.7 +/- 18.2 vs. 9.4 +/- 9.1 g of ethanol per day; p = 0.0003), and a strong, positive association between TABP and alcohol intake was found. The TABP-alcohol relationship was not confounded by concomitant differences in income level or years of formal education, and remained highly significant in subsequent analyses of nonsmokers alone. Type As and non-Type As did not differ significantly in their consumption of any other nutrient measured. The association between TABP and alcohol intake may have confounded conclusions from previous studies that focused on one or the other as a risk factor for coronary heart disease.

Alteration of type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: summary results of the recurrent coronary prevention project.

One thousand thirteen post myocardial infarction patients were observed for 4.5 years to determine whether their type A (coronary-prone) behavior could be altered and the effect such alteration might have on the subsequent cardiac morbidity and mortality rates of these individuals. Eight hundred sixty-two of these individuals were randomly assigned either to a control section of 270 participants who received group cardiac counseling or an experimental section of 592 participants who received both group cardiac counseling and type A behavioral counseling. The remaining 151 patients, serving as a "comparison group," did not receive group counseling of any kind. Using the "Intention-to-Treat" principle, we observed markedly reduced type A behavior at the end of 4.5 years in 35.1% of participants given cardiac and type A behavior counseling compared with 9.8% of participants given only cardiac counseling. The cumulative 4.5-year cardiac recurrence rate was 12.9% in the 592 participants in the experimental group that received type A counseling. This recurrence rate was significantly less (p less than 0.005) than either the recurrence rate (21.2%) observed in the 270 participants in the control group or the recurrence rate (28.2%) in those of the comparison group not receiving any special treatment. After the first year, a significant difference in number of cardiac deaths between the experimental and control participants was observed during the remaining 3.5 years of the study. Overall, the results of this study demonstrate for the first time, within a controlled experimental design, that altering type A behavior reduces cardiac morbidity and mortality in post infarction patients.

Physical health correlates of type A behavior in children and adolescents.

A physical examination including resting blood pressure, heart rate, Tanner scales, height, and weight was administered to 184 students in the fifth, seventh, and ninth grades. They completed the Physical Symptoms of Stress Inventory, Health Habits Inventory, and two self-monitoring logs of physical symptoms. School absenteeism, medical records, physician ratings, and family health history data were collected. No significant differences between high- and low-Type A behavior pattern (TABP) subjects were found on any of the physical measurements. However, retrospective and prospective reports of physical symptoms revealed a consistent pattern: high TABP subjects reported significantly more physical symptoms than low-TABP subjects. Self-ratings of stress and tension were significantly higher for high-TABP subjects. High-TABP subjects, however, neither missed more school because of illness nor used physician services more often than low subjects. Further, expected relationships between physical symptoms and illness behavior, including school absence, were evident only for low subjects.

Reduction in type A behavior in healthy middle-aged American military officers.

One hundred eighteen senior officer-students of the U.S. Army War College who were healthy but exhibited type A behavior volunteered to be randomly selected and enrolled into (1) a section of 62 officers who received group type A behavior counseling for 9 months and (2) a control section of 56 officers who received no counseling of any kind. Marked or profound reduction in type A behavior at the end of 9 months was observed in 41.9% of the 62 participants who initially were enrolled to receive type A counseling; marked or profound reduction in type A behavior, however, was observed in only 8.9% of the 56 initially enrolled control subjects. No adverse effects on the military leadership qualities of type A counseled participants were observed by their classmates. Serum total cholesterol and plasma high-density lipoprotein (HDL) cholesterol measurements were obtained monthly. The serum cholesterol of the total cohort of subjects rose significantly during a month of considerable emotional tension and stress. Those subjects who underwent a profound reduction in the intensity of their type A behavior pattern also exhibited a significantly lower serum cholesterol value as the study continued than those subjects who exhibited no change in their type A behavior. No significant changes in plasma HDL cholesterol concentrations were observed in the total cohort during the above-mentioned period of stress, nor were any differences in this particular measurement noted between the type A counseled and the control participants.