Adrian M. Ostfeld

Hostility, risk of coronary heart disease, and mortality

&NA; Level of hostility (Ho) was assessed by a 50‐item subscale of the Minnesota Multiphasic Personality Inventory at the initial examination of 1877 employed middle‐aged men who were free of coronary heart disease (CHD). Ten‐year incidence of major CHD events (myocardial infarction and CHD death) was lowest in the first quintile of the Ho scales distribution, highest in the middle quintile, and intermediate in the other three quintiles. After adjustment for age, blood pressure, serum cholesterol level, cigarette smoking, and intake of ethanol, the relative odds of a major CHD event was 0.68 for men with Ho scores less than or equal to 10 points in comparison to men with higher scores. The Ho scale was positively associated with crude 20‐year mortality from CHD, malignant neoplasms, and causes other than cardiovascular—renal diseases and malignant neoplasms. After adjustment for the risk factors listed above, the Ho scale had a statistically significant, positive, monotonic association with 20‐year risk of death from all causes combined. A difference of 23 points on the Ho scale, i.e., the difference between the means of the first and the fifth quintiles, was associated with a 42% increase in the risk of death. These results support the previous findings of Williams et al. with respect to the Ho scale and coronary atherosclerosis, and also suggest that the Ho scale may be associated with factors having broad effects on survival.

A classification of headache: Ad Hoc Committee on Classification of Headache

THE TERM HEADACHE commonly denotes head pain from brow level up. This outline defines headaches somewhat broadly; it covers both painful and nonpainful discomforts of the entire head, including the face and upper nucha. Since so much that a man describes as headache may be any abnormal head sensation, it is essential for proper treatment to determine whether the complaint is actually one of pain. A useful scheme for the classification of the varieties of headache is one based on pain mechauisms. The divisions rest on experimental and clinical data, together with reasonable inference; the story is far from complete. Yet the arrangement can serve as a framework for diagnostic criteria for the major clinical types of headache and by emphasis on basic mechanisms it offers a logical approach to the planning of therapeutic trials. For convenience, short and simple names are suggested for certain major entities and are indicated in boldface type. Essential in the study of headache in most instances is an appraisal of its close link to the patient’s situation, activities, and attitudes. Sometimes in obvious ways, more often in subtle ones, headache may be the principal manifestation of temporary or sustained dif6culties in life adjustment. These relationships are notably evident in Croups I through V.

an Epidemiological Review of the Mortality of Bereavement

&NA; Epidemiological literature revealing excess mortality in the newly widowed is reviewed. The risk varies by age and sex. Younger persons and men are at higher risk. There are manifold specific causes of death characterized by conditions manifest in middle and late life. Cause specificity also varies by sex. Methodological problems in this literature are mitigated by application of varied methodology and replication of basic findings. Socioeconomic status and “social” stress are not well controlled as independent variables. Nevertheless, they probably do not explain the large relative risk of mortality among the bereaved. Pathogenetic mechanisms resulting from a loss are probably twofold: physiologic changes associated with the loss response and behavioral changes that comprise health maintenance or chronic disease management. Because of its important as a health problems, as a fundamental human reaction, and as a research strategy for the basic psychosomatic hypothesis, bereavement is a prime target of investigation.

Prospective and retrospective psychological studies of coronary heart disease.

&NA; The Minnesota Multiphasic Personality Inventory was administered at the first and fifth annual examinations of 1990 men studied in a prospective investigation of coronary heart disease. These data were used to investigate the following questions‐‐two potential sources of error in retrospective studies: Do survivors of the illness differ, on the variables being investigated, from persons who die before they can be included in a retrospective study? Is occurrence of the illness associated with systematic changes in these variables among survivors? Both questions were answered affirmatively. The results indicate that investigation of relationships between variables of behavior or personality and the occurrence of symptomatic life‐threatening disease should proceed by the prospective method.

Social status and incidence of coronary heart disease.

Abstract This study tested the hypothesis that 5 types of incongruity in social status are associated with increased risk of coronary heart disease (CHD). It also investigated prospectively the relationship between 7 variables of social status and incidence of CHD. The cohort comprised 1472 married, middle-aged Caucasian men employed by an industry in metropolitan Chicago. All subjects were free of clinical CHD when social status was measured. Cases of CHD occurring in the subsequent 5 yr were detected by annual examinations. Results of this study support the hypothesis that incongruities in social status are associated with increased risk of CHD. Incidence of CHD increased as the number of incongruities per subject increased, and men with 4 or 5 incongruities were found to have about 6 times the risk of CHD as compared to men with none of the incongruities studied here. This association could not be explained by correlation between number of incongruities per subject and serum cholesterol, arterial pressure, blood glucose, age, educational status, relative weight, and cigarette smoking. This study also found that incidence of CHD in this cohort was associated with educational status, but that the form of the relationship varied according to the clinical form by which the disease was first manifested. Caution should be observed in generalizing these results beyond the specific social organization in which they were observed.

Personality and coronary heart disease

&NA; Three MMPI variables—HsK + Hy, neuroticism, and somatic complaints—were positively associated with incidence of uncomplicated angina pectoris and not significantly associated with incidence of myocardial infarction and coronary death in a 10‐year cohort study of 2003 employed middle‐aged men. All three were negatively associated with risk of coronary death after the diagnosis of uncomplicated angina had been established. These results support the hypothesis that tendencies to report somatic complaints or to experience negative, distressing emotions chronically are not related to incidence of coronary heart disease but are associated with incidence of a relative benign, nonatherosclerotic condition that is similar clinically to angina pectoris. Also, HsK + Hy and somatic complaints were positively associated with risk of coronary death in men who had survived an initial myocardial infarction. This result does not indicate an association with coronary hearth disease itself because all of these men already had coronary heart disease. This result may indicate that the tendency to report somatic complaints is related to increased susceptibility to acute emotional stressors that can trigger arrhythmias in an ischemic myocardium.

Crowding in prison: The relationship between changes in housing mode and blood pressure.

&NA; The relationship between change in mode of housing and corresponding blood pressure (BP) change was investigated among 568 male prisoners as an analogue to animal studies which have shown that crowding elevates BP. The transfer from single occupancy cells to multiple occupancy dormitories was associated with a statistically significant mean increase in systolic blood pressure (SBP). In contrast, men who remained in single cells had little mean change in SBP over time. Inmates who were retransferred to cells after a short stay in dormitories experienced a mean decline in SBP, which suggests that crowding may be reversible in its early stages. SBP also decreased after continued stay in the dormitories, indicating that adaptation may occur. The implications of these findings for crowding theory and their contribution to an understanding of response to the prison environment are discussed.

Epidemiology of hypertension

Summary Epidemiologic studies have demonstrated that hypertension is concentrated in the obese, the Negro, the middle-aged and elderly, and among those with a lineage of hypertension. Rapid cultural change and social conflict may also influence the prevalence of high blood pressure in a population. There is less agreement about the role of renal infection, water hardness, dietary salt, personality characteristics, and the precise genetic mode of inheritance of hypertension. It is likely that the prevalence of hypertension is decreasing in the United States, but the reasons for the decrease are unclear. Despite gaps in our knowledge, there is urgent reason for lowering even moderate elevations of blood pressure in order to attempt to prevent coronary artery disease, strokes, and the renal and ocular complications of high blood pressure.

Conscious and unconscious coping with loss.

&NA; Sixty‐seven persons were identified 1 to 2 months after the death or life‐threatening illness of their spouse and followed for 25 months. Intake measures included a) a revised Ways of Coping Scale, a structured assessment of ego defenses, sociodemographic information, and other baseline variables. Fifty‐six completed follow‐up. Outcome measures included deaths, hospitalization, self‐rated health, depressive symptoms, symptoms of anxiety, and separation distress. In our analyses, bereavement was used as a covariate and found to be unrelated to outcome. Low self‐ratings on coping by making a change and problem‐focused planning predicted higher scores on separation distress at 13 months (p < or = .05). Participants who used less problem‐focused planning were at risk for higher depression scores 13 months after the stressful event (p < or = .05). Low ego‐defensive work and high neurotic ego‐defensive ratings predicted high depression scores at 13 months (p < or = .05). At 25 months, coping by self‐blame was inversely related to scores on separation distress (p < or = .05). Coping variables predicted neither scores on anxiety symptom scales nor the outcomes of hospitalization or death over the 25‐month study period. These observations counter some prevailing clinical assumptions about coping with a loss and emphasize the value of empirical studies of coping as a mediator of outcome during the stress of a loss.

The natural history and epidemiology of migraine and muscle contraction headache.

The population studied was extremely heterogeneous in age, race, education, socioeconomic status, and previous contacts with physicians. The group of 114 persons consisted of 70 women and 44 men. The mean age of the group was 44.3 years, with a standard deviation of 9.1. Eighty-one were Caucasoid; 31, Negro; and 2, Chinese. All but 6 were born in the United States. One-third had had 8 grades or less of education. Of the remaining two-thirds, about 20 per cent had had two or more years of college. The large majority were upper lower or lower middle class. Most of the women were housewives and most of the men, white collar workers. The group represented a majority of the patients who consulted me during a four-year period. I cannot specify the hypothetical parent population of which it may be a random sample. Therefore, my observations in this population are applicable only to this population. Extrapolations from it to other groups will depend on studies of other groups. Since no hypotheses were formulated at the beginning of the survey, no statistical tests of significance were employed. The criterion for the diagnosis of migraine was identical for each subject. Patients came to the laboratory on 2 occasions within an hour after the onset of a headache attack. In randomized order and double-blind fashion, they received .07 mg. per kilogram ergotamine tartrate parenterally on 1 occasion and placebo on the other. Those whose headaches were, in their judgment, “all gone” or “much better” after ergotamine and “a little better” or “the same or worse” after placebo were called migraine patients. As stated earlier, there were 114 such patients. There were 30 subjects who received help both from placebo and from ergotamine. They are not included in the discussion.