Social Avoidance and Long-Term Risk for Cardiovascular Disease Death in Healthy Men: The Western Electric Study
Introduction
It has long been suspected that personality traits may contribute to risk for cardiovascular disease (CVD). However, inconsistent associations between the type A behavior pattern and CVD over several decades of research suggest that the search for broad behavioral or personality constructs can sometimes result in the erroneous combinations of unrelated, independent variables (1). The combination of time-urgency and hostility within the Type A behavior construct obscured the unique contributions of these component traits to the risk for CVD 2, 3. Efforts to refine the understanding of the role personality traits have continued with investigation of the subcomponents of the measure of the Cook–Medley hostility scale, the most widely studied measure of hostility in the literature 4, 5, 6.
The Cook–Medley hostility scale measures a broad variety of negative beliefs, attitudes, and behaviors. The heterogeneous content of this scale reflects an absence of a theoretical framework that is consistent with its origin, as it was empirically derived to identify teachers with difficult student relationships (7). In an effort to improve upon the measurement of hostility, Barefoot performed a focused analysis of the item content, leading to the creation of separate subscales within the Cook–Medley hostility scale (see Table 1) (5). Although four of these scales reflect hostile attitudes and behaviors, one subscale, termed “social avoidance,” was interpreted as conceptually distinct from hostility: in contrast to the overtly negative dimensions of the four hostility subscales, the social avoidance subscale described indirectly negative behaviors with a tendency to avoid social contact. Since the publication of these subscales, investigators have used some of the hostility subscales as a more specific measure of hostility in CVD research 4, 6, 8. However, to our knowledge, there has been no analysis of the association between social avoidance and CVD.
The tendency to avoid social contact reflects a broader temperament pattern characterized by a generalized fear of novelty and unfamiliarity (9) that can be observed consistently throughout childhood (10) and into adulthood 11, 12. Furthermore, a large body of research has shown this style of temperament to be associated with heightened sympathetic responses to environmental stimuli (9). Thus, we hypothesized that social avoidance might be related to CVD and coronary heart disease (CHD) death in healthy individuals. The objective of the present study was to examine the association of social avoidance with 30-year CVD, CHD, and non-CVD mortality in a large cohort of healthy men.
Section snippets
Study Sample and Covariates
The Western Electric Study is a longitudinal epidemiologic study designed to study risk factors for CVD (13). In 1957, 5397 men who had been working for the Western Electric Company's Hawthorne Works in Chicago for a minimum of 2 years and were between the age of 40 and 55 were randomly sampled, producing 3102 potential candidates for enrollment into the study. Of these, 2080 men agreed to participate. In addition, there were 27 men from the original pilot study who were included, yielding a
Baseline Characteristics
The social avoidance scores ranged from 0 to 4 (mean = 1.13; SD 1.02). Because of the limited range of responses, the number of participants in each group was not equivalent. In general, the baseline characteristics across all four groups were similar (Table 2). However, body mass index was higher and educational status lower in the groups scoring higher on social avoidance. In addition, higher levels of social avoidance were associated with higher levels of hostility and depression.
Principal Findings
In a cohort of middle-aged men, we observed that social avoidance was associated with CHD and CVD death. After multivariable adjustment for baseline covariates and established CVD risk factors, the association persisted and appeared to strengthen, if anything. The association with CHD and CVD death persisted even after further adjustment for baseline hostility measures. Of note, there was no association between social avoidance and non-CVD mortality. Thus, these findings suggest the possibility
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The investigators acknowledge support by the American Heart Association, Dallas, Texas, and its Chicago and Illinois affiliates; the National Heart, Lung, and Blood Institute (NHLBI), Bethesda, MD, grants R01-HL 15174, R01-HL 21010, and R01-HL 03387; and the Chicago Health Research Foundation, Chicago, IL. A list of colleagues who contributed to earlier aspects of this work has been published (Cardiology. 1993;82:191–222). Dr. Berry received support from a NRSA fellowship in the Department of Preventive Medicine, Northwestern University Feinberg School of Medicine (T32HL069771).