Conceptualizing Psychosocial Risk Factors for Cardiovascular Disease: A Comment on Ewart et al.

An important focus of research in behavioral medicine is the investigation of individual-level psychological characteristics that increase the risk for cardiovascular disease (CVD). Although there are significant findings linking a variety of characteristics including Type A behavior, hostility, and other anger-related traits to CVD, the literature overall is conflicted 1. Craig Ewart and colleagues Gavin Elder and Joshua Smyth argue that we can better understand the ways in which psychological factors increase cardiovascular risk by evaluating motivational goals and self-regulatory capacities 2. Working within the framework of Social Action Theory, Dr. Ewart and colleagues have developed a Social Competence Interview (SCI), which permits the assessment of implicit motivational profiles, including agonistic and transcendence striving 3. Agonistic striving reflects the desire to achieve goals by controlling other people, whereas transcendence striving involves attempts to control the self. The findings in this paper suggest that motivational goals predict ambulatory systolic blood pressure in adolescents, and the effects are moderated by self-regulatory capacities. Specifically, higher levels of an agonistic motivational drive (i. e. , reflecting a drive to control others) are associated with higher systolic blood pressure levels, particularly for those individuals whose teachers indicate that they have poor self-control or appear to be internalizing distress. The findings emerge primarily when motivational striving is assessed using implicit versus explicit or conscious methods. The authors raise important questions about both the psychological content and processes associated with psychological risk factors for cardiovascular disease. What are the key elements associated with risk—motivations, cognitions, affects, and behaviors? How can we best measure these psychological factors: through assessments of implicit attitudes or explicit cognitions, affects, and behaviors? Does each element have unique predictive properties or are they interdependent? Do psychological characteristics exert influence on psychophysiological processes only when individuals are exposed to certain stressors (e. g. , interpersonal conflict) or do these characteristics exert risk primarily because they increase exposure to stressors? Do these psychological characteristics reflect biological predispositions associated with stress reactivity and recovery or are they a function of environmental exposure (i. e. , from family or neighborhood) or an interaction between biology and environment? The struggles in the conceptualization and measurement of psychological characteristics that increase risk for cardiovascular disease have been present since the inception of psychosomatic research on CVD. Recall Type A behavior 4. As Friedman and Rosenman originally conceptualized it, Type A was not a personality trait, but rather a constellation of attitudes, affects, and behaviors that reflected a battle against the environment, a driven and angry attempt to force the world to conform to the individual's expectations and needs. The battle could be expressed in many different forms— as time urgency or excess job involvement or interpersonal hostility. During the Type A Structured Interview, the interviewers challenged the participant and examined the ways in which this interpersonal challenge elicited thoughts, feelings, and behaviors consistent with the components of Type A 5. Similarly, both the underlying formulation of the SCI and its assessment methods reflect the recognition that pathogenic elements may not be static traits (or specific affects, cognitions, or behavioral responses), but instead are composed of a dynamic interaction between interpersonal situations and the individual's own motivations. The authors recognize that accessing the underlying constructs requires an interpersonal challenge. Dr. Ewart and colleagues have conducted remarkable field studies with adolescents to test these hypotheses in the “real world. ” What are the psychological dimensions that subserve agonistic striving and other putative psychological risk factors for CVD? The approaches to assessing CVD-prone characteristics vary in the degree to which they emphasize cognitions, affects, and interpersonal behaviors. But most involve assessing fundamental attitudes about our relationships to others, including the relative importance or feasibility of asserting our rights in interpersonal relationships and the types of actions that are necessary or justified to obtain these rights. How can these social motivations influence cardiovascular risk? Agonistic and transcendence striving, as well as other CVD-related characteristics can also be conceptualized as schemas—constellations of linked affects and cognitions that influence behavior. Schemas influence our information processing: the ways in which we attend to new information or filter it out, remember it or discard it, value it or ignore it 6. These variations in information processing affect the dynamics of our interactions with the world and with each other. Because these motivational schemas reflect integrated emotion–thought–perception units, our reactions happen very quickly and often outside of conscious awareness. Implicit assessments may be better able to tap these constellations of responses. However, it may be the case that it is not the content or nature of the schema itself that drives physiological reactivity. Instead, it may be the degree to which emotions, cognitions, and behaviors are tightly intertwined. There is some research suggesting that highly interrelated negative schemas may drive pathological behavior 7, and the degree of interrelatedness among psychological elements may drive cardiovascular response as well 1. Therefore, cardiovascular risk may increase when there are several related schemas which are linked in memory. Activation of one schema may trigger activation of other closely related schemas, initiating a cascade of negative thoughts and/or emotions. As Harburg suggested in his classic field studies of blood pressure, the direction of anger expression may matter less than the degree to which it is automatic or reflexive 8. The SCI requires participants to complete a complex task in which they develop a narrative about the resolution of a salient interpersonal conflict 3. The motivational goals are revealed as the participants describe the actions, thoughts, and feelings of the characters in the narrative. Thus, agonistic striving as assessed by the SCI may capture a set of interrelated schemas about interpersonal relationships and control. If this is the case, then perhaps the underlying personal characteristics which increase risk for CVD might involve the structure or function of the neural pathways that link perception, cognition, affect, and memory or involve the neurohormonal modulators of the activation of these pathways. Individuals for whom these elements are linked more closely (regardless of content) may be at greater risk. Those who are able to inhibit or modulate these relationships (potentially those capable of certain types of pre-frontal modulation of attention or affective response) are at reduced risk. This is consistent with the authors’ report of the influence of self-regulatory processes on the relationship of agonistic motivation to ABP. The adolescents in this study came from very low-income families (most with gross household incomes below 25, 000), and many had parents with less than a high school education. We are only beginning to understand the developmental roots of characteristics that are associated with increased risk for CVD. New research from investigators studying childhood adversity suggests that highly stressful or traumatic early environments, including those characterized by low socioeconomic status or neighborhood violence, may influence our perceptions of others, foster more persistent negative moods that tie together a variety of negative beliefs about the self and others, and alter the underlying biological substrates that regulate stress reactivity and recovery 9–11. As cardiovascular-behavioral medicine research moves forward, investigators will need to consider these individual-level characteristics both in a broader context and at a more micro-level 9. It is increasingly clear that it is important to understand the environmental and personal contexts in which the psychological characteristics that increase risk for CVD develop. But it is also necessary to understand the ways in which individual-level psychological characteristics, measured with surveys and interviews, reflect underlying differences in information processing and affect modulation and in their biological substrates. As we integrate macro- and micro-information across these domains, we will develop more effective biopsychosocial models of the development of CVD.