A FACTOR ANALYTIC STUDY OF PHYSICAL RISK VARIABLES FOR CHD LOGAN WRIGHT JOSEPH CARBONARI

University of Houston University of Oklahoma

WYATT VOYLES

University of Oklahoma Medical School

The scores of 40 hospitalized male coronary heart disease (CHD) patients, for seven traditionally employed physical CHD risk factors, were subjected to a confirmatory factor analysis that employed a LISREL program. An attempt was made to confirm a two-factor solution that involved family history as one factor, and smoking, serum cholesterol level, blood pressure, physical exercise, diet, and weight control as the second. The obtained goodness-of-fit index (.84) suggests that the two-factor solution is a moderately valid one. These findings raise the question whether many of the physical risk factors for CHD simply may be manifestations of a single behavioral characteristic, perhaps best described as “lack of self-control.”

Earlier studies have examined the interrelationship of coronary heart disease (CHD) risk factors such as family history, smoking, sedentary life style, etc. (e.g., Rosenman et al., 1975). Most o f these studies have assessed the association of variables from within a single risk factor subgroup, e.g., the relationship of various blood pressure measures to one another (Jorde, Williams, & Duida, 1986); the relationship of various cholesterol measures to one another (Aursnes, Smith, Christiansen, & Berg, 1988).

The investigation of intruparamital variables also has been applied to psychosocial risk factors that are thought to be related to CHD risk (e.g., Musante, MacDougall, Dembrowski, & Van Horn, 1983; Siegel, 1984), as well as to post-mortem pathology findings (Schraufnagel, Tsao, Yao, & Wang, 1985) and to complications associated with intra-aortic balloon counterpulsation (Gottlieb et al., 1984).

Surprisingly, no studies to date report factor analytic results among the seven physical CHD risk factors. A few studies (Brand, Rosenman, Sholtz, & Friedman, 1976; Rosenman et al., 1975) have gone so far as to glimpse the interrelationship among such traditional physical risk factors as family history, smoking, blood pressure, serum cholesterol, relative body weight, diet, and active vs. sedentary lifestyle. However, none of these investigations has moved beyond intercorrelations and multivariate prediction to the level of factor analysis. This is surprising in light of the fact that factor analytic efforts such as conducted in this study have been recommended hypothetically (Baldescu, RUSU, & Steinbach, 1982).

The present investigation examined the interrelationship of the seven commonly employed physical CHD risk factors of family history, smoking, high blood pressure, serum cholesterol, sedentary life style, diet, and weight control. Based on earlier clinical observations that are described in Wright (1988), it was thought that family history for CHD may not be associated with the other six traditionally employed CHD risk factors, but that these other six, so-called “life-style” factors may be interrelated to one another.

It could, of course, be argued that some of the six life-style-related factors (such as cholesterol or weight) may have some hereditary basis and, thus, may be related to

Correspondence should be addressed to Logan Wright, Department of Psychology, University of Oklahoma, Norman, OK 73019-053s.

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family history for CHD, or at least for cholesterol. However, for the purposes of this study, no assumptions need to be made with respect to this issue. Rather, an inductive determination is attempted to see whether earlier clinical observations that concerned a possible two-factor model could be confirmed. To do so, an attempt was made, factor analytically, to confirm a two-factor structure for CHD risk factors, in which family history constituted one of the factors and the other six physical CHD risk factors con- stituted the other.

If the above-described confirmation were possible, it would suggest that six of the seven commonly measured physical risk factors might conceivably be separate manifesta- tions of a single phenomenon, possibly marked by poor self-discipline, external locus of control, impulsivity, etc. It also would suggest that rehabilitation efforts that target patients’ basic or overall lack of self-control may prove more effective than those that deal with a tendency to commit specific “sins” such as smoking, hyperphagia, hypoac- tivity, etc. Such a finding also could have heuristic benefit for cardiac rehabilitation research.

It is noteworthy that, to date, no investigation has demonstrated effective means for altering individual personality so as to lower the initial risk for CHD (Suinn, 1982). Some success has been achieved in changing Type A personality so as to reduce reoc- currence rates in heart-attack victims (Friedman, Thoresen, & Gill, 1981). However, different intervention approaches would be suggested if it were determined that most of the seven physical CHD risk factors are primarily manifestations of a single behavioral phenomenon. Programs for altering impulsivity vs. self-control style then could be ap- plied to individuals determined to be potentially at risk for self-control reasons to see whether the occurrence and/or reoccurrence of CHD could be reduced more effectively than has occurred with these populations where other means of intervention were employed. It also could be determined empirically whether self-control targeted methods were superior to traditional cardiac rehab efforts that attempt directly to change single life-style variables such as smoking behavior, eating behavior, etc.

The above observations provide the conceptual background for testing a factor analytic hypothesis that a two-factor solution could be confirmed in which one factor represented inherited CHD risk and the other consisted of what may be mainly self- imposed CHD risk.

METHOD

Subjects and Procedure Subjects were 40 married Caucasian males between 40 and 55 years of age

(A4 = 49.85 years) who were patients on a coronary care unit at a large southwestern medical center. All subjects had experienced at least one miocardial infarction (MI). Twenty-three had experienced only one MI. Eleven had experienced two, and 6 had ex- perienced three or more MIS. Twenty-four of the subjects had undergone coronary bypass surgery, and 5 had received angioplasty. There were no refusals to cooperate in the study.

Information about the seven risk factors of family history, smoking, blood pressure, serum cholesterol, diet, exercise, and weight control was obtained both from patients’ charts and from a single interview. The information was gathered by a psychologist, not one of the current authors, who was naive as to the purpose of this study. Each risk factor was scored according to a method originally suggested by Rosenman et al. (1975).

The smoking score was the average number of cigarettes per day times number of years smoked. The weight control score was a ratio determined by dividing height in inches by weight in pounds (a method advocated later by Stunkard & Baum, 1989). The other five risk factors were scored as follows:

Self- reported Family History 1 = No family history

CHD Risk and Cardiac Rehab 167

2 = Secondary family history (aunts, uncles, and grandparents only) 3 = Family history in only one immediate family member (father, mother, brother,

3 . 5 = Family history in one or more immediate family member and in one or more

4 = Family history, multiple: i.e., two or more immediate family members

sister)

secondary family member

Serum Cholesterol Average of all available combined HDL/LDL readings. (Avoided utilizing more

than one reading in any one year.) The average of multiple readings in 1 year was employed. Also, no post infarc readings from present hospitalization were employed.

Blood Pressure

(combined systolic and diastolic). Systolic and diastolic readings combined - all available readings for blood pressure

1 = below 190 and no medication 2 = 190-210 and no medication 3 = 210-230 and no medication 4 = 230 and above or on medication 5 = 230 and above and on medication

Self-reported Exercise Style 1 = Little or no exercise at work or home 2 = Moderate exercise at work; no formal exercise program 3 = Routine vigorous exercise at work, or formal exercise program (less vigorous

4 = Vigorous exercise at work and formal exercise program (less vigorous than

5 = Formal exercise program (20 minutes or more of vigorous exercise, excluding

than level 5 )

level 5 )

walking) done 3 or more days a week

Self-reported Diet Typical diet practiced prior to documentation of CHD:

1 = Deliberately restricted high-fat foods and chose high-fiber foods 2 = High fat and high fiber 3 = High fat and low fiber

Obtained data were subjected to a LISREL-type confirmatory factor analysis that used polycloric correlations (Joreskog & Sorbom, 198 1) for confirming the two-factor outcome suggested above. It was predicted that family history would be the only variable to load significantly on the first factor and that all other variables would load on the second.

RESULTS

The results of the above-mentioned factor analysis, which are shown in Table 1 ,

The intercorrelation matrix for the seven study variables is provided in Table 2. The goodness-of-fit index obtained from the LISREL factor solution was .84, which

suggests that the two-factor solution is a valid one. Also, the correlation between factors

support the two-factor hypothesis.

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Table 1 Correlations of Seven CHD Risk Variables with Each of Two Analytically Derived Factors

Factor 1 (inherited risk)

Factor 2 (self-imposed risk)

Smoking Cholesterol Blood pressure

.oo

.oo

.oo

.17

.03

.31*

Family history 1 .oo** .oo Exercise .oo .86**

Diet $00 .51** Weight control .oo .58**

*p < .025. * p < .001.

Table 2 Intercorrelation Coeficients for Seven Study Variables

Family History Smoking Cholesterol Blood press. Exercise Diet

Smoking .08

Cholesterol .07 . 07

Blood pressure - .01 .31 .35

Exercise - 3 4 .09 .03 .15

Diet - .20 .I4 - .22 .06 .37

Weight/height - .24 .18 .29 .31 .46 .19

1 and 2 was - .42, which suggests a significant, but inverse relationship between them. This implies that patients with inherited risk may be significantly less at risk from self- imposed phenomena, and vice versa.

As can be seen from Table 1, the second factor is marked best by the exercise variable and secondarily by diet and weight control. It is marked most poorly, essentially uncor- related, by serum cholesterol readings. However, cholesterol did not correlate significantly ( - .01) with factor 1, which may suggest existence of a third factor. But when such a three-factor solution was attempted, it produced a poorer goodness of fit than that ob- tained for the predicted two-factor model. A one-factor model for all variables failed to converge to a solution, an indication that it was also an unacceptable model.

DISCUSSION AND CONCLUSION

Because factor 2 does not include specific personality variables, any labeling in per- sonality terms is best considered tentative. Results of this study, however, do add substance to a question of whether two basic forms of risk may underlie CHD. One of the factors seems to entail a considerable amount of self-imposed risk, even though genetic factors may play some role in determining risk ratings for variables such as blood pressure, cholesterol readings, and weight/height ratio.

Previous reviews have suggested that CHD risk can be explained to some extent by psychosocial variables such as the Type A behavior pattern (TABP; Review Panel, 1981), or its subcomponents of anger (Dembrowski & Williams, 1989) or time urgency

CHD Risk and Cardiac Rehab 169

(Wright, 1988). However, the behavior pattern (factor 2) suggested here appears to be quite different than the TABP and may, in fact, describe a form of CHD risk more likely to be associated with being Type B.

One eventuality not considered in the present study is the fact that family history might be contaminated by family size because an individual with many relatives is more likely to have one with a history of CHD than is an individual with few relations. It also might be contaminated by age of subjects because the relatives of older subjects, probably more aged themselves, will have gone further into the risk period for CHD. A family history measure that is independent of age and family size would be useful in future research of this type.

Obviously, the findings in this investigation are tentative, and it is hoped that future research will focus on replicating the two-factor solution obtained in this study, while it relies on new and possibly larger samples. Eventually, work also might be undertaken to develop psychometric or interview techniques designed specifically for assessing factor 2. These could draw from existing measures of health locus of control, impulsivity, etc. Once developed, such measures could be construct validated and otherwise refined psychometrically. The resulting measure(s) then could be used in prospective attempts to predict CHD and other disease end points and their effectiveness compared to that of measures of Type A personality, etc.

Additional research also could address the question of whether most existing life- style-related rehabilitation efforts may be too specific and/or too targeted toward physical parameters or physical manifestations (e.g., smoking, diet, etc.). Superior results might be obtained by addressing a more pervasive, behavioral trait, i.e., factor 2. At present, much cardiac rehabilitation involves the presentation of facts about the relationship of various lifestyle components to CHD, combined with encouragement to change one’s life style with respect to smoking, exercise, etc. The outcome of such efforts has not been overly satisfying. Future studies might compare traditional life style interventions to those designed to bring about more basic forms of personality reorganization, par- ticularly in the realm of self-discipline/self-control.

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SOCIAL APPROPRIATENESS AND IMPAIRED PERSPECTIVE IN SCHIZOPHRENIA

MARGARET A. CARINI AND JEFFREY S. NEVID

St. John’s University

Self-ratings and judges’ ratings of social appropriateness were obtained based upon videotaped role-enactments of schizophrenics (n = 16), mixed psychiatric controls (n = 16). and normal controls (n = 16) in mock social interactions. Schizophrenics were rated significantly lower on social ap- propriateness and were judged on semantic differential scales as showing greater deficiencies in social behavior. As predicted, impaired perspective among schizophrenics appeared to be limited to appraisals of self. Schizo- phrenics, like the comparison groups, were able to discriminate significantly between appropriate and inappropriate behavior of others. But unlike the comparison groups, schizophrenics rated their own behavior significantly higher in social appropriateness than did judges.

Severe impairment in interpersonal functioning is considered an essential feature of schizophrenia (Morrison & Bellack, 1987). Indeed, deficits in interpersonal function- ing have been associated with conceptualizations of schizophrenia since the disorder first was described (Wixted, Morrison, & Bellack, 1988). The DSM-III-R specifies deterioration in social relations as one of the diagnostic criteria for schizophrenia and identifies social isolation or withdrawal, and impairment in role function, as frequent residual symptoms (American Psychiatric Association, 1987). Researchers have found that even when gross psychotic symptomatology is in remission, marked difficulties in social interactions persist (Serban, 1975; Strauss, Carpenter, & Bartko, 1974). Bellack,

This article is based on Margaret Carini’s doctoral dissertation, which was supervised by Jeffrey S. Nevid

Correspondence should be addressed to Jeffrey S. Nevid, Department of Psychology, St. John’s Univer- and submitted to the Department of Psychology, St. John’s University.

sity, Jamaica, NY 11439.