Psychosomatics 40:44-49, February 1999
© 1999 The Academy of Psychosomatic Medine
The Millon Behavioral Health Inventory Life Threat Reactivity Scale as a Predictor of Mortality in Patients Awaiting Heart Transplantation
Kathy L. Coffman, M.D., and
Marvin Brandwin, Ph.D.
Received November 20, 1997; revised January 21, 1998; accepted September 8, 1998. From the St. Vincent Medical Center, Los Angeles, California. Address correspondence and reprint requests to Dr. Coffman, St. Vincent Medical Center, 2200 West Third Street, Ste. 500, Los Angeles, CA 90057–1904.
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ABSTRACT
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This study examined the Millon Behavioral Health Inventory Life Threat Reactivity Scale (LTRS) as a predictor of mortality in patients awaiting heart transplantation. The one-year mortality while awaiting cardiac transplantation was more than double for the high-risk group based on the LTRS scores. The high-risk group had a 42% mortality rate versus an 18% mortality rate in the low-risk group. Mortality for those patients that received transplants was similar for both groups. A review of the medical literature regarding the role of personality traits in cardiac mortality and the findings of this study are discussed.
Key Words: Mortality • Transplantation • Millon Behavioral Health Inventory
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INTRODUCTION
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As far back as biblical times, the effects of strong emotions on the heart have been described, and accounts of sudden cardiac deaths have been used as literary devices up until now.1 However, until recently psychological stress had been viewed as a vague and subjective entity that could not be quantitated. Causal evidence of the association between psychological stress and cardiac mortality in the medical literature has been scarce.2 While working with cardiac transplant candidates with advanced disease awaiting transplant, we wondered whether there were personality traits other than the often-noted type A personality that may predispose one toward negative outcomes.
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LITERATURE REVIEW
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The relationship between level of social integration and aspects of health was addressed in a recent article by Seeman.3 There is strong documentation in the medical literature that social integration reduces risk of mortality and leads to better mental health. The evidence on outcomes with physical conditions has been less conclusive. Studies have shown that social isolation can lower immunological function and increase both neuroendocrine and cardiovascular activity.3 Seeman and Lewis have also shown that the sense of powerlessness may be associated with subsequent health problems and mortality rates.4 The relationship between personality and coronary disease was suggested by Dimsdale in 1988.5
Ahern et al. reported that in a study of 502 patients in the Cardiac Arrhythmia Pilot Study, type B behavior, higher levels of depression, and lower pulse-rate reactivity to challenge were significant risk factors for cardiac arrest or death.6 A study by Orth-Gomer and Unden7 from Sweden the same year showed contradictory results in a group of 150 men and demonstrated similar mortality in the men with type A (24%) and type B (22%) behavior. A multivariate analysis showed that lack of social support/social isolation predicted mortality independently in the type A men, but not in the type B men. Over the 10-year follow-up period, the mortality of the socially isolated type A men was 69%, compared with the mortality of 17% in the socially integrated type B men (P<0.05). Another Swedish study by Hanson et al. of 500 men born in 1914 in Malmö showed that the men with low availability of emotional support, with low adequacy of social participation, or who lived alone had a higher risk of mortality during the 5-year follow-up period.8 Denollet et al.9 have recently noted that little is known about the role of personality in long-term prognosis in patients with coronary heart disease. This group of researchers showed that type D personality was characterized by high scores on negative affectivity and social inhibition. These subjects scored high on emotional distress and low on subjective well-being. These subjects tended to show chronic suppression of negative emotions. This personality type was associated with depression, social alienation, and a four-fold higher 5-year mortality in the coronary heart disease patients, both for cardiac and noncardiac deaths, than the nontype D patients. Other studies have suggested social alienation as a factor related to prognosis after myocardial infarction.10,11 Factors associated with increased mortality in the Cardiac Arrhythmia Suppression Trial included psychosocial factors, such as higher state anxiety, lower anger outward, more past life events, and lower expectations of future life events, as well as increased depression from baseline to first follow-up.12 One study of cardiac transplant survival found that self-rated psychometric measures of coping and social support completed before transplantation provided the best significant predictors of survival. In addition, ratings done during interviews for social support and pretransplant compliance with treatment were related to posttransplant health care use.13 Numerous studies of Swedish men have pointed toward low control at work and low social support as risk factors contributing to deaths from cardiovascular causes.14 One study from Australia reported an association among marital status, social support, and mortality from stroke and coronary heart disease, although the extent of social support was not directly associated with significant differences in cardiovascular risk factors in the men or women.15
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METHODS
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This study was prospective. The subjects were 103 consecutive heart transplant candidates referred to the University of Michigan Medical Center from July 1987 through January 1989. The subjects were given the Millon Behavioral Health Inventory (MBHI)16 during their transplant evaluation by one of two psychiatrists. Tests were scored by using a computerized program.
The candidates were told that the test results would enable their psychiatrist to better understand their problems and that the results would not be used to determine whether they were listed for transplantation. The patients were blind to the results, as were the cardiologist and the thoracic surgeon providing medical management for the patients. Data were also collected to compare the subjects on indices of their cardiac function, such as left-ventricular ejection fraction (LVEF) and New York Heart Association Functional Classification (NYHAFC), as well as demographic data, such as age and gender.
The outcome of this cohort of patients was subsequently reviewed at 5 years to study the relationship among cardiac mortality, personality traits, and scores on the Life Threat Reactivity Scale (LTRS), presumed to be an indicator of an unfavorable course of an illness. A cutoff score of 70 on the LTRS was used to categorize and separate the patients into a high-risk or a low-risk group. Comparisons were made between the scores of high-risk and low-risk groups and their mortality before transplant and following transplantation. All patients were accounted for at the end of the 5-year follow-up period by verifying their status through medical records and through the Michigan Office of Vital Statistics. Our hypothesis was that those who died during the first year after listing would show a different profile on the MBHI, particularly on the LTRS. We also thought that the mortality after transplantation would reflect risk, as assessed by the LTRS.
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RESULTS
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The 1-year mortality of the patients waiting on the list did vary by risk group. The 1-year mortality of those in the high-risk group was 42%, whereas the mortality in the low-risk group was 18%. When these data were examined with a chi-square test with one degree of freedom, the calculated chi-square value was 35.17, with a significance of greater than 0.0001 (Figure 1). Another interesting observation was that the 5-year mortality of the two groups after transplantation was very similar. The high-risk group had a 29% mortality, and the low-risk group had a 22% mortality. When these data were examined by a chi-square test with one degree of freedom, the calculated chi-square value was 2.35, which was not significant (<0.01) (Figure 2). When the subjects were divided by LTRS scores, and the traits of the high-risk group were compared with the traits of the low-risk group, interesting differences appeared. The high-risk group scores were significantly different from the low-risk group on inhibition, sociability, confidence, and sensitivity, as well as pessimism, future despair, social alienation, somatic anxiety, cardiovascular tendency, recent stressors, and emotional vulnerability—all had P-values=0.0001. The P-value for introversion was 0.002, and for chronic tension was 0.02. The overall LTRS scores were significantly different, with a mean score of 80.7 for the 43 high-risk subjects vs. a mean score of 41.7 for the 60 low-risk subjects (P=0.0001).
To investigate whether there were protective factors that promoted survival in the high-risk group, the scores of the 5-year survivors were compared with those of the deceased. The MBHI variables of inhibition (P=0.02) and social alienation (P=0.05) were significant, but the cardiovascular tendency scores were not. Those who died in the high-risk group had significantly worse NYHAFC ratings and LVEF at the time of listing, in addition to higher scores on inhibition and social alienation. However, among the low-risk subjects, again there were significantly higher scores for social alienation (P=0.03 ) among the deceased, but the NYHAFC and LVEF at the time of listing were nearly identical. Therefore, even when the heart functions are the same, it appears that social alienation may play an important part in the survival of heart transplant patients. Interestingly, the variable cardiovascular tendency (P=0.006) in the low-risk group was significantly higher in the deceased.
Examination of the scores of the high-risk subjects who were transplanted revealed several interesting findings. First, the pretransplant LVEF was significantly different between the survivors and the deceased (survivors: 20.3 vs. deceased: 9.7, P=0.0004). The average length of survival after evaluation was quite different (survivors: 1,827 days vs. deceased: 826 days, P=0.0009). In addition, the survivors scored significantly higher on forcefulness (survivors: 53.2 vs. deceased: 32.5, P=0.05). Oddly, the high-risk group of transplant survivors rated themselves as significantly less cooperative before the transplant on the MBHI (survivors: 36.5 vs. deceased: 66.3, P=0.02). The high-risk survivors scored significantly higher on chronic tension (survivors: 61.6 vs. deceased: 33.5, P=0.04). Considering that all patients were alive at 5 years posttransplant, the two significant factors were age at listing (survivors mean: 47.7 vs. deceased mean: 54.7, P=0.02) and mean score on cooperation (survivors: 44.0 vs. deceased: 63.7, P=0.02) (Table 1). Examination of the scores of the patients who were not transplanted in the high-risk group revealed that the survivors scored significantly higher on cooperation (survivors: 65.6 vs. deceased: 46.4, P=0.04). The deceased in the high-risk group scored significantly higher on social alienation than the survivors (deceased: 57.7 vs. survivors: 38.1, P=0.01). When comparing the scores of the survivors and the deceased in the low-risk group who were not transplanted, the only significant difference on the MBHI scores was cardiovascular tendency (survivors: 47.9 vs. deceased: 57.8, P=0.03) (Table 2).
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DISCUSSION
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The observation that the mortality differed between the two groups before transplantation, but not after transplantation, raises a question about the mechanism involved. In other words, is survival posttransplant purely mechanical, in that the patient has a new pump, or could denervation of the new heart ameliorate the effects of detrimental psychological traits in the high-risk group? The two groups did not differ in etiology of heart disease or severity of heart disease. The two groups were well-matched for LVEF and NYHAFC. One drawback was the study's small sample size and the fact that only one rating scale was administered. However, the numbers were sufficient for the chi-square test.
How could denervation possibly affect mortality after transplantation? The effects of the sympathetic and parasympathetic pathways have been thought to influence the genesis of arrhythmias. A hypothesis was proposed by Lane and Schwartz17 that persons with more lateralized frontal-lobe activity during emotional arousal may concomitantly generate more lateralized sympathetic input to the heart, therefore increasing the risk of fatal cardiac arrhythmias. Perhaps the patients in the high-risk group are more field-dependent and less left cerebrally dominant. Subjects that are more field-dependent have been shown to be more responsive to social forces around them.18 In pigs, bilateral ablation of pathways between the frontal lobes and the posterior hypothalamus prevented the induction of fatal arrhythmias when the pigs were exposed to stress after occlusion of the coronary arteries.19 Both parasympathetic input and sympathetic input to the heart are oblated in the transplanted heart, which may prevent the induction of arrhythmias as a result of negative emotions in high-risk patients. A behavioral viewpoint might prompt a hypothesis that the high-risk group may have been more avoidant and died rather than face the prospect of a transplant, but that if they made it to the transplant, their survival improved as their fears were surmounted. Inspection of the survival curves of both groups awaiting transplantation revealed that the curve for the low-risk group leveled off after about 5 months, whereas the curve for the high-risk group did not level off until after 8 months after listing for transplantation. This curve may suggest that the low-risk group was better at adjusting to stress or used more effective coping strategies. Another possible hypothesis was that if the high-risk group was more depressed pretransplant, the transplant relieved this factor. Yet another hypothesis was whether the lower death rate in the high-risk group after transplant was due to selection. In other words, did the high-risk patients in this group die before transplant? These hypotheses were not true. The scores did not differ for pessimism or future despair, and there was no difference in the LTRS scores between the survivors and deceased in the high-risk group who were not transplanted.
These results are similar to findings of an earlier study by Ruberman et al.,20 which demonstrated the prognostic value of psychosocial influences in mortality after myocardial infarction in the Beta-Blocker Heart Attack Trial. A psychosocial interview with 2,320 male subjects was used to classify the patients by level of social isolation and degree of life stress. Those subjects rated as having high life stress and high social isolation had four times the risk of death of men with low life stress and low social isolation during a 3-year follow-up study. Further, that study hypothesized that the men who lacked a relatively strong type A behavior pattern, which was equated with the "given up" classification, were at higher risk of mortality and that those with depression would also be at higher risk of mortality after myocardial infarction. Neither variable was found to significantly influence mortality after myocardial infarction.20
Our finding that the high-risk survivors who were transplanted rated themselves as less cooperative and scored higher on chronic tension, compared with those who did not survive to 5 years, was puzzling. Intuitively, one would surmise that cooperation would be important after a transplant. Perhaps these patients changed their coping strategies after transplant. Other researchers have found that heart transplant candidates reported using different coping styles while awaiting transplant than they did after transplantation, as scored on the Jalowiec Coping Scale.21 Before transplantation the patients used more supportive coping, reliance on others, and more fatalistic coping. Posttransplant, however, the subjects reported self-reliance as a more effective coping style than before transplantation.22 Muirhead et al. also reported that the patients relied mainly on social support to cope while awaiting transplantation.23 On the Profile of Mood States, the pretransplant subjects showed elevation on depression and fatigue.24
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Conclusions
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One-year mortality while awaiting cardiac transplantation was nearly triple for the high-risk group based on the LTRS scores. The high-risk group had a 42% mortality rate vs. an 18% mortality rate in the low-risk group. The 5-year mortality after cardiac transplantation was similar for both the high-risk (29%) and the low-risk groups (22%), perhaps due to having a new pump or from denervation of the new heart. The high-risk survivors at 5-year follow-up showed significantly less inhibition and social alienation than those who died. However, the subjects who died had both worse psychosocial and cardiac indices. Scores on cardiovascular tendency were not significant predictors of mortality for the high-risk patients. The high-risk subjects who survived 5-years posttransplant scored significantly higher on forcefulness and chronic tension and lower on cooperation. Perhaps these patients were more accustomed to stress and dealt with stress in a more positive way than the deceased, who were more avoidant and inhibited. The low-risk subjects at 5-year follow-up had nearly identical cardiac indices, but the deceased had significantly higher scores on social alienation. The cardiovascular tendency scores did show a significant association with mortality in the low-risk group. Perhaps the MBHI could be useful in identifying high-risk subjects for psychosocial interventions—improvement of social support and coping strategies—to decrease mortality before and after cardiac transplantation.
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ABSTRACT
INTRODUCTION
