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Need for Control and Cardiovascular Health

There are few epidemiological studies directly investigating whether need for control is a risk factor for heart disease or CHD risk factors. Researchers in the 1970s and 1980s had suggested this association:

“The notion that a challenged need for control or loss of control is involved in the etiology of coronary heart disease has been present in the field of cardiovascular research for many years. However, no epidemiological study has directly addressed the question of whether or not those who are in high need for control as a personality characteristic, or those who lose control over their environment, are at increased risk for myocardial infarction. Generally speaking, need for control or loss of control are only mentioned in the discussion sections of empirical papers. Rosenman, for example, makes use of the control concept in an attempt to achieve greater insight into the origins of type A behavior.” (Appels, 1989). “The Type A behavior pattern (TABP) may be a characteristic style of response to environmental stressors that threaten an individual’s sense of control over his or her environment. Thus, Type A behavior appears to be an enhanced performance to assert and maintain control over the environment whenever this control is challenged or threatened. The high drive and pace of Type A persons reflect their need for mastery over their environment.” (Rosenman, 1986). David Glass should be credited as being the first author to draw attention to loss of control as a possible determinant of myocardial infarction and sudden cardiac death. His basic assertion is that Type A individuals exert greater efforts than their Type B counterparts to control stressful events that are perceived as threats to their sense of control. These active coping attempts eventually extinguish, for without reward, the relentless striving of the Type A individual leads to frustration and psychic exhaustion, which culminates in a reduction of efforts at control (Glass, 1977). This description illustrates the notion that type A individuals who suffer from coronary heart disease(CHD) have passed through a state of frustration and exhaustion prior to myocardial infarction. Glass described this state as a “prodromal depression.” He suggested that this state is characterized by a change from initial hyper-responsiveness into subsequent hypo-responsiveness.” (Appels, 1989). “The precise role of initial hyper-responsiveness and subsequent hypo-responsiveness (helplessness) in the development of cardiovascular pathology remains unclear.”(Glass, 1977).

Appels (1989) has “hypothesized that a successful type A individual is not at increased risk for myocardial infarction but that the type A person who has lost control over his or her environment is at elevated risk. An additional hypothesis was that type A individuals are at increased risk of losing control because of their deep commitment to their vocation (both in relation to occupation and family life) makes them rather vulnerable when negative events occur in their immediate environment.” (Appels, 1989)

However, this earlier work failed to adequately describe the nature of the environment which promotes or interacts with an unhealthy level of “need for control” in producing CHD risk. In other words, why does exertion of control sometimes lead success and rewards and sometimes lead to frustration, overcommitment and failure?

Effort-Reward Model

Recent research by Johannes Siegrist and colleagues has attempted to describe the possible harmful interactions between the personality characteristic “need for control” and environmental conditions which allow little control. The “effort-reward” model of work stress, developed by Siegrist and colleagues, defines threatening job conditions as a “mismatch between high workload (high demand) and low control over long-term rewards” (Siegrist, Peter et al., 1990, p. 1128). Effort is defined as either the demands of the job (“extrinsic effort”) or the personality characteristic of “immersion” in the job (“intrinsic effort”). Low reward includes concepts such as low “esteem reward” (e.g., low social support), low income, and low “status control” (e.g., poor promotion prospects, job insecurity). In this model, high effort and low reward can each have significant main effects on risk of cardiovascular disease (CVD), and they can also interact to further increase CVD risk.

Siegrist emphasizes personal control over long-term reward since “distressing experiences often result from basic threats to the continuity of a crucial social role”, among adults, often the occupational role. This is clearly the case “with job termination or job instability. However, related conditions of low reward and low security may also be identified, such as forced occupational change, downward mobility, lack of promotion prospects, jobs held with inconsistent educational background (status inconsistency)” (Siegrist, Peter et al., 1990, p. 1128). These aspects of work life may threaten a person’s “sense of mastery, efficacy and esteem by evoking strong recurrent negative emotions of fear, anger or irritation” (Siegrist, 1996, p. 30).

Factor analysis of items measuring the psychological component of the model (the coping pattern of “need for control”) identified two relevant coping variables — “vigor”, a state of active efforts with a high probability of positive feedback, and “immersion” a state of exhaustive coping reflecting frustrated, but continued efforts and associated negative feelings. “Immersion” is considered to increase an individual’s vulnerability to experiences of high extrinsic demand and low status control.

In a prospective study of 416 German factory workers aged 25-55, status inconsistency (odds ratio (OR)=4.4), job insecurity (OR=3.4), work pressure (OR=3.4), and immersion (OR=4.5) independently predict CHD incidence after adjusting for other behavioral and somatic risk factors (Siegrist, Peter et al., 1990). The effort and reward variables have also been associated with CHD or CHD outcomes in other studies. For example, in a cross-sectional study of Stockholm area residents, effort-reward ratio >1 was associated with hypertension (OR=1.62) and cholesterol/HDL ratio (OR=1.26) among men. Among women, the association with hypertension (OR=1.56) did not reach statistical significance (Peter, Alfreddson et al., 1997). Immersion was associated with LDL cholesterol (OR=1.39) but only among women.

In developing the effort-reward model, Siegrist and colleagues have made a major contribution to our understanding of the health effects of work stress. First, they have expanded the concept of control typically used in research on the job demands-control model to include job security, respect, reward and upward mobility (promotion prospects). They emphasize control over long-term rewards, primarily the continuity of a crucial adult social role (i.e., occupation). Second, they have shown associations between their exposure measures and a wide variety of outcome measures, including coronary heart disease, coronary risk factors, cardiovascular reactivity, musculoskeletal symptoms, gastrointestinal symptoms, fatigue and sickness absence. In addition, in some studies, they were able to employ objective measures of stressors, for example, job insecurity (employment in a factory undergoing layoffs), wage level, piecework, shiftwork, and noise (Siegrist, Peter et al., 1990). However, the model and its use raise several important theoretical and methodological questions, which need to be addressed.

Does an unhealthy level of “need for control” result from socialization or

stressful experiences?

“Need for control” (and its components “vigor” and “immersion”) is considered to be “a personal characteristic which is rather stable over time” (Siegrist, Peter et al., 1990, p. 1128) in Siegrist’s model. However, it remains to be determined to what extent they are influenced by levels of work control or other job characteristics over the course of a person’s work history. For example, in a group of Swedish men aged 45-64, “immersion” was more prevalent in men with job strain (43%) than those without job strain (30%) (Peter, 1997). In the Whitehall II study, personality measures related to “immersion” (hostility, psychiatric disorder, negative affectivity, angry coping and unassertive coping) were more common among men and women with lower job control compared to those with higher job control (Bosma, Stansfeld & Marmot, 1997).

In articles about the effort-reward model, there is little discussion of this possible socialization effect. In one, Peter and Siegrist (1997, p. 1113) do offer a hypotheses about occupational factors which may promote active as opposed to passive coping (withdrawal): “the possible costs produced by disengagement (e.g., the risk of being laid off or of facing downward mobility) may outweigh the costs of accepting inadequate benefits.” In another, Siegrist (1996, p. 31) points out that “blue-collar workers with reduced opportunities of changing jobs will not minimize their effort at work even if their gain is low” because of these “costs of disengagement”. However, the “need for control” variable is typically discussed as a “stable” person characteristic (Siegrist, Peter et al., 1990; Siegrist, 1996).

Implications for prevention and treatment

Therefore, the effort-reward model relies, in part, upon a clinical psychological (individual) explanation of a phenomenon which may have a strong sociological component. This issue is not only theoretical, but also very practical — it has important implications for intervention. What will our prescription be for “immersion”, “need for control” or, for other psychological states or traits that may be predictive of CHD, such as “hostility”? The psychological approach would prescribe counseling or psychotherapy, valuable components of any treatment for stress-related illness. A sociological approach would allow us to consider preventive public health measures such as workplace redesign or legislative reforms, in addition to individual approaches, to solve the problem of unhealthy “immersion”.

Occupational socialization — influences on “need for control”

Several studies provide evidence for the process of adult socialization. For example, in a U.S. study, the substantive complexity of work (analogous to decision latitude) predicted increased intellectual flexibility, non-authoritarianism, and intellectually demanding leisure time 10 years later (Kohn & Schooler, 1982). In Sweden, workers whose jobs became more “passive” (low demand-low latitude) over six years reported less participation in political and leisure activities. In contrast, workers in jobs, which became more “active”, participated more in these activities (Karasek & Theorell, 1990, p. 53). Statistical control for current measures of job characteristics may help to solve the question of the extent of influence of work history on personality, since job characteristics often change over time (Schnall et al., 1998; Johnson et al., 1996).

A broader sociological approach to this issue would also encompass influences on personality development that precede working life. For example, parental child-rearing practices, values, and self-esteem, which are shaped by their social class and work experiences, can play an important role in shaping their children’s psychological and personality development (Sennett & Cobb, 1973; Rubin, 1975). Thus, their children’s level of “need for control”, “vigor”, “immersion”, “need for approval”, “competitiveness”, “impatience” and “hostility”, which are created, to some extent, before their children’s entry in the workforce, are not random but the result of generations of class and work (as well as race and gender) experiences. A full sociological model of work stress would need to consider such factors. Thus, research on the social determinants of personality measures believed to be associated with illness outcomes needs to be a major priority in future research.


Due to the lack of epidemiological studies directly assessing the issue of whether need for control is a risk factor for CHD, few conclusions can be drawn. Need for control has been suggested to be an important component of TABP (Please see our review of the evidence of TABP as a CHD risk factor). Type A individuals may have a higher need for control. Future research is needed to begin to determine whether TABP or unhealthy levels of “need for control” in combination with limited control over the environment leads to increased CHD risk. Lastly, more research is needed on the determinants of the need for control, such as social class and job stress.


Appels, A. (1989). Loss of control, vital exhaustion and coronary heart disease. In A. Steptoe and A. Appels (Eds.), Stress, Personal Control and Health (pp. 215-235). New York, NY: John Wiley & Sons.

Bosma H, Stansfeld SA, Marmot M. Personal characteristics and the association between work and heart disease. In: Socio-economic variations in cardiovascular disease in Europe: The impact of the work environment and lifestyle (The Heart at Work Network) (pp. 33-38). London: University College London, Department of Epidemiology and Public Health, 1997.

Glass, D.C.(1977). Behavior Patterns, Stress and Coronary Disease. Hillsdale: Lawrence Erlbaum

Johnson JV, Stewart W, Hall EM, Fredlund P, Theorell T. Long-term psychosocial work environment and cardiovascular mortality among Swedish men. Am J Public Health 1996;86:324-331.

Kohn, M.L., & Schooler, C.(1982). Job conditions and personality: A longitudinal assessment of their reciprocal effects. American J. Sociology, 87(6), 1257-1286.

Karasek RA, Theorell T. Healthy Work. New York: Basic Books, 1990.

Kohn ML, Schooler C. Job conditions and personality: A longitudinal assessment of their reciprocal effects. Am J Sociol 1982;87:1257-86.

Peter R, Siegrist J. Chronic work stress, sickness absence, and hypertension in middle managers: General or specific sociological explanation? Soc Sci Med 1997;45(7):1111-20.

Peter R. Comparative analysis of the effort-reward imbalance model and the job strain model: preliminary results from a Swedish case-control study. In: Socio-economic variations in cardiovascular disease in Europe: The impact of the work environment and lifestyle (The Heart at Work Network) (pp. 102-4). London: University College London, Department of Epidemiology and Public Health, 1997.

Peter R, Alfredsson L, Hammar N, Siegrist J, Theorell T, Westerholm P. High effort, low reward and cardiovascular risk factors in employed Swedish men and women – baseline results from the WOLF study. In: Socio-economic variations in cardiovascular disease in Europe: The impact of the work environment and lifestyle (The Heart at Work Network) (pp. 108-14). London: University College London, Department of Epidemiology and Public Health, 1997.

Rosenman, R.H.(1986). Current and past history of type A behavior pattern. In T. Schmidt, T. Dembroski, and G. Blumchen (Eds.), Biological and Psychological Factors in Cardiovascular Disease(p. 23). Berlin: Springer Verlag.

Rubin LB. Worlds of pain. New York: Basic Books, 1976.

Schnall PL, Schwartz JE, Landsbergis PA, Warren K, Pickering TG. The effect of job strain on the 3-year change in mean ambulatory blood pressure of male employees Psychosomatic Medicine (in press).

Sennett R, Cobb J. The hidden injuries of class. New York: Vintage Books, 1973.

Siegrist J, Peter R, Junge A, Cremer P, Seidel D. Low status control, high effort at work and ischemic heart disease: Prospective evidence from blue-collar men. Soc Sci Med 1990;31:1127-34.

Siegrist J. Adverse health effects of high-effort/low-reward conditions. Journal of Occupational Health Psychology 1996;1:27-41.Appels, A.(1989). Loss of control, vital exhaustion and coronary heart disease. In A. Steptoe and A. Appels(Eds.), Stress, Personal Control and Health (pp. 215-235). New York, NY: John Wiley & Sons.

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