Journal of Occupational Health Psychology Copyright 1996 by the Educational Publishing Foundation

1996, Vol. 1, No. 1,9-26 1076-8998/96/J3.00

Current Issues Relating to Psychosocial Job Strain and Cardiovascular

Disease Research
Tores Theorell Robert A. Karasek
Karolinska Hospital University of Massachusetts Lowell

The authors comment on recent reviews of cardiovascular job strain research by P. L. Schnall and
P. A. Landsbergis (1994), and by T. S. Kristensen (1995), which conclude that job strain as denned
by the demand-control model (the combination of contributions of low job decision latitudes and
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high psychological job demands) is confirmed as a risk factor for cardiovascular mortality in a
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large majority of studies. Lack of social support at work appears to further increase risk. Several
still-unresolved research questions are examined in light of recent studies: (a) methodological
issues related to use of occupational aggregate estimations and occupational career aggregate
assessments, use of standard scales for job analysis and recall bias issues in self-reporting; (b)
confounding factors and differential strengths of association by subgroups in job strain-
cardiovascular disease analyses with respect to social class, gender, and working hours; and (c)
review of results of monitoring job strain-blood pressure associations and associated methodologi-
cal issues.

The relationship between the psychosocial environ-
ment and cardiovascular illness risk has attracted
considerable attention during recent years. In modern
Western societies, this seems to be logical because
physical demands are diminishing and the increasing
complexity of a modern society increases the
demands on psychosocial interaction. In several
countries an increasing number of national federa-
tions of employers and trade unions have realized that
poor psychosocial work conditions are bad for both
the production and the health of the employees.
Another reason why the development in this field is
accelerating is that methods for monitoring physiologi-
cal changes, such as blood pressure, and endocrine-
logical processes that are consequences of a bad
psychosocial work environment have become inexpen-
sive and practically feasible. When mechanisms in
the interplay between the environment and bodily
function become known, medical professionals may
accept these relationships more willingly.
Although a comprehensive review of research on
psychosocial issues at work and cardiovascular
Tores Theorell, National Institute of Psychosocial Factors
and Health and Department of Occupational Health,
Karolinska Hospital, Stockholm, Sweden; Robert A. Karasek,
Department of Work Environment, University of Massachu-
setts Lowell.
Correspondence concerning this article should be ad-
dressed to Tores Theorell, National Institute of Psychosocial
Factors and Health, Department of Occupational Health,
Karolinska Hospital, Stockholm Box 230, Stockholm,
Sweden 17177. Electronic mail may be sent via Internet to
tores.theorell@ipm.ki.se.
illness is beyond the scope of this article, a brief
history of the demand-control model research can be
sketched. In the 1960s research on job conditions and
heart disease had begun with the exploration of
working demands and working hours (Biorck,
Blomqvist, & Sievers, 1958; Buell & Breslow, 1960;
Hinkle et al., 1968; Kasanen, Kallio, & Forsstrom,
1963; Kittel, Komitzer, & Dramaix, 1980; Kornitzer
& Kittel, 1986; Kornitzer, Kittel, Dramaix, & de
Backer, 1982a, 1982b; Russek & Zohman, 1958).
However, the sources of risk underlying these
findings remained unclear and most work on psycho-
social causes of chronic disease focused on life events
outside of work. Meanwhile, review of organizational
structural impacts of the work situation had focused
more narrowly on job dissatisfaction. In the mid
1970s, Karasek (1974, 1976) observed that both
health and behavioral effects of jobs appeared to be
the combined result of the psychological demands of
work and structural characteristics of the job relating
to the possibility of making decisions and using skills.
Particularly important were several research findings.
In the area of illness and mental strain, Seligman
(1975) had observed depression and learned helpless-
ness in conditions of intense demand with restricted
control, and Sundbom (1971) had observed symp-
toms of psychological strain in "mentally heavy
work," which actually was measured by questions
relating to heavy mental pressures and monotonous
work (presumably also representing restricted con-
trol). Behavioral outcomes appeared to be effected by
the same two broad job characteristics but in a
different
 10 THEORELL AND KARASEK
combination. Kohn and Schooler (1973) had ob-
served that active orientations to the job were the
consequence of both high skill and high autonomy
levels, plus psychologically demanding work. Meis-
ner (1971) had also found that leisure behavior was
affected by opportunities to make decisions on the job
and mentally challenging work. Simultaneously,
Csikszentmihalyi (1975) found that "active experi-
ence" (flow) resulted from situations that involved
both psychological challenges and high levels of
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competence.
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These two sets of finding were integrated to
develop a new joint model for a broad range of
psychosocial effects of working conditions. The
resulting demand-control model, predicting both
illness symptoms and leisure and political behavioral
correlates of psychosocial working conditions
(Karasek, 1974) was tested on a representative
national sample of Swedes by Karasek (1976)
working in Stockholm. This confirmed hypotheses in
both areas, mainly independent of confounding
factors, with cross-sectional data, and with somewhat
imprecise job characteristic measures.
Associations with job strain and heart disease
symptoms for the Swedish data were only an
appendix table in that first report. To follow up those
findings Karasek sought out Theorell—who had
significant background in cardiovascular epidemiol-
ogy and in occupational psychosocial stress epidemi-
ology. Theorell was also working in Stockholm and
had experience with the same database, which
enabled him to further explore the heart disease
associations with "job strain" hypothesis of the
demand-control model. Thus, this joint collaboration
of Karasek and Theorell began and led first to the
hypothesis of Swedish demand-control job strain and
then to heart disease findings (Karasek, Baker,
Marxer, Ahlbom, & Theorell, 1981).
Simultaneously, in the early and mid 1960s the
field of psychosocial factors was expanding with a
number of related concepts that substantially enriched
the research dialogue and the range of hypotheses to
be tested: Gardell's (1971) studies on work alienation
and psychosocial job conditions; person-environ-
ment fit, role ambiguity, and role conflict; as well as
empirical research showing that such concepts might
be linked to risk factors for coronary heart disease
(Katz & Kahn, 1966). However, these concepts used
primarily unidimensional models of demand (under-
load and overload; quantitative and qualitative
demands). Cardiovascular epidemiology was also
going through a transformation with respect to
implications for job risk factors as more and more
findings began to confirm that a negative association—
not the previously detected positive association—
existed between social class and coronary heart
disease (Pell & d'Alonzo, 1963). These findings and
findings with the demand-control model and stress
symptoms in the United States and Sweden (Karasek,
1979) raised the suspicion that psychosocial stress
may not be exclusively an "executive" problem for
people with a lot of responsibility but an additional
burden of the working class.
Karasek (1979), building on a large research
tradition of the 1970s (Hackman & Lawler, 1971,
Kohn & Schooler, 1973), also observed that the
possibility to use and develop skills (skill utilization),
a concept developed in work psychology, was closely
related to authority over decisions in U.S. and
Swedish national databases. In a factor analysis of
responses to questions about work content these two
factors mostly go together, and accordingly they have
been added to one another to constitute decision
latitude (Karasek, 1976, 1979; Karasek & Theorell,
1990). The other dimension, psychological job
demands, measuring mental work load and arousal
demands (but not physical demands), included
qualitative as well as quantitative demands, mental
loads, and demands of interpersonal interactions.
The original hypotheses (see Figure 1), which
included a high level of psychological demands
combined with a low level of decision latitude
(termed job strain) was predicted to increase the risk
of psychological strain and illness. However, high
levels of psychological demands combined with a
high level of decision latitude was labeled an active
job situation, which led to the "desirable stress"
outcome of increased motivation and learning oppor-
tunity. In the remaining two cells of Figure 1,
situations with low levels of psychological demands
and with high and low decision latitude, respectively,
the labels were relaxed and passive job situations.
The second hypothesis concerning learning of new
patterns of behavior and skills on the basis of
psychosocial job experience, which could accrue over
a lifetime of work experience, has been less
investigated than the job strain hypothesis. However,
epidemiological studies in Sweden have indicated
that the active job situation is associated with high
rates of participation in socially active leisure and
political activities (see Karasek & Theorell, 1990). In
our opinion, the "active-passive" dimension of the
model has been underutilized in job strain research
and needs more attention: Certainly patterns of active
coping behavior could effect the progression of
disease development.
 SPECIAL SECTION: JOB STRAIN AND CVD RESEARCH 11

Psychological Demands g
LOW HIGH X
S Learning
\ Motivation to
\ Develop
\ New Behavior
V
HIGH Low-strain Active Patterns
N >
®\ /®
Decision \ {
Latitude
(control) / \
/ \
/
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\
\.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

LOW Passive High-strain

/© ©N\ Risk of
/
f
\ Psychological Strain
and Physical Illness
\
A

Figure 1. Psychological demand-decision latitude model.

The conditions under which excessive psychologi-
cal demands interact with lack of decision latitude
over time to generate increased risk of cardiovascular
disease is further developed in the "dynamic version
of the demand-control model," which is shown in
Figure 2. Figure 2 shows the relationship between the
original demand-control model of psychosocial
environmental effects and the temporal interaction
with the individual state-trait factors that also impact
psychophysiological and behavioral outcomes. The
interaction of both current environmental situation
and past environments via impacts on current
individual psychosocial state and traits can be
examined (Karasek & Theorell, 1990). Thus, the
worker's possibility to use control over his working
situation may also influence his orientation to many
other life experiences; of course, environmental
impacts may be moderated by individual response
characteristics. According to dynamic demand-
control hypotheses, the active job situation, over a
significant period of time, is associated with the
development of a feeling of mastery that in turn
inhibits the perception of job strain during periods of
overload—thus reducing the psychophysiological
impact of stressful situations at work. The second
loop in the dynamic model predicts how, on the
contrary, daily residual strain arising from a stressful
job situation gives rise to accumulated feelings of
exhaustion, which may inhibit learning attempts by
leading to withdrawal from learning challenges
present on the job.
In this article, we briefly review epidemiological
tests of the relationship between the original demand-
control model and coronary heart disease risk, review
methodological developments related to testing of the
model (and some model expansions such as social
support), and finally review recent developments in
physiological research, in particular with blood
pressure.
Review of Epidemiological Evidence
Significant reviews of the job strain and cardiovas-
cular illness research have been recently published by
Schnall and Landsbergis (1994) and by Kristensen
(1995). We briefly summarize these findings. Schnall
and Landsbergis (1994) have noted that a large
percentage of studies have found a significant
association with job strain and cardiovascular mortal-
ity or morbidity. By augmenting the findings in the
original review with several additional studies
(Landsbergis, personal communication, September
1995), we can summarize: 16 of 22 studies have
confirmed a job strain association, including 7 of 11
cohort studies and 2 of 3 cross-sectional studies, 4 of
4 case-control studies, and 3 of 3 studies using
coronary heart disease symptom indicators. These
studies include Alfredsson (1983); Johnson and Hall
(1988); Alfredsson and Theorell (1983); La Croix
(1984); Karasek et al. (1981,1988); Schwartz, Pieper,
and Karasek (1988); Reed, La Croix, Karasek, Miller,
and McLean (1989); Moller, Kristensen, and Hollna-
gel (1991); Alterman, Shekelle, Vernon, and Burau
(1993); and Haan (1985). As noted below, the studies
have used a wide range of methodologies.
In general, studies of job strain and coronary heart
 12 THEORELL AND KARASEK
Psychological Demands
LOW HIGH
HIGH
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o
•o
in
o
o
O
LOW
Figure 2. The environment, the worker, and illness: Dynamic associations linking
environmental strain and learning to evolution of personality.
disease have shown much more consistent results
than studies of job strain and biomedical risk factors
for coronary heart disease such as serum cholesterol,
smoking, and even blood pressure when measured in
the conventional manner of large epidemiological
field studies. Schnall and Landsbergis (1994) found
no significant findings for job strain and serum
cholesterol in three studies; two studies among four
found significant findings between job strain and
smoking, and only one study of nine found significant
associations between casual blood pressure measure-
ments and job strain. However, we discuss below that
blood pressure studies using more sophisticated
ambulatory methods yielded rather consistent signifi-
cant job strain findings. Schnall and Landsbergis
(1994) also found that five out of nine studies yielded
significant findings and all nine studies showed a
positive trend. Clearly, more sophisticated physiologi-
cal research methods are needed. Also, the conven-
tional risk factor findings may simply indicate that the
Accumulated Anxiety Inhibits
Learning Attempts
Feeling of Mastery Inhibits
Strain Perception
mechanisms behind the association between job
strain and coronary heart disease is mediated through
other physiological pathways than the conventional
cardiovascular risk factors such as the psychoendo-
chrine hormone hypotheses or the system disequilib-
rium hypotheses (leading to sudden death) noted in
Karasek and Theorell (1990, chapter 3).
Only three studies, the Hawaii cardiovascular
survey (Reed et al., 1989), the Glostrup study in
Denmark (Moller et al., 1991), and the General
Electric study in the United States (Alterman et al.,
1994) showed no clear or only weak associations
between high demand-low decision latitude and
cardiovascular illness risk. All of these studies were
based on aggregated occupation scores. Furthermore,
many participants in these three studies were either
relatively old already at the start of follow-up
(approaching retirement age) or retired before the end
of the follow-up period. Studies of participants
younger than 55 years of age in general have shown
 SPECIAL SECTION: JOB STRAIN AND CVD RESEARCH
stronger associations than those including older
participants, and a large part of the participants in the
three studies have been fairly old at the end of the
follow-up. In a large proportion of the studied cases,
the participants had retired. In addition, during a long
follow-up period work conditions may change many
times.
Another observation is that the high demand-low
decision latitude has proven to be a more powerful
predictor of cardiovascular illness risk in blue-collar
than in white-collar men. For instance, a Finnish
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study (Haan, 1985) included mainly blue-collar
workers and showed a strong association. The study
by Johnson and Hall (1988) included separate
analyses of blue-collar and white-collar men that
illustrate this point. For further discussion see
Marmot and Theorell (1988).
A small, clinical 5-year follow-up study of men age
45 or younger in Stockholm who had suffered a
myocardial infarction indicated that returning to a job
perceived as psychologically demanding and with
low decision latitude may be associated with
increased risk of reinfarction death (Theorell, Perski,
Orth-Gome~r, Hamsten, & de Faire, 1991). This was
true even after adjustment for biomedical risk factors,
degree of coronary atherosclerosis, Type A behavior,
and education. If this finding can be verified in future
research it may be an indication that caregivers in
cardiac rehabilitation will have to analyze not only
physical job demands, which they have been doing,
but also psychosocial work conditions before they
send patients back to work.
True (multiplicative) interactions between psycho-
logical demands and decision latitude have been
observed only in a minority of studies (Alfredsson &
Theorell, 1983; Johnson & Hall, 1988), whereas in
the majority of studies additive interactions were
seen. However, confirmation of an interaction effect,
independent of additive effects at a strict confidence
level, can only be done on large databases or for
continuous dependent variables. There is no doubt,
however, that the use of the two dimensions together
have provided better predictions than either one of
them alone.
Discussion of Model Expansions, Confounding
Factors, and Intervention Studies
Social Support
Johnson (1989) has included social support as an
extension of the demand-control model. Social
support at work had been introduced earlier in
cardiovascular epidemiological research by other
13
researchers (e.g., House, 1981). In this area there has
recently been methodological development. By means
of a series of factor analyses Johnson, Hall, and
Theorell (1989); Johnson, Stewart, Fredlund, Hall,
and Theorell (1990); and Hall (1992), as well as
Orth-Gomer and Und6n (Ud6n, Orth-Gome'r, &
Elofsson, 1991), have developed scales for measuring
instrumental, emotional, and other basically different
kinds of social support at work. As pointed out by
Johnson, the use of the support concept is compli-
cated by the fact that collective support may provide
the individual with increased possibilities to perceive
improved control, and thus support and control may
under certain conditions be exchangeable. A preva-
lence study of cardiovascular self-reported morbidity
showed that social support at work added substan-
tially to the original demand-control model in
predictions (Johnson & Hall, 1988). The joint action
of high demands and lack of control (decision
latitude) is of particular importance to blue-collar
men, whereas the joint action of lack of control and
lack of support is more important for women and
white-collar men. The multiplicative interaction
between all the three of them (iso-strain) was tested in
a 9-year prospective study of 7,000 randomly selected
Swedish working men. Interestingly, for the most
favored 20% men (low demands, good support, good
decision latitude) the progression of cardiovascular
mortality with increasing age was slow and equally so
in the three social classes. In blue-collar workers,
however, the age progression was much steeper in the
worst iso-strain group than it was in the correspond-
ing iso-strain group in white-collar workers (Johnson
etal., 1989).
Social Class
It has been speculated that the relationship between
psychosocial work factors and cardiovascular mor-
bidity-mortality may be due to the well-known
relationship between low social class and high risk of
developing coronary heart disease (Albright,
Winkleby, Ragland, Fisher, & Symer, 1992). On the
contrary, it could also be argued that the relationship
between social class and coronary heart disease could
be due to the higher prevalence of adverse psychoso-
cial job conditions in the lower social classes. One
argument against both these hypotheses is that some
of the relevant psychosocial risk factors, in particular
psychological demands, are more common in the
upper social classes, which is quite contrary to the
expectations. Conversely, most of the relevant ones,
namely lack of decision latitude, lack of social
support, lack of social reward, and shift work, are all
 14 THEORELL AND KARASEK
indeed more common in the lower classes. Therefore
we would expect, on balance, that psychosocial work
factors would contribute to the association between
low social class and cardiovascular risk. The efforts
that had been made to analyze this empirically by
means of confounding analysis have indeed verified
that some of the variance in cardiovascular illness risk
between social classes can be explained by means of
psychosocial job conditions (Marmot & Theorell,
1988). It should be emphasized, however, that social
class does not seem to explain away all of the
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associations between psychosocial work conditions
and coronary heart disease risk (see Karasek &
Theorell, 1990). Our emphasis on work organization
is related to our conviction that work organization
could be changed, whereas social class is not in itself
changeable.
Effort-Reward Model as a Variation
A model related to the demand-control model, but
with a more macro-occupational sociological focus,
has been developed and tested by Siegrist and his
colleagues (Siegrist & Peter, 1992; Siegrist, Peter,
Junge, Cremer, & Seidel, 1990; Siegist, Siegrist, &
Weber, 1986). Their model uses "effort" and "social
reward" as the crucial dimensions, the hypothesis to
be tested being that high effort without social reward
is pathogenic. The social reward dimension has
elements both of decision latitude and of social
support. In a recently published study of industry
workers, (Siegrist et al., 1990), it was shown that
combinations of high effort and lack of reward
predicted increased myocardial infarction risk indepen-
dently of biomedical risk factors. The relative risk
was in the order of 4:1. Studies have also been made
on middle managers, with similar results. This model
should be used as a supplement to the demand-
control model in future studies.
The demand-control model and the Siegrist
"effort-reward imbalance model" can be compared.
Overlaps exist when occupational career is conceived
of as status promotions yielding both control changes
and income changes. However, the demand-control
model's prediction of a second set of negative
outcomes—passivity in addition to strain—differenti-
ates it from the imbalance model in two ways: (a) at a
microlevel, the demand-control model reflects physi-
ological differentions between independent mecha-
nisms of physiological activation and protection
under duress and between active relaxation and
inactivity; (b) at a macrolevel, the dual predictions of
the demand-control model emphasize the necessity
of going beyond a unidimensional "cost-benefit"
model structure to describe the occupational system's
health effects (simplistically stated, lack of control is
a problem independent of its possible low-income
consequences).
Working Hours
Another important area in work organization that
has been studied during the past two decades is
working hours. Although previously no relationship
was believed to exist between exposure to shift work
and risk of myocardial infarction, several new studies
support the hypothesis that there is a relationship. For
example, a study of a cohort of paper-pulp factory
workers in northern Sweden showed that there was
such a relationship that became successively stronger
with longer duration of exposure—up to 20 years of
exposure when the relationship was attenuated and
even reversed (Knutsson, Akerstedt, Jonsson, &
Orth-Gom6r, 1986). The authors speculated that the
attenuated effect after the longest exposure periods
could be a selection effect—only the most healthy
workers remained until the end. Aggregated studies of
typical shift work occupations have also shown
increased myocardial infarction risk compared with
other occupations (Akerstedt, Alfredsson, & Theorell,
1987). There have been speculations regarding
mechanisms underlying these relationships. Both
direct (catecholamines) and indirect mechanisms—
via, for instance, unhealthy diet during night work
hours—have been discussed (Lennernas, 1993).
There is also an indication that improved shift work
schedules may be associated with improved cardiovas-
cular risk profiles (Orth-Gomdr, 1983). Long working
hours have also been studied. The classical study by
Hinkle and coworkers (Hinkle et al., 1968) at the Bell
Telephone Company indicated that men who worked
full time and also went to night college had an
increased age-adjusted cardiovascular death risk.
Gender
It has been pointed out in several recent studies that
men and women have different combinations of
adverse work and home circumstances. Predictions of
health using information about work, conditions only
seem to be more successful for men than for women.
Among women the total psychological load in the
home situation seems to interact more with the
working situation in generating illness symptoms
than among men (Hall, 1989, 1992), and accordingly
information about the home situation is needed in
studies of work and health in women. This could
 SPECIAL SECTION: JOB STRAIN AND CVD RESEARCH
make it more difficult to establish an association
between cardiovascular illness and job strain in
women than in men. Conversely, women report more
symptoms, both psychological and psychosomatic
ones, than men in population studies (Theorell, 1991).
This could be of significance in various ways to our
studies of job strain. For instance, we could speculate
that women are more honest than men in describing
work conditions—men tend to deny difficulties more
frequently than women—although further research
would be needed to confirm this. If this were the case,
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it would be more easy to establish an association
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between job strain and blood pressure in women than
in men.
The age factor may also be important with relation
to gender. Karasek (1990) and Karasek, Gardell, and
Lindak (1987), in a study of men and women in
white-collar occupations, found that overtime work
was associated with symptom reporting in women
above age 40 in the same way as in men. In women
below age 40, the pattern was strikingly different.
Gender and Working Hours Interactions
The study of working men and women in five
counties in Sweden provided an analysis of the 1-year
incidence of hospitalization for myocardial infarction
(Alfredsson, Spetz, & Theorell, 1985). The results
indicated a pronounced difference between men and
women. Men in occupations classified as "overtime
occupations" in the national surveys had a lower
age-adjusted hospitalization incidence than other
working men, even after adjustment for a number of
possible social confounders. For women the opposite
was true; "overtime work" occupations had higher
hospitalization incidence than others. An overtime
occupation was defined as an occupation in which at
least 10 hours of overtime work per week was
frequently (occupations with above median fre-
quency) reported. We emphasize that this is a
relatively modest cutoff point. The level of overtime
work in the study by Hinkle et al. (1968), for instance,
is much higher. The gender difference is most likely
due to the double role of women. Because women in
Sweden as well as in other countries have more
responsibility for home and children, it is more
difficult for them to handle overtime work. The
interactive effects between home work and paid work
on psychosomatic symptoms are more pronounced
for women than for men (Hall, 1992). Another
possible explanation may have to do with the fact that
men perceive that they have a higher level of skill
utilization and authority over decisions than do
women (Hall, 1989). Accordingly, overtime work
15
could be less rewarding for women than for men.
Correspondingly, a modest level of overtime work for
a man is more frequently associated with stimulating
work.
Studies in this area are difficult to interpret,
however, and it should be pointed out that the most
recent study (Hammar, Alfredsson, & Theorell, 1994)
did not confirm this differential effect of long working
hours on women and men, respectively. Again, the
crucial concept may be "possibility to control."
Overtime work that is forced on the individual and
very excessive overtime work that may entail
increasing numbers of unpredictable conflicts and
complications do have in common the effect that the
individual has few possibilities to take control.
Experiments With Increased Possibilities for
Workers to Control Their Own Job Situation
Relatively few studies have evaluated the effects of
work organization changes strictly compatible with
the demand-control model (see Karasek, 1990).
However, from a broad psychosocial perspective, a
large number of studies is indeed accumulating.
Nineteen such studies of job redesign to reduce
psychosocial stress organized by the International
Labor Office with 90% having some significant form
of success, are reviewed by Karasek (1992). A strict
evaluation is difficult because attention to individual
risk factors and individual counseling concerning
them has turned out to be a necessary motivational
factor in work organization change processes (Theo-
rell, 1992). In line with the quality of working life
research, the changes that have been tried were
focusing on improved social support and increasing
decision latitude. One example was to increase the
number of structured staff meetings, which enabled
increased social support as well as improved democ-
racy in decision making in the work site. Few studies
have tried such changes and evaluated them in
relation to cardiovascular disease. One example is
from a Swedish study (Orth-Gome'r, Eriksson, Moser,
Theorell, & Fredlund, 1994) that administered a
program of individual counseling as well as explora-
tion of the work organization and subsequent
initiation of changes differently in four work sites. In
one work site (active), the employees were more used
to organizational work and the supervisors were more
inclined to be actively engaged in such work. In the
other work sites (passive), the employees were less
prepared for organizational changes and the supervi-
sors were not interested. Plasma cortisol levels
developed differently in these groups. In both groups,
 16 THEORELL AND KARASEK
there was a tendency for the cortisol levels to increase
initially during the process, but subsequently they
diminished in the active group and increased in the
passive group. There was also a tendency for plasma
testosterone levels to rise more in the active group
(particularly in women) than in the passive group, and
this increase was still observed at the time of
follow-up 4 months later (Theorell, Orth-Gomer,
Und6n, Eriksson, & Moser, 1995).
A control group did not go through an intervention
program. The comparison between the total experi-
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ment group and the control group showed that an
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improved lipoprotein pattern was found in the
experimental work sites but not in the control work
sites (Orth-Gome'r et al., 1994). More research of this
kind is needed in which quasi experiments with
before and after observations may be the most
realistic alternative. Psychological as well as physi-
ological observations will be necessary.
Methodological Issues in the Study of Job
Strain and Cardiovascular Disease Associations
The methodology of the epidemiological studies
above has varied considerably. In general, some of the
methodologies have focused on the individual's
perception or description of control, whereas others
have been oriented toward the group's perception or
description. The most important distinction is that
some studies were using the patients' own descrip-
tions of their work situations, whereas other studies
have used aggregated job descriptive data based on
representative workers in the occupations in the
population. Both methods have advantages and
disadvantages. However, individual traits may be
associated with systematically distorted work descrip-
tions, and this systematic distortion may be related to
illness risk, with both overestimation and underestima-
tion as possible results. A recent study (Landsbergis,
Schnall, Dietz, Friedman, & Pickering, 1992) showed
that the risk of individual distortion caused by
"negative affectivity" may not be a problem.
Methodological advantages of aggregated job descrip-
tions are discussed below.
Occupational Aggregate Scoring Systems
One advantage with the use of aggregated data is
that it gives an opportunity to avoid individual
distortion (although of course collective distortion
may still take place; Karasek, Schwartz, & Theorell,
1982). One disadvantage is that some of the true
variations are eliminated. This may lead to underesti-
mation of true associations (Alfredsson, 1983). The
underestimation problem in the use of aggregated
data is probably more pronounced in estimating the
importance of psychological demands because this
variable shows most of its variance within occupa-
tions. Decision latitude, however, shows considerable
variance—in fact more variance than income—
between occupations (Karasek & Theorell, 1990).
Even the aggregation methodology has varied
across studies. In some studies, the classifications
have been based on combined measures (two or more
questions) of each one of the three dimensions of
psychological demands, decision latitude, and social
support (Johnson et al., 1990; Schwartz, Pieper, &
Karasek, 1988). In other studies, single questions
have been used to represent the dimensions and
several combinations of questions (e.g., demand-skill
utilization and skill-authority over decisions) have
been tested, in regard to hectic-monotonous and
hectic-nonlearning types of work.
Findings With Occupational Aggregate Studies
Schnall and Landsbergis (1994, augmented as
above) reported that 7 of 11 studies that used a data
linkage methodology based on occupational aggre-
gate scores found significant job strain associations.
An example of the latter type of aggregated study is
the following (Hammar et al., 1994): A large number
of cases of myocardial infarction were identified by
means of the nationwide Swedish death register and
by means of county registers including hospitaliza-
tions. Controls stratified with regard to gender, age,
and geographical area were selected randomly from
the population. Analyses were confined to "occupa-
tionally stable" participants who stayed in the same
occupation during the two most recent censuses
(which were 5 years apart) and to those who had a
first myocardial infarction (in contrast to subsequent
infarctions). The results were typical for this kind of
study, with stronger age-adjusted relative risks among
the younger men (see Table 1). The expected pattern
with the strongest relative risk in the strain quadrant
was observed. The results for women were not as
clearly in line with the job strain hypothesis, and we
point out that the job strain hypothesis has been less
well documented for women than for men.
The summary of relative risks indicates, as
expected, that studies using self-reported work
descriptions have shown higher relative risks (2.0-
4.0:1 vs. 1.3-2.0:1). Demands have been shown to be
relatively more important in studies using self-
reported data than in studies using aggregated data.
Some of the studies have covered other risk factors. In
 SPECIAL SECTION: JOB STRAIN AND CVD RESEARCH 17

Table 1
Relative Risk (RR) With 95% Confidence Interval (CI) of a First Myocardial Infarction for Participants Who
Did Not Change Type of Occupation Between 1970 and 1975 in Different Types of Occupations
Type of occupation"
6
Low strain Active Passive High strain
Hectic work
combined with: Rc 95% CI RRC 95% CI RRC 95% CI RRC 95% CI
Men 30-64 years
Monotony 1.0 — 1.0 0.9-1.0 1.2 1.1-1.3 1.2 1.1-1.4
Few possibilities to learn
new things 1.0 — 1.0 0.9-1.1 1.2 1.1-1.3 1.3 1.2-1.5
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Low influence on planning

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of work 1.0 — 1.0 0.9-1.2 1.2 1.1-1.3 1.3 1.2-1.5

Low influence on work
tempo 1.0 — 1.0 0.9-1.1 1.2 1.1-1.3 1.2 1.1-1.3
Low influence on working
hours 1.0 — 1.0 0.9-1.1 1.2 1.1-1.3 1.3 1.2-1.5
Men 30-54 years
Monotony 1.0 — 0.9 0.8-1.1 1.1 1.0-1.4 1.2 1.0-1.5
Few possibilities to learn
new things 1.0 — 1.0 0.8-1.2 1.3 1.1-1.6 1.4 1.2-1.7
Low influence on planning
of work 1.0 — 1.1 0.9-1.3 1.3 1.0-1.6 1.6 1.2-2.0
Low influence on work
tempo 1.0 — 1.0 0.8-1.2 1.1 0.9-1.4 1.2 1.0-1.5
Low influence on working
hours 1.0 — 1.1 0.9-1.3 1.1 0.9-1.7 1.5 1.2-1.8
Women 30-64 years
Monotony 1.0 — 1.4 1.0-2.0 1.3 1.0-1.8 1.4 1.0-1.9
Few possibilities to learn
new things 1.0 — 1.2 0.9-1.5 1.4 1.1-1.8 1.3 1.1-1.6
Low influence on planning
of work 1.0 — 1.0 0.7-1.4 1.2 1.0-1.6 1.3 1.1-1.6
Low influence on work
tempo 1.0 — 1.1 0.8-1.6 0.9 0.5-1.5 1.1 1.0-1.3
Low influence on working
hours 1.0 — 1.1 0.8-1.5 1.1 0.8-1.5 1.2 1.0-1.4
Note. Dashes indicate data not available. From "Job Characteristics and Incidence of Myocardial Infarction," by N.
Hammar, L. Alfredsson, & T. Theorell, 1994, International Journal of Epidemiology, 28, p. 281. Copyright 1994 by Oxford
University Press. Reprinted with permission.
The basis for classification of type of occupation was as follows. The job was above or below median in the proportion
reporting low strain: below for hectic work and above for decision latitude; active: above for hectic work and for decision
latitude; passive: below for hectic work and for decision latitude; high strain: above for hectic work and below for decision
latitude.
""Reference category.
'Relative risk adjusted for age, county, and calendar year.

general, the adjustment for standard risk factors for
cardiovascular disease does not eliminate the associa-
tion between the high demand-low decision latitude
combination and cardiovascular disease risk. In one
case, the Framingham study (La Croix, 1984), the
adjustment for other risk factors strengthened the
association. Caution should be issued in controlling
for biomedical risk factors. For instance, because job
strain may affect blood pressure, controlling for blood
pressure may be an example of overcontrol. Similar
arguments could be used with regard to smoking.
A general problem that has been discussed by
Karasek and Theorell (1990) is that participants select
themselves out of job strain occupations. Therefore,
an underestimation of the true risk associated with job
strain may arise.
Occupational Careers
Attempts are now being made to use the occupa-
tional classification systems to describe the psychoso-
cial work career. Researchers (House, Stretcher,
Metzner, & Robbins, 1986) have pointed out that an
estimate of work conditions at one point of time may
 18 THEORELL AND KARASEK
provide only a very imprecise estimation of the total
exposure to adverse conditions. Descriptions of all
the occupations during the whole work career are
obtained for the participants. Occupational scores are
subsequently used for a calculation of the "total
lifetime exposure." The "total job control exposure"
in relation to 9-year age-adjusted cardiovascular
mortality in working Swedes was studied. It was
observed for both men and women that the cardiovas-
cular mortality differences between the lowest and
highest quartiles were twofold (Johnson, Hall,
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Stewart, & Theorell, 1991) even after adjustment for
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age, smoking habits, and physical exercise. A case
referent study in Stockholm (Johnson et al., 1990)
indicated that the occupationally inferred decision
latitude scores in middle aged men who have suffered
a recent myocardial infarction tend to decrease during
the 3 years preceding the myocardial infarction and to
increase during the same period in the matched male
referents, with a resulting significant difference in the
development of decision latitude (Theorell et al.,
1994). This finding is presently being further
explored in relation to subgroups of the total
population of myocardial infarction patients in the
greater Stockholm area (the SHEEP [Stockholm
Heart Epidemiology] study)—in relation to gender,
social group, and illness preceding the myocardial
infarction.
A Special Case of Occupational Studies:
Inner-City Bus Drivers, Specifying Within an
Occupation, What Low Decision
Latitude Means
Previously, we have been discussing psychosocial
work conditions in general terms. Several practi-
tioners have been asking what these general factors
mean when they are translated to a real-life situation.
One area that has developed more specifically than
other research endeavors in this field is the study of
inner-city bus drivers. There is now overwhelming
evidence that bus drivers, particularly those driving in
inner-city areas, have an excess risk of developing
myocardial infarction (Alfredsson, Hammar, & Hog-
stedt, 1993; Belkic, Savic, et al., 1992; Rosengren,
Anderson, & Wilhelmsen, 1991) at an early age
compared with other workers. Possible reasons for
this excess risk have been explored. It has been shown
that standard risk factors cannot explain all of it
(Rosengren et al., 1991). It has previously been
suspected that exposure to carbon monoxide may be
of importance but at present this seems most unlikely
(Kristensen, 1989). Other lexicological exposure may
be of importance, for instance combustion products
(Gustavsson, 1989). However, it has been empha-
sized in recent research that job strain may be a very
important factor (Hedberg, Jacobsson, Janlert, &
Langendoen, 1991) and some physiological conse-
quences of job strain in bus drivers have been
explored. Catecholamines (Evans & Carrere, 1991)
have been shown to be elevated in bus drivers when
job strain increases. However, more specific hypoth-
eses have also been developed. Belkic and colleagues
(e.g., Belkic, Ercegovac, et al., 1992) have found that
bus drivers seem to develop more rapidly than others
an aroused electrophysiological response to "the
glare pressor test," particularly when instructions
simulate a traffic situation. It is possible that
professional drivers have an accumulated experience
of dangerous situations associated with sudden glares
particularly at night and that this may be a potent
factor explaining why bus drivers develop an excess
risk for myocardical infarction after some years of
driving: Drivers become constantly hyperalert during
driving and this may be of importance to several of
the risk factors. Accordingly, it seems important to
diminish the number of driving hours and to try to
improve external conditions for bus driving, for
example, by creating special bus routes, by educating
pedestrians, and by reinventing the conductor's job
(because conductors are taking away some of the
stressors from the bus drivers'job).
Methodological Aspects of the Self-Reported
Measurements
We make a few notes on psychometric properties
of some of the demand-control support measures
because they may be of more general interest in the
field of psychosocial methodology. Although in
general decision authority and skill discretion are
highly correlated in most occupations (which together
constitute the decision latitude scale; Karasek &
Theorell, 1990), these correlations can show substan-
tial differences across occupational groups (Theorell,
Michelsen, & Nordemar, 1993). Furthermore, analy-
ses of internal consistency show that Cronbach alpha
coefficients are high when mixed working popula-
tions are studied but are considerably lower when
homogenous occupation groups are studied, for
instance in health care (Theorell, Ahlberg-Hulteii,
Jodko, Sigala, & Soderholm, 1992). One possible
reason for this may be that decision latitude is
determined to a great extent by the content of work in
the occupation, whereas demands and social support
reflect to a greater extent local work site conditions
and individual perception.
 SPECIAL SECTION: JOB STRAIN AND CVD RESEARCH
Questionnaire Instruments for Measuring the
Demand-Control Model
Several different forms of the demand-control
support questionnaires are have been used in past
studies, and currently two are widely used. The first
and most widely used, the Job Content Questionnaire
(Karasek, 1985), is an expansion of Karasek's (1979)
original questionnaire, which has a core of nationally
standardizable questions from the U.S. Quality of
Employment Surveys studies. This instrument has
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been tested extensively and has been used particularly
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in the United States but also in several countries in
Europe and in Japan. It has been translated into nine
languages and is currently being used for a 65,000-
participant study of cardiovascular illness and absen-
teeism in six European countries. The decision
latitude scale is based on a larger number of questions
than the original one; in addition, other scales have
been included such as the social support scale, the
physical demands scale, and the personal insecurity
scale. The second questionnaire has been used mainly
in Sweden. It is shorter and does not have as many
dimensions as the American one. It also uses only
four response categories for each question and a
frequency-based rather than intensity-based grading,
which many participants perceive as more adequate.
The Swedish version has five questions dealing with
(mainly quantitative) psychological demands and six
questions dealing with decision latitude (four about
intellectual discretion and two about authority over
decisions). The American questionnaire is more
established in epidemiological studies, but the
Swedish version has also been used in many studies.
Recall Bias
Recall bias is a tendency in patients who have
suffered a myocardial infarction to remember selec-
tively. This may in turn introduce bias in the sense
that these patients only remember factors that they
believe are important. This source of error is a
potentially important problem in case-referent stud-
ies. Its importance is indirectly studied in the ongoing
case-referent study in Stockholm (Theorell et al.,
1994): A direct comparison between inferred psycho-
social job conditions (based on the attribution system;
Johnson et al., 1990) and self-reported job conditions
showed that the same expected linear relationship
existed on the group level between inferred and
self-reported decision latitude for both men and
women and for both the patient and the referent
group. For psychological demands, the expected
relationships existed for the male and female referent
19
groups but not for male myocardial infarction
patients; male patients with high demands according
to the classification self-reported lower mean levels
than expected, and those with low classified demands
self-reported higher mean demands than expected.
These findings are presently being explored in more
detail, but if they can be verified they may indicate
that there may be more recall bias for psychological
demands in male patients who have recently suffered
a myocardial infarction than for the other studied
groups. For decision latitude, however, these findings
indicate that recall bias may not be a significant
problem.
Methodological Observations With Job
Strain and Blood Pressure and Other
Physiological Indicators
The physiological basis for the associations be-
tween psychosocial factors and coronary heart
disease has been a lively research field during the past
two decades. Catecholamines have been suspected of
mediating some of the relationship, and during the
period it has become possible not only to study
urinary excretion (which is still a good way of
collecting data on sympathoadrenal activity during
integrated periods of time) but also to study the small
concentrations that exist during rest in venous
plasma. A study by Knox, Theorell, Svensson, and
Waller (1985) has shown that poor social network and
support as well as a job "classified" as boring all
contribute to an elevated venous plasma adrenaline at
rest in the 28-year-old men studied. On the whole,
however, the main endeavor has been the study of
urinary catecholamine excretion (Frankenhaeuser &
Johansson, 1986). Recently, epidemiological studies
have shown a correlation between poor social
network and high urinary excretion of catecholamines
(Eide, 1982) and also between poor decision latitude
and high catecholamine excretion (Harenstam &
Theorell, 1988). Conversely, it has also been found
that sympathoadrenal reactions in different organs
may be specific and generalizations should accord-
ingly not be made in all instances (Hjemdahl et al.,
1989).
The possibilities to monitor physiological func-
tions continuously have induced a revolution in the
field of cardiovascular research. For instance, because
we can now study heart rate and blood pressure
during activity and sleep we have started to explore
how psychosocial factors relate to development of
coronary atherosclerosis, for instance. The lowest
recorded heart rate during sleep in an individual was
 20 THEORELL AND KARASEK
shown to be correlated with degree and progression of
coronary atherosclerosis (Perski, Hamsten, Lindvall,
& Theorell, 1989; Perski et al., 1992). It could be that
inability to relax is associated with a high heart rate
during sleep as well as with progression of coronary
atherosclerosis. Similarly, Und6n, Orth-Gomer, and
Elofsson (1991) have shown that poor social support
at work is associated with a high heart rate throughout
the day and night. The interpretations of these
associations are not clear, but it is possible that
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feelings of loneliness may activate the sympathoadre-
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nal system.
Coagulation: A Crucial Research Field
A growing field that relates to catecholamines is
coagulation. For instance, a boring job (or job strain)
has been related to high plasma fibrinogen levels
(Markowe et al., 1985), and recently lack of reward
was shown to be associated with high plasma
fibrinogen levels among middle managers (Siegrist &
Peter, 1992). The complex relationship between a
boring job, a low social class, and fibrinogen levels
has been discussed (Moller & Kristensen, 1991). The
question that arises could be formulated in the
following way: Is there a relationship between
boredom and atherosclerosis? Certainly the common
themes in lack of social support in life in general and
lack of possibilities to learn and to influence decisions
at work may be boredom and lack of reward. In a
recent study no relationship was found between job
strain and coagulation factors (Eliasson, 1995).
Blood Pressure: A Special Example
A relatively large number of studies have been
performed on the relationship between blood pressure
on one hand and psychological demands and decision
latitude on the other hand. Thus, we place special
emphasis on this topic in the following discussion. In
general, studies on blood pressure during activity at
work have shown a significant relationship to job
strain—and in this case the combination of high
demands and low decision latitude seems to be of
particular relevance. Blood pressure measured in the
conventional way has not shown a consistent
relationship with job strain, however. We offer a more
detailed description of some of the empirical findings
in order to give the reader an idea of the methodologi-
cal problems that are encountered in this special field.
Empirical Studies of Blood Pressure
and Job Strain
A study (Theorell, Knox, Svensson, & Waller,
1985) on young men in Stockholm who had gone
through the compulsory medical screening for
military service at the age of 18 comprised a
follow-up 10 years later. These men were divided into
two groups: those who had had a high blood pressure
recording (measured conventionally) at the screening
occasion and those who had had low or normal blood
pressure on the screening occasion. Working condi-
tions were recorded by means of a job classification
system. All participants working in a given occupa-
tion received the same scores for hectic tempo and
monotony (an index of low decision latitude). Thus,
the exposure measures were crude and not distorted
by individual characteristics. The participants were
instructed to make self-triggered measurements of
their own blood pressure approximately once every
hour during a normal working day, both during
working hours and during leisure hours. The results
showed that systolic (but not diastolic) blood pressure
was high during working hours in participants with
high-strain occupations (high tempo and high mo-
notony) who had high blood pressure at the screening
occasion 10 years earlier. There were no significant
findings for diastolic blood pressure, none for leisure
hours, and none for participants in nonstrain occupa-
tions. The methodology for exposure measurement
was crude but unbiased, and the blood pressure
measurements may not have been optimal because
self-triggered measurements were used. None of the
men were stigmatized by a long-lasting hypertension
diagnosis; the blood pressure elevation may not have
lasted long enough to produce a continuously
elevated blood pressure.
The next study (Theorell et al., 1988) was
longitudinal. In this case 58 men and women in six
different occupations were followed on four occa-
sions during a year. They were instructed to measure
their own blood pressure once every hour during 4
working days corresponding to these occasions.
Furthermore, they filled out self-administered ques-
tionnaires regarding psychological demands and
decision latitude on these same occasions. The ratio
between demands and decision latitude was used as
an indicator of job strain. The results showed that the
mean systolic blood pressure during working hours
increased significantly and progressively with increas-
ing job strain and that this increase was more
pronounced for participants with a positive family
history of hypertension than for others. No significant
 SPECIAL SECTION: JOB STRAIN AND CVD RESEARCH
findings were made for leisure hours. A longitudinal
study of this kind is a solution to some of the
methodological problems. For instance, although
different individuals may have different levels of
perceived problems, the variations across time should
be associated with blood pressure variations in the
predicted way if the hypothesis is correct. Both in the
first and the second studies, self-monitored blood
pressure measurements were used. These have been
shown to be well correlated with conventionally
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measured blood pressure readings performed in close
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conjunction with them, and Theorell et al. (1992)
have also shown a good agreement with mean levels
obtained from fully automated measurements in close
conjunction with them. At least this is true for systolic
blood pressure; however, the measurements of
diastolic blood pressure seem to less reliable.
In the longitudinal study, the blood concentration
of one hormone indicating anabolic activity, testoster-
one, was studied in relation to individual changes in
job strain. It was shown that testosterone concentra-
tion decreased as job strain increased and vice versa.
This may indicate one other potentially important
research area in the future: If the health promoting
anabolism is stimulated by decreasing job strain, a
general vulnerability factor may decrease (Theorell,
Karasek, & Eneroth 1990).
One study (Theorell, de Faire, et al., 1991) was
based on men participating in a blood pressure
screening study. The participants lacked medication
and symptoms of high blood pressure, but all of them
had a recorded borderline hypertension in the
screening. In this case fully automated blood pressure
measurements were performed. A job classification
system based on occupation was used. The results
showed that the diastolic blood pressure was higher
during sleep as well as work hours and leisure hours
in participants with job strain occupations than in
other participants, and this relationship showed a
dose-response relationship. The findings were signifi-
cant only for sleep and work hours, not leisure hours.
Both for sleep and work hours the findings became
more significant after participants in physically
demanding occupations had been excluded, and they
remained significant after adjustment for body mass
index and age. No significant relationships were
found between job strain and systolic blood pressure
in this study.
A study of women (Theorell, Ahlberg-Hulte'n,
Jodko, Sigala, & de la Torre, 1993) was performed on
health care personnel who were asked to measure
their own blood pressure once an hour during an
ordinary working day. They were also asked to fill out
21
once an hour a checklist regarding emotional states as
well as a self-administered questionnaire regarding
psychological demands, decision latitude, and social
support at work. The results showed significant
relationships between job strain and mean systolic as
well as mean diastolic blood pressure during working
hours. These findings were still significant after
adjustment for age, education, body mass index, and
emotional states (joyful states were associated with
lowered blood pressure). A corresponding result (still
significant after adjustment) was found for systolic
blood pressure at rest but not for diastolic blood
pressure. No associations at all were found between
job strain and blood pressure during leisure hours.
In all of the studies that have been referred to there
have been few significant findings between psycho-
logical demands (as a single factor) and blood
pressure and no significant findings between decision
latitude (as a single factor) and blood pressure. The
consistent finding has been that the combination of
high psychological demands and low decision lati-
tude has been important. This is consistent with the
findings of Schnall, Schwartz, Landsbergis, Warren,
& Pickering (1992).
The most extensive study of job strain in relation to
ambulatory blood pressure in men has been the study
of Schnall et al. (1990) in New York. After screening
2,556 employed men at several work sites in New
York, 87 cases of hypertension and 128 controls were
studied. In a multiple logistic regression model,
self-reported job strain was significantly related to
hypertension, with an estimated odds ratio of 3.1:1,
after adjusting for age, race, body mass index, Type A
behavior, alcohol intake, smoking, work site, 24-hour
urine sodium excretion, education, and physical
demand. Controlling for the same variables, it was
furthermore shown that in participants 30 to 40 years
of age (but not in older participants) with job strain,
the heart muscle was thicker than in participants
without job strain in the same age group. Studies of
heart muscle thickness, which can be performed with
simple noninvasive methods, could be a very
important contribution to mechanism studies in this
field.
The New York study showed that the most stable
estimates of the effects of job strain are found when
job strain is operationalized in such a way that
approximately 30% of the study's participants are
defined as having job strain (Landsbergis, Schnall,
Warren, Pickering, & Schwartz, 1994). A more
detailed summary of the findings in these studies has
been presented by Schnall and Landsbergis (1994).
It is interesting that similar findings have been
 22 THEORELL AND KARASEK
made across the studies despite differences in gender,
blood pressure level (all participants in one sample
had borderline hypertension), and measurement
technique (although the self-triggered measurements
were less successful in establishing relationships with
diastolic blood pressure than the fully automated
technique). In most studies the finding has been that
job strain correlates more with blood pressure levels
during working hours than during other activities.
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Degree of Awareness of Blood Pressure
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Disorder in Studied Participants
An interesting and important aspect of blood
pressure as outcome in epidemiological studies is that
elevated blood pressure is mostly asymptomatic. At
least in early stages of development there is no
specific symptom associated with elevated blood
pressure, and therefore blood pressure variations may
reflect direct psychophysiological reactions. Accord-
ingly, this relatively easily available physiological
marker has been considered to be of particular
importance to this area.
There is considerable difference between partici-
pants who know that they have an elevated blood
pressure, particularly if they have symptoms and
medication associated with this, and participants who
have an asymptomatic blood pressure elevation. High
blood pressure without symptoms has been recorded
in participants with few life events during the recent
past year (Theorell, Svensson, Knox, Waller, &
Alvarez, 1986). It has been speculated that these
individuals suffer from a hampered ability to describe
emotions (Isaksson, Konarski, & Theorell, 1992;
Knox, Svensson, Waller, & Theorell, 1988). Such a
lack of ability to describe emotions may be part of a
general tendency of underreporting adverse life
conditions including those conditions at work (Theo-
rell, 1990a). Awareness of high blood pressure,
however, may be associated with overreporting
adverse conditions; persons in the daily environment
are always telling the patients to be careful with blood
pressure, and this affects the patient's attitude to and
description of external conditions (Rostrup & Eke-
berg, 1992). A classical observation of relevance to
this phenomenon is that patients who become aware
of their high blood pressure have higher sick leave
rates than they had before they knew about it
(Haynes, Sackett, Taylor, Gibson, & Johnsen, 1978).
One way of avoiding this problem in epidemiological
studies is to analyse participants who take hyperten-
sion medication (who are more aware of their blood
pressure level than other hypertensive participants)
separately from the study sample. Schnall et al.
(1990), however, did not find that participants on
hypertensive medication differed with regard to Type
A behavior, symptom reporting, or anxiety from those
not taking medication.
Further Notes on Social Support at Work
It has been shown that continuously monitored
heart rate is associated with job social support—the
poorer support the higher the heart rate (Unde'n et al.,
1991). One study (Theorell, 1990b) has shown that
spontaneous variations in social support at work are
associated with variations in mean systolic blood
pressure during a working day. During periods of
poor support the systolic blood pressure is higher, and
vice versa. This observation was based on working
men and women in six occupations who were
observed on 4 different days 3 to 4 months apart.
Blood pressure was measured once every hour on
each of these days (Theorell, 1990b).
Family History of Hypertension
Studies have shown that participants with a family
history of hypertension are more reactive to stressors
in the environment long before any hypertension has
developed. It has also been shown that this reactivity
is associated with a tendency of such participants to
underreport problems in life (Jorgensen & Houston,
1986). This may have a great significance to the kinds
of studies we are discussing because exactly those
participants who react more vigorously to the
environment also tend to underreport problems in the
working environment. Thus, a large proportion of
(nonhypertensive) participants with a family history
of hypertension may bias the findings toward
negative findings (Jorgensen & Houston, 1986).
Occupational Groups and the Study of Blood
Pressure
First of all, it is important to consider the amount of
variance in job strain and its components that exist in
the study sample. If a sample is studied that is very
homogenous with regard to work content, there may
indeed be very little possibility to show any
relationship between job strain and blood pressure.
Furthermore, different occupational groups may
differ with regard to verbal insight into their own
psychosocial job situation. For instance, bus drivers
may not have analyzed their psychosocial job
situation extensively and may therefore be unaware of
 SPECIAL SECTION: JOB STRAIN AND CVD RESEARCH
psychosocial problems, whereas personnel working
as caregivers may be more accustomed to these kinds
of analyses and accordingly are more aware of
problems. In these two examples, there would be a
tendency in the former case toward negative findings
and in the latter case toward positive findings.
Differences in Blood Pressure Measurements
It has been pointed out that conventional measure-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ments of blood pressure may be less informative in
This document is copyrighted by the American Psychological Association or one of its allied publishers.
relation to cardiovascular prognosis (for instance left
ventricular hypertrophy) than measurements of blood
pressure means obtained during normal activity
(Devereux et al., 1983), particularly at work.
Furthermore, it is plausible to hypothesize that
measurements of blood pressure levels during work
activities are more closely associated with job strain
measures than blood pressure during leisure activi-
ties. Accordingly, we would expect to find more
relationship between job strain and blood pressure in
studies using measurements during activity and
particularly at work than in studies using conven-
tional blood pressure measurements performed in the
doctor's office after 10 min of resting. The best
available technology is one that uses fully automated
equipment, but self-triggered repeated measurements
could also be used for the study of blood pressure
during active periods.
Conclusion
The introduction of the demand-control support
model has stimulated many research projects during
recent years. A clear relationship between adverse job
conditions (particularly low decision latitude) and
coronary heart disease has been established. What has
been accomplished is the documentation of the
importance of social and psychological factors in the
structure of current occupations as a risk for one of
industrial society's most burdensome diseases. From
the perspective of several decades ago and to the
questions then raised about "what specifically is the
nature of social risks of modern occupations," this
model provides detailed explanations and challenges
modern medicine to take the social environment
seriously. This challenge is only beginning to be met,
and medicine could probably profit from demand-
control studies in many chronic disease areas and in
many social contexts. From the perspective of today,
however, we must admit that it is difficult for us to be
precise about which aspect of psychological demands
or decision latitude are most important, and for what
23
categories of workers. Answers to these questions
require more depth of explanation of the operational
effects of psychological demands, decision latitude,
and social support than these concepts presently
include. Most likely this further clarification will
require more precise understanding of the physiologi-
cal mechanisms by which specific factors of work
have their effects. We hope that the observations
discussed above on new monitoring technologies
provide some suggestions. It is important to recall
that the psysiological effects may also have their
impacts at a systemic level as well as on specific
physiological markers. More research is clearly
needed here. Longitudinal studies are needed to
evaluate such relationships. We must also acknowl-
edge that the rather microlevel nature of the
demand-control support dimensions may give an
inprecise reflection of macrosocial factors that need
to be seriously measured in their own right, another
important area for further research. Nonetheless, in a
more metaphorical sense, demand-control research
may have an unfortunately bright future. We perceive
that the intensity of work in modern industrial society
is increasing, and that there is a reduced sense of
control in occupational life arising from many factors.
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Received March 3,1995
Revision received July 14, 1995
Accepted July 14, 1995