TYPE D PERSONALITY IN PATIENTS WITH CARDIOVASCULAR DISEASES

P E R S O N A L I T Y A N D C A R D I O VA S C U L A R DISEASES (CVD)

The etiologies and pathogenesis of CVD as hypertension, coronary artery disease (CAD) and heart failure are complex. These include both biological factors such as increased blood pressure, increased inflammation and increased cardiac sympathetic tone (1, 2), and a wide variety of psychosocial and behavioral factors as depression (3, 4), chronic stress (5), anxiety (5, 6), decreased social support (7), and personality (8, 9, 10). These psychological factors often aggregate in cardiac patients thus further increasing the risk of CV events (5,11, 12, 13).
Personality is a dynamic and a highly complex structure, biologically, psychosocially and culturally conditioned. It constitutes the fundamental component of the terrain upon which psychopathological disorders appear and develop. Its structure integrates a complex of cognitive, emotional, volitional-instinctual, motivational and relational features, called dimensions. These dimensions are general human features present, in varying degrees, in all individuals with normal personality, in the disharmonic structures of personality and are markers of vulnerability for both psychiatric and somatic diseases. All the population, normal and pathological people as well, have the same dimensional universe, the same substrate structure. Abnormal, maladaptive features of personality, even those considered as diagnostic criteria for some specific personality disorders can be met in normal individuals (14). Recognizing these maladaptive personality features is important from the perspective of somatic diseases, especially CVD, because they determine lifestyle, behavior such as low adherence to treatment, neglect of physical activity, unhealthy diet and smoking.
N o n – p s y c h o p a t h o l o g i c a l b e h a v i o r a l characteristics were associated for the first time with somatic diseases in the 1950s when M. Friedman and Rosenman discovered (1959) a cluster of symptoms and behavioral signs that predispose to risk of heart disease, defined as type A behavior pattern. This pattern is one of the competitive types with a tendency to interact with others in an aggressive or hostile manner (12). It includes ambitiousness, aggressiveness, competitiveness, impatience, muscle tenseness, alertness, rapid and empathic vocal style, irritation, cynicism, hostility and increased potential for anger. Hostility was considered one of the core features (15, 16, 17).
Psychological reverse of type A is the type B behavior pattern that describes tolerant, tempered individuals, which are not at increased risk for heart disease.
During the 1970s and 1980s several clinical trials have evaluated the role of type A as a predictor of adverse CV events related to CAD, establishing a small relationship between angiographically determined CAD and type A behavior pattern among younger patients (18). Subsequently, due to these relatively unsatisfactory results related to the type A behavior pattern, personality factors have been mostly neglected in CV research since (19, 20). Depression and to a lesser extent anxiety entered into the spotlight. Although depression and depressive symptoms are strong predictors of onset and progression of heart disease (21, 22), the attempts to successfully reduce biomedical risk factors (RF) by treating depression have yielded mixed findings (23, 24).
In the last 20-25 years, researches have begun to regain the interest on the role of personality in health and disease (25, 26). This renewed attention is justified by the fact that personality features may have greater explanatory power than depression (5, 27, 28). There is growing evidence that underline that dimensions such as neuroticism are the base of psychiatric diagnoses such as major depression (29, 30). Personality can have a significant predictive value regarding the prognosis of patients with CVD. Because of the known clustering of unfavorable psychosocial characteristics (5), it is important that a personality approach is taken in identifying those patients who are at increased risk for emotional stress-related cardiac events.
In 1995 a new personality type was introduced as a vulnerability characteristic of patients with heart disease:
the type D or „distressed” personality (27, 31, 32). This combines the traits negative affectivity (NA) and social inhibition (SI) (8, 31). Both are viewed as global traits, considered relevant in many situations. As in other models of personality, these traits reflect emotional and behavioral consistency. The combination of these two personality traits has shown to reliably predict adverse outcome in several groups of patients suffering from CVD (33, 34, 35). Although the relationship between type D personality and CV events is increasingly recognized, the mechanisms underlying this relationship are largely unclear.
FEATURES OF TYPE D PERSONALITY
The description of the type D personality or “distressed” was started from the existing personality theory, according to which the interaction of specific traits may have harmful effects on the health condition (5). The term “distressed” refers to a discrete personality configuration designating individuals who are inclined to experience emotional and interpersonal difficulties, which is likely to affect physical health (35). This differs from other psychological measures which are currently being evaluated as predictors in the prognosis of CVD such as social support or major depressive disorder. Although major depression reflects a psychopathological condition, type D personality is a common structure, its prevalence being in the general population between 13 to
25 percent and it’s even higher in the patients with CVD, 26%-53% (34, 36, 37, 38).
Type D individuals have fewer interpersonal relationships and tend to feel uncomfortable in the presence of strangers (31). The tendency seen in type D individuals to experience negative emotions and to inhibit self-expression in a social context is a synthesis of the traits NA and SI (13). The amalgamation of the two constructs, NA and SI into the type D personality has been demonstrated empirically in patients with CAD (39, 40). Individuals with type D personality score highly on the mentioned personality dimensions.
NEGATIVE AFFECTIVITY
It is a complex personality trait defined as the tendency to experience negative emotions, including depressed mood, anxiety, anger and hostile feelings (41). This tendency was observed in a significant proportion of cardiac patients (13). Individuals scoring high on NA do not only experience states of dysphoria and tension but also have a negative view of self, report more somatic symptoms and have an attention bias towards adverse stimuli (42). Individuals characterized by high NA find themselves more often exposed to stressful events and tend to react more intensely to them (43). NA is closely related to neuroticism, because it correlates highly (r = 0.68) with the Neuroticism scale from the NEO–Five Factor Inventory in healthy participants and with the Neuroticism scale (r = 0.64) from the Eysenck Personality Questionnaire in patients with ischemic heart disease (13, 44, 45, 46, 47).
SOCIAL INHIBITION
Represents the stable tendency of inhibiting the expression of emotions, thoughts and behavior in social interactions. It is defined as the tendency to avoid the potential dangers of social interaction and anticipate negative reactions or disapproval of others. Individuals scoring high on SI frequently feel inhibited, tense, uncomfortable and insecure in the company of others and therefore prefer to keep distance in social relations. In concert with these behavioral predispositions, highly socially inhibited individuals are less likely to seek social support (48, 49). A negative correlation has been shown between SI and extraversion in healthy participants (r = – 0.59) and cardiac patients (r = – 0.65) (37). Avoidance temperament, a concept closely linked to SI, has also been associated with neuroticism (r = 0.86), behavioral inhibition (r = 0.65) and negative emotionality (r = 0.93) (50). In conclusion, SI is a global trait associated with high negative emotionality and personal distress and refers to individual differences in reticence, withdrawal and non- expression (13).
SI is a moderator, it attenuates the effects of NA on clinical outcome (8, 27). Only those individuals that score high on both subcomponents are at increased CV risk. The prevalence of major adverse CV events (death, myocardial infarction (MI), coronary artery bypass graft or percutaneous coronary intervention (PCI)) for patients with CAD with high score on NA but low score on SI is lower than for that individuals scoring highly on both subcomponents (51).
TYPE D PERSONALITYASSESSMENT
Over the past years several methods of assessment have been used to determine the type D personality. In the beginning, a combination of scales methods was used in order to obtain the appropriate item combination. The type D structure was originally developed on Belgian cardiac patients in an attempt to investigate the role of personality traits in the prognosis of CAD. In this early study of type D, the survivors of a MI were asked to complete the Heart Patients Psychological Questionnaire (52), which assessed the SI component of type D and the Trait Scale of the Spielberger State-Trait Anxiety Inventory (53), which assessed the second dimension (NA) of the distressed personality. From the 105 patients 26.7% were classified as having distressed personality (high score on both dimensions). After a median follow-up period of 3.8 years, 15 patients had died. A significant number (n = 10) of these patients had distressed personality (type D) (p <0.01) (36). In 1998 a questionnaire was introduced, consisting of 16 items, to assess the type D personality. In the DS16 all items are answered on a 5-point Likert scale ranging from 0 (false) to 4 (true). It yields four personality types, but only those who score high on both subcomponents were classified as having a type D personality. The psychometric qualities and the prognostic power of the scale have proven satisfactory for Belgian cardiac patients with Cronbach's α of 0.89 and 0.82 and test-retest reliability of 0.78 and 0.87 for NA and SI, respectively (46). Nowadays, the type D personality is assessed using the DS14 scale. The DS16 was revised to include the most prominent low-order traits from the NA and SI domains. It includes 7 items that assess NA and 7 items that assess SI. Similar to DS16, all items are answered on a 5-point Likert scale ranging from 0 (false) to 4 (true). It yields four personality types, but only those who score above a predetermined, standardized, cut-off score of ≥10 on both subcomponents are classified as having a type D personality. The psychometric properties of the DS14 are good with Cronbach's α of 0.88 for NA and 0.86 for SI. Temporal stability over a 3-month period was high (r = 0.82 and 0.72 for NA and SI, respectively) (37). It has been validated in several languages (54, 55), making it widely applicable. Because of its brevity, DS14 proved to be a practical screening instrument for the influence of psychosocial factors in clinical practice (11). TYPE D PERSONALITYAND CV EVENTS
Type D personality is defined by a high score on both NA and SI. The merger of the two constructs into the type D personality was empirically demonstrated in patients with CAD (39, 40). Cardiac patients with this type D profile have not only an increased risk of emotional distress but also an increased risk of adverse CV events (8, 36). In a study of patients with CAD, deaths from cardiac causes were four times more common in those with type D personality compared with non-type D patients, even after controlling for conventional RF (8). The same thing was observed in a later study performed on more than 300
CAD patients, who received optimal treatment in terms of medication, surgery and rehabilitation over 5 years. Type D personality in these patients had a significant predictive value (OR = 8.9, p = 0.0001), independent of biomedical factors, such as left ventricular ejection fraction, age and despite appropriate treatment. Co-occurrence of these conventional RF further increased the risk of poor outcome even more (9). Both high levels of baseline stress (OR = 2.01, p = 0.054) and presence of type D personality (OR = 2.90, p = 0.003) were independent predictors of CV events over a 5-year period. This result highlights that type D is a stable construct that helps in risk stratification above and beyond more temporary states, such as in this case, current stress levels (56). Type D personality and older age were independent predictors of the development of cancer in patients with CAD (57).
A study investigated the effect of type D personality on the occurrence of adverse events at 9 months in patients with CAD after PCI and implantation of bare metal stents or sirolimus-eluting stents. Type D patients had a cumulative increased risk of adverse events compared with non-type D subjects (58).
Another study suggested that patients with type D personality and implantable cardioverter defibrillator (for primary or secondary prevention of sudden cardiac death) were more likely to suffer from anxiety or symptoms of depression. Type D personality (OR=7.03), use of psychotropic medication (OR=8.16) and lack of social support (OR=0.97) were independent determinants (p <0.05) of symptoms of anxiety in these patients. Type D personality remained a significant determinant of symptoms of depression among other contributors (OR=7,40) (59). It independently predicts the onset of depressive symptoms in patients with CAD and PCI (60). This result supports the idea that personality factors may underlie the presence of depressive disorder (13, 29, 30). Type D patients have higher levels of circulating tumor necrosis factor alpha (TNF-α) and soluble TNF-α receptors that are predictors of mortality in congestive heart failure (61, 62). CV patients with type D personality accuse more frequently impaired physical and mental health status compared to their non-type D counterparts (62). This might be the result of their inadequate symptom and illness perception (63). Individuals with type D personality may be more likely to be more aware of normal bodily sensations and to interpret them as painful or pathological (42), and also, they tend to believe that their illness will have more serious consequences and that treatment will be less effective (64). This health condition reported by patients has been shown to have a significant predictive value over indicators of disease severity in predicting mortality and rehospitalization (63). Type D personality is associated with an unhealthy lifestyle (e.g. smoking, alcohol consumption, physical inactivity) (65), medication non-adherence (66) and inadequate consultation behavior (67, 68). CONCLUSIONS
Type D personality was associated with increased morbidity and mortality in different CV populations independently of conventional biomedical RF (69, 70) and with an increased prevalence of CV RF (71). Individuals with this type of personality have an increased risk of developing psychiatric and medical disorders (31,32).
When one considers the rhythm and the socio- economic particularities of our contemporary society of hyper-consumption, evaluating the contributions of personality factors, in the determinism and dynamics of CVD, becomes a paramount medical and social goal. Studies have shown that type D personality is an important and easily assessable negative prognostic predictor that should be considered in clinical practice. It can be regarded as a psychopathological condition that can affect health and longevity and may require psychosocial and / or pharmacological interventions (72).
Further studies are needed to determine how to deal, from a therapeutic point of view, with individuals that have type D personality, in order to improve their physical and mental health and to positively influence the progression of CVD in this group of patients with increased risk.

Without conflicts of interest. No funding was necessary for this research.
Abbreviations: CAD- coronary artery disease, CV- cardiovascular, CVD- cardiovascular diseases, NA- negative affectivity, OR- Odds Ratio, PCI- percutaneous coronary intervention, RF- risk factor, SI- social inhibition, TNF-α- tumor necrosis factor alpha.

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