Type D personality as a prognostic factor in heart disease: assessment and mediating mechanisms

Type D personality, a synergy between negative affectivity and social inhibition, has established itself as a serious risk factor for morbidity and mortality in patients suffering from cardiovascular disease. In this review, we summarize studies on the validity of the assessment methods of Type D, emphasizing its role as an independent vulnerability factor in the progression of cardiovascular disease. We further present evidence on the physiological characteristics that accompany the 2 psychological traits negative affectivity and social inhibition and may mediate the relation between personality and prognosis in heart disease. Further research needs to determine the mechanisms by which Type D affects the course and outcome of cardiovascular disease as well as how Type D patients may benefit from psychosocial intervention.     

Type D personality predicts poor medication adherence in myocardial infarction patients

Type D personality, the combination of negative affectivity (NA) and social inhibition (SI), is an emerging risk factor in cardiovascular disease. This study aimed to examine one possible behavioural mechanism to explain the link between Type D and ill-health. It was hypothesised that Type D personality would predict medication adherence in myocardial infarction (MI) patients. In a prospective study, 192 MI patients (54 females and 138 males) completed measures of Type D personality and provided demographic and medical information 1 week post-MI, and then 131 patients went on to complete a self-report measure of medication adherence 3 months post-MI. It was found that Type D personality predicts adherence to medication, after controlling for demographic and clinical risk factors. Critically, the constituent components of Type D, NA and SI, interact to predict medication adherence, after controlling for the effects of each component separately. Poor adherence to medication may represent one mechanism to explain why Type D cardiac patients experience poor clinical outcome, in comparison to non-Type D patients. Interventions, which target the self-management of medication, may be useful in these high-risk patients.     

Type D personality predicts poor medication adherence in myocardial infarction patients

Type D personality, the combination of negative affectivity (NA) and social inhibition (SI), is an emerging risk factor in cardiovascular disease. This study aimed to examine one possible behavioural mechanism to explain the link between Type D and ill-health. It was hypothesised that Type D personality would predict medication adherence in myocardial infarction (MI) patients. In a prospective study, 192 MI patients (54 females and 138 males) completed measures of Type D personality and provided demographic and medical information 1 week post-MI, and then 131 patients went on to complete a self-report measure of medication adherence 3 months post-MI. It was found that Type D personality predicts adherence to medication, after controlling for demographic and clinical risk factors. Critically, the constituent components of Type D, NA and SI, interact to predict medication adherence, after controlling for the effects of each component separately. Poor adherence to medication may represent one mechanism to explain why Type D cardiac patients experience poor clinical outcome, in comparison to non-Type D patients. Interventions, which target the self-management of medication, may be useful in these high-risk patients.     

Type D personality and the development of PTSD symptoms: a prospective study

Psychological trauma and prolonged stress may cause mental disorders such as posttraumatic stress disorder (PTSD). Pretrauma personality is an important determinant of posttraumatic adjustment. Specifically, trait neuroticism has been identified as a risk factor for PTSD. Additionally, the combination of high negative affectivity or neuroticism with marked social inhibition or introversion, also called Type D personality (Denollet, 2000), may compose a risk factor for PTSD. There is no research available that examined pretrauma Type D personality in relation to PTSD. The present study examined the predictive validity of the Type D personality construct in a sample of Dutch soldiers. Data were collected prior to and 6 months after military deployment to Afghanistan. Separate multiple regression analyses were performed to examine the predictive validity of Type D personality. First, Type D personality was defined as the interaction between negative affect and social inhibition (Na × Si). In a second analysis, Type D was defined following cutoff criteria recommended by Denollet (2000). Results showed that negative affectivity was a significant predictor of PTSD symptoms. Social inhibition and the interaction Na × Si did not add to the amount of explained variance in postdeployment PTSD scores over the effects of childhood abuse, negative affectivity, and prior psychological symptoms. A second analysis showed that Type D personality (dichotomous) did not add to the amount of explained variance in postdeployment PTSD scores over the effects of childhood abuse, and prior psychological symptoms. Therefore, Type D personality appears to be of limited value to explain development of combat-related PTSD symptoms.     

Type D personality,but not Type A behavior pattern,is associated with coronary plaque vulnerability

Personality traits are associated with major adverse coronary events (MACE) in patients with coronary artery disease (CAD). However, the link between personality traits and intravascular morphology in CAD patients is poorly understood. This study investigated the relationship between personality traits, specifically Type A behavior pattern and Type D personality, and plaque vulnerability. After adjustment for demographic and clinical factors, multivariable regression analysis showed no association between Type A and optical coherence tomography indices. However, Type D personality was independently associated with lipid plaque, thin cap fibroatheroma (TCFA), and fibrous cap thickness. More specifically, negative affectivity of Type D was related to lipid plaque, TCFA and fibrous cap thickness, and social inhibition was associated with plaque rupture. Our results show that Type D personality was associated with plaque vulnerability, independent of clinical factors. Measurement of negative affectivity and social inhibition will increase our understanding of the progressive phase of the plaque vulnerability, which can contribute to the early identification of high risk patients and reduce the incidence of MACE.     

Construct, concurrent and discriminant validity of Type D personality in the general population: associations with anxiety, depression, stress and cardiac output

The Type D personality, identified by high negative affectivity paired with high social inhibition, has been associated with a number of health-related outcomes in (mainly) cardiac populations. However, despite its prevalence in the health-related literature, how this personality construct fits within existing personality theory has not been directly tested. Using a sample of 134 healthy university students, this study examined the Type D personality in terms of two well-established personality traits; introversion and neuroticism. Construct, concurrent and discriminant validity of this personality type was established through examination of the associations between the Type D personality and psychometrically assessed anxiety, depression and stress, as well as measurement of resting cardiovascular function. Results showed that while the Type D personality was easily represented using alternative measures of both introversion and neuroticism, associations with anxiety, depression and stress were mainly accounted for by neuroticism. Conversely, however, associations with resting cardiac output were attributable to the negative affectivity-social inhibition synergy, explicit within the Type D construct. Consequently, both the construct and concurrent validity of this personality type were confirmed, with discriminant validity evident on examination of physiological indices of well-being.     

The distressed (Type D) and Five-Factor Models of personality in young,healthy adults and their association with emotional inhibition and distress

The distressed (Type D) personality (the combination of negative affectivity and social inhibition traits) has been associated with adverse health outcomes. This study investigated the validity of the Type D construct against the Five-Factor Model (FFM) of personality, and its association with emotional control and distress. In total 498 university students (mean age 28.9 ± 8.4 years) completed the Type D scale (DS14), and measurements for the FFM of personality, emotional control, anxiety, depression and stress. The construct validity of the Icelandic DS14 was confirmed. The Type D components negative affectivity and social inhibition were strongly associated with neuroticism and extraversion of the FFM (r = 0.82 and r = −0.67, respectively). Negative affectivity also correlated with rehearsal/rumination (r = 0.58) and social inhibition with emotional inhibition (r = 0.54), indicative of emotional control. Type D personality (40% of sample) was associated with higher levels of anxiety, depression and stress. The Type D personality components were associated with the FFM of personality, emotional control and emotional distress. Importantly, social and emotional inhibition were closely related, providing novel information about the presence of emotional inhibition within the social inhibition trait.     

Type D personality and cardiovascular reactivity to an ecologically valid multitasking stressor

Previous research investigating the influence of Type D personality on cardiovascular reactivity to stress in healthy young adults is somewhat mixed. The present study sought to investigate this question using an ecologically valid laboratory stressor. Beat-to-beat blood pressure and heart rate were measured in 77 healthy young adults during exposure to multitasking stress. Mood and background stress were both associated with Type D personality when Type D was conceptualised as a dimensional construct, with less robust findings observed using the traditional dichotomous typological approach. However, the continuous Type D construct added limited predictive value of the self-report measures above that of its constituent components, negative affectivity (NA) and social inhibition (SI). Further, an inverse relationship between the continuous Type D construct and blood pressure reactivity to multitasking stress was observed. In summary, our findings suggest that Type D personality is predictive of blunted cardiovascular reactivity to stress in healthy individuals when Type D is considered as a dimensional construct and the independent influence of NA and SI is controlled for. Further, our findings suggest that Type D does not predict additional variance in mood and background stress above that of NA and SI when these constituent factors are considered independently.     

D型人格：心血管疾病的重要心理危险因素

D型人格（又称忧伤人格）是指经历消极情感与社会压抑的混合倾向。对于心血管疾病患者来说,这种心理危险因素与其生活质量下降、梗死复发甚至死亡等有着密切联系。作者总结了D型人格与心血管疾病关系的研究现状,阐述了D型人格对于识别早期高危患者的临床价值,探讨了神经内分泌学、免疫学及心理学等方面的机制,并评价了对D型人格进行心理干预的可行性。     

Type D personality, physical symptoms and subjective stress: the mediating effects of coping and social support

Coping style and social support may represent mechanisms to explain the relationship between Type D personality and ill-health. This study investigated whether Type D is associated with physical symptoms and perceived stress in a non-cardiac population, and if these relationships are mediated by coping and social support. In a cross-sectional study, 304 participants (110 males, mean age 22.1 years) completed measures of Type D, physical symptoms, coping, perceived stress and social support. Results showed that Type D, the interaction of negative affectivity and social inhibition (NA × SI), was positively correlated with physical symptoms, perceived stress, and avoidant coping, and negatively correlated with social support, problem-focused coping and emotion-focused coping. A series of bootstrapped multiple mediator tests showed that social support and avoidant coping fully mediated the relationship between Type D and physical symptoms. Furthermore, social support and emotion-focused coping partially mediated the relationship between Type D and perceived stress. These findings demonstrate for the first time that Type D personality is associated with physical symptoms in a non-cardiac population. Social support and coping style represent mechanisms that can, in part, explain the relationship between Type D and physical symptoms, and Type D and perceived stress.     

Type D personality,physical symptoms and subjective stress: The mediating effects of coping and social support

Coping style and social support may represent mechanisms to explain the relationship between Type D personality and ill-health. This study investigated whether Type D is associated with physical symptoms and perceived stress in a non-cardiac population, and if these relationships are mediated by coping and social support. In a cross-sectional study, 304 participants (110 males, mean age 22.1 years) completed measures of Type D, physical symptoms, coping, perceived stress and social support. Results showed that Type D, the interaction of negative affectivity and social inhibition (NA?×?SI), was positively correlated with physical symptoms, perceived stress, and avoidant coping, and negatively correlated with social support, problem-focused coping and emotion-focused coping. A series of bootstrapped multiple mediator tests showed that social support and avoidant coping fully mediated the relationship between Type D and physical symptoms. Furthermore, social support and emotion-focused coping partially mediated the relationship between Type D and perceived stress. These findings demonstrate for the first time that Type D personality is associated with physical symptoms in a non-cardiac population. Social support and coping style represent mechanisms that can, in part, explain the relationship between Type D and physical symptoms, and Type D and perceived stress.     

Type D assessment in patients with chronic heart failure and peripheral arterial disease: evaluation of the experimental DS(3) scale using item response theory

Type D personality refers to a clustering of 2 stable personality traits, namely negative affectivity and social inhibition. Currently Type D is standardly assessed using the DS14. An experimental Type D personality scale, the DS((3)), was developed to examine an avenue for assessing Type D more efficiently. The DS((3)) differs from the DS14 in its use of a 3-point Likert scale to rate responses, use of all negatively worded items, and a rearranged presentation of items. This article examines the psychometric properties of this questionnaire by examining its dimensionality, item and scale properties, and cutoff scores to screen for Type D personality. Data from 2 clinical samples were analyzed using item response theory. The results suggest that the DS((3)) is a potentially suitable instrument for Type D assessment. It has high reliability, and Type D personality classification based on this scale corresponds well with the current standard Type D assessment based on the DS14.     

Type D personality and the Five-Factor Model: A facet-level analysis

Objective: This study assessed the degree to which NEO-PI-R facets contribute to understanding of Type D personality over and above the Big 5. Method: Healthy participants (n = 268) completed the DS14 and the NEO-PI-R. In addition to analyzing the Type D subscales of social inhibition and negative affectivity, we computed a continuous measure of Type D scored as the sum of the two subscales. Results: Facets provided moderate incremental prediction of Type D subscales. The facets of assertiveness, self-consciousness, and positive emotion provided incremental prediction of negative affectivity, and warmth, activity, and gregariousness provided incremental prediction of social inhibition. Facets provided minimal incremental prediction of continuous Type D. The Big 5 explained substantially more variance in continuous Type D (71%) than negative affectivity (59%) or social inhibition (61%). Conclusions: Overall, the facet-level analysis provided additional insights into the nature of Type D. The incremental prediction of the Type D subscales by facets supported the idea that Type D scales are narrower constructs than the Big 5. However, the strong prediction of continuous Type D by the Big 5 and the lack of incremental prediction by facets points to the overall Type D construct being well represented by the Big 5.     

Perfectionism Dimensions and Dependency in Relation to Personality Vulnerability and Psychosocial Adjustment in Patients with Coronary Artery Disease

The present study sought to illuminate self-criticism and personal standards dimensions of perfectionism and dependency as specific cognitive-personality vulnerability factors that might contribute to a better understanding of numerous psychosocial problem areas that are relevant to coronary artery disease (CAD). One hundred and twenty-three patients diagnosed with clinically significant CAD completed self-report questionnaires. Zero-order correlations and factor analysis results revealed that self-criticism was primarily related to personality vulnerability (aggression/anger/hostility, Type D negative affectivity) and psychosocial maladjustment (depressive symptoms, worry, avoidant coping, support dissatisfaction), whereas personal standards was primarily related to adaptive coping (problem-focused coping, positive reinterpretation) and dependency was primarily related to worry. Hierarchical regression results demonstrated the incremental utility of self-criticism, personal standards, and dependency in relation to (mal)adjustment over and above aggression/anger/hostility, negative affectivity, and social inhibition. Continued efforts to understand the role of perfectionism dimensions and dependency in CAD appear warranted.     

A Normative Study of TAT Ambiguity

Type D personality refers to a clustering of 2 stable personality traits, namely negative affectivity and social inhibition. Currently Type D is standardly assessed using the DS14. An experimental Type D personality scale, the DS⁽³⁾, was developed to examine an avenue for assessing Type D more efficiently. The DS⁽³⁾ differs from the DS14 in its use of a 3-point Likert scale to rate responses, use of all negatively worded items, and a rearranged presentation of items. This article examines the psychometric properties of this questionnaire by examining its dimensionality, item and scale properties, and cutoff scores to screen for Type D personality. Data from 2 clinical samples were analyzed using item response theory. The results suggest that the DS⁽³⁾ is a potentially suitable instrument for Type D assessment. It has high reliability, and Type D personality classification based on this scale corresponds well with the current standard Type D assessment based on the DS14.     

The distressed (Type D) personality mediates the relationship between remembered parenting and psychological distress in cardiac patients

Objective: Both the distressed (Type D) personality (i.e. the combination of negative affectivity and social inhibition traits) and dysfunctional parenting styles are associated with anxiety and depression. As parenting styles have been related to personality development, dysfunctional parenting styles may also be associated with Type D personality. We examined whether remembered parenting was associated with anxiety and depression in cardiac patients and whether Type D personality mediated this relationship.

Methods: Our sample comprised 435 patients treated with percutaneous coronary intervention (PCI) and 123 patients with congestive heart failure (CHF). Patients completed the Hospital Anxiety and Depression Scale, Type D Scale (DS14), and Remembered Relationship with Parents (RRP¹⁰) scale.

Results: Remembered parenting was significantly associated with higher anxiety and depression levels and Type D personality. In multivariable linear regression analyses, Type D personality accounted for 25–29% of the variance in anxiety and 23–46% of the variance in depression, while remembered parenting was no longer significantly associated with these domains. Sobel tests and bootstrapping indicated that Type D personality mediated the relationship between remembered parenting and anxiety and depression.

Conclusion: Type D personality mediated the relationship between remembered parenting and anxiety and depression in both PCI and CHF patients.     

Type D personality and social relations in adults with diabetes: results from diabetes MILES – The Netherlands

Abstract

Objective: To examine whether individual differences in Type D personality (combination of negative affectivity (NA) and social inhibition (SI)) could explain heterogeneity in perceived social support and relationship adjustment (intimate partner relationship) among people living with diabetes.

Design: In the Diabetes MILES—The Netherlands survey, 621 adults with type 1 or type 2 diabetes (54% female, age: 56?±?14 years) completed measures of Type D personality (DS14), perceived social support and relationship adjustment. We used established DS14 cut-off scores to indicate Type D personality, high NA only, high SI only and reference groups.

Results: Participants from the Type D and NA only groups perceived lower levels of social support (Welch[3,259]?=?37.27, p?<?0.001), and relationship adjustment (Welch[3,191]?=?14.74; p?<?0.01) than those from the SI only and reference groups. Type D was associated with lower social support (lowest quartile; adjusted OR?=?8.73; 95%CI?=?5.05?～?15.09; p?<?0.001) and lower relationship adjustment (lowest quartile; adjusted OR?=?3.70; 95%CI?=?2.10?～?6.53; p?<?0.001). Type D was also associated with increased levels of loneliness.

Conclusion: Participants with Type D and participants with high NA only tend to experience less social support and less relationship adjustment. Type D personality was also associated with more loneliness. Experiencing lower social support and relationship adjustment may complicate coping and self-management in people with diabetes.     

Modeling Interactions Between Latent Variables in Research on Type D Personality: A Monte Carlo Simulation and Clinical Study of Depression and Anxiety

Several approaches exist to model interactions between latent variables. However, it is unclear how these perform when item scores are skewed and ordinal. Research on Type D personality serves as a good case study for that matter. In Study 1, we fitted a multivariate interaction model to predict depression and anxiety with Type D personality, operationalized as an interaction between its two subcomponents negative affectivity (NA) and social inhibition (SI). We constructed this interaction according to four approaches: (1) sum score product; (2) single product indicator; (3) matched product indicators; and (4) latent moderated structural equations (LMS). In Study 2, we compared these interaction models in a simulation study by assessing for each method the bias and precision of the estimated interaction effect under varying conditions. In Study 1, all methods showed a significant Type D effect on both depression and anxiety, although this effect diminished after including the NA and SI quadratic effects. Study 2 showed that the LMS approach performed best with respect to minimizing bias and maximizing power, even when item scores were ordinal and skewed. However, when latent traits were skewed LMS resulted in more false-positive conclusions, while the Matched PI approach adequately controlled the false-positive rate.     

Psychometric properties of the Type D scale (DS14) in Norwegian cardiac patients

Bergvik, S., Sørlie, T., Wynn, R. & Sexton, H. (2010). Psychometric properties of the Type D scale (DS14) in Norwegian cardiac patients. Scandinavian Journal of Psychology. The combination of negative affectivity (NA) and social inhibition (SI) – the Type D Personality – is associated with poor outcomes in coronary artery disease (CAD) patients. A Norwegian translation of the standard instrument measuring Type D (DS14) was tested on 432 CAD patients receiving coronary revascularization treatment. Factor analysis produced two factors with high inter‐item reliability, indicating that the Norwegian DS14 has acceptable psychometric properties. Eighteen percent were classified as Type D, lower than has been reported elsewhere. Type D was associated with anxiety, depression, and passive coping. NA correlated positively with depression, anxiety, and passive coping. SI correlated positively with depression and anxiety, and negatively with active coping. The prevalence of Type D was higher among women, and negatively correlated with time since treatment. The variation in Type D prevalence among studies needs further elucidation as does the predictive power of continuous scoring of the Type D trait.     

Replicating and Extending Past Personality/Job Satisfaction Meta-Analyses

A meta-analysis summarizing results of 187 studies reporting cross-sectional and longitudinal relationships between job satisfaction and personality is described. The Big Five factor of Neuroticism related most strongly and negatively to job satisfaction (?.25), with the other factors ranging from .16 (Conscientiousness) to ?.02 (Openness to Experience). Job satisfaction was positively related to internal locus of control (LOC), positive affectivity, and Type A (achievement striving). Results showed negative relationships with external LOC, trait anger, Machiavellianism, negative affectivity/trait anxiety, and Type A (global and impatience/irritability). Job satisfaction had a very weak, negative correlation with narcissism that was indistinguishable from zero. These relationships were similar, although the effect sizes were generally not as strong, when examined in a longitudinal context. The distinctiveness of Extraversion and positive affectivity, as well as that of global and composite measures of job satisfaction, are discussed.