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.     

Cognition and incident coronary heart disease in late midlife: The Whitehall II study

The purpose of this study was to investigate whether cognitive function in midlife predicts incident coronary heart disease (CHD), followed up over 6 years. Data on 5292 (28% women, mean age 55) individuals free from CHD at baseline were drawn from the British Whitehall II study. We used Cox regression to model the association between cognition and CHD in analyses adjusted for socio-demographic variables, cardiovascular risk factors and health behaviors. The results show a one standard deviation lower score on the “general” cognitive measure and measures of reasoning and vocabulary to be associated with elevated CHD risk. There was some evidence that these effects differed between high and low socioeconomic status (SES) groups with associations only seen in the low SES group. These results were not explained by threshold effects or by the different SES groups representing different parts of the cognitive test score distribution. Three other possible explanations of these results are discussed: sub clinical vascular disease drives the observed association but no effect is observed in the high SES group due to compensation provided by greater cognitive reserve, cognition is a marker of overall bodily integrity particularly in low-SES groups, and SES is a moderator of the association between cognition and CHD, because it marks a range of other risk factors.     

Correlates of hypoglycemic fear in type I and type II diabetes mellitus.

We examined whether fear of hypoglycemia in insulin-dependent diabetes mellitus was associated with (a) higher levels of trait anxiety and general fearfulness, (b) difficulty in differentiating symptoms of anxiety and hypoglycemia, and (c) past experience with hypoglycemia. Joslin Diabetes Center outpatients with Type I and Type II diabetes (N = 232), all requiring insulin, were surveyed. Type I patients experienced significantly more fear of hypoglycemia than Type II patients. For the Type I and Type II groups, higher scores on the Worry subscale of the Hypoglycemia Fear Survey (HFS-W) were associated with higher levels of trait anxiety and fear. Higher scores on the Behavior subscale (HFS-B) were associated with higher levels of fear. Among Type I subjects only, HFS-W scores were also positively associated with past hypoglycemic experience and with difficulty in differentiating anxiety and hypoglycemic symptoms. These latter relations remained significant even after the variance resulting from trait anxiety and fear was removed. Other significant associations with HFS-B scores were not observed.     

Personality as a risk factor in coronary heart disease

The pioneering work of the authors of the Type A personality concept has now been shown to be seriously flawed, with only the traits of anger, aggression, and hostility remaining as risk factors for coronary heart disease (CHD). There is now evidence for a much stronger relationship between CHD and personality involving a rather different set of concepts and theories. The evidence for such a relationship is summarized, and a causal link suggested. It is also shown that the CHD-prone type of behaviour can be changed by behaviour therapy, decreasing considerably the risk of dying from CHD.     

Polyneuropathy and residual insulin secretion in diabetes mellitus type I

In 145 patients suffering from type-I-diabetes with or without signs or symptoms of polyneuropathy basal and glucose-glucagon-induced secretion of insulin was determined. Patients without remaining insulin secretion exhibited somewhat more often polyneuropathies, slowing of nerve conduction, or reduced respiratory heart arrhythmia. If diabetes lasts for more than 10 years, insulin secretion ist reduced to such a low level that its may not have any significant preventive capability with respect to polyneuropathy.     

Self-management of diabetes mellitus: a critical review

Diabetes has no known cure and is a leading source of morbidity and mortality. Clinical management involves patients managing a complex and variable regimen. This article reviews the determinants of effective self-management and the methods of promoting better self-management. Trait variables (e.g., personality and demographics) have been presumed to affect self-management, but evidence suggests they have little impact. The important determinants of self-management are transient situational factors such as psychological stress and social pressure to eat. Interventions to promote better self-management have reported initial improvements in blood glucose control, but the long-term effects are unclear. We conclude that self-management has been inadequately assessed and that attempts to improve self-management have relied excessively on providing information. More research is needed to clarify determinants of self-management, and interventions to improve self-management will need to change these determinants.     

Self-regulation and mortality from cancer, coronary heart disease, and other causes: A prospective study

This article introduces a new personality inventory dealing with self-regulation. This is in some ways the opposite of neuroticism, and measures personal autonomy or independence, particularly as far as emotional dependence is concerned. Our concern was the relation between self-regulation and health, and large samples of healthy men and women were tested and followed up to demonstrate high predictability of mortality from cancer, coronary heart disease and other causes of death from scores on the questionnaire. It was also demonstrated that psychological risk factors were largely independent from physical risk factors, and could be changed by behavioural-cognitive treatment, reducing mortality.     

The short-term effects of a hostility-reduction intervention on male coronary heart disease patients.

This preliminary study examined the effects of a hostility-reduction intervention on patients with coronary heart disease (CHD). Twenty-two high-hostile CHD men were matched on age and hostility and then randomly assigned to a hostility intervention (N = 10) or an information-control group (N = 12). Patients were reassessed immediately and 2 months posttreatment on hostility (with self-report and structured interview) and resting blood pressure. The intervention's overall effect size was moderately strong (d' = .62). Intervention patients reported at both reassessments and were observed at follow-up to be less hostile than controls. At follow-up, intervention patients had significantly lower diastolic blood pressure (DBP) than controls. Finally, reductions in hostility were significantly and positively correlated with reductions in DBP. Replication with a larger sample and CHD outcomes is recommended.     

Increases in depressive symptomatology in the rural elderly: results from a cross-sectional and longitudinal study.

Depressive symptomatology was examined in a large sample of noninstitutionalized older adults using the Center for Epidemiological Studies-Depression scale (CES-D). Both cross-sectional and longitudinal data showed age-related increases in mean CES-D scores and increases in the percentage of respondents scoring at or above the cutoff score of 16. Variables collected at baseline in the longitudinal study from 2,032 participants 65 years of age and older were significant predictors of depressive symptomatology 3 and 6 years later. Baseline CES-D scores accounted for the largest proportion of the variance.     

Accuracy of diagnosis of depression in patients with Type 1 diabetes mellitus

This study assesses the clinical accuracy of physicians (Specialists in Endocrinology and Nutrition: SEN) to make the diagnosis of depression in patients with Type 1 diabetes mellitus (DM1). This study involved 11 SEN physicians, and 153 patients with DM1. The diagnosis of depression was performed using the SCID-1 structured interview and clinical assessment. From the initial sample, 50 patients were randomly selected (imposing the condition that it was included 25 patients with depression and 25 without depression). The results show that clinicians performed a higher percentage of negative diagnoses (patients without depression) than positive ones (patients with depression). A significant percentage of patients with depression were not diagnosed (25%). It therefore seems necessary to provide adequate clinical protocols to evaluate the presence of this disorder in DM1, as well as continuing research into the diagnostic process for clinical decision making.     

A meta-analysis of psychoeduational programs for coronary heart disease patients.

In a meta-analysis of 37 studies, the effects of psychoeducational (health education and stress management) programs for coronary heart disease patients were examined. The results suggest that these programs yielded a 34% reduction in cardiac mortality; a 29% reduction in recurrence of myocardial infarction (MI); and significant (p < .025) positive effects on blood pressure, cholesterol, body weight, smoking behavior, physical exercise, and eating habits. No effects of psychoeducational programs were found in regard to coronary bypass surgery, anxiety, or depression. The results also suggest that cardiac rehabilitation programs that were successful on proximal targets (systolic blood pressure, smoking behavior, physical exercise, emotional distress) were more effective on distal targets (cardiac mortality and MI recurrences) than programs without success on proximal targets.     

The assessment of type a behavior and the prediction of coronary heart disease: A review

The literature regarding the Type A behavior pattern and its association with the incidence of coronary disease has been accumulating for over 20 years. For any researcher contemplating the investigation of this syndrome and its pathological implications, a daunting and time-consuming task is presented in deciding which Type A measurement technique to use to identify Type A individuals. This article is designed to aid this process by presenting a review of all the prospectively validated Type A measures that have been shown to be predictive of coronary disease. Each measure is described, its development is outlined, and its advantages, disadvantages, and limitations are highlighted. This work was supported by a grant from the Health Education Council, London, under the supervision of Professor J.R. Eiser at the Department of Psychology, University of Exeter.     

Hostility, the metabolic syndrome, and incident coronary heart disease.

This invesgation examined the impact of hostility and the metabolic syndrome on coronary heart disease (CHD) using prospective data from the Normative Aging Study. Seven hundred seventy-four older, unmedicated men free of cardiovascular disease were included in the study. The total Cook-Medley Hostility (Ho) Scale score, anthropometric data, serum lipids, fasting insulin concentrations, blood pressure, cigarette smoking, alcohol consumption, and total dietary calories were used to predict incident CHD during a 3-year follow-up interval. Multivariate analysis indicated that only Ho positively predicted and high-density lipoprotein cholesterol level negatively predicted incident CHD. Ho's effects on CHD may be mediated though mechanisms other than factors that constitute the metabolic syndrome.     

Support, stress, and recovery from coronary heart disease: a longitudinal causal model

Measures of support, stress, distress, and cardiac symptoms were obtained from a cohort of 73 male cardiac patients at hospitalization and at 3, 6, and 12 months thereafter. Sets of general and alternative hypotheses regarding the direction of causality among these variables were drawn from the literature on cardiac rehabilitation, stress, and support. Structural equation modeling was used to evaluate the stability and duration of these hypotheses over three time-lags. The results showed strong support for the general hypotheses and minimal support for the alternative hypotheses. Support ameliorated the subsequent experience of stress and distress and had opposing effects to these variables on cardiac symptoms. Support was more influential in the first half of the year than it was in the second half, however, whereas stress was predominant causally in the second half. Implications of this pattern for clinical intervention are drawn and directions for further research are proposed.     

The effects of stereotype activation on behavior: a review of possible mechanisms.

Considerable recent research has examined the effects that activated stereotypes have on behavior. Research on both self-stereotype activation and other-stereotype activation has tended to show that people behave in ways consistent with the stereotype (e.g., walking more slowly if the elderly stereotype is activated). Interestingly, however, the dominant account for the behavioral effects of self-stereotype activation involves a hot motivational factor (i.e., stereotype threat), whereas the dominant account for the behavioral effects of other-stereotype activation focuses on a rather cold cognitive explanation (i.e., ideomotor processes). The current review compares and contrasts the behavioral research on self- and other-stereotype activation and concludes that both motivational and cognitive explanations might account for effects in each domain.     

Psychosocial adjustment to and control of diabetes mellitus: differences by disease type and treatment

The relationship of diabetic patients' psychosocial adjustment to disease type, treatment mode, and indexes of control was examined in a representative community population. The psychometric properties of the Diabetes Educational Profile (DEP) and its application to psychosocial research in diabetes were also investigated. Findings support the reliability and validity of the DEP. Various measures of psychosocial adjustment were related to diabetes control but the specific relationships depended on the particular aspect of adjustment, the specific measure of diabetes control, and the type of disease and treatment. The findings suggest that analyses that aggregate dissimilar patient groups are subject to misinterpretation due to ecological masking and supressor effects. The results indicate that clinicians and researchers must recognize that patients with different disease types and treatment modes have different norms for psychological adjustment and diabetes control. Further, the particular aspects of psychosocial adjustment associated with diabetes control differ across patient groups.     

Assessment of hostility in patients with coronary heart disease

One of the problems in efforts to more clearly conceptualize hostility is the amount of method variance, which ranges from self-report techniques to interview-based methods and mirrors the multidimensional nature of hostility and related constructs. In addition, rather few studies concerned with the assessment of hostility have specifically used samples of coronary heart disease (CHD) patients. The purpose of this study was, therefore, to examine the multidimensionality of the construct of hostility in a sample of male coronary patients with some frequently used instruments. Factor analysis was used to detect the relevant underlying constructs, which were assessed using a variety of hostility measures in a sample of cardiac patients undergoing baseline assessment in an ongoing health-education intervention study. Measurement included both questionnaires and interviews. Participants (N = 235) were divided into 3 diagnostic groups: patients who had recently undergone (a) a myocardial infarction, (b) coronary artery bypass grafting, or (c) percutaneous transluminal coronary angioplasty. A 4-factor solution appeared to provide the best fit, and the following factors were isolated: Anger-Out, Negative Affect, Coping, and Anger-In. All intercorrelations were less than .50. Medical diagnosis did not differ with regard to the 4 factors found. The total hostility construct as measured by the structured interview (SI) did not fit into the 4-factor model. This study was the first to show that dimensions of anger and hostility constitute valid and relevant aspects of the general construct of hostility for a representative group of CHD patients. The 4 aspects of hostility isolated using some well-known hostility questionnaires and the SI explained most of the observed variance. Although the SI appeared to tap more general state anger, the 4 aspects of hostility may be differentially related to health in those who are coronary prone. Future studies on the role of hostile or negative emotions in CHD patients should, therefore, pay greater attention to the multidimensional nature of hostility and may clearly benefit from the use of the 4-factor model described in this article.     

Associations among behavior, personality, and traditional risk factors for coronary heart disease: a study at a primary health care center in mid-Norway

The continuing presence of different negative emotions has been suggested as an important factor in the development of coronary heart disease (CHD). The present study was carried out at a medical center to investigate the presence of negative emotions and Type A behavior in a group of 40-yr.-old men and women. The National Institute of Public Health in Norway carried out the data-collection as a part of their CHD risk factor screenings. The correlation between hostility and total cholesterol is negative as is that between systolic blood pressures and the feeling of guilt for women. There was no further support for earlier findings of relationships between either Type A behavior pattern and negative emotions or Type A and elevated cholesterol values. A number of possible explanations are offered. In the study, assessment of hostility was questioned; there was possible support for poor assessment of hostility on the Karolinska Scales of Personality employed in the study.     

Reliability and validity of a twelve-minute walking test for coronary heart disease patients

This study examined the reliability and validity of a 12-min. walking test for coronary heart disease patients. CHD patients (28 men, 18 women) were recruited out of 86 CHD patients of the Martini Hospital Groningen, The Netherlands. 46 CHD patients (age M=66.0 yr., SD=6.8) participated in the reliability study and 24 (age M=62.0 yr., SD=9.2) in the validity study. A test-retest analysis showed a satisfactory Bland-Altman plot and an intraclass coefficient of .98. The Pearson correlation between the score on the test and the VO2 peak was .77. This test gives a reliable and valid assessment of cardiorespiratory fitness of CHD patients.