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Type-D Personality and Adverse Health Outcomes- An Overview

Dr. Jasbir Rishi

Associate Professor

HMV, Jalandhar

India

Abstract

Type D personality, a concept used in the field of medical psychology, is defined as the joint

tendency towards negative affectivity (egg. Worry, irritability, gloom) and social inhibition

(e.g. reticence and a lack of self-assurance). The letter D stands ‗distressed‘. Type-D can be

assessed with the standardized 14-item Type-D Scale (DS14) that measures negative

affectivity and social inhibition (7 items for each domain) (Denollet, 2005). Several studies

have demonstrated that Type D is associated with a four-fold increased risk of mortality in

coronary heart disease (CHD) patients, independent of traditional biomedical risk factors

(Denollet et al.,2000; Denollet et al., 2006).The studies included in this review showed that

the presence of Type D characteristics had a negative impact on mental health status (more

symptoms of depression, anxiety, post-traumatic stress disorder, mental distress, passive

coping, and less social support) and physical health status (more somatic complaints, lower

health status, more influenza-like illness reporting). Other studies reported on behavioural

and biological mechanisms of disease in apparently healthy individuals with a Type D

personality.

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REVIEW OF STUDIES

Psychological factors such as health related belief social, coping styles and personality type

are important predictors of health and illness. Acute and chronic psychological distress has

been associated with the pathogenesis of coronary heart disease (CHD). People with

‗distressed‘ type D personality may face a higher risk of the future cardiovascular problems.

Medicine and Psychology have long been separate discipline, despite the lack of

interdisciplinary studies and research doctors are aware that psychological traits influence the

incidence as well response to the treatment. Psychological factors such as health related

belief, social support, coping styles and personality type are important predictors of health

and illness. The individuals with different personality characteristics have been found to

differ in the way they explain symptoms and seek medical assistance.

The personality classification system that identified ,‖Type A‖ decades ago, more recently

defined ―Type-D‖ as a personality marked by chronic negative emotions , pessimism and

social inhibition. The Type-D profile is relatively new, but the number of studies tracking

Type-D patients and future health is growing. Recent studies have uncovered biologica and

behavioural pathways that may explain the adverse effect of Type-D.

Individual with a Type D personality have the tendency to experience increased negative

emotions across time and situations and tend not to share these emotions with others, because

of fear of rejection or disapproval. John Denollet (1996) professor of medial psychology at

Tilburg university, Tilburg, The Netherlands, developed the construct based on clinical in

cardiac patients, empirical evidence, and existing theories of personality. The prevalence of

type D personality is 21% in the general population Denollet (2005) an ranges between 18 to

53% in cardiac patients Pedersen and Denollet (2006)

Type-D patients appear to respond differently to cardiovascular stress. Type-D is associated

with differences in cortisol , stress hormones that can temporarily increase blood pressure. It

also may be related to elevated levels of inflammation. In addition, heart patients with Type-

D personality may be less likely to get regular medical checkups or communicate effectively

with their physician ( Science daily 2010). Thus the research in the field shows the use of

Type-D personality construct in clinical practice is of practical value.

Type D is a personality construct that is used to describe individuals that experience high

levels of negative affect along with high levels of social inhibition (Denollet et al, 1996).

Research has examined the effect of Type D on patients with established cardiovascular

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disease (CVD),and has indicated that Type D individuals have a poorer clinical prognosis

than non-Type D individuals (e.g. Denollet at al. 2006).

Type-D personality, a concept used in the field of medical psychology, is defined as the joint

tendency towards negative affectivity (e.g. worry, irritability, gloom) and social inhibition

(e.g. reticence and a lack of self- assurance). Research has shown that CHD patients with a

Type-D personality have a worse prognosis following a myocardial infarction (MI) as

compared to patients without a Type-D personality. . Seven items refer to negative

affectivity, and seven items refer to social inhibition. People who score 10 points or more on

both dimensions are classified as Type D. There is increasing evidence that cardiac patients

with a distressed (Type-D) personality comprise high risk patient, and that Type-D is an

important determinant of patient centered and clinical outcome. People who are Type-D,

says J.Denollet, a professor of psychology at Tilburg university in Netherland, have a

negative outlook on life and tend to suppress these feelings and emotions A high score on

the two stable personality traits , negative affectivity and social inhibition defines patients

with the personality D Type (Denollet ,2005).In a study published in ―circulation‖ Denollet

and his colleagues pooled 19 studies involving more than 6000 patients with Type-D

personalities and measured their rates of recurrent heart events compared to non-Type-D

individuals. Type D has been associated with a 4-fold increased in morbidity and mortality in

patients with (CHD) independent of established biomedical ethic factors. Denollet et.al

(1996, 1998). Research on the Type A behaviour pattern suggested that psychological factors

were related to increased risk of heart attacks, but further investigations on Type A behavior

were inconclusive (Rozanski et al., 1999). Subsequently, researchers turned their focus

towards isolated factors such as hostility, depression, anxiety, social isolation, and chronic

stress (Matthews, 2005; Rozanski et al., 1999, 2005; Strike & Steptoe, 2004) to document a

relationship between psychological factors and poor cardiac prognosis (Rozanski et al.,

2005).

More recent studies have also demonstrated a similar relationship between Type D and

mortality in patients with chronic heart failure (CHF) (Schiffer et al., 2010), and peripheral

arterial disease (PAD) (Aquariuset al., 2009). Research has also found that Type D

personality is associated with maladaptive Health related behaviour Type-D patients appear

to respond differently to cardiovascular stress. Type-D is associated with differences in

cortisol stress hormone that can temporarily increase blood pressure. It also may be related to

elevated levels of inflammation. In addition, heart patients with Type-D personality may be

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less likely to get regular medical checkups or communicate effectively with their physician (

Science daily 2010).Thus the research in the field shows the use of Type-D personality

construct in clinical practice is of practical use in clinical and epidemiological research.

The DS14 scale has been validated in Belgian (Denollet, 2005), Chinese (Yu et al., 2008),

Danish (Pedersen &Denollet, 2004; Spindler et al., 2009), Dutch (Denollet, 2005), German

(Grande et al., 2004), Italian (Gremigni & Sommaruga, 2004) and Ukrainian (Pedersen et al.,

2009) cardiac patients and healthy controls. The individuals with different personality

characteristics have been found to differ in the way they explain symptoms and seek medical

assistance.

The personality classification system that identified ,‖Type A‖ decades ago, more recently

defined ―Type-D‖ as a personality marked by chronic negative emotions , pessimism and

social inhibition. The Type-D profile is relatively new, but the number of studies tracking

Type-D patients and future health is growing. Recent studies have uncovered biological and

behavioural pathways that may explain the adverse effect of Type-D

Type-D personality was studied on the populations included policemen, nurses, psychiatrists,

prison workers, employees at a manufacturing plant, female teachers, right-handed males,

university students, undergraduates, youngsters, twins, and respondents from the general

population. The most frequently used questionnaire to determine Type D personality was the

14-item DS14 scale.

Another study assessed Type D by a combination of the Amsterdam Biographical

Questionnaire, the Spielberger Trait Anxiety Inventory and the Young Adult Self-

Report after the combination of scales method, 20 items were selected and used to determine

Type D status.

Whereas the majority of publications on Type D personality among patients with

cardiovascular diseases originate from the Center of Research on Psychology in Somatic

diseases (CoRPS) at Tilburg University, the Netherlands, only 6 studies in the present review

originated from CoRPS and 13 studies on Type D in the general population were performed

by other research groups. The studies were conducted in populations from 8 different

countries: Netherlands (n = 8), United Kingdom (n = 4), Belgium (n = 3), Germany (n = 2),

Canada, Ireland, Poland, and Ukraine.

Type-D personality have the tendency to experience increased negative emotions across time

and situations and tend not to share these emotions with others, because of fear of rejection or

disapproval. Johan Denollet (1996) professor of medical Psychology at Tilburg University,

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Tilburg, The Netherlands, developed the construct based on clinical observations in cardiac

patients, empirical evidence, and existing theories of personality. The prevalence of Type D

personality is 21% in the general population Denollet (2005) and ranges between 18 to 53%

in cardiac patients Pedersen and Denollet (2006).

People who are Type-D, says J. Denollet, a professor of psychology at Tilburg university in

Netherlands, have a negative outlook on life and tend to suppress these feelings and emotions

A high score on the two stable personality traits, negative affectivity and social inhibition

defines patients with the personality D Type (Denollet ,2005).In a study published in

―circulation‖ Denollet and his colleagues pooled 19 studies involving more than 6000

patients with Type-D personalities and measured their rates of recurrent heart events

compared to non-Type-D individuals. Type D has been associated with a 4-fold increased

inmorbidity and mortality in patients with (CHD) independent of established biomedical

ethic factors. Denollet et.al (1996, 1998).

The study, Heritability of type-D personality Kupper N & Denollet J. (2009) provides strong

evidence that genes are important in determining individual differences in type-D personality

and the type-D subcomponents negative affectivity and social inhibition. This study

determined type-D personality by applying the "combination of scales" method to survey data

collected by the Netherlands Twin Register in 3331healthy, young adult twins. Using

structural equation modeling (SEM), the relative contributions of additive genetic, no

additive genetic, and no shared environmental factors to the variance in type-D and its

subcomponents were determined. To explore the prevalence of Type D personality—the

combination of negative affectivity and social inhibition—in the general population and its

relationship to other cardiovascular risk factors, including psychopathological symptoms,

Rebecca Emeny & Jens Baumert (2009), identified Type D personality as a prognostic risk

factor for various cardiovascular disease conditions. The study further said that a Type D

personality disposition can be found in about a quarter of the general population, which is

comparable to the prevalence of classical cardiovascular risk factors. In both sexes, an

independent association to Type D appeared mainly in psychopathological symptoms. Type

D constitutes a relevant and independent risk marker in the community and should receive

attention in clinical practice. Type D personality is a vulnerability factor for general

psychological distress that affects mental and physical health status and is associated with

disease-promoting mechanisms and work-related problems in apparently healthy individuals.

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Type D personality in the general population: a systematic review of health status,

mechanisms of disease, and work-related problems by Floortj Mols & Johan Denollet (2010)

was done to review all available literature concerning Type D (distressed) personality among

the general population and to discuss its implications for research on health status, disease-

promoting mechanisms and work-related problems in non-clinical populations.

In a cross-sectional study on 1592 participants, done by Mommersteeg P,M&Kupper N

(2008) clearly indicates that type D personality is related to an increased prevalence of

metabolic syndrome and unhealthy lifestyle, which suggests both behavioral and biological

vulnerability for development of cardiovascular disorders and diabetes. People with Type D-

Distressed-personality have a general tendency towards increased negative affectivity (NA),

while at the same time inhibiting these emotions in social situations (SI). Type D personality

is associated with an increased risk of adverse outcomes in patients with cardiovascular

disease. Whether Type D personality is a cardiovascular risk factor in healthy populations

remains to be investigated. In the present study, the relations between Type D personality and

classical cardiovascular risk factors, i.e. metabolic syndrome that personality and lifestyle

were investigated in a Dutch community sample.

symptoms Johan Denollet & Paula M.C (2010) studied Type D p, depressive and

work-related health outcomes and it was found Individuals with Type D personality reported

more burnout (27% vs 8%), disability pension (32% vs 11%), and had an increased

incidence of short-term sick leave as compared to non-Type D‘s. Type D was significantly

related to burnout (odds ratio (OR) = 4.16) and disability pension (OR = 2.62) independent of

confounders. The Sobel test indicated significant mediation of depression on the relation

between Type D personality and the work-related health outcomes. After mediation Type D

personality remained significantly relate d to burnout, indicating a unique unshared effect. It

was concluded that Type D personality is related to adverse health outcomes in the working

population, mediated by depression, which warrants further research for this personality type.

Johan Denollet & Angélique A. Schiffer (2008) studied A General Propensity to

Psychological Distress Affects Cardiovascular Outcomes (Type D (Distressed) Personality

Profile) and found evidence Specific negative emotions have been related to adverse cardiac

events, but a general propensity to psychological distress may also affect cardiovascular

outcomes. A reliable estimate of the prognostic risk associated with Type D (distressed)

personality, a general propensity to distress that is defined by high scores on the ―negative

affectivity‖ and ―social inhibition‖ traits.

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Quantitative analyses of prospective studies that included a total of 6121 patients with a

cardiovascular condition indicated that Type D personality was associated with a more than

3-fold increased risk of adverse events (9 studies) and long-term psychological distress (11

studies). In addition, a narrative review of 29 studies showed that Type D personality and

depression are distinct manifestations of psychological distress, with different and

independent cardiovascular effects. There are also plausible biological and behavioral

pathways that may explain this adverse effect of Type D personality. The findings reported

support the simultaneous use of specific and general measures of distress in cardiovascular

research and practice.

Type D personality in the general population: a systematic review of health status,

mechanisms of disease, and work-related problems was done by FloortjeMols& Johan

Denollet (2010.) The objective was to review all available literature concerning Type D

(distressed) personality among the general population and to discuss its implications The

Finally, some studies also showed a negative effect for research on health status, disease-

promoting mechanisms and work-related problems in non-clinical population. The studies

included in this review showed that the presence of Type D characteristics had a negative

impact on mental health status (more symptoms of depression, anxiety, post-traumatic stress

disorder, mental distress, passive coping, and less social support) and physical health status

(more somatic complaints, lower health status, more influenza-like illness reporting). Other

studies reported on behavioral and biological mechanisms of disease in apparently healthy

individuals with a Type D personality. Finally, some studies also showed a negative effect of

Type D personality on work-related problems (Higher absence-leave, higher levels of vital

exhaustion and burnout, and more work-related stress. Type D personality is a vulnerability

factor for general psychological distress that affects mental and physical health status and is

associated with disease-promoting mechanisms and work-related problems in apparently

healthy individuals.

In a study of Type-D personality but not depression predicts severity of anxiety in heart

failure patients at 1-year follow-up by Pedersen S, S & Denollet J. (2010), the results were

that at 12 months follow-up, 26% (9/35) of type-D patients had clinically significant anxiety

versus only 6% (7/114) of the non-type-Ds (p=0.001). In univariable analyses, type-D

personality (OR=5.3; p=0.002) and anxiety sensitivity (OR=4.5; p=0.009), but not depressive

symptoms (p=0.27) predicted clinically significant anxiety.

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Type-D remained an independent predictor of anxiety at 1 year (OR=5.7; p=0.01), controlling

for depressive symptoms, anxiety sensitivity, socio-demographic and clinical variables.

Adding type-D in a hierarchical logistic regression model, comprising standard and

psychological risk factors, enhanced the level of prediction of clinically significant anxiety

substantially (-2 LL=75.16 chi(2)=26.46; p=0.009) and the conclusion was Type-D

personality, but not depressive symptoms predicted 1-year clinically significant anxiety. The

type-D scale could be used to identify CHF patients at high risk of anxiety, as these patients

may be at an increased risk of adverse prognosis and impaired quality of life.

In a cross-sectional study Type D personality is associated with increased metabolic

syndrome prevalence and an unhealthy lifestyle in a cross-sectional Dutch community

sample. Mommersteeg P,M & Kupper N (2008),1592 participants were included, aged 20-80

years. Metabolic syndrome was defined by self-report, following the International Diabetes

Federation-IDF-guidelines including an increased waist circumference, dyslipidemia,

hypertension, and diabetes. In addition lifestyle factors smoking, alcohol use, exercise and

dietary habits were examined. Metabolic syndrome prevalence was stratified by Type D

personality (a high score on both NA and SI), lifestyle and c onfounders age, gender, having

a partner, higher education level, cardiac history, family history of cardiovascular disease.

Results were strongly supporting that Metabolic syndrome was more prevalent in persons

with a Type D personality (13% vs. 6%). Persons with Type D personality made poorer

lifestyle choices, adhered less to the physical activity norm (OR = 1.5, 95%CI = 1.1-2.0, p =

.02), had a less varied diet (OR = 0.50, 95%CI = 0.40-0.70, p < .0005), and were less likely to

restrict their fat intake (OR = 0.70, 95%CI = 0.50-0.90, p = .01). Type D personality was

related to a twofold increased risk of metabolic syndrome (OR = 2.2, 95%CI = 1.2-4.0, p =

.011), independent of lifestyle factors and confounders and it was summed up that Type D

personality is related to an increased prevalence of metabolic syndrome and unhealthy

lifestyle, which suggests both behavioural and biological vulnerability for development of

cardiovascular disorders and diabetes.

Type-D personality mechanisms of effect: the role of health-related behavior and social

support was investigated by Greatly M, A & O'Carroll R,E (2010). The objectives of the

study were to(a) investigate the prevalence of type -D personality (the conjoint effects of

negative affectivity and social inhibition) in a healthy British and Irish population; (b) to test

the influence of type-D on health-relate d behavior, and (c) to determine if these relationships

are explained by neuroticism. A cross-sectional design was employed; 1012 healthy young

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adults (225 males, 787 females, mean age 20.5 years) from the United Kingdom and Ireland

completed measures of type-D personality, health behaviors, social support, and neuroticism.

The prevalence of type-D was found to be 38.5%, significantly higher than that reported in

other European countries. In addition, type-D individuals reported performing significantly

fewer health-related behaviors and lower levels of social support than non-type-D

individuals. These relationships remained significant after controlling for neuroticism. These

findings provide new evidence on type-D and suggest a role for health-related behavior in

explaining the link between type-D and poor clinical prognosis in cardiac patients.

Xiao-nan Yu & Jianxin Zhang (2010) investigated Coping Mediates the Association between

Type D Personality and Perceived Health in Chinese Patients with Coronary Heart Disease

.This study examined the association between Type D personality, coping, and perceived

health among Chinese patients with coronary heart disease (CHD). One hundred seventeen

CHD patients completed the assessments on Type D personality, coping, perceived severity

of CHD, and morale.

It was found there was no difference on se verity of coronary artery stenosis between Type D

and non-Type D patients. Compared to the non-Type D patients, the Type D patients

perceived higher severity of CHD (5.31 ± 2.41 versus 4.45 ± 2.17, p < 0.05) and lower

morale (12.67 ± 4.71 versus 15.00 ± 4.43, p < 0.05), and used less confrontation (16.90

±5.39 versus 20.88 ± 4.95, p < 0.001) and more acceptance–resignation coping (10.16 ±3.50

versus 8.35 ± 3.48, p < 0.05). Mediation analyses showed that confrontation coping mediated

the association between Type D personality and perceived severity of disease, and

acceptance–resignation coping mediated the association between Type D personality and

morale after controlling for age, gender, and clinical variables. Conclusion: The Type D

patients used maladaptive coping in response to disease. These coping strategies fully

mediated the association between Type D personality and perceived health. Implications for

integrating coping training into the intervention for patients with a Type D personality are

discussed.

Cortisol awakening response is elevated in acute coronary syndrome patients with type-

D personality was studied by Daisy L,W & Linda P,P (2008)

Salivary cortisol was assessed eight times over a 24-h period in 72 patients within 5 days of

admission for ACS. Depressive symptoms were measured with the Beck Depression

Inventory (BDI), and type-D personality was measured with the Type-D Scale-16. Particular

attention was given to cortisol awakening response (CAR), which was measured as the

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difference in cortisol between waking and peak responses 15–30 min later. Cortisol showed a

typical diurnal pattern, with low levels in the evening, high levels early in the day, and CAR

averaging 7.58±10.0 nmol/l. Cortisol was not related to the severity of ACS or underlying

coronary artery disease or to BDI scores. The CAR was positively associated with type-D

personality independently of age, gender, and body mass (P=.007). Linear regression showed

that type-D personality accounted for 7.9% of the variance in CAR after age, sex, body mass,

BDI, cortisol level on waking, and fatigue had been taken into account ( P=.008). Type-D

personality may be associated with disruption of HPA axis function in survivors of acute

cardiac events and may contribute to heightened inflammatory responses influencing future

cardiac morbidity.

Denollet J & Heijnen C,J (2009) studied Type D personality, temperament, and mental

health in military personnel awaiting deployment. In this study Type D personality,

temperament, and questionnaires on mental health were filled out by 86 healthy male Dutch

military personnel before UN deployment to Afghanistan. The results were that Type D

personality was present in 16% of healthy military personnel before deployment. The Type D

components social inhibition (α  =  0.89) and negative affectivity (α  =  0.85) correlated

positively with harm avoidant temperament (r =  0.66 and 0.46) and negatively with self-

directed character (r  =  -0.33 and -0.57). In addition, these four traits loaded on the same

broad personality dimension. Military men with a Type D personality not only reported

significantly less self-directedness and more harm avoidance as compared to non-Type D

men (p <  0.001) but also more symptoms of PTSD, general emotional distress, and hostility

(all p <  0.012).

The findings were concluded as Type D personality was associated with harm avoidance,

low self-directedness, and increased symptoms of PTSD and host ility in men awaiting

deployment. This association was not caused by any somatic confounding in these young,

healthy men.

Type D is also associated with poor health status (including symptoms of anxiety and

depression, and lower quality of life) in various cardiovascular disease patient groups,

studied by Johnston D,W & Hay J,L(2010)

Type D personality (the combination of negative affect and social inhibition) is associated

with poor prognosis in cardiac patients. The current study aims to investigate the relationship

between Type D and health-related behaviours. In a cross-sectional study, 200 healthy

participants completed measures of Type D personality, and health-related behaviours. The

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results showed that Type D individuals engaged in more unhealthy behaviours including

smoking, poor diet and lack of physical activity than non-Type D individuals. The association

between Type D personality and maladaptive health behaviours may represent one

mechanism to explain the link between Type D and ill-health

A study of Negative affective, social inhibition (Type D personality) and Depression of

C.H.D., Diabetes, kidney and Blood pressure patients was done by Zala, K,J,(2010). In this

research two test were administrated individually as well as on male and female of different

Dieses, while collecting data for the study before attempting the questionnaire. In a

representative sample of 320 individuals (Different 4 dieses). Type D was assessed with the

Gujarati version for Dennollet Type D Scale-14 and Depression assessed for Lonard and

Deragreties scale. There is significance difference each of Dieses and there is significance

difference between sex (male and female), Area (Rural and Urban) and social economic

status (High, medium , Low) variables.

A study of Depression and Type D personality between psychosomatic male and female by

Herachi, S.H, (2009)showed that there is significance difference for male and female

between Negative affectivity and social inhibition (Type D personality), and also a

significance difference between male and female on Depression.

A study of Depression and Type D personality between psychosomatic patients and Normal

people by Thomas, S,R,(2009) concluded that There is significance difference between

psychosomatic patients and Normal people on Depression and there is significance difference

for psychosomatic patients and Normal people on Type d personality. There is also

significance difference between male and female on Depression and type d personality.

assessed on Type D personality, mental distress, perceived social support and HRQoL with

the following self-administered questionnaires: the Type D personality scale - 14, the

Hospital Anxiety and Depression scale, the Multidimensional Scale of Perceived Social

Support and the Minnesota Living with Heart Failure Questionnaire.

Results were that she prevalence of Type D personality within the study population was

33.5%. Type D personality, anxiety symptoms, depressive symptoms and social support were

all found to be determinants of decreased HRQoL (p‘s < 0.001), once age, gender, NYHA

functional class and acute myocardial infarction were adjusted for. Anxiety, depressive

symptoms and social support were found to mediate the relationship between Type D

personality and HRQoL. Type D personality exerted a stable effect on HRQoL over

24 months follow-up period. Type D personality has an independent significant effect on the

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HRQoL in CAD patients with heart failure, and this relation is mediated by anxiety and

depressive symptoms, social support.

Type D personality trait is associated with numerous adverse behavioral and biological traits

that can predispose towards progression of heart failure and worse patient outcomes. For

example, it has been demonstrated in patients with established heart failure, that Type D

personality is associated increased risk for poor treatment adherence and greater serum

inflammatory marker concentrations .Mommersteeg PM, Pelle AJ, Ramakers C, Szabo BM,

Denollet J, Kupper (2012).

Type D personality is defined as having a high score on two stable personality traits, negative

affectivity and social inhibition. Inhibited individuals are more vulnerable for developing

anxiety and therefore Type D personality patients are at risk to experience increased levels of

anxiety symptoms. In heart failure patients, Type D personality, but not depressive symptoms

predicted clinically significant anxiety at 1-year follow-up. These findings suggest that

assessment of type D status could be used to identify heart failure patients at high risk for

future anxiety that can subsequently contribute towards impaired quality of life .Bunevicius

A, Staniute M, Brozaitiene J, Stropute D, Bunevicius R, DenolletJ(2013).Type D personality

patients experience increased levels of depressive symptoms For example, in one-year

follow-up study of heart failure patients, Type D personality trait was independently

associated with greater depressive symptom severity. It is well established that depression.

Kupper N, Pedersen SS, Höfer S, Saner H, Oldridge N, Denollet J (2013).

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