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Type D personality and vulnerability to adverse outcomes in heart disease

August 1, 2011|Cleveland Clinic Journal of Medicine
Johan Denollet, PhD;Viviane M. Conraads, MD, PhD
Author and Disclosure Information

Johan Denollet, PhD
CoRPS–Center of Research on Psychology in Somatic diseases, Tilburg University, Tilburg, The Netherlands; Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium

Viviane M. Conraads, MD, PhD
Department of Cardiology, Antwerp University Hospital, Antwerp, Belgium

Correspondence: Johan Denollet, PhD, CoRPS, Department of Medical Psychology and Neuropsychology, Tilburg University, P.O. Box 90153, 5000 LE Tilburg, The Netherlands; denollet@uvt.nl

Both authors reported that they have no financial relationships that pose a potential conflict of interest with this article.

This work was supported by the Netherlands Organization for Scientific Research (The Hague, The Netherlands) with a VICI grant (453-04-004) to Dr. Johan Denollet.

ABSTRACTGeneral distress, shared across depression, anxiety and anger, partly accounts for the link between mind and heart. The type D (distressed) personality profile identifies individuals who are particularly vulnerable to the adverse effect of general distress. Type D individuals frequently experience negative emotions and are socially inhibited. This profile is more stable than that associated with episodes of clinical depression and describes the chronic nature of distress in some patients. Type D may also partly account for the effect of emotional distress on cardiac prognosis. Type D is associated with a threefold increased risk of adverse cardiovascular outcomes, even after adjustment for depression. This relationship is less obvious in patients with heart failure. Plausible pathways linking type D to cardiovascular complications include hypothalamic-pituitary-adrenal–axis hyperreactivity, autonomic and inflammatory dysregulation, and increased oxidative stress. Research needs to further clarify these pathways and investigate whether type D patients may benefit from closer monitoring of risk factors and a personalized approach to behavioral intervention. The DS14 is a brief, well-validated measure of type D that could be incorporated into clinical research and practice to identify high-risk patients.

Depression has been studied extensively in relation to cardiovascular disease.1–3 In addition to depression, anger4 and anxiety5 also may promote coronary artery disease (CAD), suggesting that emotional distress in general may be related to increased cardiovascular risk. Evidence indicates that the general distress shared across depression, anger, and anxiety predicts CAD, even after controlling for each of these specific negative emotions.6

THE CONCEPT OF TYPE D PERSONALITY

Lately, there is a renewed interest in broad individual differences in general distress and heart disease.7 Since psychologic factors often cluster together in individual patients, biobehavioral research may benefit from the identification of discrete personality subtypes.8 This focus on the identification of psychologically vulnerable patients who are at increased risk for adverse outcomes has led to the introduction of the distressed9 or type D10 personality profile in cardiovascular research. This personality construct is defined as follows:

“The type D (distressed) personality profile refers to a general propensity to psychological distress that is characterized by the combination of negative affectivity and social inhibition.”10

Negative affectivity, or the tendency to experience negative emotions across time and situations, is a major determinant of emotional distress in cardiac patients.9,10 Patients who score high on this trait frequently report feelings of dysphoria, worry, and tension. Social inhibition, or the tendency to inhibit the expression of emotions or behavior, is a major determinant of social distress.9,10 Patients who score high on this trait tend to avoid negative reactions from others.

Both traits define psychologically vulnerable patients and can be assessed with the type D scale (DS14).10 This brief measure consists of a seven-item negative affectivity subscale (eg, I often feel unhappy) and a seven-item inhibition subscale (eg, I am inhibited in social interactions), and has a clear two-factor structure and good reliability (Cronbach’s α = .88 and .86). Patients are classified as type D if they score 10 or higher on both DS14 subscales.10 The prevalence of type D personality ranges between 20% and 40% across different types of cardiovascular conditions.

The type D construct was designed for the early identification of chronically distressed patients. This article reviews (1) the risk of adverse events associated with type D, (2) the extent to which type D is distinct from depression, (3) the biologic pathways of type D, and (4) the implications of the type D personality profile.

RISK ASSOCIATED WITH TYPE D

Several prospective studies from our group have examined the notion that type D patients are particularly vulnerable to adverse events (Table 1). In patients with CAD, evidence indicates that type D personality is an independent predictor of adverse events, including (cardiac) death, myocardial infarction, and need for revascularization procedures.11–16 In these studies, type D also emerged as an independent predictor of adverse events after adjustment for anxiety,11 stress,13 depression,16 disease severity,11–16 and type of invasive treatment.14 This increased risk associated with the type D profile was observed in the broader group of patients with CAD,11–15 as well as in patients who survived an initial myocardial infarction.16

The relationship between type D personality and adverse events has also been investigated in other cardiovascular conditions. Type D has been associated with poor prognosis in patients with peripheral arterial disease,17 but evidence for the prognostic role of type D in patients with chronic heart failure is mixed. In a study of patients with heart failure following myocardial infarction, type D predicted cardiac death independent of disease severity18; in a study of heart failure patients who underwent cardiac transplantation, type D was associated with early allograft rejection and increased mortality.19 However, type D was not associated with cardiac death in a recent, larger heart failure study.20 The link between psychologic factors and heart failure is complex3 and may be less obvious than the type D-CAD link.20 Type D has also been associated with the occurrence of life-threatening arrhythmias following implantable cardioverter defibrillator (ICD) treatment,21 and it has been shown to predict an increased risk for mortality in ICD patients, independent from shocks and disease severity.22

The wide range in odds ratios and confidence intervals indicates disparity in data across these type D studies (Table 1). We recently performed a metaanalysis of prospective studies between 1996 and 2009 to provide a more reliable estimate of the risk associated with type D. In this analysis, type D was associated with a threefold increased risk of adverse events23; the confidence interval of this pooled odds ratio ranged from 2.7 to 5.1. In addition, type D personality was associated with a threefold increased risk (range, 2.6 to 4.3) of emotional distress over time.23 From the recent studies that were not included in this meta-analysis, one reported negative findings20 and three others positive findings16,21,22 on the risk associated with type D.

COMPARING DEPRESSION AND TYPE D

Many studies report on depression and cardiac disease,1–3 but both conceptual differences and clinical evidence indicate that type D and depression are distinct forms of distress (Table 2). Conceptually, type D focuses not only on depressive affect but also on the general distress shared across negative emotions,10 and it is based on the notion that social inhibition modulates the effect of negative emotions on cardiac prognosis.24 While depression refers to an episodic distress factor (patients may go in and out of depressive episodes), the type D construct focuses on an underlying factor that predisposes patients to more chronic forms of distress.8

Clinical evidence shows that, after adjustment for depression, type D remained a predictor of adverse cardiac events in CAD.16,24,25 Following ICD implantation, anxious type D patients were at risk of ventricular arrhythmias, whereas depression did not predict arrhythmias.21 Type D also exerts an adverse effect on patients’ health status following coronary bypass surgery,26 heart failure,27 or myocardial infarction,28 adjusting for depressive symptoms. Type D is related to biomarkers of increased stress levels independent of depression29–31 and, unlike depression, type D is not confounded by the severity of cardiac disorder.32

Following myocardial infarction, only one of four distressed patients met criteria for both type D and depression; most had one form of distress but not the other.32 Research in healthy33 and in cardiac34 populations confirmed that items from depression and type D scales reflect different distress factors. After adjustment for depression at baseline, type D also predicted the incidence,35 persistence,36 and severity37,38 of depression and anxiety. However, these findings do not imply that depression and type D are antonymous perspectives or that one perspective is better than the other in predicting outcomes; rather, we would like to argue that both constructs represent complementary perspectives that have added value.23

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