Running Head: TYPE D PERSONALITY     

  

 Evaluating the Relationship between Type D Personality and

Cardiovascular Disease      

Abstract

The purpose of this paper is to investigate the potential relationship between Type D Personality

(the tendency to inhibit negative emotions) and cardiovascular disease. The literature review

conducted, supports an association of individuals with Type D personality having an increased

mortality with cardiovascular disease. People with Type D personality in comparison to those

with non-Type D personalities were found to experience adverse events typical of cardiovascular

disease, such as death and myocardial infarction, despite receiving medical treatment for the

disease (Pedersen et al., 2006). Furthermore, these findings suggest that individuals with

cardiovascular disease and Type D personality may need programs such as cardiac rehabilitation

which has been found to be helpful in reducing the negative aspects of this personality type.    

   

Introduction

Since the landmark paper by Friedman and Rosenman (1959), the relationship between

personality factors and cardiovascular disease has been studied extensively. Initially, Friedman

and Rosenman reported an association between Type A behavior, which is exhibited by

individuals who are hard-charging, competitive and driven, and the prevalence of coronary heart

disease (Friedman, 1977). However, due to inconsistencies found by researchers, Case, Heller,

Case and Moss (1985), Type A personality is no longer seen as a risk factor for cardiovascular

disease. Type A personality also does not predict the later development of coronary heart disease

as hypothesized by Friedman (Leon, Finn, Murray, & Bailey, 1988). Due to the lack of sufficient

evidence linking cardiovascular disease to Type A personality a recent approach is investigating

a potential relationship between Type D Personality (TDP), which is described as the tendency to

inhibit negative emotions, and cardiovascular disease.

TDP was coined by Johan Denollet in 1996 (Denollet et al., 1996) who noticed that

cardiac patients either remained cheerful or pessimistic after suffering major damage to their

hearts (Harvard Heart Letter, 2005). Cheerful patients were more likely to get involved in the

rehabilitation activities whilst pessimistic patients declined rehabilitation programs, regardless of

the severity of heart damage (Brooks, 2006). On making this observation, Denollet coined the

term TDP which he used to describe the personality of the pessimistic patients who tended to

“simultaneously experience negative emotions and inhibit self-expression” (Denollet et al.). TDP

is characterized by negative affectivity (emotional distress) and social inhibition, the reluctance

or inability to confide in others. TDP is also known as the “distressed” personality and is defined

as the type of personality in which negativity flourishes through hostility, insecurity, worry,

tension, and other negative emotions (Harvard Heart Letter, 2005). A person with this

personality type is characterized as having low self-esteem, being socially withdrawn and

depressed (Smith, n.d). In another framework, TDP may represent the “driven” personality

where a person would be “aggressive, outgoing and decisive” (Smith).

Since Denollet’s observation there has been much research on TDP (e.g., Pedersen et al.,

2006, Schiffer et al., 2005 and Denollet, 1991). A primary research focus has centered on the

finding that TDP persons tend to make a “big deal” out of stressful situations by focusing on the

negative and not the positive. According to Cadena (2006), people with TDP tend to have high

anxiety and stress levels which are known to be associated with a negative impact on the heart. It

is findings such as these that prompted the conjecture of cardiovascular disease being linked to

TDP.

It is well established that those with cardiovascular disease, changes in one’s lifestyle are

necessary for preventing cardiac death (American Heart Association, 2009). The research

on TDP reports a decreased lifespan when this personality pattern is coupled with cardiovascular

disease (Pedersen et al., 2004). These negative effects associated with TDP suggest an urgency

to adopt an approach which clearly identifies the personality profile in order to distinguish those

at increased risk for cardiac events. The purpose of this paper is to examine the relationship

between TDP and cardiovascular disease.  In addition, it will also examine how TDP may be a

predictor of some adverse events that accompany cardiovascular disease such as depression,

anxiety or exhaustion.

Understanding TDP - Negative Affectivity and Social Inhibition

Both negative affectivity and social inhibition are typically demonstrated in persons with

TDP (Denollet et al., 1996). The main feature of negative affectivity is an increased tendency to

display and experience negative emotions across situations as a coping technique to life’s

demands. This approach differs from other methods of coping wherein the behavior would be to

avoid distress via repressive coping. Denollet (1991) investigated negative affectivity and

distress avoidance as displayed by repressive coping to determine if coping style influenced the

amount of physical and psychological health complaints reported by male patients with coronary

heart disease going through rehabilitation. Participants were divided into three groups: high

negative affectivity, low negative affectivity and repressive coping. Results showed that negative

mood states and health complaints were reported more by individuals with high negative

affectivity in comparison to those with low negative affectivity and repressive coping. The study

also found that persons with the tendency to experience negative emotions, high negative

affectivity patients also exaggerated their physical problems more than the persons with high

repressive coping who tend to avoid distress.

     More recently, Jonas and Lando (2000) set out to test the hypothesis that negative affectivity

is a risk factor for hypertension. Additionally, they explored whether one’s race would impact

the results in healthy men and women. In order to measure negative affectivity, Jonas and Lando

administered several scales (e.g., General Well-Being Schedule and Minnesota Multiphasic

Personality Inventory) which measured symptoms of depression, anxiety, nervousness, stress,

tension, unhappiness and despair.  At baseline, no participant had hypertension but during a four

wave follow-up spanning ten years Jonas and Lando found that several men and women of both

races developed hypertension in later assessments. The results showed that all individuals with

negative affectivity at baseline had elevated relative risk for hypertension. However, consistently

throughout each wave, black women with negative affectivity, had the highest rate of

hypertension.

TDP may also play a role in a more serious cardiovascular disease, chronic heart failure.

Pelle, Pedersen, Szabo and Denollet (2009) investigated the reported health status of chronic

heart failure patients with TDP, non-TDP patients with low positive affect (also called

anhedonia) and non-TDP individuals with high positive affect (energy, enthusiasm and an upbeat

attitude) to determine who would report having a lower health status. Pelle, Pedersen, Szabo and

Denollet hypothesized that TDP may lead to impaired health status in persons with chronic heart

failure. At baseline and at the twelve month follow-up, patients completed questionnaires on

health status, TDP, positive affect and health complaints. Results showed that individuals with

TDP and those non-TDP individuals with low positive affect had lower health status and

reported more disabilities than non-TDP persons with high positive affect. Additionally, TDP

individuals experienced more cardiac symptoms than non-TDP participants with high and low

positive affect suggesting that the negative affectivity component of TDP may have an impact on

health status.      

Cardiac resynchronization therapy (CRT), a treatment for chronic heart failure, and its

possible relation to negative affectivity, was investigated by Schiffer, Denollet, Pederson, Broers,

& Widdershoven (2008). Participants receiving this therapy filled out the DS14, and other scales

that measured disease-specific health status, cardiac symptoms and perceived disability. They

also performed six-minutes of walking as a test of their functional capacity. Generally, due to the

CRT there was improvement in disease-specific health status, cardiac symptoms, perceived

disability, and functional capacity for those with low negative affectivity. This differed from

those with high negative affectivity, who were more likely to report impaired health status,

perceived disability and cardiac symptoms.  

Although it is normal to experience negative emotions, it is the inhibition of these

emotions that may be detrimental to one’s health (Denollet et al., 2006). This second feature, the

inhibition of negative emotions that TDP individuals often experience, is termed social

inhibition. Social inhibition and negative affectivity after percutaneous coronary intervention, a

procedure used to treat narrowed arteries of the heart, was studied by Denollet et al. Denollet et

al. found that approximately 11% of cardiac patients experienced a major adverse clinical event

at the nine month follow-up after the percutaneous coronary intervention. Individuals classified

with low social inhibition and high negative affectivity experienced no adverse events. However,

individuals with high negative affectivity and high social inhibition were found to be at increased

risk for adverse cardiac events such as death and myocardial infarction. The results of Denollet et

al. indicate that increased levels of social inhibition, as well as the combination of social

inhibition and negative affectivity increase the likelihood of poor clinical outcome following

percutaneous coronary intervention.

Assessing Type D Personality

Historically, the Global Mood Scale (GMS) (Watson & Tellegen, 1985) was used to assess individuals with TDP (Denollet, 1993). The GMS was developed using fifty-six mood

terms reflecting positive and negative mood states which led to a twenty item mood state scale measuring negative and positive affect. In examining the psychometric properties of the GMS, Denollet administered the twenty-item GMS measure (ten positive and ten negative mood states) to patients with coronary heart disease in order to determine how the scale correlated with other accepted measures of emotional distress (Profile of Mood States, State-Trait Anxiety Inventory, Heart Patients Psychological Questionnaire and Marlowe-Crowne scale). The sensitivity of the GMS to changes in affect was completed by patients three months after the first completion of the GMS. Results showed the GMS to be reliable and correlations with other measures of emotional distress showed good convergent validity in patients with coronary heart disease. Results also indicated that the GMS was sensitive to change as indicated by a difference in scores before and after rehabilitation.

Denollet and Vries (2006) further investigated the validity of the GMS by comparing it to

the Positive and Negative Affect Schedule (PANAS)(Watson & Tellegen, 1988). The GMS and

PANAS assess two different facets of negative affectivity: unhappiness and deactivation, and

arousal and anxious apprehension, respectively. Both measures define positive affect similarly.

Findings from this study showed the GMS to be valid and highly correlated with PANAS,

making a good measure of the global construct negative affectivity.

Social inhibition and negative affectivity are the key components that characterize TDP;

however there has been some concern over the validation of TDP as it relates to emotional

distress (Denolett & Fruyt, 2002). Due to this concern, Denolett and Fruyt (2002) investigated

how TDP could be understood by way of the NEO Five Factor Inventory, the short version of the

NEO-Personality Inventory which measures neuroticism, extraversion, openness to experience,

agreeableness and conscientiousness. The Job Stress Survey (containing 30 items measuring

stress faced by people at their job) and the General Health Questionnaire (GHQ28, a 28 item

scale measuring individual health status and well-being) were administered to healthy

individuals. Denollet and Fruyt found that TDP and non-TDP individuals both experience similar

job stress but TDP individuals scored higher on the depression scale of the GHQ28. They also

found that TDP could be understood in terms of the Neuroticism and Extraversion dimensions of

the Five Factor Model which were positively correlated with Negative Affectivity (0.74) and

negatively correlated with Social Inhibition (-0.61) respectively. Overall, the research further

validated TDP as a predictor for emotional distress.

Several existing scales including the GMS, have been used to measure the two

components of TDP - social inhibition and negative affectivity. However, an assessment that

specifically measures both components was desirable. For this reason, the Type D Scale 16

(DS16) was developed (Denollet, 1998). The scale consists of sixteen items, which relate to

negative affectivity and social inhibition that reflected anxiety, irritability, dominance,

discomfort and social poise. By using a three month interval of test-retest measurement, the

psychometric reliability of DS16 indicated that the scale is a good assessment tool for both

negative affectivity (0.78) and social inhibition (0.87). Using Cronbach’s alpha, negative

affectivity (0.89) and social inhibition (0.82) were found to have good internal consistency.

Denollet found the DS16 to be both valid and reliable as well as a good measure of the two main

components, social inhibition and negative affectivity.      

After the DS16 was introduced, Denollet (2000) set out to construct the DS24. Denollet’s

study involved hypertensive patients who were asked to complete the DS24 which comprised of

thirteen items from the DS16 and eleven items that were developed to improve upon the

assessment of the two components. Negative affectivity items better reflected dysphoria and

tension and social inhibition items better reflected reticence and withdrawal. Principal

components analysis was used to examine the structural validity of the items and Cronbach’s

alpha was used to measure internal consistency. Results showed that all negative affectivity and

social inhibition items correlated with their personality domains with an internal consistency of

0.89.    

Denollet once again sought to improve the assessment of social inhibition and negative

affectivity by offering a briefer version of the DS16 called the Type D Scale 14 (DS14). The

DS14 differed from the DS16 in that negative affectivity items were added to better reflect

anxiety and irritability. Also, the DS16 dominance items were replaced by social inhibition items

of the DS14 that reflected the tendency to avoid potential dangers of social interaction. Denollet

(2005) examined the validity of the DS14, by investigating the stability of negative affectivity

and social inhibition as well as determining the prevalence of TDP. To determine the prevalence

of TDP, individuals from the general population were compared to patients with coronary arterial

disease and patients with hypertension. Denollet found that the prevalence of TDP in patients

with coronary arterial disease (28%) and hypertension (53%) was greater than those in the

general population (21%). To test the scales’ test-retest reliability, cardiac rehabilitation patients

filled out the DS14 at the beginning and at the end of the rehabilitation program. The DS14

appeared to have good temporal stability with test-retest results showing social inhibition to be

0.82 and negative affectivity to be 0.72. To test the scale’s internal validity, two factors from the

NEO-Five Factor Inventory scale, neuroticism and introversion, were compared with negative

affectivity and social inhibition, respectively. Results indicated that negative affectivity and

social inhibition positively correlated with neuroticism and introversion showing that the DS14

has good internal validity. Overall, results showed the DS14 scale to be valid and reliable.

Further investigation of the DS14 suggests that the scale has good external validity. For

example, the Chinese version of the DS14 was administered to patients with coronary heart

disease and healthy persons to test the scale reliability and validity (Yu, Zhang and Liu, 2008).

Overall results of Yu, Zhang and Liu suggest that the DS14 is an effective assessment tool of

TDP in Chinese populations.

In order to assess the external validity of the items that make up the DS14, Emons, Meijer

and Denollet (2007) compared responses from the general population and individuals with

coronary heart disease and hypertension. A difference in item responses in different populations

with the same trait values of this kind would mean that the scale is biased against a particular

population. Fortunately the scale, along with its components, was found to be comparable

between the clinical and the general population suggesting that the scale is valid across all

groups.             

TDP and Cardiovascular Disease

     The relationship between TDP and cardiovascular disease has been studied across several

factors including quality of life, vital exhaustion, depression, anxiety, and cancer. Additionally,

the role of social support in recovery has been addressed as this has been shown to alleviate the

distress associated with TDP and assisting in coping with cardiovascular disease.

Impact on Quality of Life

Several studies indicate that TDP has an effect on the quality of life of patients after

treatment for a cardiac condition (e.g., Pederson et al., 2006; Pedersen et al., 2004). Pederson et

al. (2006) administered a survey to heart transplant patients which was used to measure their

health related quality of life. The survey contained questions on physical, social and emotional

functioning, mental and general health, and bodily pain. Heart transplant patients also completed

the DS14. Pedersen et al. found that persons with the TDP had lower scores on the physical

component summary and mental component summary than non-TDP individuals suggesting that

TDP may be a predictor in determining which patients may be more at risk for an impaired

quality of life. Specifically, TDP was associated with a three to six fold risk of impaired health

related quality of life compared with non-TDP. In a similar study, Pedersen et al. (2007)

investigated the relevance of TDP as a predictor of one’s health status in percutaneous coronary

intervention patients. Although there was a significant improvement in health status after the

percutaneous coronary intervention, TDP patients had poorer health status than non-TDP patients

at a six and twelve month follow-up period.

In order to evaluate if impaired quality of life and cardiac events are affected by the

emotional distress of a patient, Denollet, Vaes and Brutsaert (2000) examined patients with

coronary heart disease for five years. Their findings suggested that cardiac events, onset of

coronary heart disease at a younger age, and TDP were all independent predictors of reported

impaired quality of life. In addition, when two or more of these risk factors were present, a four-

fold risk of adverse health outcomes was observed. Regardless of treatment, Denollet et al.

argued the need to screen patients for TDP since a risk for poor prognosis is found if emotional

distress is present.

Though used as a positive tool in the prevention of cardiac death, the question arose as to

whether there were any potential adverse effects of the implantable cardioverter-defibrillator. An

implantable cardioverter-defibrillator is a device that uses electrical pulses or shocks to help

control life-threatening, irregular heartbeats, especially those that cause sudden cardiac

arrest. Pedersen, Theuns, Muskens-Heemskerk, Erdman and Jordaens (2007), investigated the

potential negative impact of TDP and the implantable cardioverter defibrillator three months

post-implantation. A day after implantation TDP and non-TDP patients experienced no

significant differences in shocks (which according to the American Heart Association, occur

during an abnormal heartbeat to return the heart to its normal rhythm). However, at the three

month follow-up, TDP patients reported having poorer health related quality of life in

comparison to non-TDP patients with implantable cardioverter defibrillator, independent of

shocks.

TDP may play a role in the health related quality of life in individuals who suffer from

peripheral arterial disease (American Heart Association, 2008). Aquarius, Denollet, Vries and

Hamming (2007) found impairment in the health related quality of life in persons with peripheral

arterial disease and TDP at both the time of treatment as well as one year later at follow-up

compared with individuals not having TDP. Although there was a general improvement in the

health related quality of life in all patients at follow-up, those with TDP had a significantly

poorer quality of life than non-TDP patients. Forty six percent of TDP participants had poor

general health versus 18% who had non-TDP, and 42% of TDP patients scored poorly in the

mental health questionnaire versus 11% of non-TDP patients. Results showed an increased risk

of poor physical and reported psychological health in TDP patients after being treated for the

peripheral artery disease. These studies all indicate that TDP negatively impacts health-related

quality of life.

     One major adverse event of patients with cardiovascular disease is the increased likelihood of

death. Pedersen et al. (2004), examined patients with ischemic heart disease nine months after

having stents implanted for blocked coronary arteries. The aim was to find out if TDP could

predict death or myocardial infarction in this population. Results indicated that those ischemic

heart disease patients with TDP were at an increased risk of death or myocardial infarction

compared to those with non-TDP (5.6% versus 1.3%).

Denollet et al. (1996) tested the hypothesis that personality was an independent predictor

of long-term mortality in patientswith coronary heart disease. The study included patients with

coronary heart disease, 60% of whom had a recent myocardial infarction. The remaining 40%

did not have a recent myocardial infarction but underwent coronary bypass surgery or

angioplasty. At the six to ten year follow-up from the coronary event, 13% of the patients had

died; 63% of these deaths were due to cardiac events; and the other 37% of the deaths were from

natural causes. Of the 85 patients in this study with TDP, 27% died while only 7% of the 218

non-TDP patients died. Overall, these results showed an increased high risk of cardiac events and

subsequent death in patients with both coronary heart disease and TDP.  

Cardiac patients may find their health in a more diminished state than healthy individuals

because of their failure to discuss their symptoms and lack of self-management. Schiffer,

Denollet, Widdershoven, Hendriks, and Smith (2007) examined these two factors, failure to

discuss symptoms and lack of self-management in chronic heart failure patients in order to

determine the relationship to TDP. It was found that for patients with TDP there was a threefold

increased likelihood of worrying in comparison to non-TDP patients.  Interestingly enough,

although persons with TDP were usually quite worrisome about their health, individuals with this

personality type were less likely to consult a doctor about their symptoms and lacked self-

management, thereby exposing themselves to more than a twofold increased risk of experiencing

a cardiac event. Thus, TDP persons may find themselves at higher risk for mortality than non-

TDP individuals.

Denollet, Sys, & Brutsaert (1995) studied a group of men two to five years following

myocardial infarction. Denollet et al. found that personality type, in particular the “distressed”

personality type, was linked to post myocardial infarction mortality. Participants with TDP

reported lack of social support, more stress, depressive cognitions, and more somatization

symptoms than any other personality type. Out of 105 participants 14% died and of those 73%

had TDP. Results indicate that TDP patients have a higher mortality risk than non-TDP patients

following a myocardial infarction. This increased risk is thought to be influenced by greater

psychosocial risk due to personality factors.  

With the aim of determining what effect psychological stress and TDP may have on

cardiac prognosis, Denollet, Pedersen, Vrints, and Conraads (2006) examined the overall health

of 337 patients with coronary heart disease. Results indicate that, after five years, 14% of

patients experienced adverse events such as cardiac death, myocardial infarction or cardiac

revascularization. Results also showed a threefold risk of cardiac events being present in TDP

patients with psychological stress in comparison to non-TDP patients experiencing similar

psychological stress.

More recently, Schiffer, Smith, Pedersen, Widdershoven and Denollet (2009), examined

the prognostic value of TDP for patients with chronic heart failure in an outpatient setting.

Seventy-nine percent were classified as non-TDP and 21% were classified as having TDP. At the

30.7 month follow-up from diagnosis, 20% of patients had died due to cardiac causes. Of

importance, was a higher incidence of cardiac mortality in TDP patients (31.3%) than non-TDP

patients (17.4%). Results of the study indicate that TDP is a valuable prognostic tool for people

with chronic heart failure with TDP patients having a higher likelihood of death than non-TDP

patients. 

When it comes to treating cardiac patients, those with TDP may not be willing to reveal

their emotional distress even if it leaves them feeling vulnerable. Denollet, Nyklicek, Conraads,

and Gelder (2008), examined the role of TDP and repressive coping styles in patients with

coronary artery disease. Denollet et al. administered scales that measure distress, defensiveness,

and the TDP in patients with coronary artery disease. Out of all the patients, 22% were classified

as repressive, 49% were non-repressive and 29% were classified as TDP. Overall, Denollet et al.

found that the repressive group and TDP groups were more at risk than the non-repressive group

for a clinical event. This may be due to TDP and repressive groups being less inclined to report

their true level of distress, thus increasing their risk of long term mortality. TDP and repressive

coping were also considered to be good predictors of cardiac death. Therefore, ascertaining the

personality type and coping methods of an individual may be vital in improving their medical

treatment.Impact on Vital Exhaustion

Vital exhaustion, characterized by unusual fatigue and weakness, increased irritability,

and symptoms of depression, has been found to be associated with the production and

development of cardiovascular disease (Bages, Appels and Falger, 1999). In order to examine the

impact of TDP on exhaustion, Pederson et al. (2007), studied 419 angina patients after

percutaneous coronary intervention with a drug eluting stent implantation. In addition to TDP,

age and gender, which are established predictors of exhaustion, were evaluated. Results showed

TDP patients exhibited more chronic and persistent symptoms of exhaustion than non-TDP

patients regardless of age and gender. In fact, TDP’s impact on vital exhaustion was independent

of both gender and age, thus suggesting that personality type may be an essential factor in

identifying high-risk patients. Subsequently, Pederson and Middel (2001) examined how gender,

angina pectoris, and TDP were related to vital exhaustion in patients before and after coronary

angiography. Pederson and Middel found that only TDP was an independent predictor of vital

exhaustion before and after the intervention. These studies indicate that TDP plays a critical role

in vital exhaustion experienced by cardiac patients.

Impact on Depression and Anxiety

Since both TDP and depression involve the experience of negative emotions, it is

important to clarify if someone with TDP also has depression. Denollet et al. (2009) investigated

whether TDP and depressive disorder are different forms of distress. Denollet et al., screened

patients with myocardial infarction using the Beck Depression Inventory and the DS14. They

were then divided into four groups: depression and TDP, depression only, TDP only, and neither

TDP nor depression. Results showed that of the distressed persons, only 7% of them had both

depression and TDP, 34% had depression only and 39% had TDP only. These findings suggest

that, although TDP and depression share similar characteristics, TDP and depression are different

forms of distress. 

Aquarius, Denollet, Hamming, Henegouwen and Vries (2007) found that impaired

quality of life and depressive symptoms were linked to TDP patients with peripheral arterial

disease. When compared to an ankle brachial index (which measures the severity of peripheral

arterial disease), the severity of a person’s peripheral arterial disease did not predict an impaired

quality of life or depression. However, TDP did with such individuals experiencing depressive

symptoms and significantly poorer quality of life scores than non-TDP patients (Aquarius et al.,

2007).  

     After a myocardial infarction, patients may experience depressive symptoms (post myocardial

infarction depression). The potential course and predictor of these depressive symptoms were

investigated by Martens, Smith, Winter, Denollet and Pedersen (2007). Within the first year after

the myocardial infarction, patients were classified into four groups: non-depressed, mildly

depressed, moderately depressed and severely depressed. Classification was determined through

use of the Beck Depression Inventory, a widely used measure of depressive symptoms. At the

one year follow-up, depressive symptoms remained stable for each group. However, it was found

that TDP, cardiac history and a history of Major Depressive Disorder were risk factors for post

myocardial infarction depression with patients having all three risk factors experiencing a greater

likelihood of moderate and severe depressive symptoms.    

With the aim of assessing the association of TDP and increased depressive symptoms,

patients with chronic heart failure were examined (Schiffer et al., 2005). Forty-seven percent of

TDP patients reported having symptoms of depression compared with 13% of non-TDP patients.

The results of Schiffer et al. (2005) were found to be consistent with Pedersen et al. (2006), who

studied TDP to determine the risk of depressive symptoms. Participants had percutaneous

coronary intervention and had no depressive symptoms at baseline. However, at the twelve

month intervention follow-up, 36% of patients who experienced depressed symptoms were more

likely to have TDP than patients who were not depressed (16%). Both of these studies suggest a

positive relationship between TDP and depressive symptoms.   

As discussed, TDP has been shown to be an independent predictor of depressive

symptoms, but the role of TDP on anxiety remains unanswered. Splinder, Pedersen, Serruys,

Erdman and Domburg (2007) investigated TDP as a possible predictor of chronic anxiety after

percutaneous coronary intervention. Patients with coronary artery disease completed the DS14,

and anxiety and depression questionnaires at baseline and again at follow-up (twelve months

after post percutaneous coronary intervention). Sixty-five percent of patients who experienced

anxiety at baseline still experienced anxiety at the follow-up and were more likely to have TDP

than non-TDP patients. Thus, results indicated that TDP is related to a threefold increased risk of

chronic anxiety.        

Possible determinants of anxiety, TDP and depression, in those with chronic heart failure

were investigated by Schiffer, Pedersen, Broers, Widdershoven and Denollet (2008). Patients

completed anxiety and depression questionnaires and the DS14 as well as being interviewed at

one year follow-up. It was found that 26% of TDP patients had a clinically significant amount of

anxiety compared with 6% of those who were non-TDP. Depressive symptoms were not found to

be a predictor of anxiety, unlike TDP. TDP patients’ risk of anxiety was more than five-fold.

Similar results were also found in a study of post-percutaneous coronary intervention patients,

with TDP individuals showing higher levels of anxiety than non-TDP patients (Gestel et al.,

2007). Additionally, results showed TDP having a stable effect on anxiety over a period of

twelve months with 67% of patients who were anxious at baseline still being anxious at follow-

up.

Pedersen, Splinder, Johansen, & Mortensen (2009) examined patients with implantable

cardioverter defibrillators to determine the influence of two psychosocial risk factors (TDP and

poor device acceptance) on anxiety and depressive symptoms. These patients were divided into

four groups: no risk factors (no poor device acceptance or TDP), TDP only, poor device

acceptance only, and clustering (both poor device acceptance and TDP). Both psychosocial

factors have been found to impair one’s quality of life and cause psychological distress. Results

of Pedersen et al., suggest that 26.5% of patients with TDP and 30% of patients with poor device

acceptance were more likely to experience anxiety symptoms compared with those with no risk

factors. Also, 19.1% of patients with poor device acceptance and 23.5% of TDP patients were

more likely to have depressive symptoms than patients with no risk factors.

As a way of preventing cardiac death an implantable cardioverter defibrillator may be

employed instead of antiarrhythmic medication. Although there are many benefits of an

implantable cardioverter defibrillator, patients may express several concerns and worries about

its effects (such as getting shocked). Therefore, Pederson, Theuns, Erdman, & Jordaens (2008)

examined the impact that device related concerns and TDP may have on depresson and anxiety.

Patients with implantable cardioverter defibrillator were divided into four risk groups: non-TDP

patients with no concerns about the implantable cardioverter defibrillator; implantable

cardioverter defibrillator concerns only; TDP concerns only; and both TDP and implantable

cardioverter defibrillator concerns. Assessment tools included the DS14, the Hospital Anxiety

and Depression Scale (depression and anxiety) and the Implantable Cardioverter Defibrillator

Concerns questionnaire. The results showed that those with TDP were more likely to have device

related concerns than those with non-TDP (63.2% vs. 26.8%). TDP also had a great impact on

anxiety and depression, suggesting that personality type may be an important consideration in

treatment protocols.

Impact on Cancer

     The discussion thus far suggests that TDP appears to have adverse effects on individuals with

cardiovascular disease. Another issue, whether those with coronary heart disease may be at

higher risk for cancer was indicated. Denollet (1998) observed men between the ages of 31-79

with coronary heart disease who were cancer-free at the beginning of the study. At a follow-up,

six to ten years later, 5% of participants were diagnosed with cancer, 75% of these patients died.

Out of these patients who develop cancer by the time of follow-up, 13% of the men had TDP and

2% had non-TDP. These findings suggest that for persons with coronary heart disease, emotional

distress may increase the likelihood of getting cancer.

Impact of Social Support

    With the many adverse events that an individual with cardiovascular disease may

possibly face, the presence of social support, e.g. being loved and cared for by others through the

provision of physical and emotional comfort, is essential. An example of an especially difficult

situation where social support is needed is after myocardial infarction. Pedersen, Middel, and

Larsen (2002) examined if the level of social support may determine whether a patient is likely

to report more or less distress following a myocardial infarction. They also examined personality

traits that may hinder the development of social contacts thereby receiving less social support.

Pedersen, Middel and Larsen found that patients who reported higher satisfaction with their

social support system also reported lower distress and health complaints than those less satisfied

with their social support. The less satisfied patients reported more health complaints and were at

an increased risk for anxiety, depression, and posttraumatic stress disorder. However, the

personality trait that Pedersen et al. (2002) found to be a true independent predictor of all

outcome measures was neuroticism, which Denollet and Fruyt (2002) indicate is similar to

TDP’s negative affectivity component.  These results suggest that personality traits play a role in

a patient’s outcome.     

For a person dealing with cardiovascular disease, a partner can be a good source for

social support, though it may be possible that the partner giving the support may also be

experiencing the same distress as the patient. Pedersen, Domburg, Theuns, Jordaen, and Erdman

(2004) examined personality factors and social support to determine their influence on distress

and the prevalence of anxiety and depression in patients and their partners. Patients with an

implantable cardioverter defibrillator along with their partners completed various questionnaires

on depression, anxiety, TDP, and perceived social support. In examining personality factors and

social support, TDP was deemed more important in predicting distress levels than social support.

In both the partners and patients, TDP was an independent predictor of depression and anxiety in

comparison to those with non-TDP. In addition, it was found that partners with TDP experienced

depression levels similar to non-TDP patients but higher levels of anxiety than the TDP patients.

The results of Pedersen et al. suggest that programs should be developed for, or extended to

partners of patients with implantable cardioverter defibrillator to help them to cope with their

distress.

Impact of Rehabilitation

In a series of studies, Denollet and colleagues found that emotional distress associated

with cardiac events may be reduced by rehabilitative interventions. Denollet (1993), found a

significant increase in positive affect and a significant decrease in negative affect in coronary

heart disease three months after receiving rehabilitation. Similarly, Denollet and Brutsaert (1995)

examined the role cardiac rehabilitation plays in enhancing the emotional wellness

of patients with coronary heart disease. The control group received standard medical care and the

treatment group participated in an outpatient rehabilitation program. The rehabilitation program

consisted of aerobic exercise performed a few times a week. A psychosocial component was also

included for the treatment groups which included education about the disease and healthy

behaviors as well as emotional support. The control and treatment groups filled out

questionnaires after having an acute myocardial infarction, coronary bypass surgery or coronary

angioplasty and after engaging in rehabilitation or standard medical care. Questionnaires focused

on perceived health, and positive and negative affect. It was found that rehabilitated patients had

a significant decrease in negative affect and a significant increase in positive affect. There was

also a reduction in health complaints (both somatic and cognitive) and disabilities. These

findings suggest that cardiac rehabilitation is beneficial for TDP persons with coronary heart

disease.     

Once individuals have been identified with TDP, many methods can be used to reduce

the emotional distress so quality of life may be improved. Denollet and Brutsaert (2001)

examined the effect of treating emotional distress on those with heart disease. In this study, men

were divided into two groups: those who received rehabilitation and those who received the

usual medical care (control group). It was found that those who received rehabilitation reported

more improvement and decreased negative affect than the control group. There was also a

decrease in mortality within the nine year follow-up for the rehabilitation group, with the rate of

death for the control group being 17% and for rehabilitation group, 4%. These results suggest

there is a need for rehabilitation for TDP patients as this has an effect on cardiac prognosis and

negative affectivity.

Using a single-center randomized controlled trial, Karlsson et al. (2007) designed a study

to determine if the use of expanded cardiac rehabilitation would have an effect on depression,

anxiety and the quality of life in TDP patients versus non-TDP patients. Participants who either

had a planned coronary artery by-pass graft operation or an acute myocardial infarction were

divided into one of two groups – the intervention and control group. The control group

participated in usual rehabilitation care such as physical exercise, information/counseling, heart

school (education on cardiovascular disease), outpatient clinic and individual counseling. The

intervention group was involved in expanded rehabilitation care, consisting of all the previous

activities of the routine rehabilitation care as well as stress management program, a five day stay

at the patient hotel, cooking sessions and counseling regarding diet. Measures consisted of the

DS24 (TDP), the Cantril Ladder of Life Scale (quality of life), the Hospital Anxiety and

Depression Scale (depression and anxiety) and the Sense of Coherence scale (coping ability). At

baseline, patients with a high TDP score experienced poorer sense of coherence, a lessened

quality of life, more depression and increased anxiety than patients with a low TDP score

(Karlsson et al.). At the one year follow-up, the control group showed no significant changes in

depression, anxiety and TDP score but showed improvement in quality of life. However, the

intervention group showed an improvement in quality of life, decrease in anxiety and depressive

symptoms and a decrease in TDP score. Results showed that the majority of scores of these

measures were improved due to the expanded rehabilitation care.

Conclusion

     A person with TDP is described as one experiencing negative affectivity and inhibiting these

emotions in social situations, or social inhibition. Measures of TDP such as the DS14, DS16 and

DS24 scales, have been found to be psychometrically sound instruments, which are brief and

easy to use for patients with cardiovascular disease. Based on the studies examined, it is highly

likely that TDP is closely linked to cardiovascular disease in that TDP may be a predictor of

negative events, such as depression and anxiety, that may accompany the disease. This is of

importance in that TDP patients with cardiovascular diseases have a higher likelihood of death

than non-TDP patients (Pedersen et al., 2004). Much of the research mentioned, suggests the

need for hospitals to screen for TDP before treating these patients, as having this personality type

may delay their recovery. Further research should be done on cardiac rehabilitation programs

geared towards TDP patients, as they have shown promise in improving the quality of life of

these patients, especially when medical care alone does not help. 

 

 

 

 

 

 

 

 

 

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