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 Denollets 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 ones 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 lifes
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 ones 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 ones 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 Cronbachs 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. Denollets
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 Cronbachs
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 scales 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 ones 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, TDPs 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 persons 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 ones 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
TDPs negative affectivity component. These results suggest that personality traits play a role in
a patients 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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