شخصیت نوع D: یک عامل خطر بالقوه تصفیه شده

Abstract Objective. Acute and chronic psychological distress have been associated with coronary heart disease (CHD) but little is known about the determinants of distress as a coronary risk factor. Broad and stable personality traits may have much explanatory power; this article selectively focuses on negative affectivity (NA; tendency to experience negative emotions) and social inhibition (SI; tendency to inhibit self-expression in social interaction) in the context of CHD. Methods. The first part of this article reviews research on NA and SI in patients with CHD. The second part presents new findings on NA and SI in 734 patients with hypertension. Results. Accumulating evidence suggests that the combination of high NA and high SI designates a personality subtype (“distressed” type or type D) of coronary patients who are at risk for clustering of psychosocial risk factors and incidence of long-term cardiac events. Type D and its contributing low-order traits (dysphoria/tension and reticence/withdrawal) could also be reliably assessed in a community-based sample of patients with hypertension. This finding was replicated in men and women, and in Dutch- and French-speaking subjects. Type D hypertensives reported more depressive affect than their non type D counterparts. Conclusions. There is an urgent need to adopt a personality approach in the identification of patients at risk for cardiac events. NA and SI are broad and stable personality traits that may be of special interest not only in CHD, but in other chronic medical conditions as well.

In recent years, a wide variety of psychosocial factors has been associated with the incidence and progression of coronary heart disease (CHD). Most of this research focused on affective disorder [1], [2], [3] and [4], negative emotions [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18] and [19], and social isolation [20], [21], [22] and [23] as risk factors. Hence, depression and low perceived social support are often considered to be the psychosocial features that are most prominently linked to CHD morbidity and mortality [24]. One generally assumes that depression is the psychosocial factor that should be accounted for in the prognosis of patients with CHD, at the risk of ignoring other psychosocial variables that may be of equal importance. Many negative affective states other than depressed affect (e.g., anxiety, anger, hostility, vital exhaustion) have been associated with CHD as well [25], [26], [27] and [28]. In addition, the specificity of the relationship between clinical depression and CHD may be limited, e.g., only 7 out of 19 patients who died from cardiac causes at 18 months follow-up in the Frasure-Smith et al. study (a frequently cited study in favor of the depression — CHD hypothesis) were classified as clinically depressed [29], implying that 63% of the cardiac deaths were not diagnosed with a depression at baseline. The findings of this study also indicated that clinical depression, as opposed to self-reported depressive symptoms, did not improve the predictive ability of the standard risk factors. Others have shown that depressive symptoms as a risk factor for CHD may reflect a chronic psychological characteristic rather than a discrete, transient psychiatric condition [6], [30] and [31]. These observations do not refute the notion that clinical depression [32], [33] and [34] and depressive symptoms [5], [6], [7], [8], [9] and [29] are important risk factors in the context of CHD. Rather they point out the importance of examining multiple psychosocial factors — both acute and chronic — in the evaluation of individuals at risk of coronary events [35], [36] and [37]. In addition, there is an urgent need to document the determinants of depression [38] and psychological distress [39] and [40] in CHD patients. In nonclinical populations, evidence suggests that broad and stable personality traits represent major determinants of depression [41], psychological distress [42], life stress [43], and subjective mood [44] and well-being [45]. Individual differences in personality and coping have also been associated with psychological distress in CHD [39] and [40]. Hence, in addition to focusing on specific psychological risk factors, there is a need to adopt a personality approach in the early identification of those coronary patients who are at risk for emotional stress-related cardiac events. Evidence suggests that psychological risk factors tend to cluster together and that clustering of these factors, in turn, substantially elevates the risk for cardiac events [37]. Broad and stable personality traits may have much predictive value regarding this clustering of risk factors in patients with CHD [39] and [46]. Therefore, the present article emphasizes the potential role of personality as determinant of emotional distress in patients with CHD. More specifically, this article will selectively focus on the “distressed” personality type or “type D,” i.e., those individuals who simultaneously tend to (a) experience negative emotions and (b) inhibit self-expression [47]. The present article is organized in two separate parts, each with its own specific perspective on type D. The first part focuses on the conceptual framework that guided research on type D personality and CHD, and briefly reviews some of the empirical findings. The second part presents new findings on the structural validity of the type D construct and its relationship with depressive affect in a hypertensive population. This article concludes with some observations about the role of type D personality in clinical research and practice. Yet another personality construct? In the past decade, there was a resurgence of interest in the role of personality in health and disease [48] and [49]. Personality refers to a complex organization of trait dispositions [41]; these traits reflect consistencies in the general affective level and behavior of individuals. Hence, personality is conceived as a complex system of structures and processes that underlie these consistencies in human affect and behavior [50]. Different models of personality have identified two [51], three [52] and [53], or five [54] and [55] global traits that are relevant in a large number of situations. This paper is based on the notion that negative affectivity and social inhibition are two global traits that can be linked to important health outcomes in CHD. Negative affectivity and social inhibition