Original articleIncreased emotional distress in type-D cardiac patients without a partner
Introduction
There is increasing emphasis on patient-centered outcomes in cardiovascular disease (CVD), such as quality of life and emotional distress [1]. Knowledge of the determinants of these outcomes is also important in order to facilitate identification of high-risk patients in clinical practice [1]. The distressed (type-D) personality may be an important determinant of individual differences in outcomes, as this personality disposition has been associated with an increased risk of adverse prognosis [2], [3], [4], [5], impaired quality of life and health status [6], [7], exhaustion and fatigue [8], and a wide range of emotional distress, including anxiety [9], depressive symptoms [9], [10], and posttraumatic stress disorder [11]. Type-D has been shown to be a risk factor for adverse health outcomes across different types of CVD, including peripheral arterial disease [6], coronary artery disease (CAD) [12], chronic heart failure [10], arrhythmias [9], and heart transplantation [13], [14]. The risk associated with type-D in relation to clinical outcome is on par with established biomedical risk factors such as left ventricular dysfunction [3], [4], [15].
Type-D personality is characterized by the two stable personality traits negative affectivity (the tendency to experience negative emotions across time and situations) [16] and social inhibition (the tendency to inhibit the expression of emotions and behaviors in social interactions to avoid disapproval by others) [17]. The prevalence of type-D ranges from 24–34% in patients with CAD [3], [4] and arrhythmias [9] to 33–53% in patients with hypertension [18], peripheral arterial disease [6], and chronic heart failure [10], [19].
Little is known about factors that may influence the impact of type-D personality on prognosis, quality of life, and emotional distress. Knowledge of these factors is important for optimizing risk stratification in clinical practice and may also point to targets for intervention. There are several pathways that may link type-D to adverse health outcomes, including physiological and behavioral pathways. As for physiological pathways, they may comprise inflammation [19], [20], blood pressure reactivity to stress [21], and hyperactivity of the hypothalamic–pituitary–adrenal axis, including increased levels of cortisol [21], [22]. Potential behavioral pathways comprise health-related behaviors, including failure to change risk factors, such as smoking, and poor treatment adherence [3], [23]. In addition, because type-D patients inhibit behavior in social interactions, it is likely that communication with doctors is impaired, which may also hinder effective treatment [24]. However, to date, these potential mechanisms have not been examined in type-D patients.
A potentially important behavioral factor influencing the relationship between type-D and health outcomes is social support. Since social support has been shown to buffer the effects of stress on both well-being [25] and cardiovascular function [26], [27], lack of support may enhance the adverse effects of type-D personality on health outcomes, including emotional distress. By analogy, since type-D patients have been shown to have fewer social ties and to experience less social support than non-type-D patients [3], type-D patients who have a fulfilling relationship with a partner may be at less risk for adverse health outcomes than patients without a partner.
Therefore, the aim of this study was to determine the combined effect of type-D personality and not having a partner on symptoms of anxiety and depression across different CVD treatment groups, that is, in patients with acute myocardial infarction (MI) or patients who received an implantable cardioverter defibrillator (ICD). An additional advantage of pooling data was to enhance the statistical power of the study, which has also been advocated by others [28].
Section snippets
Patient population and design
Patients hospitalized for acute MI or ICD implantation between May 2003 and December 2005 were included from five hospitals in the Netherlands (Catharina Hospital, Eindhoven; Amphia Hospital, Breda; St. Elisabeth Hospital, Tilburg; TweeSteden Hospital, Tilburg; and St. Anna Hospital, Geldrop). Inclusion criteria were hospitalization for acute MI (n=452) or ICD implantation (n=210). Exclusion criteria were significant cognitive impairments (e.g., dementia) and severe life-threatening
Patient characteristics
No significant differences between ICD patients and MI patients were found for either type-D personality or partner status, although type-D personality was slightly more prevalent in ICD patients than in MI patients [27% vs. 20%, χ2(3)=3.40, P=.07]. In the total patient group, 121 patients (22%) were classified as type-D and 89 patients (16%) had no partner. Partner status did not differ in type-D versus non-type-D patients [17% vs. 16%, χ2(1)=0.25, P=.88].
Patient characteristics stratified by
Discussion
This is the first study to examine the combined effect of type-D personality and not having a partner on emotional distress in cardiac patients. Stratifying by personality and partner status showed that non-type-D patients without a partner had a twofold increased risk of both anxiety and depressive symptoms followed by type-D patients with a partner with a threefold risk and, most importantly, type-D patients without a partner having a six- to eightfold risk compared to non-type-D patients
Acknowledgments
This research was supported by a VENI grant (451-05-001) to Dr. S.S. Pedersen from the Netherlands Organization for Scientific Research (NWO), The Hague, The Netherlands. No financial support or conflict of interest exists for any of the other authors.
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The distressed (Type D) personality in both patients and partners enhances the risk of emotional distress in patients with an implantable cardioverter defibrillator
2011, Journal of Affective DisordersCitation Excerpt :Distress levels in patients may also be related to partner factors. In a mixed sample of post-myocardial infarction patients and ICD patients, patients with a Type D (distressed) personality without a partner showed higher distress levels than Type D patients with a partner (Van den Broek et al., 2007). Higher distress levels in cardiac patients have also been related to higher distress levels in their partners (Pihl et al., 2005), and research has shown that partner distress levels can be as high as distress levels in patients with an ICD (Pedersen et al., 2009b).
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