Elsevier

Psychiatry Research

Volume 152, Issues 2–3, 30 August 2007, Pages 243-252
Psychiatry Research

Comorbidity and personality traits in patients with different levels of posttraumatic stress disorder following myocardial infarction

https://doi.org/10.1016/j.psychres.2007.02.008Get rights and content

Abstract

More research is needed to further our understanding of posttraumatic stress responses and comorbidity following myocardial infarction (MI), and to help us identify more clearly the personality traits which indicate that a person is more prone to developing post-MI posttraumatic stress disorder (PTSD). This study aimed to 1) investigate the comorbidity of patients who suffered from different levels of posttraumatic stress disorder following myocardial infarction (i.e. post-MI PTSD), and 2) investigate to what extent patients with different levels of post-MI PTSD differed in their personality traits. One hundred and twenty MI patients from two general practices were recruited for the study. They were asked to complete the Posttraumatic Stress Diagnostic Scale (PDS), the General Health Questionnaire-28 (GHQ-28) and the NEO-Five Factor Inventory (NEO-FFI). They were divided into a no-PTSD group, a partial-PTSD group and a full-PTSD group, according to the scores of the PDS. One hundred and sixteen members of the general public were also recruited for comparison purposes. They were asked to complete the GHQ-28. The results showed that patients with full-PTSD reported significantly more somatic problems, anxiety, social dysfunction and depression than the other two patient groups and the control group. When age, bypass surgery, mental health problems before MI and angioplasty were controlled for, patients with full-PTSD also reported greater symptom severity of the four GHQ subscales than the other two patient groups. Patients with full-PTSD were significantly more neurotic than those with no-PTSD and partial-PTSD. Patients with full-PTSD were less agreeable than patients with no-PTSD. Regression analyses showed that personality did not moderate the relationship between PTSD and comorbidity. To conclude, following MI, those with full-PTSD tend to report more severe comorbidity than those who have not developed PTSD fully. The former can also be distinguished from the latter by virtue of their specific personality traits.

Introduction

People are diagnosed to suffer from posttraumatic stress disorder (PTSD) when they have experienced an event involving threatened death or serious injury to themselves, when their response to the event involved fear, helplessness or horror, and when they experience persistent re-experiencing, avoidance and hyperarousal symptoms for more than 1 month. These symptoms also impair their social, occupational or other important areas of functioning (American Psychiatric Association, 1994). One such traumatic event is myocardial infarction (MI). It is reasonable to postulate the link between the experience of MI and PTSD reactions (i.e. post-MI PTSD) because MI is a sudden, life-threatening illness which provokes fear, helplessness or horror among sufferers. The prevalence rates of post-MI PTSD vary, ranging from 0% to 16% (Bennett and Brooke, 1999, Bennett et al., 2001, Bennett et al., 2002, Kutz et al., 1994, van Driel and Op den Velde, 1995). One recent study revealed a higher prevalence rate than reported previously (22%) between 4 and 6 weeks post-MI (Pedersen et al., 2003). Nine months later, it dropped to 14% (Pedersen et al., 2004).

PTSD symptoms often occur in conjunction with other disorders (Solomon et al., 1991). Several large scale population surveys have shown that people with PTSD tend to develop comorbid disorders such as obsessive-compulsive disorder, dysthymic disorder, schizophrenia, panic disorder, social phobia, substance abuse and personality disorder (Davidson et al., 1991, Helzer et al., 1987, Keane and Wolfe, 1990, Norris et al., 2002). Studies on post-MI PTSD thus far have mainly focused on depression and anxiety as the comorbid disorders (Bennett et al., 2002, Pedersen et al., 2003). In this study, we broaden the comorbid disorders by focusing on not only anxiety and depression but also somatic complaints and social dysfunction.

The foregoing prevalence rates of post-MI PTSD indicate that not all MI patients will develop PTSD. Indeed, large scale epidemiological studies on PTSD have unveiled one important fact; while 40 to 90% of the general population may experience a traumatic event at some point during their lifetime, less than 10% develop PTSD (Breslau et al., 1991, Breslau et al., 1998, Kessler et al., 1995, Norris, 1992, Davidson et al., 1991, Helzer et al., 1987). In other words, one's exposure to a traumatic experience, in this case MI, is probably not sufficient to explain the etiology of PTSD. Other factors may affect the relationship between trauma exposure and PTSD. Personality has been postulated to be one such factor.

One theoretical justification for linking PTSD and personality is that according to Horowitz and collaborators (Horowitz, 1986, Horowitz et al., 1993), we have within us pre-existing schemas of the world and of ourselves are termed “self-schemas." Using these self-schemas, we organize or interpret incoming information for ourselves, including the information which is derived from our exposure to a trauma. With different schematic structures, people organize and interpret the trauma information differently. These pre-existing self-schemas constitute partly our personality traits (e.g. Markus, 1977). These traits are dimensions of individual differences which tend to show consistent patterns of thoughts, feelings and actions (McCrae and Costa, 1990). They are thought to be able to influence biochemical processes (although more work is needed to understand how), the way we perceive distress and illness, and the way we interact with health-care providers and comply with medical advice (Clark et al., 1994, Costa and McCrae, 1990, Miller, 2003).

To date, studies focusing on post-MI PTSD have shown the link between post-MI PTSD and such personality traits as alexithymia, negative affect, Type D (i.e. negative affectivity and social inhibition) and neuroticism. They found that the alexithymic factor of difficulty in identifying feelings was positively associated with post-MI PTSD symptoms and diagnosis. Low positive and high negative affects predicted PTSD symptoms (Bennett and Brooke, 1999, Bennett et al., 2001, Bennett et al., 2002). Type D was also associated with PTSD symptoms (Pedersen and Denollet, 2004). One component of Type D, negative affectivity, conceptualized also as neuroticism, has been shown to be associated with post-MI PTSD symptoms (Pedersen and Denollet, 2004) and to predict anxiety, depression, and somatic and cognitive health complaints (Pedersen et al., 2002).

To shed further light on the relationship between personality traits and post-MI PTSD, in this study, we wish to broaden the dimensions of personality traits and examine the role that five personality factors (neuroticism, extraversion, openness to experience, agreeableness and conscientiousness) play in patients' manifestation of post-MI PTSD and comorbidity. So far, this has not been investigated in the post-MI PTSD literature. To differentiate particular personality traits among MI patients is important because it would help identify those who are at risk of full-PTSD and indeed recurrent cardiac events (Pedersen et al., 2002). The association between the five personality factors and PTSD symptoms is known among other kinds of victims. The overall findings from these studies suggest that neuroticism, less extraversion, less agreeableness, less conscientiousness and less openness account for a risk of developing PTSD or PTSD symptoms (Haisch and Myers, 2004, Hyer et al., 2003, Malec et al., 2004, Nightingale and Williams, 2000).

In our present investigation, we need to take account of a range of factors which have been found to be associated with post-MI PTSD and which may therefore affect the outcome of our study. Age was found to be negatively associated with post-MI PTSD symptoms and the diagnosis (Bennett and Brooke, 1999). Patients' previous traumatic experiences was another associative factor in that an accumulated burden of adversity may make patients more susceptible to the PTSD resulting from a recent traumatic illness such as MI (e.g. Alonzo, 1999, Alonzo, 2000, Bremner et al., 1993, Davidson and Baum, 1993, Falger et al., 1992, Zaidi and Foy, 1994). Other factors include MI patients' undergoing cardiac surgery which was found to be associated with post-MI PTSD as well as depression (Doerfler et al., 1994, Götzmann and Schnyder, 2002, Chessick, 1995). Heart-transplant was also found to be associated with PTSD symptoms (PTSD-T), major depressive disorder and adjustment disorder in the long term (Dew et al., 1996, Dew et al., 1999, Dew et al., 2001). Cardiac arrest (CA) patients also tend to report significantly more depression and avoidance symptoms and suffer from higher incidents of PTSD than patients without CA (Ladwig et al., 1999, O'Reilly et al., 2004). The risk of patients with heart failure developing PTSD was about one and a half times greater than those without heart failure (Martz and Cook, 2001).

Controlling for these factors, this study aims to investigate 1) the comorbidity of patients who suffered from different levels of post-MI PTSD and to compare them with those without MI, and 2) to what extent patients with different levels of post-MI PTSD differed in their personality traits. We hypothesized that patients with full-PTSD would report more severe comorbidity than those with partial-PTSD, no-PTSD and the control. We also hypothesized that patients with full-PTSD would be more neurotic, less extraverted, less agreeable, less conscientious and less open than those in the other groups. The rationale for classifying patients according to different levels of PTSD is based on existing literature suggesting that PTSD occurs along a continuity of normal to abnormal stress reactions. The implication is that it is not always helpful to view PTSD simply in terms of either having PTSD or not having PTSD (Joseph et al., 1997). Following a trauma, some people may not fulfil the full diagnostic criteria for PTSD but still have experienced quite severe impairment in functioning. They still require the same level of care as those with a full diagnosis of PTSD. Thus, some researchers see the need to classify PTSD reactions at different levels such as partial-PTSD (Blank, 1993, Carlier and Gersons, 1995).

Section snippets

Participants

One hundred and twenty MI patients (78% males) with an average age of 67 (S.D. = 9.74, range: 40–91) participated in the study. Most were married, while 14% were widowed and less than 10% single. All participants were Caucasian, apart from one Asian. The majority were in the low income category: 61% were retired, 5% were unable to return to work due to their MI and 7% were unemployed. Seven percent worked in factories, shops, dockyard and domestic cleaning. Most of the patients had had only one

Results

According to the diagnosis of PTSD using part II of the Posttraumatic Stress Diagnostic Scale (PDS), the patients were classified into a no-PTSD group (n = 29, 79% males), a partial-PTSD group (n = 54, 81% males) and a full-PTSD group (n = 37, 73% males). By way of comparison, they were matched with a control group of 116 participants (69% males) who suffered no MI or any other major illness. The patient groups and the control group were matched in their demographic variables of age, gender, marital

Discussion

The findings of the present study supported hypothesis one in that patients with full-PTSD reported more severe comorbidity, characterized by somatic problems, anxiety, social dysfunction and depression, than those with partial-PTSD, no-PTSD and the control. Looking at the three patient groups only, the full-PTSD patients reported significantly more severe comorbidity than the other two patient groups. These findings are consistent with existing literature suggesting that patients with PTSD

References (79)

  • S.S. Pedersen et al.

    Posttraumatic stress disorder in first-time myocardial infarction patients

    Heart and Lung

    (2003)
  • B.A. van der Kolk et al.

    Inescapable shock, neurotransmitters and addiction to trauma: Toward a psychobiology of posttraumatic stress

    Biological Psychiatry

    (1985)
  • J.M. Zelenski et al.

    The distribution of emotions in everyday life: A state and trait perspective from experience sampling data

    Journal of Research in Personality

    (2000)
  • A.A. Alonzo

    Acute myocardial infarction and posttraumatic stress disorder: the consequences of cumulative adversity

    Journal of Cardiovascular Nursing

    (1999)
  • American Psychiatric Association

    Diagnostic and Statistical Manual of Mental Disorders

    (1994)
  • D.H. Barlow

    Anxiety and its Disorders: The Nature and Treatment of Anxiety and Panic

    (2002)
  • P. Bennett et al.

    Intrusive memories, posttraumatic stress disorder and myocardial infarction

    British Journal of Clinical Psychology

    (1999)
  • P. Bennett et al.

    Personality, social context and cognitive predictors of posttraumatic stress disorder in myocardial infarction patients

    Psychology and Health

    (2002)
  • A.S. Blank

    The longitudinal course of posttraumatic stress disorder

  • J.D. Bremner et al.

    Childhood physical abuse and combat-related posttraumatic stress disorder in Vietnam veterans

    American Journal of Psychiatry

    (1993)
  • N. Breslau et al.

    Traumatic events and posttraumatic stress disorder in an urban population of young adults

    Archives of General Psychiatry

    (1991)
  • N. Breslau et al.

    Trauma and posttraumatic stress disorder in the community: the 1996 Detroit area survey of trauma

    Archives of General Psychiatry

    (1998)
  • I.V.E. Carlier et al.

    Partial posttraumatic stress disorder (PTSD): the issue of psychological scars and the occurrence of PTSD symptoms

    Journal of Nervous and Mental Disease

    (1995)
  • I.V.E. Carlier et al.

    Stress reactions in disaster victims following the Bijlmermeer plane crash

    Journal of Traumatic Stress

    (1997)
  • I.V.E. Carlier et al.

    Risk factors for posttraumatic stress symptomatology in police officers: a prospective analysis

    Journal of Nervous and Mental Disease

    (1997)
  • R.D. Chessick

    Psychosis after open heart surgery: a phenomenological study

    American Journal of Psychotherapy

    (1995)
  • M.C. Chung et al.

    A multiple-indicator multiple-cause model for posttraumatic stress reactions: personality, coping and maladjustment

    Psychosomatic Medicine

    (2005)
  • L.A. Clark et al.

    Temperament, personality, and the mood and anxiety disorders

    Journal of Abnormal Psychology

    (1994)
  • P.T. Costa et al.

    Personality: another ‘hidden factor’ in stress research

    Psychological Inquiry

    (1990)
  • P.T. Costa et al.

    Trait psychology comes of age

  • J.E. Dalton et al.

    MBTI profiles of Vietnam veterans with post-traumatic stress disorder

    Journal of Psychological Type

    (1993)
  • L.M. Davidson et al.

    Predictors of chronic stress among Vietnam veterans: stress exposure and intrusive recall

    Journal of Traumatic Stress

    (1993)
  • J.T. Davidson et al.

    Post-traumatic disorder in the community: an epidemiological study

    Psychological Medicine

    (1991)
  • T.M. Dembroski et al.

    Assessment of coronary-prone behavior: a current overview

    Annals of Behavioral Medicine

    (1988)
  • T.M. Dembroski et al.

    Components of hostility as predictors of sudden death and myocardial infarction in the multiple risk factor intervention trial

    Psychosomatic Medicine

    (1989)
  • M.A. Dew et al.

    Prevalence and predictors of depression and anxiety-related disorders during the year after heart transplantation

    General Hospital Psychiatry

    (1996)
  • M.A. Dew et al.

    Prevalence and risk of depression and anxiety-related disorders during the first three years after heart transplantation

    Psychosomatics

    (2001)
  • D.R. Eizenman et al.

    Intraindividual variability in perceived control in an older sample: the MacArthur successful aging studies

    Psychology and Aging

    (1997)
  • P.R.J. Falger et al.

    Current posttraumatic stress disorder and cardiovascular disease risk factors in Dutch resistance veterans from World War II

    Psychotherapy and Psychosomatics

    (1992)
  • Cited by (42)

    • Temperament profiles and posttraumatic stress disorder symptoms: A comparative study between uniformed services, HIV-infected patients and a nonclinical sample

      2022, Personality and Individual Differences
      Citation Excerpt :

      Numerous authors have observed that personality traits play a moderating role in responding to traumatic experiences (see meta-analyses: Cyniak-Cieciura & Zawadzki, 2019; Ozer et al., 2003), acting as risk or protective factors against posttraumatic stress disorder (PTSD; Lauterbach & Vrana, 2001). The Big Five personality traits, including neuroticism (e.g., Ceobanu & Mairean, 2015; Chung et al., 2007; Engelhard et al., 2003) and the temperament traits identified by Cloninger (see harm avoidance; e.g., North et al., 2012; Yoon et al., 2009), are the most frequently examined personality taxonomies. The aforementioned personality traits correlate with the temperament traits from the regulative theory of temperament (RTT) (Strelau, 2008), which is the focus of the present study.

    • Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

      2021, General Hospital Psychiatry
      Citation Excerpt :

      1136 items were first excluded based on titles and abstracts and 1835 items (91.1%) were further excluded after full-text examination. The remaining 292 studies (8.9%) were included for analysis as depicted in Figure 1 [20–26,30–33,61–341]. Diseases most studied in terms of PTSD prevalence were ICU stay (n=108 articles) followed by burns (n=62 articles).

    • The link between death anxiety and post-traumatic symptomatology during terror: Direct links and possible moderators

      2016, Psychiatry Research
      Citation Excerpt :

      Additionally, other researchers have indicated that low emotional stability contributes to one's vulnerability to PTSD symptoms (Jakšić et al., 2012; Knezevic et al., 2005; Perrin et al., 2014; Guo et al., 2015), whereas the remaining four of the Big Five personality dimensions – agreeableness, conscientiousness openness and extraversion – yield inconsistent results, which may be due to differences in the instruments used to assess personality (Knezevic et al., 2005). Nevertheless, Jakšić et al. (2012) found that PTSD symptoms were negatively associated with extraversion and conscientiousness, although other studies failed in reporting on such link (e. g., Chung et al., 2007). An additional issue which merits examination is the possibility that personality factors may provide a moderating effect on the connection between death anxiety and post-traumatic symptomatology.

    • Posttraumatic stress disorder and psychiatric co-morbidity following stroke: The role of alexithymia

      2011, Psychiatry Research
      Citation Excerpt :

      In addition to previous traumatic life events, we could have taken account of personality traits especially neuroticism and negative affect, since both were shown to have a role to play in post-stroke PTSD (Sembi et al, 1998; Merriman et al, 2007). That said, it has been well documented that neuroticism, which has a robust association with negative affect, is a form of stress proneness affecting people's general well-being (Matthews et al., 2009) and people with traumatic experiences (e.g., Chung et al., 2005, 2007; Borja et al., 2009). To this end, we were not surprised by the results of neuroticism and negative affect on people with stroke and deliberately chose not to revisit these traits but focused on the under-researched trait of alexithymia.

    • Posttraumatic stress in physical illness

      2023, Posttraumatic Stress in Physical Illness
    View all citing articles on Scopus
    View full text