Biobehavioral research on coronary heart disease: where is the person?

Association of Type D personality with increased vulnerability to depression: Is there a role for inflammation or endothelial dysfunction? - The Maastricht Study

BACKGROUND

Type D personality - the combination of negative affectivity (NA) and social inhibition (SI) - has been associated with depression but little is known about underlying mechanisms. We examined whether (1) Type D is a vulnerability factor for depression in general, (2) Type D is associated with inflammation or endothelial dysfunction, and (3) these biomarkers alter the possible association between Type D and depression.

METHODS

In the Maastricht Study, 712 subjects underwent assessment of NA, SI and Type D personality (DS14), depressive disorder (Mini-International Neuropsychiatric Interview) and depressive symptoms (Patient Health Questionnaire-9). Plasma biomarkers of inflammation (hsCRP, SAA, sICAM-1, IL-6, IL-8, TNF-α) and endothelial dysfunction (sVCAM-1, sICAM-1, E-selectin, vWF) were measured with sandwich immunoassays or ELISA and combined into standardized sumscores.

RESULTS

Regarding personality, 49% of the study population was low in NA and SI, 22% had SI only, 12% NA only and 17% had Type D. Depressive disorder and depressive symptoms were significantly more prevalent in Type D versus the other three personality subgroups. Multivariable regression analyses showed that Type D was associated with inflammation (β=0.228, p=0.014) and endothelial dysfunction (β=0.216, p=0.022). After adjustment for these biomarkers, Type D remained independently associated with increased vulnerability to depressive disorder (OR=13.20, p<0.001) and depressive symptoms (β=3.87, p<0.001).

LIMITATIONS

The cross-sectional design restrained us to draw any conclusions on causality. The relatively low prevalence of depressive disorder restrained us to adjust for more potential confounders.

CONCLUSIONS

Type D personality may be a vulnerability factor for depression, irrespective of levels of inflammation or endothelial dysfunction. Future research should examine possible underlying mechanisms.

Type D personality is associated with impaired psychological status and unhealthy lifestyle in Icelandic cardiac patients: a cross-sectional study

BACKGROUND

Type D (distressed) personality has been associated with adverse cardiac prognosis and poor emotional well-being in cardiac patients, but it is still unclear what mechanisms link Type D personality with poor clinical outcomes in cardiac patients. In the present cohort of Icelandic cardiac patients, we examined potential pathways that may explain this relationship. The objectives were to examine 1) the association between Type D personality and impaired psychological status, and to explore whether this association is independent of disease severity; and 2) the association between Type D personality and an unhealthy lifestyle.

METHODS

A sample of 268 Icelandic coronary angiography patients (74% males (N = 199); mean age 62.9 years (SD 10.5), range 28-85 years) completed the Type D Scale (DS14), Hospital Anxiety and Depression Scale (HADS), and Perceived Stress Scale (PSS) at hospitalization. Health-related behaviors were assessed 4 months following angiography. Clinical data were collected from medical files.

RESULTS

Type D personality was associated with an increased risk of anxiety (OR 2.97, 95% CI:1.55-5.69), depression (OR 4.01, 95% CI:1.42-11.29), and stress (OR 5.99, 95% CI:3.08-11.63), independent of demographic variables and disease severity. Furthermore, fish consumption was lower among Type Ds, as 21% of Type Ds versus 5% of non-Type Ds consumed fish < 1 a week (p < 0.001). Type D patients were also more likely to smoke at follow-up (22% versus 10%, p = 0.024) and to use antidepressants (17% versus 9%, p = 0.049) and sleeping pills (49% versus 33%, p = 0.019) compared to non-Type Ds. Type D personality was not associated with other health-related behaviors, aside from trends towards less fruit and vegetable consumption, and more weight gain.

CONCLUSION

Type D personality was associated with psychological distress and an unhealthy lifestyle in Icelandic cardiac patients. Future studies should further investigate the association between Type D personality and health-related behaviors.

Validity of Type D personality in Iceland: association with disease severity and risk markers in cardiac patients

Type D personality has been associated with poor prognosis in cardiac patients. This study investigated the validity of the Type D construct in Iceland and its association with disease severity and health-related risk markers in cardiac patients. A sample of 1,452 cardiac patients completed the Type D scale (DS14), and a subgroup of 161 patients completed measurements for the five-factor model of personality, emotional control, anxiety, depression, stress and lifestyle factors. The Icelandic DS14 had good psychometric properties and its construct validity was confirmed. Prevalence of Type D was 26–29%, and assessment of Type D personality was not confounded by severity of underlying coronary artery disease. Regarding risk markers, Type D patients reported more psychopharmacological medication use and smoking, but frequency of previous mental problems was similar across groups. Type D is a valid personality construct in Iceland, and is associated with health-related risk markers, but not cardiac disease severity.

Anger, suppressed anger, and risk of adverse events in patients with coronary artery disease

Anger is associated with cardiovascular stress reactivity; however, little is known about the effect of suppressed anger in patients with coronary artery disease (CAD). We examined whether patients with CAD who suppress their anger are at risk of adverse events. At baseline, 644 patients with CAD completed measures of anger, anger-in (reluctance to express anger), and Type D personality (tendency to experience distress and to be inhibited). The combination of high anger and anger-in scores was used to identify the presence of suppressed anger. The end points were major adverse cardiac events (a composite of death, myocardial infarction, and revascularization) and cardiac death/myocardial infarction. After an average follow-up of 6.3 years (range 5 to 10), 126 patients (20%) had experienced a major adverse cardiac event, and 59 (9%) had experienced cardiac death or myocardial infarction. Anger (p = 0.009) and suppressed anger (p = 0.011) were associated with future major adverse cardiac events, but these associations were no longer significant after adjustment for clinical characteristics. However, suppressed anger remained associated with the more rigorous end point of cardiac death or myocardial infarction (odds ratio 2.87, 95% confidence interval 1.15 to 7.15, p = 0.024) after controlling for decreased systolic function, poor exercise tolerance, extent of CAD, and revascularization. Anger alone was not independently associated with this end point. Patients with a Type D personality had a fourfold rate of suppressed anger, and an adjustment for a Type D personality attenuated the observed association between suppressed anger and adverse cardiac events. In conclusion, patients with CAD who suppress their anger were at increased risk of adverse cardiac events, and this was accounted for by individual differences in Type D personality.

The association of type D personality with quality of life in patients with Parkinson's disease

OBJECTIVES

Personality traits appear as determinants of quality of life (QoL) in most chronic diseases. Type D personality is characterized by ineffective coping strategies that reduce QoL in patients with coronary heart disease. The aim of this study was to evaluate whether Type D personality also predicts QoL in patients with Parkinson's disease (PD). In addition, gender differences in Type D personalities are explored.

METHODS

The sample consisted of 153 PD patients (51.4% males; mean age 67.9 +/- 9.3 years). DS-14 was used to measure Type D personality, negative affectivity (NA) and social inhibition (SI). The Parkinson's Disease Quality of Life Questionnaire (PDQ-39) was used to assess QoL, and the Unified Parkinson's Disease Rating Scale (UPDRS) was used to assess functional status. The regression model consisted of disease severity, disease duration, age and DS-14 and its two scales (NA and SI).

RESULTS

Type D is negatively associated with overall QoL in PD patients and most subscales of the PDQ-39. Type D explained emotional well-being in both genders but was significant in the models for stigma, cognition, and communication only in men. NA and SI played a less important role in women in comparison with men.

CONCLUSION

Type D personality is an important part of the QoL model in PD patients of both genders, especially in the NA scale. The gender differences suggest that male and female PD patients require different coping strategies.

Risk of ventricular arrhythmia after implantable defibrillator treatment in anxious type D patients

OBJECTIVES

We sought to examine the combination of adverse psychological factors (anxiety, depression, and distressed or Type D personality) as a predictor of ventricular arrhythmias in patients with implantable cardioverter-defibrillators (ICDs).

BACKGROUND

Little is known about the role of psychological factors and their clustering in the occurrence of life-threatening arrhythmias.

METHODS

In this prospective study, 391 patients with an ICD (81% men, age 62.3 +/- 10.4 years) completed anxiety, depression, and Type D personality scales at the time of implantation. The end point was occurrence of ventricular arrhythmia, defined as appropriate ICD therapies, in the first year after implantation.

RESULTS

Ventricular arrhythmias occurred in 19% (n = 75) of patients. Increased symptoms of depression (p = 0.81) or anxiety (p = 0.31) did not predict arrhythmias. However, anxious patients with a Type D personality had a significantly increased rate of ventricular arrhythmias (21 of 71; 29.6%) as compared with other ICD patients (54 of 320; 16.9%; hazard ratio [HR]: 1.89; 95% confidence interval [CI]: 1.14 to 3.13; p = 0.013). When controlled for the effects of sex, age, ischemic etiology, left ventricular dysfunction, prolonged QRS duration, and medication, anxious Type D patients (HR: 1.72; 95% CI: 1.03 to 2.89; p = 0.039) and secondary prevention patients (HR: 1.91; 95% CI: 1.14 to 3.20; p = 0.014) were at increased risk of ventricular arrhythmias.

CONCLUSIONS

Personality modulated the effect of emotional distress; anxiety predicted a 70% increase in risk of arrhythmia in Type D patients but not in other patients. Anxious Type D patients may be identified and offered additional behavioral support after ICD implantation.

Personality dimensions of people who suffer from visual stress

Personality dimensions of participants who suffer from visual stress were compared with those of normal participants using the Eysenck Personality Inventory. Extraversion-Introversion scores showed no significant differences between the participants who suffered visual stress and those who were classified as normal. By contrast, significant differences were found between the normal participants and those with visual stress in respect of Neuroticism-Stability. These differences accord with Eysenck's personality theory which states that those who score highly on the neuroticism scale do so because they have a neurological system with a low threshold such that their neurological system is easily activated by external stimuli. The findings also relate directly to the theory of visual stress proposed by Wilkins which postulates that visual stress results from an excess of neural activity. The data may indicate that the excess activity is likely to be localised at particular neurological regions or neural processes.

Introduction to the special issue on personality assessment in medical settings

This special issue of the Journal of Personality Assessment brings together 3 review articles and 5 research studies on personality assessment in medical settings that should help clinicians become more familiar with the current status of this field. In 1 review article, Sirri, Fabbri, Fava, and Sonino (2007/this issue) summarize evidence of a new approach to the assessment of psychological syndromes in somatizing patients based on the Diagnostic Criteria for Psychosomatic Research (Fava et al., 1995). The other reviews focus on 2 personality constructs widely used in investigations with medical patients. Kupper and Denollet (2007/this issue) review the Type D personality, whereas Lumley, Neely, and Burger (2007/this issue) provide an overview of alexithymia. Of the research articles, 2 also focus on alexithymia, specifically on the factor structure of the 20-item Toronto Alexithymia Scale (Bagby, Parker, & Taylor, 1994), which is the best-validated and most commonly used measure of alexithymia (Bagby, Taylor, Quilty, & Parker, 2007/this issue; Gignac, Palmer, & Stough, 2007/this issue). The other 3 research studies examine the relationship between specific personality dimensions (behavioral problems relevant to medicine, resiliency, and interpersonal sensitivity) and medical outcomes (adherence to treatment, coping with injury, and postsurgical sexual functioning) from medical samples of patients with HIV, spinal cord injury, and prostate carcinoma (Berry, Elliott, & Rivera, 2007/this issue; Cruess, Meagher, Antoni, & Millon, 2007/this issue; Siegel et al., 2007/this issue). Each article touches on the role person variables can play in the expression of medical problems.

Type D personality as a prognostic factor in heart disease: assessment and mediating mechanisms

Type D personality, a synergy between negative affectivity and social inhibition, has established itself as a serious risk factor for morbidity and mortality in patients suffering from cardiovascular disease. In this review, we summarize studies on the validity of the assessment methods of Type D, emphasizing its role as an independent vulnerability factor in the progression of cardiovascular disease. We further present evidence on the physiological characteristics that accompany the 2 psychological traits negative affectivity and social inhibition and may mediate the relation between personality and prognosis in heart disease. Further research needs to determine the mechanisms by which Type D affects the course and outcome of cardiovascular disease as well as how Type D patients may benefit from psychosocial intervention.

The use and reporting of cluster analysis in health psychology: a review

PURPOSE

Cluster analysis is a collection of relatively simple descriptive statistical techniques with potential value in health psychology, addressing both theoretical and practical problems. There are many methods of cluster analysis from which to choose, with no clear guidelines to aid researchers. In the absence of guidelines it is likely that methods already reported by published researchers will be adopted, and so clear reporting of statistical methodology, while always important, is particularly crucial with cluster analysis. The aim of this review is to describe and evaluate the reporting of cluster analysis in health psychology publications.

METHODS

Electronic searches of 18 health psychology journals identified 59 articles using cluster analysis published between 1984 and 2002. Articles were submitted to systematic evaluation against published criteria for the reporting of cluster analysis.

RESULTS

Just 27% of the papers reviewed met all five criteria, although 61% met at least four. Details of the similarity measure and the computer program used were most frequently omitted. Furthermore, while researchers usually reported the procedures employed to determine the number of clusters and to validate the clusters, these procedures were often lacking in rigour, and were reported in insufficient detail for replication.

CONCLUSIONS

The reporting of cluster analysis was found to be generally unsatisfactory, with many studies failing to provide enough information to allow replication or the evaluation of the quality of the research. Clear guidelines for conducting and reporting cluster analyses in health psychology are needed.

Type A behavior pattern, risky driving behaviors, and serious road traffic accidents: a prospective study of the GAZEL cohort

The type A behavior pattern (TABP), characterized by impatience, time urgency, and hostility, was originally developed in relation to coronary heart disease. Since 1986, there has been a debate on whether the TABP is also associated with risky driving behaviors leading to increased risks in road traffic accidents (RTAs). The authors examined prospectively the relation among risky driving behaviors, serious RTAs, and the TABP in a cohort of 20,000 French employees of Electricité de France-Gaz de France who were aged 39-54 years in 1993. A total of 11,965 participants were included in this study. The TABP was assessed in 1993 using the French version of the Bortner Rating Scale. Driving behaviors and serious RTAs were recorded in 2001. Sociodemographic and alcohol consumption data were available from the cohort's annual follow-up. The impact of the TABP on the risk of serious RTAs was assessed using the Cox proportional hazards regression model with time-dependent covariates. After adjustment for potential confounders, the risk for serious RTAs increased proportionally with TABP scores: hazard ratios were 1.29 (95% confidence interval: 1.03, 1.63) for intermediate-level scores and 1.48 (95% confidence interval: 1.16, 1.90) for high-level scores relative to low TABP scores. The authors concluded that type A drivers had an increased risk of RTAs. Implications of this finding for traffic safety are discussed.

Type D personality, cardiac events, and impaired quality of life: a review

BACKGROUND

Psychological distress has been associated with the pathogenesis and progression of coronary heart disease (CHD) but little is known about the determinants of distress as a coronary risk factor. Although it has become unfashionable to focus on personality factors since research on Type A behaviour yielded inconsistent findings, personality may comprise a major explanatory factor of individual differences in stress-related CHD. This article focuses on Type D--the distressed--personality, which describes patients who experience increased negative emotions and tend to inhibit the expression of these emotions in social interactions.

METHODS

The article reviews research on Type D personality in the context of CHD.

RESULTS

Accumulating evidence indicates that cardiac patients with the Type D personality are at increased risk for cardiovascular morbidity and mortality (odds ratios ranging from 4.1-8.9, P<0.0001) independent of standard cardiac risk factors. Type D patients are also at increased risk for psychological distress, clustering of psychosocial risk factors, impaired quality of life, and seem to benefit less from medical and invasive treatment. Preliminary evidence suggests that physiological hyper-reactivity and activation of pro-inflammatory cytokines may be responsible for the detrimental effect of Type D personality on cardiac prognosis.

CONCLUSIONS

There is an urgent need to adopt a personality approach in the identification of patients at risk for stress-related cardiac events. Type D is a stable personality construct that may be of special interest not only in CHD, but in other chronic cardiac conditions as well.

Type D personality. A potential risk factor refined

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.

Assessment of hostility in patients with coronary heart disease

One of the problems in efforts to more clearly conceptualize hostility is the amount of method variance, which ranges from self-report techniques to interview-based methods and mirrors the multidimensional nature of hostility and related constructs. In addition, rather few studies concerned with the assessment of hostility have specifically used samples of coronary heart disease (CHD) patients. The purpose of this study was, therefore, to examine the multidimensionality of the construct of hostility in a sample of male coronary patients with some frequently used instruments. Factor analysis was used to detect the relevant underlying constructs, which were assessed using a variety of hostility measures in a sample of cardiac patients undergoing baseline assessment in an ongoing health-education intervention study. Measurement included both questionnaires and interviews. Participants (N = 235) were divided into 3 diagnostic groups: patients who had recently undergone (a) a myocardial infarction, (b) coronary artery bypass grafting, or (c) percutaneous transluminal coronary angioplasty. A 4-factor solution appeared to provide the best fit, and the following factors were isolated: Anger-Out, Negative Affect, Coping, and Anger-In. All intercorrelations were less than .50. Medical diagnosis did not differ with regard to the 4 factors found. The total hostility construct as measured by the structured interview (SI) did not fit into the 4-factor model. This study was the first to show that dimensions of anger and hostility constitute valid and relevant aspects of the general construct of hostility for a representative group of CHD patients. The 4 aspects of hostility isolated using some well-known hostility questionnaires and the SI explained most of the observed variance. Although the SI appeared to tap more general state anger, the 4 aspects of hostility may be differentially related to health in those who are coronary prone. Future studies on the role of hostile or negative emotions in CHD patients should, therefore, pay greater attention to the multidimensional nature of hostility and may clearly benefit from the use of the 4-factor model described in this article.

Defensiveness status predicts 3-year incidence of hypertension

OBJECTIVE

A growing body of research indicates that defensive personality styles (in particular, self-deception) may be related to higher resting blood pressure and stress reactivity levels. This study is the first, however, to examine the value of defensiveness as a prognostic indicator for the development of clinical hypertension.

METHODS

Participants were 127 initially normotensive male and female adults who completed a comprehensive protocol including psychological testing, assessment of smoking, physical activity and body fat levels, and 8-12 h ambulatory blood pressure monitoring. Participants returned 3-years later for an identical follow-up protocol. Defensiveness was assessed using the Balanced Inventory of Desirable Responding.

RESULTS

At 3-year testing, 15 of 127 participants (12%) met criteria for hypertension (i.e. ambulatory mean blood pressure > 140/90). Comparisons between defensiveness groups showed that 12 of 60 (20%) high defensiveness participants met hypertension criteria, whereas only three of 67 (4.5%) low defensiveness participants were hypertensive. Logistic regression equations adjusted for age, alcohol usage, bodyfat, self-reported exercise levels, smoking, and year-1 ambulatory blood pressure, revealed that membership in the high defensiveness group was associated with more than a sevenfold risk of 3-year hypertension (adjusted risk ratio, 7.5; 95% confidence interval, 1.5-39.2).

CONCLUSIONS

These findings link defensive characteristics to an increased prospective risk of hypertension using state of the art ambulatory monitoring techniques, and were robust after controlling for established risk factors. We conclude that the current results add to the hypertension literature by demonstrating associations between personality and clinically relevant blood pressure criteria.

Personality and coronary heart disease: the type-D scale-16 (DS16)

Clinical diagnoses of depression, self-reported negative emotions, and personality traits have been associated with both the development and progression of coronary heart disease (CHD). This article focusses on negative affectivity (the tendency to experience negative emotions) and social inhibition (the tendency to inhibit self-expression in social interaction) in CHD patients. Two independent samples of patients with CHD were included in this study. Both empirical and internal-structural criteria were used to devise a brief self-report measure comprising an eight-item negative affectivity and an eight-item social inhibition scale in Sample 1 (N = 400). These scales were internally consistent (alpha = .89 and .82), stable over time (three-month test-retest reliability = .78 and .87) and were validated against standard personality scales. CHD patients with a "distressed" personality (Type-D) report high levels of negative affectivity and social inhibition; accordingly, this self-report measure was termed Type-D Scale-16 (DS16). Previous research showed that Type-D was associated with cardiac events and incidence of cancer in patients with CHD. Type-D as measured by the DS16 was associated with depressive affect and symptoms, stress, poor self-esteem, dissatisfaction with life, and low positive affect in Sample 2 (N = 100) of the present article. It is concluded that research on CHD should focus on affective disorder, specific negative emotions, and global personality traits, and that the DS16 is a practical, sound research tool that can be used to assess Type-D.

Personality and mortality after myocardial infarction

Previous research showed: a) emotional distress is a risk factor for mortality after myocardial infarction (MI) and b) emotional distress is linked to stable personality traits. In this study, we examined the role of these personality traits in mortality after MI. Subjects were 105 men, 45 to 60 years of age, who survived a recent MI. Baseline assessment included biomedical and psychosocial risk factors, as well as each patient's personality type. After 2 to 5 (mean, 3.8) years of follow-up, 15 patients (14%) had died. Rate of death for patients with a distressed personality type (11/28 = 39%) was significantly greater than that for patients with other personality types (4/77 = 5%) (p < .0001). Patients with this personality type tend simultaneously to experience distress and inhibit expression of emotions. Low exercise tolerance, previous MI (p < .005), anterior MI, smoking, and age (p < .05) were also associated with mortality. A logistic regression model including these biomedical factors had a sensitivity for mortality of only 27%. The addition of distressed personality type in this model more than doubled its sensitivity. Of note, among patients with poor physical health, those with a distressed personality type had a five-fold mortality risk (p < .005). Consistent with the findings of other investigators, depression (p < .005), life stress, use of benzodiazepines (p < .01), and somatization (p < .05) were also related to post-MI mortality. These psychosocial risk factors were more prevalent in the distressed personality type than in the other personality types (p < .001-.05). Multiple logistic regression indicated that these psychosocial factors did not add to the predictive value of the distressed personality type. Hence, an important personality effect was observed despite the low power. This suggests that personality traits may play a role in the detrimental effect of emotional distress in MI patients.

Dexamethasone enhances accumulation of cholesteryl esters by human macrophages

The effects of dexamethasone on lipid accumulation by human monocyte-derived macrophages were investigated. Preincubation of macrophages with dexamethasone for a period of 16-20 h resulted in a reproducible increase (3.5-fold) in the incorporation of oleate into cholesteryl esters. The effect was specific because no alterations were observed in oleate incorporation into triglycerides or phospholipids. Measurement of cellular cholesteryl esters indicated a fourfold increase after preincubation with dexamethasone. This increase was mediated by opposite effects on synthesis and breakdown of these lipids. Dexamethasone produced a 60% increase in activity of the enzyme acyl-CoA: cholesterol O-acyltransferase (ACAT), active in synthesis of cholesteryl esters, and a 40% decrease in that of neutral cholesteryl esterase, active in cholesteryl ester breakdown. The increased ACAT activity appeared to reflect increased mRNA for the enzyme. The effects of dexamethasone on cholesteryl ester accumulation by macrophages reached statistical significance at a concentration of 100 nM. They were dose dependent, and saturation was observed at around 1 microM. The effects were significant at low concentrations of cholesterol in the medium. At high-medium cholesterol, there was a large cholesterol-induced increase in ACAT activity that obscured most of the effect of dexamethasone. In general, the data suggest that high glucocorticoid levels enhance lipid accumulation by macrophages and thus would have an atherogenic action that is independent of serum cholesterol.

Emotional distress and fatigue in coronary heart disease: the Global Mood Scale (GMS)

Evidence indicates that emotional distress has a long-term impact on morbidity and mortality in patients with coronary heart disease (CHD), and that symptoms of depression, fatigue, and reduced energy may identify high-risk patients. This study was designed to: (1) devise a sound and practical measure of emotional distress in CHD patients; (2) examine the relationship between emotional distress and fatigue following CHD; and (3) examine changes in emotional distress as a function of cardiac rehabilitation. A sample of 478 men with CHD (mean age = 57.8 +/- 8.7 y) filled out questionnaires 3-6 weeks following a myocardial infarction (N = 110), bypass surgery (N = 302), or coronary angioplasty (N = 66). Statistical analyses of 56 Dutch mood terms were used to produce the 20-item Global Mood Scale (GMS) which measures negative affect (characterized by fatigue and malaise), as well as positive affect (characterized by energy and sociability), in patients with CHD. The GMS was found to be a reliable scale (alpha > 0.90; r > 0.55 over a 3-month period), and correlations with existing measures of emotional functioning and self-deception indicated its convergent and discriminant validity. Most importantly, fatigue was not related to cardiorespiratory fitness in a subset of 140 patients, but clearly was associated with negative affect. Consistent with the self-efficacy model, scores on the GMS mood scales improved significantly as a function of rehabilitation (P < 0.0001). Although symptoms of emotional distress are easily explained away by situational factors, previous research suggests that failure to recognize the clinical significance of these symptoms in CHD patients may result in the delay of much needed intervention. The current findings suggest that the GMS is a theoretically and psychometrically sound measure of emotional distress in CHD patients, and that this scale is sufficiently sensitive to assess change.