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Torgersen KS, Sverre ECB, Weedon-Fekjær H, Andreassen OA, Munkhaugen J, Dammen T. Risk of recurrent cardiovascular events in coronary artery disease patients with Type D personality. Front Psychol 2023; 14:1119146. [PMID: 37057178 PMCID: PMC10088369 DOI: 10.3389/fpsyg.2023.1119146] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 02/28/2023] [Indexed: 03/30/2023] Open
Abstract
IntroductionData on the association between Type D personality, its traits negative affectivity (NA) and social inhibition (SI), and risk of major adverse cardiac events (MACE) in coronary outpatients is sparse. Furthermore, the associations between Type D subgroups and cardiovascular risk factors are largely unknown.MethodsWe investigated i) Type D personality, NA and SI and risk of recurrent MACE, and ii) the relationship between Type D subgroups and risk factors in a coronary population. This prospective cohort study included 1083 patients` median 16 months after a myocardial infarction and/or a revascularization procedure who were followed-up for 4.2 (SD 0.4) years. Type D personality was assessed by DS14. Anxiety and depression, statin adherence, and risk factors were assessed by patients’ self-report and a clinical examination with blood samples. MACE, defined as cardiovascular death, myocardial infarction, revascularization, stroke or heart failure, were obtained from hospital records from index event to end of study lasting 5.7 years. Data were analyzed by Cox proportional hazard regression.ResultsIn all, 352 MACE occurred in 230 patients after average 4.2 years follow-up. Higher NA score was associated with MACE after adjustment for age, risk factors and comorbidity (HR 1.02 per unit increase, 95% CI 1.00-1.05), whereas we found a weaker, not statistically significant estimated effect of higher SI score. After additional adjustment for symptoms of anxiety and depression, we found a weaker, not statistically significant association between NA and MACE (HR 1.01 per unit increase, 95% CI 0.98-1.05). Low statin adherence and smoking were more prevalent in the Type D and high NA group.DiscussionOur results indicate that the NA trait is related to worse prognosis in outpatients with coronary artery disease.
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Affiliation(s)
- Kristin Stensland Torgersen
- Department of Behavioural Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Elise Christine Bjørkholen Sverre
- Department of Behavioural Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Drammen Hospital, Drammen, Norway
| | - Harald Weedon-Fekjær
- Oslo Center for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Ole A Andreassen
- NORMENT: Norwegian Centre for Mental Disorders Research, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - John Munkhaugen
- Department of Behavioural Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Drammen Hospital, Drammen, Norway
| | - Toril Dammen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Section of Psychiatric Treatment Research, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
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Influence of Type D Personality on Health Promoting Behaviours and Quality of Life in Stroke Patients: A Cross-Sectional Study in South Korea. J Stroke Cerebrovasc Dis 2021; 30:105721. [PMID: 33735669 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105721] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Type D personality is vulnerable to stress and is associated with high symptom severity, unhealthy behaviors, and low quality of life (QoL) in patients with chronic diseases. This study aimed to identify the influence of type D personality on health promoting behaviors and QoL in patients with ischemic stroke in South Korea. MATERIALS AND METHODS A descriptive, cross-sectional design was used. This study collected data from a convenience sample of 170 patients with ischemic stroke. Demographic and clinical characteristics, health promoting behaviors, and QoL were compared between the type D personality group and the non-type D group. Stepwise multiple regression analysis was performed to identify factors influencing patients' QoL. RESULTS Of the 170 subjects, 39 (22.9%) were classified as having type D personality. Type D personality was associated with higher National Institutes of Health Stroke Scale scores at admission and discharge, higher modified Rankin Scale (mRS) scores at 3 months after stroke, lower scores for health promoting behaviors, and lower QoL. Regression analysis showed that mRS score 3 months after stroke was the most significant factor influencing QoL, followed by health promoting behaviors, type D personality, speech deficits, and family income. CONCLUSIONS Type D personality should be considered together with health promoting behaviors and QoL in patients with ischemic stroke. Interventions considering type D personality may be helpful in improving health promoting behavior and QoL for the stroke patients.
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Köbling T, Váradi Z, Katona É, Somodi S, Kempler P, Páll D, Zrínyi M. Predictors of dietary self-efficacy in high glycosylated hemoglobin A1c type 2 diabetic patients. J Int Med Res 2020; 48:300060520931284. [PMID: 32588697 PMCID: PMC7325457 DOI: 10.1177/0300060520931284] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To predict dietary self-efficacy behaviors in high glycosylated hemoglobin A1c (HbA1c) patients using type D personality (TDP) and other psychosocial measures. Methods A cross-sectional, predictive research design was implemented. Participants were type 2 diabetes mellitus patients diagnosed more than 2 years prior to the study. Data were collected for demographics, dietary self-efficacy and psychological measures. Spearman’s rank-order correlation was used to test for relationships, the Mann–Whitney test was used to test for differences and multiple linear regression was used to examine predictors of dietary self-efficacy. Results Lower dietary self-efficacy was strongly correlated with greater social isolation (r = 0.93) and moderately correlated with more mental health problems (r = 0.20) and higher TDP scores (r = 0.17). Higher HbA1c was inversely related to self-reported physical health (r = −0.19). Social and emotional isolation and time since diagnosis predicted dietary self-efficacy (greater isolation was associated with more dietary management difficulties). Conclusions Regression outcomes suggested that a 10% decrease in social isolation improves dietary self-efficacy by 30%, a significant boost to therapeutic adherence. We recommend assessment of social isolation to improve dietary self-efficacy and achieve better patient adherence to therapy.
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Affiliation(s)
- Tamás Köbling
- Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Zita Váradi
- Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Éva Katona
- Department of Medicine, University of Debrecen, Debrecen, Hungary
| | - Sándor Somodi
- Emergency Clinic, University of Debrecen, Debrecen, Hungary
| | - Péter Kempler
- Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Dénes Páll
- Department of Medicine, University of Debrecen, Debrecen, Hungary.,Coordination Center for Drug Development, University of Debrecen, Debrecen, Hungary
| | - Miklós Zrínyi
- Coordination Center for Drug Development, University of Debrecen, Debrecen, Hungary
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Arrebola-Moreno M, Petrova D, Garrido D, Ramírez-Hernández JA, Catena A, Garcia-Retamero R. Psychosocial markers of pre-hospital decision delay and psychological distress in acute coronary syndrome patients. Br J Health Psychol 2020; 25:305-323. [PMID: 32065483 DOI: 10.1111/bjhp.12408] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 01/18/2020] [Indexed: 12/28/2022]
Abstract
Objectives Both pre-hospital decision delay - the time patients wait before seeking medical attention after symptoms have started - and high psychological distress after the cardiac episode predict poor prognosis of patients with acute coronary syndromes (ACS). We aimed to identify psychosocial markers of these prognostic factors. Design A cross-sectional study of 102 consecutive, clinically stable ACS survivors. Methods Participants completed a questionnaire measuring pre-hospital decision delay, psychological distress, and several known psychosocial factors related to cardiovascular health: type D personality, resilience, social support, and concerns during the cardiac event. Multiple linear regression and mediation analyses were conducted. Results Type D personality and fewer concerns about the serious consequences of delaying help-seeking were related to more psychological distress post-ACS, and these relationships were mediated by longer pre-hospital decision delay. In contrast, resilience was related to lower psychological distress. Social support and social concerns about help-seeking were not related to the outcome variables. Conclusions Type D personality may be a risk factor for more delayed help-seeking for an ACS and higher psychological distress after the cardiac event. Resilience, in contrast, emerged as a potential protective factor of patients' mental health after the cardiac event. Pre-hospital decision delay was related to thinking about serious consequences (e.g., complications, protecting one's family) but not about social concerns (e.g., wasting other people's time) during the cardiac episode. Statement of Contribution What is already known on this subject? Longer pre-hospital decision delay, that is waiting longer to seek medical attention after symptoms have started, predicts poor prognosis of acute coronary syndrome patients. High psychological distress post-ACS, such as the development of anxiety and/or depression, also predicts poor prognosis of these patients. What does this study adds? This study identifies several psychosocial markers of longer prehospital decision delay and high psychological distress post-ACS. Prehospital decision delay was related to thinking about serious consequences (e.g., complications, protecting one's family) but not about social concerns (e.g., wasting other people's time) during the cardiac episode. Type D personality and fewer concerns about the serious consequences of delaying help-seeking were related to more psychological distress, and these relationships were mediated by longer prehospital decision delay. Resilience was related to lower psychological distress post-ACS.
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Affiliation(s)
| | - Dafina Petrova
- Escuela Andaluza de Salud Pública, Granada, Spain.,Instituto de Investigación Biosanitaria ibs.GRANADA, University of Granada, Spain.,CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Dunia Garrido
- Mind, Brain, and Behavior Research Center (CIMCYC), University of Granada, Spain
| | - José Antonio Ramírez-Hernández
- Instituto de Investigación Biosanitaria ibs.GRANADA, University of Granada, Spain.,Cardiology Department, Virgen de las Nieves University Hospital, Granada, Spain
| | - Andrés Catena
- Mind, Brain, and Behavior Research Center (CIMCYC), University of Granada, Spain
| | - Rocio Garcia-Retamero
- Mind, Brain, and Behavior Research Center (CIMCYC), University of Granada, Spain.,Harding Center for Risk Literacy, Max Planck Institute for Human Development, Berlin, Germany
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Arrebola-Moreno M, Petrova D, Sánchez MJ, Rivera-López R, Ramírez-Hernández JA. Who does what the cardiologist recommends? Psychosocial markers of unhealthy behavior in coronary disease patients. PLoS One 2020; 15:e0228262. [PMID: 32004332 PMCID: PMC6993961 DOI: 10.1371/journal.pone.0228262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 01/12/2020] [Indexed: 01/04/2023] Open
Abstract
Patients diagnosed with coronary heart disease should follow lifestyle recommendations that can reduce their cardiovascular risk (e.g., avoid smoking). However, some patients fail to follow these recommendations and engage in unhealthy behavior. With the aim to identify psychosocial factors that characterize patients at high risk of repeated cardiovascular events, we investigated the relationship between social support, mental health (coping, self-esteem, and perceived stress), and unhealthy behavior. We conducted a cross-sectional study of 419 patients recently diagnosed with coronary heart disease (myocardial infarction or angina) who participated in the National Health Survey in Spain (2018). Unhealthy behaviors were defined according to the European Guidelines on cardiovascular disease prevention. Only 1% of patients reported no unhealthy behaviors, with 11% reporting one, 40% two, 35% three, and 13% four or more unhealthy behaviors. In multiple regression controlling for demographic and traditional risk factors, mental health was the only significant psychosocial factor, doubling the odds of accumulated unhealthy behaviors, OR(high vs. low) = 2.03, 95% CI [1.14, 3.64]. Mental health was especially strongly related to unhealthy behavior among patients with obesity, OR(high vs. low) = 3.50, 95% CI [1.49, 8.45]. The relationship between mental health and unhealthy behaviors suggests that a large proportion of patients may not adhere to lifestyle recommendations not because they purposefully choose to do so, but because they lack coping skills to maintain the recommended healthy behaviors. Low mental well-being may be especially detrimental for behavior change of patients with obesity.
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Affiliation(s)
| | - Dafina Petrova
- Escuela Andaluza de Salud Pública, Granada, Spain
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
- * E-mail:
| | - María-José Sánchez
- Escuela Andaluza de Salud Pública, Granada, Spain
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Madrid, Spain
- University of Granada, Granada, Spain
| | - Ricardo Rivera-López
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- Cardiology Department, Virgen de las Nieves University Hospital, Granada, Spain
| | - José Antonio Ramírez-Hernández
- Instituto de Investigación Biosanitaria ibs.GRANADA, Granada, Spain
- Cardiology Department, Virgen de las Nieves University Hospital, Granada, Spain
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Fernandez GV, Fitriyah R, Samudera WS, Arifin H, Wulandari SM. A Review of Personality Type D on Cardiovascular Disease Patients. JURNAL NERS 2019. [DOI: 10.20473/jn.v14i3.16976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: The type of personality that a patient has as a psychosocial factor has been associated with the incidence and progression of cardiovascular disease. The aim of the study was to review the evidence and correlation between personality type and the development of cardiovascular disease.Methods: Articles were searched for using the PRISMA approach in the CINAHL, Science Direct and Scopus databases, limited to the last 5 years. The articles were from 2013 to 2018 and the language used was English. The studies focused on personality type D and cardiovascular disease, and the participants were above 18 years old.Results: Most of the findings of the studies showed that individuals with a type D personality have a relationship with more severe heart disease, which relates to several physiological factors, namely emotion increase, anxiety, stress, biological factors, cognitive decline and the decrease in quality of life.Conclusion: Individuals with type D personality have a higher level of stress, significant blood pressure, higher pulse and they experience an increase in cortisol compared to non-type D personalities. Individuals who suffer from cardiovascular disease with personality type D tend to experience a more severe progression of the condition of cardiovascular disease.
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Kheirabadi G, Bagherian-Sararoudi R, Mohammad M, Feizi A, Saneai H. A comparative study of left ventricular function of people with and without D-type personality hospitalized for first-time myocardial infarction. INTERNATIONAL ARCHIVES OF HEALTH SCIENCES 2019. [DOI: 10.4103/iahs.iahs_25_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Social support buffers the negative effects of stress in cardiac patients: a cross-sectional study with acute coronary syndrome patients. J Behav Med 2018; 42:469-479. [PMID: 30523503 DOI: 10.1007/s10865-018-9998-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 11/29/2018] [Indexed: 12/12/2022]
Abstract
Cardiac patients who have social support generally have better prognosis than patients who lack social support. Several theoretical mechanisms have been proposed to explain this protective effect, including the capacity of social support to buffer the negative effects of stress. We tested this buffering effect in a study of patients hospitalized for acute coronary syndrome (ACS) in Spain. Several days after the cardiac event patients answered a questionnaire measuring stressful events during their lifetime, perceived social support around the time of the cardiac event, and depression symptoms in the past week. Results showed that stressful life events were related to depressive symptoms and worse renal function post-ACS only among patients with low perceived social support. Among patients who reported enough social support, lifetime stress was not related to depressive symptoms. No similar effects were observed on other prognostic indicators such as troponin levels or the number of obstructed arteries. These results suggest that social support can buffer the negative effects of stress on the mental and physical well-being of cardiac patients.
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Abstract
PURPOSE OF THE REVIEW This review article synthesizes recent research findings on the psychological context of Type D personality and the mechanisms through which Type D affects disease progression and prognosis among patients with coronary heart disease (CHD). RECENT FINDINGS One in four patients with CHD has a Distressed (Type D) personality, which is characterized by two stable traits: social inhibition and negative affectivity. Type D personality predicts increased mortality and morbidity burden, and poorer health-related quality of life. Type D is part of a family of psychosocial risk factors that affect CHD prognosis. The pattern of co-occurrence of these psychosocial factors and intra-individual differences in psychosocial profiles may affect risk prediction accuracy. Multiple biological and behavioral processes have been associated with Type D personality. Identifying pathways explaining the observed associations between Type D personality and CHD is important to improve etiological and pathophysiological knowledge and to design personalized interventions, and targeting specific risk-associated pathways.
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10
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Syeda JN, Rutkofsky IH, Muhammad AS, Balla Abdalla TH, Saghir Z. The Psycho-cardiac Coupling, Myocardial Remodeling, and Neuroendocrine Factor Levels: The Psychosomatics of Major Depressive Disorder. Cureus 2018; 10:e2464. [PMID: 29900084 PMCID: PMC5997425 DOI: 10.7759/cureus.2464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
The association of major depressive disorder (MDD) with myocardial infarction (MI) and vice versa is not unknown. Depression, along with many other systemic factors like atherosclerosis, obesity, diabetes and vascular dysfunction, contributes to the development of adverse cardiac events in the future and, has always been a topic of interest in the fields of cardiology and psychosomatics. We wrote this review article to elaborate this relationship in detail. This article suggests that the individuals with type D personality who already had cardiovascular disease had undergone more serious myocardial damage. In addition, we elucidated the effects of depression on sympathetic activity and remodeling of myocardium after MI. The alterations in the neuroendocrine factors, which included the changes in levels of Serotonin (5-HT), Norepinephrine and Corticosterone, also geared towards the changes associated with depression-induced myocardial injury. However, we need more studies in the near future to further dig into this association process. Therefore, we recommend more research to explore the relationship of psychological factors and adverse cardiac outcomes.
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Affiliation(s)
- Javeria N Syeda
- Department of Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, CA, USA
| | - Ian H Rutkofsky
- Department of Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, CA, USA
| | - Adnan S Muhammad
- Department of Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, CA, USA
| | - Tarig H Balla Abdalla
- Department of Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, CA, USA
| | - Zahid Saghir
- Department of Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, CA, USA
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Petrova D, Garcia-Retamero R, Catena A, Cokely E, Heredia Carrasco A, Arrebola Moreno A, Ramírez Hernández JA. Numeracy Predicts Risk of Pre-Hospital Decision Delay: a Retrospective Study of Acute Coronary Syndrome Survival. Ann Behav Med 2017; 51:292-306. [PMID: 27830362 DOI: 10.1007/s12160-016-9853-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Many patients delay seeking medical attention during acute coronary syndromes (ACS), profoundly increasing their risk for death and major disability. Although research has identified several risk factors, efforts to improve patient decision making have generally been unsuccessful, prompting a call for more research into psychological factors. PURPOSE The purpose of this study is to estimate the relationship between ACS decision delay and numeracy, a factor closely related to general decision making skill and risk literacy. METHODS About 5 days after experiencing ACS, 102 survivors (mean age = 58, 32-74) completed a questionnaire including measures of numeracy, decision delay, and other relevant factors (e.g., anxiety, depression, symptom severity, knowledge, demographics). RESULTS Low patient numeracy was related to longer decision delay, OR = 0.64 [95 % confidence interval (CI) 0.44, 0.92], which was in turn related to higher odds of positive troponin on arrival at the hospital, OR = 1.37 [95 % CI 1.01, 2.01]. Independent of the influence of all other assessed factors, a patient with high (vs. low) numeracy was about four times more likely to seek medical attention within the critical first hour after symptom onset (i.e., ORhigh-low = 3.84 [1.127, 11.65]). CONCLUSIONS Numeracy may be one of the largest decision delay risk factors identified to date. Results accord with theories emphasizing potentially pivotal roles of patient deliberation, denial, and outcome understanding during decision making. Findings suggest that brief numeracy assessments may predict which patients are at greater risk for life-threatening decision delay and may also facilitate the design of risk communications that are appropriate for diverse patients who vary in risk literacy.
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Affiliation(s)
- Dafina Petrova
- Mind, Brain, and Behavior Research Center, University of Granada, Campus Universitario de Cartuja s/n, 18071, Granada, Spain.
| | - Rocio Garcia-Retamero
- Mind, Brain, and Behavior Research Center, University of Granada, Campus Universitario de Cartuja s/n, 18071, Granada, Spain.,Max Planck Institute for Human Development, Berlin, Germany
| | - Andrés Catena
- Mind, Brain, and Behavior Research Center, University of Granada, Campus Universitario de Cartuja s/n, 18071, Granada, Spain
| | - Edward Cokely
- Max Planck Institute for Human Development, Berlin, Germany.,National Institute for Risk and Resilience, and Department of Psychology, University of Oklahoma, Norman, OK, USA
| | - Ana Heredia Carrasco
- Mind, Brain, and Behavior Research Center, University of Granada, Campus Universitario de Cartuja s/n, 18071, Granada, Spain
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Timmermans I, Versteeg H, Duijndam S, Graafmans C, Polak P, Denollet J. Social inhibition and emotional distress in patients with coronary artery disease: The Type D personality construct. J Health Psychol 2017; 24:1929-1944. [PMID: 28810489 PMCID: PMC6749748 DOI: 10.1177/1359105317709513] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
We examined the validity of the social inhibition component of Type D, its distinctiveness from negative affectivity, and value regarding emotional distress as measured with the DS14 in 173 coronary artery disease patients. In dimensional analysis, social inhibition and negative affectivity emerged as distinct traits. Analysis of continuous negative affectivity and social inhibition measures showed main effects for several emotional and inhibition markers and an interaction effect for social anxiety. Categorical analysis indicated that Type D patients reported more depression, negative mood, social anxiety, and less positive mood. Social inhibition is not a redundant trait, but has additional conceptual value.
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Affiliation(s)
- Ivy Timmermans
- Tilburg University, The Netherlands.,University Medical Center Utrecht, The Netherlands
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