Personality and heart disease
A Steptoe, G J Molloy
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Heart 2007;93:783–784. doi: 10.1136/hrt.2006.109355
See article on page 814
our social worlds. They underpin the consistency
with which we think, act and feel across different
situations and over time. Adult personality traits
are thought to be derived from early life differ-
ences in temperament; these are partly genetically
determined and shape exposure to social experi-
ences.1There have been many taxonomies of
personality traits, but research over the past
20 years has converged on the view that there
are five broad personality dimensions, each of
which accommodates a number of lower-order
traits. The five factors are: extraversion or positive
emotionality (incorporating traits such as socia-
bility, energy, shyness and dominance/subordina-
(including lower-order traits such as proneness
to anxiety, irritability, sadness, insecurity and
guilt); conscientiousness (factors such as reliabil-
ity, carefulness, persistence and self-control);
generosity, kindness and politeness); and open-
ness to experience (imaginativeness, insight and
aesthetic sensitivity). Individuals vary on all these
dispositions, so each person is thought to have a
Personality traits predict a range of outcomes with
moderate consistency, including quality of social
and family relationships, marital status and
satisfaction, occupational choices, political atti-
tudes and criminality.2
See end of article for
Dr A Steptoe, Department
of Epidemiology and Public
Health, University College
London, 1–19 Torrington
Place, London WC1E 6BT,
ersonality traits are broad dimensions of
individual differences between people that
relate to the way in which we engage with
combinationof trait strengths.
PERSONALITY AND HEART DISEASE
The role of personality in coronary heart disease
(CHD) first came to prominence nearly 50 years
ago with the concept of type A behaviour, a
compound of hostility, impatience, competitive-
ness and dominance.3When type A behaviour was
studied in different countries and social groups, it
was found not to be a robust predictor of CHD,4
and later work has focused on negative affectivity
traits such as depression, anxiety and anger–
hostility.5A body of observational epidemiological
and experimental studies has linked these disposi-
tions to cardiovascular morbidity and mortality,
and a number of intervening behavioural and
biological mechanisms have been proposed to
explain the association. However, findings have
not been consistent across all of these negative
affective traits, and a conceptual debate continues
about whether anger, anxiety and depression are
distinct phenomena, or whether they reflect a
general disposition towards negative moods and
dysphoria. The strongest evidence has emerged for
depression, which seems to be both an indepen-
dent predictor of future CHD and a determinant of
morbidity, adaptation and quality of life after an
acute coronary syndrome and coronary artery
bypass surgery.6The pathways through which a
depressed mood might be related to cardiovascular
disease include biological processes such as heigh-
tened vascular inflammation, endothelial dysfunc-
behavioural factors such as physical inactivity,
smoking and failure to adhere to medication and
TYPE D DISTRESSED PERSONALITY
Type D or the distressed personality type was
formulated by Denollet8in response to the findings
that depression and low perceived social support
are related to cardiovascular morbidity and mor-
tality. He proposed a personality type that might
predispose people to depression and social isola-
tion by combining two personality traits, namely
negative affectivity (the tendency to experience
negative emotions) and social inhibition, or the
tendency to inhibit self-expression in social inter-
actions. Type D personality has been shown in a
series of studies to predict adverse clinical out-
comes in patients after acute coronary syndrome
and revascularisation, and in patients with chronic
heart failure.9 10It has also been associated with
heightened proinflammatory cytokine activation in
patients with heart failure,11and with disturbances
in cortisol secretion after acute coronary syn-
The article by Schiffer et al13(see page 814)
highlights a particular behavioural mechanism
that might partially explain the link between type
D personality and health outcomes in heart failure.
The study found that patients with type D
personality with chronic heart failure stated that
they would be less likely to report cardiac
symptoms such as swollen legs and feet or short-
ness of breath to clinical staff than would other
patients. Interestingly, this tendency of individuals
with type D personality not to consult clinical staff
was not because they did not experience symp-
toms; in fact, their symptom reports were greater
than those of other patients, suggesting that their
reluctance was a consequence of increased levels of
social inhibition. This behaviour may increase the
likelihood of adverse clinical outcomes by jeopar-
dising appropriate adjustments in clinical care.
This may be a pathway through which the
Abbreviation: CHD, coronary heart disease
relationship between type D personality and cardiovascular Download full-text
morbidity could be explained. The findings were, unfortunately,
limited to self-report, and objective corroboration of failure to
consult appropriately would be valuable in future works.
This kind of study is critical for a fuller understanding of the
influence of personality on cardiovascular outcomes and, also,
for the development of practical intervention strategies that aim
to reduce the excess risk conferred by type D characteristics. In
the case of heart failure, it may be that patients with type D
personality require more detailed information about the
consequences of ignoring symptoms and encouragement or
guidance with consultation behaviour after the onset of
symptoms. Another avenue for future research would be to
attempt to change potentially damaging behaviour patterns, as
has been attempted for type D individuals with CHD.14
DO WE NEED ANOTHER PERSONALITY TYPE?
There has been vigorous debate among psychosocial researchers
about the validity and usefulness of the type D construct. One
issue is whether it adds to the better-established evidence
concerning depression, since the negative affectivity component
of type D strongly overlaps with depression. The second
question is whether type D is really a stable personality type
rather than a response to illness, since, in most studies, it is
assessed in patients with diagnosed cardiovascular disease;
perhaps the knowledge of having a serious illness affects
people’s moods and confidence in social interactions. More
broadly, we need to understand better the interpersonal context
of individual characteristics such as type D. Personality traits
are latent constructs that predict action and feelings in people’s
personal lives and in their interactions with society at large, but
this is not to say that individuals with particular dispositions
will always behave in a predictable way. Understanding the role
of the social context is crucial in defining the influence of
personality on cardiovascular health.15The social context of the
family life of a patient with heart failure is of particular
importance.16It is likely that consultation behaviour in this
condition, where symptoms such as breathlessness and fatigue
will be obvious to the patient’s closest family members, will
often be a consequence of an interactive process between a
patient and his or her spouse or informal carer, rather than
being some unilateral decision-making process.
AS and GJM are supported by the British Heart Foundation.
A Steptoe, G J Molloy, Department of Epidemiology and Public Health,
University College London, London, UK
Competing interests: None declared.
1 Caspi A, Roberts BW, Shiner RL. Personality development: stability and change.
Annu Rev Psychol 2005;56:453–84.
2 Ozer DJ, Benet-Martinez V. Personality and the prediction of consequential
outcomes. Annu Rev Psychol 2006;57:401–21.
3 Friedman M, Rosenman RH. Overt behavior pattern in coronary disease.
Detection of overt behavior pattern A in patients with coronary disease by a new
psychophysiological procedure. JAMA 1960;173:1320–5.
4 Rozanski A, Blumenthal JA, Kaplan J. Impact of psychological factors on the
pathogenesis of cardiovascular disease and implications for therapy. Circulation
5 Suls J, Bunde J. Anger, anxiety, and depression as risk factors for cardiovascular
disease: the problems and implications of overlapping affective dispositions.
Psychol Bull 2005;131:260–300.
6 Steptoe A, ed. Depression and physical illness. Cambridge: Cambridge
University Press, 2006.
7 Rieckmann N, Gerin W, Kronish IM, et al. Course of depressive symptoms and
medication adherence after acute coronary syndromes: an electronic medication
monitoring study. J Am Coll Cardiol 2006;48:2218–22.
8 Denollet J. DS14: standard assessment of negative affectivity, social inhibition,
and type D personality. Psychosom Med 2005;67:89–97.
9 Pedersen SS, Denollet J. Type D personality, cardiac events, and impaired quality
of life: a review. Eur J Cardiovasc Prev Rehabil 2003;10:241–8.
10 Denollet J, Pedersen SS, Ong AT, et al. Social inhibition modulates the effect of
negative emotions on cardiac prognosis following percutaneous coronary
intervention in the drug-eluting stent era. Eur Heart J 2006;27:171–7.
11 Denollet J, Conraads VM, Brutsaert DL, et al. Cytokines and immune activation in
systolic heart failure: the role of type D personality. Brain Behav Immun
12 Whitehead DL, Perkins-Porras L, Strike PC, et al. Cortisol awakening response is
elevated in acute coronary syndrome patients with type D personality.
J Psychosom Res 2007;62:412–25.
13 Schiffer AA, Denollet J, Widdershoven JW, et al. Failure to consult for symptoms
of heart failure in patients with a type-D personality. Heart 2007;93:814–18.
14 Denollet J, Brutsaert DL. Reducing emotional distress improves prognosis in
coronary heart disease: 9-year mortality in a clinical trial of rehabilitation.
15 Smith TW, MacKenzie J. Personality and risk of physical illness. Annu Rev Clin
16 Molloy GJ, Johnston DW, Witham MD. Family caregiving and congestive heart
failure. Review and analysis. Eur J Heart Fail 2005;7:592–603.
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