Type D Personality
KeywordsCoronary Artery Calcification Personality Disorder Emotional Expressiveness Social Inhibition Experience Heart Failure
Type D personality (TDP), where “D” is for distressed, is more often a characteristic of those who dwell on negative emotions and are often afraid to express themselves in social situations. Natural pessimists are always waiting for the worst to happen. This trait is generally characterized by the joint tendency toward negative affectivity (e.g., worry, irritability, gloom) and social inhibition (e.g., reticence and a lack of self-assurance). Type D personality may further be defined or characterized as those who tend to be direct, decisive, and/or dominant, preferring to lead than follow, have high self-confidence, be self-starters, be a risk taker, and/or be a problem-solver.
Personality traits in general refer to enduring patterns of perceiving, relating to, and thinking about oneself and the environment that people exhibit by their actions within a wide range of contexts (American Psychiatric Association 2013). While Type D is thought of as a discrete type, this form of personality actually requires the examination of a synergistic effect of two stable personality traits. One such trait is negative affectivity (NA) wherein individuals experience high levels of negative emotion. This trait is negatively correlated with conscientiousness, extraversion, and agreeableness (Filip De Fruyt and Johan Denollet 2002). Unique to TDP is that NA is experienced simultaneously with that of a second trait – social inhibition (SI) – meaning those who have the tendency to inhibit emotions in social situations (Denollet 2005; Nyklicek et al. 2013; Schiffer et al. 2010). Pervasive characteristics among those with social inhibition include non-expression, withdrawal, and insecurity when with others (Denollet 1998). Being introverted, for example, is a type of SI, which for some could be a result of insecurity and/or tension (Denollet 2005). Overall, TDP is characterized as having a tendency to experience negative emotions, paired with the non-expression of these emotions in social interactions (Williams et al. 2009). Individuals need to score high on both negative affectivity and social inhibition indicators to be described as Type D (Denollet 2005).
While this type of personality is thought by some to only be another measure of negative affect, Williams et al. (2009) indicate TDP is much more than that. Rather, TDP behavior they argue also conveys ways in which people actually deal with this negative affect. Moreover, according to Howard and Hughs (2012), having TDP shows strong associations with health-related outcomes. Indeed, there has been accumulating evidence for some time that suggests that inhibition of the expression of emotions, for example, may be associated with negative effects on subjective and objective health status, as well as on well-being (Pennebaker and Traue 1993).
Type D personality is highly prevalent within the general population, with a rate of about 13–32.5 percent. This is important in so far as interest in and research into Type D personality in the first place arose from its now determined association with increased risk for cardiovascular disease morbidity and mortality (Bibbey et al. 2015). Indeed, TDP appears to be particularly evident in approximately 27–31 percent of those with cardiac problems and up to 45 percent of the time among those who experience heart failure (Denollet 2005). TDP has been mainly studied among cardiovascular patients in part because this type of personality is often highly correlated/associated with experiencing hypertension.
According to Oliva et al. (2016), those who have chronic hypertension are individuals who are more prone than others to having/exhibiting such traits as neuroticism and hostility. In general, the prevalence of Type D personality among patients with hypertension appears higher than that of the general population, as much as 2.5-fold (Oliva et al. 2016). That having hypertension has been linked to exaggerated levels of cortisol in the human body, which has been determined to be directly associated with coronary artery calcification and greater cardiovascular disease risk, can be a concern of those with TDP (Bibbey et al. 2015).
Historically the exact mechanisms by which TDP impacts a person’s health have been unclear. However, recent research by Conraads et al. (2006), for example, is shedding greater light that TDP is uniquely related to immune activation. Specifically, Conraads et al. report that those who have Type D personality have an increased risk of acquiring circulating levels of soluble tumor necrosis factor (sTNF)-alpha. Acquiring this is a powerful predictor of mortality in patients with chronic heart failure. Overall, TDP appears to incur a risk on par with established biomedical risk factors, with Type D patients/individuals experiencing a fourfold increased risk of an adverse clinical outcome, including death and myocardial infarction (Williams et al. 2009).
Among a wide variety of non-cardiovascular patient populations, evidence is also emerging that having a Type D personality (TDP) increases a person’s vulnerability to having decreased physical and mental health status, as well as poor self-management traits (Mols and Denollet 2010). Even healthy individuals with a Type D personality perform fewer health-related behaviors than non-Type D’s (Mommersteeg et al. 2010).
Upon a review of studies published from 2007 to 2009 on the implications of Type D personality among non-cardiovascular patient populations, Mols and Denollet (2010) found that such was associated with an increased severity of reported health complaints. TDP has been found, for example, to be a significant predictor of somatic complaints; sleeping problems; increased psychological distress, including symptoms of exhaustion (both physical and mental), anger, and depression, plus the reporting of a greater number of disability; as well as social alienation issues (De Fruyt and Denollet 2002; Denollet and Brutsaert 1998; Pedersen et al. 2004; Volz et al. 2011; Wu and Moser 2014). Further, while some have argued that TDP and depression overlap, there are studies to indicate that Type D personality is an independent predictor of poor health outcomes, independent of depression (Schiffer et al. 2005).
A person’s coping style and their level of social support may represent mechanisms to help further explain the relationship between Type D personality and ill-health (Williams and Wingate 2012). Chen et al. (2015) report that individuals with TDP are more likely to report having less social support and to adopt more negative coping strategies than those without TDP. For example, Wu and Moser (2014) indicate that having TDP may be predictive of poor medication adherence among patients with heart failure. Poor to nil medication adherence often leads to even poorer health outcomes. Other research has indicated that those with TDP may be more prone to acquire behavioral challenges such as compulsive overeating and active engagement in substance abuse.
Moreover, having lower social support may potentially contribute to such outcomes as poorer work satisfaction and, overall, high(er) levels of anxiety and stress (Polman 2010). Williams et al. (2009) support this assertion, finding in their own study that those with strong TDP traits tend to self-report significantly higher feelings of subjective stress compared to those with weak or no Type D personality traits.
Overall, on the one hand, individuals with a Type D personality style may tend to be direct and decisive and are sometimes described as dominant. They would prefer to lead than follow and lean toward leadership and management positions. They tend to be highly motivated by new challenges, setting and achieving goals, and seeing tangible results. They appreciate receiving verbal recognition from others as well as rewards. They enjoy power and authority to take risks and make decisions. Freedom from routine and mundane tasks is important to them. Since repetition is frustrating for this personality type, changing environments in which to work and play can be highly motivating. Of interest, Type D people are often those whom others turn to when looking for support. Compassionate individuals by nature tend to make some of the best friends and confidants.
Unfortunately, those with TDP who are unable to avoid the downfalls of their personality traits (e.g., depression and negativity) tend to experience poorer health status, increased risk of mortality, psychological problems, and decreased quality of life (Pedersen and Denollet 2006). Such outcomes may be more prevalent or exasperated when accompanied by long-term illnesses and/or chronic diseases (Chen et al. 2015). However, the risks for high blood pressure and cardiovascular disease in people with Type D personality may potentially be reduced by efficient stress management and social skill training strategies. Stress management strategies could include light exercise (e.g., yoga, tai chi), meditation, quality sleep, and most importantly balanced nutrition. Deficiency of many vitamins, minerals, essential amino acids, and/or essential fatty acids can all lead to stress and depression. Such tends to be exacerbated in people with Type D personality (Habra et al. 2003).
To help assess Type D personality, the Type D Scale-14 (DS14) is used. While there are different formats of this scale, such as the German and Italian versions, they closely align to the original DS14 which was developed by Denollet (2005). It includes two subscales to measure negative affectivity (NA) and social inhibition (SI). Example questions used to measure Type D personality (TDP) include “I find it hard to start a conversation” and “I am a closed kind of person.” Sample questions to help measure NA include “I am often in a bad mood” and “I often make a fuss about unimportant things.” Each subscale contains seven items rated on a five-point Likert-type scale. Individuals who obtain a score of greater than ten (>10) on measures pertaining to negative affectivity (NA) and social inhibition (SI) are categorized as having TDP. The DS14 shows good internal consistency and reliability in epidemiologic and clinical research. In general, both construct and concurrent validities of TDP have been confirmed, with discriminant validity evident on examination of physiological indices of well-being (Howard and Hughs 2012). As reported by Wu and Moser (2014), a taxometric analysis of the measure of TDP has shown that this type of personality may be better considered as a dimensional construct than a categorical construct. There are concerns about the late use of potentially artificial cut points to construct typology which may result in the likelihood of spurious results (Suls and Bunde 2005).
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