Overlap and distinctiveness of psychological risk factors in patients with ischemic heart disease and chronic heart failure: Are we there yet?

doi:10.1016/j.jad.2008.05.017

Journal of Affective Disorders

Volume 113, Issues 1–2, February 2009, Pages 150-156

https://doi.org/10.1016/j.jad.2008.05.017 Get rights and content

Abstract

Objective

Growing evidence supports the importance of psychological factors in the etiology and progression of cardiovascular disease (CVD). However, this research has been criticized due to overlap between psychological constructs. We examined whether psychological questionnaires frequently used in cardiovascular research assess distinct constructs in a mixed group of ischemic heart disease (IHD) and chronic heart failure (CHF) patients.

Methods

565 patients with CHF (n = 118) or IHD (n = 447) completed the Type D scale (DS14), Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI), and State Trait Anxiety Inventory (STAI). Pearson product moment correlations were computed to determine the interrelatedness between psychological constructs. Principal component analyses (PCA) were conducted on both scale scores and items to determine higher-order constructs and distinctiveness of psychological questionnaires.

Results

Two higher-order constructs were identified, namely negative affect and social inhibition. PCA on all 69 items showed that anxiety, depression, negative affectivity, and social inhibition were distinct constructs. The original structure of the DS14 was confirmed, whereas items of the HADS and BDI loaded more diffusely; items of the STAI reflected two different components.

Conclusion

The use of multiple questionnaires in cardiac patients is justified, as the higher order construct negative affect comprised different facets. Social inhibition was also shown to be a distinct construct, indicating that it may timely for cardiovascular research to look at the role of inhibition in addition to negative emotions. Future studies are warranted to determine whether these findings are replicable in other cardiac samples and to specify the unique prognostic value of these psychological facets.

Introduction

During recent years growing evidence supports the importance of psychological factors in the etiology and progression of cardiovascular disease (CVD) (Rozanski et al., 2005), with depression, anxiety, general distress, vital exhaustion, and Type D personality having been shown to predict mortality (Frasure-Smith et al., 2000, Todaro et al., 2003, Denollet et al., 2006b), recurrent cardiac events (Kop et al., 1994), and impaired health status (Rumsfeld et al., 2003, Al-Ruzzeh et al., 2005) in patients with established heart disease independent of biomedical risk factors.

Psychological risk factors are most often assessed by means of self-report, but since psychological constructs overlap, the main criticism of research on the role of psychological factors in CVD has been that instruments might not measure distinct concepts, but reflect a higher-order construct (Suls and Bunde, 2005, Ketterer et al., 2002). Besides theoretical importance, this issue is pertinent from a clinical and epidemiological point of view, in order to avoid redundancy and to determine which instruments to use in clinical practice to identify patients with a high-risk psychological profile.

The issue of conceptual distinctiveness of psychological constructs has been addressed previously in a sample of 822 healthy working men (Kudielka et al., 2004). Depression, vital exhaustion, and negative affectivity were shown to be distinct psychological constructs, and the factor structure of the original questionnaires was underpinned. However, these findings may not be applicable to patients with established CVD. Furthermore, the issue of the examined psychological factors reflecting a higher-order construct was not addressed in the latter study (Kudielka et al., 2004). In the context of cardiac patients, few studies have evaluated whether the assessment of multiple questionnaires is redundant, with these studies having used different statistical approaches (Denollet and Brutsaert, 1998, Ketterer et al., 2002).

Therefore, the objective of the current study was to determine whether psychological questionnaires frequently used in cardiovascular-research assess distinct psychological constructs, using a mixed group of patients with ischemic heart disease (IHD) and chronic heart failure (CHF) in order to enhance generalizability across different stages of CVD.

Section snippets

Participants and procedure

The sample comprised a mixed group of 600 cardiac outpatients diagnosed with IHD or CHF recruited from Holbæk Hospital, Denmark. Final analyses were based on 565 patients (CHF: n = 118; IHD: n = 447), since for 35 patients all data on questionnaires were missing. The mean age of the total sample was 65.8 ± 10.4 years with 421 patients (74.5%) being men. The study protocol was approved by the ethics committee of the hospital. The study was conducted according to the Helsinki Declaration.

Demographic and clinical variables

Demographics

Demographic and clinical characteristics

CHF and IHD patients differed on some baseline characteristics, with CHF patients being older(t (163) = 2.50, p = .01), having a lower LVEF (t (490) = − 16.7, p < .001), more often smoking (X²(1) = 5.69, p = .02), and more frequently having co-morbid respiratory disease (X²(1) = 7.97, p = .005) compared to IHD patients. Patient characteristics stratified by disease type, as well as for the total sample, are presented in Table 1. The Strengthening the Reporting of Observational Studies in Epidemiology

Discussion

In a mixed cardiac sample of IHD and CHF patients, we found that negative affect and social inhibition comprise conceptually different higher-order constructs, with social inhibition providing information about how patients deal with emotions (i.e. the tendency not to share these feelings with others). Factor analysis on item level showed that anxiety, depression, negative affect, and social inhibition were distinct components, assessed by means of different questionnaires. Of all

Role of funding source

Funding for this study was in part provided by a VICI-grant (453-04-004) from the Netherlands Organisation for Scientific Research (NWO), The Hague, The Netherlands, to Dr. J. Denollet the NWO had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

All authors declare that they have no conflicts of interest.

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Is Type D personality a risk factor for all-cause mortality? A prospective population-based study among 2625 colorectal cancer survivors from the PROFILES registry
2017, Journal of Psychosomatic Research
Citation Excerpt :
It is important to note, that overlap exists regarding the constructs NA and depression, the conceptual difference lies within the fact that personality is a permanent trait while depression is a disorder and thus a temporary state [31]. Psychometrically, depressive symptoms, load on different higher-order constructs or factors than Type D personality and its sub-traits NA and SI [32] To exemplify the difference between NA and depression we performed sensitivity analyses described below. Follow-up time was calculated as the time from questionnaire completion to death or 31-12-2013 whichever came first.
Objective
Our goal was to examine whether Type D personality and its components, negative affectivity (NA) and social inhibition (SI), were associated with all-cause mortality among colorectal cancer (CRC) patients.
CRC patients diagnosed between 2000 and 2009, as registered in the Dutch population-based Eindhoven Cancer Registry, received a questionnaire on Type D (DS14) on average 5.3 years after diagnosis. Survival status (31-12-2013) was obtained from the Central Bureau for Genealogy. We used a Cox proportional hazard model to relate personality to all-cause mortality, while adjusting for demographics, clinical characteristics and cardiovascular disease (CVD).
Fifty percent was categorized as the ‘reference group’ (n = 1281), 17% as ‘SI only’ (n = 421), 12% as ‘NA only’ (n = 309), and 21% as ‘Type D’ (n = 532). After adjustment, CRC patients in the ‘NA only’ and ‘Type D’ groups showed an increased risk (HR = 2.0, 95% CI = 1.4–2.8, p < 0.01, and HR = 1.7, 95% CI = 1.3–2.4, p < 0.01) for all-cause mortality. This adverse effect of NA was limited to men aged > 70. There was an additional adverse effect of SI on all-cause mortality in older men without CVD (HR = 2.3, 95% CI = 1.2–4.4, p = 0.01). Personality was not related to mortality in women. Entering personality continuously, showed an increased risk for NA among older survivors, men and patients with comorbid CVD. Neither SI nor the interaction term was predictive in both the un- and adjusted Cox models.
Our findings suggest that it is the NA component that drives the adverse effect of psychological distress on survival in CRC patients, which is most prominent among older men.
Differences in quality of life, Anxiety and depression in patients with paroxysmal atrial fibrillation and common forms of atrioventricular reentry supraventricular tachycardias
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Citation Excerpt :
There is preliminary evidence showing that the reliability and the validity of the Greek translation of the STAI questionnaire are generally similar to those reported in the international literature [19]. Depression was diagnosed and its severity quantified using the Beck Depression Inventory (BDI) that is commonly used worldwide [20,21]. Various translations of the BDI have been published and this scale was proved to be psychometrically strong and appropriate for use.
The aim of this study was to evaluate the differences in quality of life and psychosocial stress parameters among patients with paroxysmal atrial fibrillation (AF) and common forms of atrioventricular reentry supraventricular tachycardias (SVTs).
The total study population included 106 patients, 54 patients with paroxysmal AF (32 males, age 56.64 ± 12.50 years) and 52 with SVTs (25 males, age 40.46 ± 14.96 years). General health (p < 0.01), physical function (p = 0.004), role emotion (p = 0.002) and role physical (p < 0.01) scores were lower in patients who suffered AF. SF-36 physical and mental health summary measures were also significantly lower in the AF group compared to those in SVT group (p < 0.01 and p = 0.001, respectively). Lower SF-36 total score was observed in patients with AF compared to those with SVTs (p < 0.01). Comparing the anxiety and depression scores all the values were higher in patients with AF. Higher STAI-state scores (p < 0.01), STAI-trait scores (p = 0.039) and BDI scores (p = 0.077) were seen in patients who suffered AF comparing to those with SVTs.
Quality of life is significantly impaired and the level of anxiety is significantly higher in patients with AF comparing to those with common forms of SVTs.
Type D personality in never-depressed patients and the development of major and minor depression after acute coronary syndrome
2014, Journal of Affective Disorders
Citation Excerpt :
To elucidate the relationship between TDP and depression, previous studies, using factor analysis, found a partial overlap between NA and depression (Kudielka et al., 2004) or anxiety (Pelle et al., 2009); suggesting that NA might also measure some features of depression and anxiety rather than solely a personality disposition. This suggestion, was supported by a recent study which stressed that “NA comprises state as well as trait facets” (Pelle et al., 2009). These findings underscore the need for assessing depression and anxiety levels when TDP is evaluated as a risk factor for depression in ACS; this implies that the predictive power of TDP should be adjusted for depression and anxiety at baseline.
Type D personality (TDP) has been proposed as a risk factor for the development of depressive symptoms after an acute coronary syndrome (ACS). However, contrasting findings emerged about its predicting power on the onset of depression, since an overlap between TDP and depressive symptoms has been proposed. The present study was aimed to verify whether TDP predicts the development of a depressive disorder in the 6 months after the discharge from hospital.
Two hundred fifty consecutive patients were recruited, at the Coronary Intensive Care Unit at the University Hospital of Parma, who were both presenting their first ACS and had no history of depression. The presence and the severity of major (MD) and minor (md) depression were evaluated with the Primary Care Evaluation of Mental Disorders (PRIME-MD) and the Hospital Anxiety and Depression Scale (HADS) respectively. Type D Personality was assessed with the DS14, both at baseline and at 1, 2, 4 and 6 month follow ups.
Out of 250 subjects (81.2% males), MD was diagnosed in 12 patients (4.8%) and md in 18 patients (7.2%). At baseline risk factors for a post-ACS depressive disorder were HADS depression scores, whereas TDP, or its subscales, did not showed any effect.
The small amount of patients with incidence of depression, due to highly selective inclusion criteria, tempers the reliability of our results.
Our data suggests that TDP does not predict the development of depressive disorders in never-depressed patients at their first ACS, when the baseline depression severity was controlled.
On the protective effect of resilience in patients with acute coronary syndrome
2014, International Journal of Clinical and Health Psychology
Research on the contribution of positive personality traits to the progression of coronary heart disease (CHD) is notably absent. Resilience is the capacity to develop oneself successfully despite adverse circumstances. In a study of patients with acute coronary syndrome (ACS), the authors investigated the effect of resilience on indicators of CV severity and the physiological mechanisms underlying this effect. Patients (n = 134) completed a scale measuring resilience. The authors measured troponin-I and myoglobin as indicators of ACS severity, and white blood cell (WBC) count and neutrophils as inflammatory markers. Results showed that self-efficacy-a component of resilience-was negatively related to both myoglobin and troponin after the acute coronary event. The relationship between resilience and these prognostic markers was mediated by the WBC count. Importantly, this result held significant after controlling for the effect of classic CV risk factors and demographics. The authors conclude that resilience decreases the extent of the myocardial infarction by affecting the inflammatory response, showing a protective effect.
En la actualidad la investigación sobre la influencia de los rasgos de personalidad positivos sobre la enfermedad coronaria (EC) es escasa. La resiliencia se define como la capacidad para autodesarrollarse con éxito a pesar de las circunstancias adversas. En un estudio, los autores han investigado el efecto de la resiliencia en varios indicadores de severidad en pacientes con síndrome coronario agudo (SCA; n=134) y los mecanismos que subyacen a este efecto. Los pacientes completaron una escala que medían sus niveles de resiliencia. Los autores midieron los niveles de troponina-I y mioglobina como indicadores de la severidad del SCA, y el número total de glóbulos blancos (NGB) y neutrófilos como marcadores de inflamación. Los resultados han puesto de manifiesto que el nivel de auto-eficacia –un componente de la resiliencia– se relaciona negativamente con los niveles de mioglobina y troponina después de un evento coronario agudo. La relación entre la resiliencia y estos marcadores está mediada por el NGB. Este resultado se mantiene tras controlar el efecto de los factores cardiovasculares clásicos y demográficos. Los autores concluyen que la resiliencia reduce la extensión del infarto de miocardio influyendo en la respuesta inflamatoria, mostrando un efecto protector.
The distressed (Type D) and Five-Factor Models of personality in young, healthy adults and their association with emotional inhibition and distress
2013, Personality and Individual Differences
Citation Excerpt :
Within the Type D construct, the NA trait refers to a stable and long-term tendency towards negative affect, while depression refers to more short-term episodes of depressed mood (Pedersen & Denollet, 2006). Psychometric investigations have shown that NA items load on a different dimension than items assessing anxiety (Pelle, Denollet, Zwisler, & Pedersen, 2009) and depression (Kudielka, von Känel, Gander, & Fischer, 2004; Pelle et al., 2009), indicating that they measure distinct psychological concepts. Other studies have shown that depression and Type D personality represent different kinds of emotional distress (Denollet et al., 2009), and that Type D predicts depression and anxiety independent of baseline depression levels (Denollet, Schiffer, et al., 2010).
The distressed (Type D) personality (the combination of negative affectivity and social inhibition traits) has been associated with adverse health outcomes. This study investigated the validity of the Type D construct against the Five-Factor Model (FFM) of personality, and its association with emotional control and distress. In total 498 university students (mean age 28.9 ± 8.4 years) completed the Type D scale (DS14), and measurements for the FFM of personality, emotional control, anxiety, depression and stress. The construct validity of the Icelandic DS14 was confirmed. The Type D components negative affectivity and social inhibition were strongly associated with neuroticism and extraversion of the FFM (r = 0.82 and r = −0.67, respectively). Negative affectivity also correlated with rehearsal/rumination (r = 0.58) and social inhibition with emotional inhibition (r = 0.54), indicative of emotional control. Type D personality (40% of sample) was associated with higher levels of anxiety, depression and stress. The Type D personality components were associated with the FFM of personality, emotional control and emotional distress. Importantly, social and emotional inhibition were closely related, providing novel information about the presence of emotional inhibition within the social inhibition trait.
Type D personality is independently associated with major psychosocial stressors and increased health care utilization in the general population
2011, Journal of Affective Disorders
Citation Excerpt :
In general, Type D personality is considered a general propensity for mental distress, poor health status, reduced help seeking behavior and poor self-management among community and patient populations (Denollet et al., 2010; Mols and Denollet, 2010a,b). The Type D personality is considered as a stable, heritable, and non-psychopathological character trait (Mommersteeg et al., 2010, 2011), which could be clearly separated from mental disorders like depression (Denollet et al., 2010; Pelle et al., 2009). However, the relationship of Type D with other mental disorders has been less thoroughly studied in the general population.
Type D is considered as a non pathological personality trait and propensity for mental distress. Its relationship with mental distress has been mainly studied in cardiovascular patients and with respect to depression. The knowledge about the relationship of Type D with mental disorders, psychosocial stressors and health care utilization in the general population is insufficient. Therefore the present study sought to determine the associations of Type D with mental distress, major psychosocial stressors, health status, and health care utilization in the general population.
Cross-sectional analysis in a representative population based sample of n = 2495 subjects (mean age 49 years, range 14–92 years) of whom 33.1% had Type D personality.
Individuals with Type D had an increased risk for clinically significant depression, panic disorder, somatization and alcohol abuse. After adjustment for these mental disorders Type D was still robustly associated with all major psychosocial stressors. The strongest associations emerged for feelings of social isolation and for traumatic events. After comprehensive adjustment Type D still remained associated with increased help seeking behavior and utilization of health care, especially of mental health care.
The main limitation is the reliance on self-report measures and the lack of information about the medical history and clinical diagnosis of the participants.
Type D identifies persons with severely increased risk for mental distress, major psychosocial stressors and increased health care utilization. As a frequent disposition, Type D is assumed to be of high relevance for health care.

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^☆: This work was presented at the annual meeting of the American Psychosomatic Society, March 12, 2008, Baltimore, USA.

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Research reportOverlap and distinctiveness of psychological risk factors in patients with ischemic heart disease and chronic heart failure: Are we there yet?☆

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Participants and procedure

Demographic and clinical variables

Demographic and clinical characteristics

Discussion

Role of funding source

Conflict of interest

Clin. Psychol. Rev.

J. Psychosom. Res.

Am. J. Cardiol.

J. Psychosom. Res.

Am. J. Cardiol.

J. Psychosom. Res.

J. Psychosom. Res.

J. Psychosom. Res.

J. Am. Coll. Cardiol.

J. Am. Coll. Cardiol.

Psychosomatics

Am. J. Cardiol.

Predictors of poor mid-term health related quality of life after primary isolated coronary artery bypass grafting surgery

Heart

A note on the multiplying factors for various chi-square approximations

J. R. Stat. Soc. B

Manual for the Revised Beck Depression Inventory

The meaning and strategic use of factor analysis

DS14: standard assessment of negative affectivity, social inhibition, and type D personality

Psychosom. Med.

Personality, disease severity, and the risk of long-term cardiac events in patients with a decreased ejection fraction after myocardial infarction

Circulation

Research report
Overlap and distinctiveness of psychological risk factors in patients with ischemic heart disease and chronic heart failure: Are we there yet?☆