Type D personality: a relevant psychosocial risk factor for coronary heart disease?

This editorial refers to ‘Type D Personality As a Risk Factor for 3-Year Cardiovascular Events in Patients With Coronary Artery Disease and Their Spouse: A Prospective Cohort Study’, by Y. Wang et al. https://doi.org/10.1093/eurjpc/zwae377. In the 1990s, the Belgian researcher Johann Denollet made an important contribution to the field of psychocardiology, when he was the first to describe the relationship between the ‘Type D personality’ (‘D’ is an acronym for ‘Distressed’) and unfavourable prognosis in coronary heart disease (CHD). The Type D personality, assessed with a psychometric questionnaire (Type D scale 14), describes a maladaptive personality pattern in which the prognostic impact of established psychosocial risk factors such as depression/anxiety/anger (negative affectivity) may be increased by an inability to express emotions in social relationships (social inhibition). At that time, Denollet was able to show in several high-impact publications that CHD patients with a Type D personality had up to four times increased risk of cardiac events and/or mortality.1–3 Subsequent studies (e.g.4,5) did not confirm the association between the Type D personality and unfavourable prognosis to the extent described above; however, the most recent meta-analysis concludes that the Type D personality is associated with an increased risk of major adverse cardiac events (MACE) in patients with CHD (OR 1.14), but does not increase the rate of myocardial infarction, cardiac mortality, or all-cause mortality.6 From a clinical and epidemiological point of view, the Type D personality is prevalent in one of four patients with CHD and overlaps with clinically relevant depression (depressive adjustment disorder or depressive episode according to ICD-10) in ∼50% of patients with Type D personality.7 In addition, in a study of CHD patients with mild-to-moderate depression, the Type D personality was associated with an increased likelihood of enduring mental disorders like dysthymia (OR 1,8), obsessive-compulsive personality disorder (OR 2,6), social phobia (OR 4,0), or self-unconfident-avoidant personality disorder (OR 9,0), thus reflecting that depressive patients with the Type D personality suffer from more complex mental disorders with higher demands with respect to psychosocial treatments.8 From a pathogenetic perspective, it is evident that the Type D personality leads to chronic stress experience, which is associated with all well-known negative implications with regard to stress physiology and health behaviour,7,9 constituting a plausible mechanism for its negative impact on prognosis. In this issue of the European Journal of Preventive Cardiology, Wang et al.10 present data from a prospective cohort study of CHD patients after their first coronary intervention (n = 4035) and their spouses, recruited from January 2017 to July 2020 in China. After 3 years of follow-up, the presence of the Type D personality (assessed by the Type D Scale-14) in patients and their spouses was associated with significant higher risk for MACE not only in in patients (HR 3,8), but also in spouses (HR 2,7), compared with patients and spouses without Type D personality. Wang et al. also describe that there is an increased risk for worse prognosis, if the patient or the spouse shows a Type D personality, with highest risk if ‘negative affectivity’ is high in both partners.10 The authors conclude that assessing the Type D personality in CHD patients and their spouse could yield valuable insights into specific psychological profiles associated with elevated risk in CHD, and thus, could inform comprehensive CHD therapy.10 To my best knowledge, this is the first study not only assessing the Type D personality in CHD patients, but also in their spouses, and then evaluate its impact on MACE after 3 years in both. The rationale behind this study design is reasonable, because, as said before, the specific aspect of the Type D personality is not only a higher extend of ‘negative affectivity’ (i.e. depression, anxiety, anger), but also ‘social inhibition’, i.e. the inability to express emotions in social relationships. Thus, a well-known and important stress buffer, emotional supportive relationships,9 is lacking, which could increase CHD risk in couples, irrespective whether they initially suffer from CHD or not. But, if we conclude that the Type D personality could be relevant for prevention and treatment of CHD, how could we deal with it in clinical practice? Wang et al.10, in this issue, recommend that couple-centred interventions should be tested. In fact, evidence on the efficacy of couple-centred interventions in patients with CHD is sparse. More research is warranted, before we can give sound recommendations. Until then, the current ESC Guideline on cardiovascular disease prevention in clinical practice11 recommends the assessment of psychosocial risk factors on an individual level, and treatment of patients with stress and/or mental comorbidities using established therapeutic principles like individual or group psychotherapy and/or antidepressants. The future will show, whether couple-based interventions can add extra value in specific situations. The author received no financial support for the research, authorship, and/or publication of this article.