JMIR Publications

ABSTRACT

Background:

Cardiovascular diseases (CVDs) remain a leading cause of mortality worldwide and often involve a complex interplay of physiological, psychological, and behavioral factors [1]. While traditional risk factors such as genetics, lifestyle, and medical history are well-established, increasing attention has been given to the role of psychological states and personality traits in the development and progression of CVDs. Type D personality, characterized by high levels of negative affectivity and social inhibition, has been associated with poor mental health outcomes, including depression, anxiety, and chronic stress—factors that independently and collectively contribute to adverse cardiac events [2,3]. Research has shown that depression doubles the risk of myocardial infarction and significantly increases overall cardiac morbidity and mortality. Anxiety, post-traumatic stress, and chronic stress are also linked to the onset and exacerbation of heart disease. These findings are supported by studies such as those by Chauvet-Gelinier and Bonin (2017) [4], who emphasized the importance of psycho-biological mechanisms in understanding the brain-heart connection. Their review also highlighted the critical window that cardiac rehabilitation offers for identifying and addressing emotional distress in patients. Furthermore, individuals with Type D personalities tend to engage in fewer health-promoting behaviors, are less likely to seek medical help, and often experience reduced quality of life [5]. Studies by Denollet and colleagues suggest that these traits not only increase vulnerability to CVDs but also negatively influence disease management and prognosis [6,7]. Mols and Denollet (2010) [8] additionally note that early life experiences and social environments contribute to the development of this personality pattern, which may persist into adulthood and increase the risk of various chronic conditions, including cardiovascular disease. Other research demonstrates that stress and negative emotional states contribute to physiological changes—such as inflammation, autonomic dysfunction, and hormonal imbalances—that exacerbate cardiovascular risk [9]. The INTERHEART study ranked psychosocial stress, including depression, as one of the top three risk factors for coronary artery disease [10]. These insights underline the need for a holistic approach to cardiac care that incorporates psychological assessment and intervention. Despite the growing body of literature linking psychological factors to cardiovascular health, gaps remain in fully understanding the specific role of Type D personality and its interaction with stress, anxiety, and depression in cardiac populations. While many studies have explored these factors separately, fewer have examined them concurrently in the context of actual cardiac events or disease progression. Moreover, the underlying mechanisms—behavioral and biological—through which these psychological characteristics affect cardiovascular outcomes are still being uncovered. This study aims to address these gaps by providing a more integrated view of the psychological profile of cardiac patients, with an emphasis on Type D personality. The research holds significant clinical relevance, as early identification of at-risk individuals could lead to the implementation of targeted interventions, such as psychological screening, stress management programs, and personalized cardiac rehabilitation strategies. By improving our understanding of how personality and emotional distress contribute to heart disease, this study may help optimize prevention efforts and improve both short- and long-term outcomes in cardiac care. The present study seeks to examine the relationship between Type D personality traits and the presence of psychological distress—including symptoms of depression, anxiety, and stress—among individuals diagnosed with cardiovascular disease. Specifically, the research aims to determine whether individuals with Type D personality report higher levels of emotional distress compared to those without this personality pattern. In light of previous research findings and theoretical frameworks linking personality and emotional regulation to cardiovascular health, the following hypotheses are proposed: 1. Individuals with Type D personality will report significantly higher levels of depression, anxiety, and stress than those without Type D personality traits. 2. Type D personality will be a significant predictor of psychological distress, even after controlling for demographic and medical variables. By addressing these objectives, the study aims to contribute to a more nuanced understanding of the psychological profile of cardiac patients and to inform early screening and intervention efforts within cardiovascular care settings.

Objective:

The study aims to contribute to a more nuanced understanding of the psychological profile of cardiac patients and to inform early screening and intervention efforts within cardiovascular care settings.

Methods:

Study Design This study employed a cross-sectional quantitative research design aimed at examining associations between Type D personality traits, depressive symptoms, and cardiovascular history among adults aged 30 to 85 years. Convenience and snowball sampling methods were used to recruit participants via online social media platforms. Sample and Population The study sample consisted of 146 participants, including 49 men (33.6%) and 97 women (66.4%), with ages ranging from 30 to 85 years (M = 52.4, SD = 12.3). Participants’ ages ranged from 30 to 85 years, with a mean age of 52.4 years (SD = 12.3). Of these, 40 participants (27.4%) reported a history of cardiovascular disease (CVD) or related cardiac events, while 106 participants (72.6%) reported no such history. Participants represented a broad demographic spectrum in terms of religion, education, and socio-economic background. Research Variables Dependent Variables • Type D Personality: Measured by the DS14 questionnaire [7], which assesses two core dimensions: Negative Affectivity (NA) and Social Inhibition (SI). The questionnaire consists of 14 items, each rated on a 5-point Likert scale (1 = "not at all" to 5 = "very much"). A participant is classified as Type D if scoring 10 or higher on both NA and SI subscales, following Denollet’s established cutoff criteria. • Depression, Anxiety, and Stress: Assessed by the Depression Anxiety Stress Scales (DASS-21) [11], a validated 21-item self-report instrument. The scale includes three subscales (Depression, Anxiety, Stress), each with seven items rated from 0 ("did not apply to me") to 3 ("applied to me very much or most of the time"). A composite distress score was calculated by averaging all items. Independent Variable • Cardiovascular History: Determined by self-report to a direct question regarding diagnosed cardiovascular disease or cardiac events, coded dichotomously as "Yes" or "No." Research Instruments Demographic and Medical Background Questionnaire: Developed for this study to capture key demographic characteristics (age, gender, marital status, number of children, education, religion, self-identification) and cardiovascular history. DS14 Type D Personality Scale [7]: Demonstrates high internal consistency (Cronbach’s alpha > 0.80) for both NA and SI subscales, widely validated across populations with and without cardiac conditions. DASS-21 [11]: Has demonstrated excellent psychometric properties, with high reliability for each subscale (Cronbach’s alpha typically > 0.85) and validated for assessing emotional distress in both clinical and non-clinical populations. Data Collection Procedure Ethical approval was obtained from the Ruppin Academic Center Ethics Committee (Approval Code: 251-L/22). The questionnaire was implemented using Google Forms and distributed online via social media channels (Facebook, WhatsApp). Recruitment continued until April 2022. Informed consent was obtained electronically from all participants before they accessed the survey. Participation was voluntary, anonymous, and confidential. Instructions and contact information for support were provided. Statistical Analysis Data analyses were conducted using SPSS version 28. Initial data screening included checks for missing data, outliers, and assumptions of normality. Descriptive statistics summarized demographic variables, cardiovascular history, and psychological measures. Group Comparisons: Independent-samples t-tests and chi-square tests examined differences between participants with and without cardiovascular history, and between those classified as Type D versus non-Type D, on continuous and categorical variables respectively. Correlation Analysis: Pearson’s correlation coefficients assessed relationships between continuous measures of Type D subscales (NA, SI) and depression scores. Classification of Type D Personality: Followed the standard criterion of scoring 10 or higher on both DS14 subscales (NA and SI). Prevalence rates were calculated accordingly. Adjustment for Confounders: Exploratory analyses controlled for potential confounding variables such as age and gender using ANCOVA or logistic regression, to isolate the effect of Type D personality on depressive symptoms and cardiovascular status. Reliability Analysis: Cronbach’s alpha coefficients were computed to assess internal consistency of the DS14 and DASS-21 scales in this sample. All statistical tests were two-tailed with significance set at p < 0.05. Effect sizes (Cohen’s d or Cramér’s V) were reported to provide context for the magnitude of observed differences.

Results:

Results Sample Characteristics The sample consisted of 146 participants, of whom 40 (27.4%) reported a history of cardiovascular disease, while 106 (72.6%) did not. Participant ages ranged from 30 to 85 years. Among those without a cardiac history, 50% were younger than 40, whereas in the cardiac history group, 50% were younger than 60. Overall, 66.4% (n = 97) of the sample were female, and 95.9% identified as Jewish. Most participants identified as secular (over 70%), were married (75%), and were parents (85%). Additionally, approximately 80% had attained a higher education degree. Descriptive Statistics and Reliability of Measures Table 1 displays descriptive statistics and internal consistency values for the primary variables. The average score for Type D personality was 1.21 (SD = 0.55), while mean scores for depression, anxiety, and stress were 0.93 (SD = 0.71), 1.05 (SD = 0.74), and 1.18 (SD = 0.65), respectively, suggesting generally low levels of distress in the sample. Internal consistency was high for all scales, with Cronbach’s alpha coefficients ranging from 0.83 to 0.94. Table 1. Descriptive Statistics and Internal Consistency for Study Variables Cronbach’s α SD Mean Variable 0.83 0.55 1.21 Type D Personality 0.87 0.71 0.93 Depression 0.89 0.74 1.05 Anxiety 0.91 0.65 1.18 Stress 0.94 0.65 1.06 Distress (Total) Type D Personality Classification Using the standard criterion (scores ≥10 on both the Negative Affectivity [NA] and Social Inhibition [SI] subscales), 62 participants (42.5%) were classified as having a Type D personality, while 84 participants (57.5%) were classified as Non-Type D. Table 2. Prevalence of Type D Personality Percentage (%) Number of Participants Classification 42.5 62 Type D Personality 57.5 84 Non-Type D Independent samples t-tests showed that individuals classified with a Type D personality exhibited significantly higher levels of depression, anxiety, and stress compared to Non-Type D individuals (all p < .001). Table 3: Group Differences in Psychological Distress p t Non-Type D (n = 84) Mean (SD) Type D (n = 62) Mean (SD) Variable <.001 8.12 11.3 (4.5) 19.2 (5.0) Depression <.001 7.89 9.7 (3.9) 16.5 (4.6) Anxiety <.001 8.48 12.1 (4.8) 21.0 (5.3) Stress Group Differences Based on Cardiac History and Type D Personality To test the first hypothesis, t-tests compared participants by cardiac history and Type D personality classification. Participants with a history of cardiovascular disease reported significantly higher Type D scores (M = 1.42, SD = 0.61) than those without (M = 1.13, SD = 0.50), t(144) = 2.97, p < .01. Additionally, individuals with cardiovascular disease reported significantly higher levels of depression (M = 1.23, SD = 0.82 vs. M = 0.81, SD = 0.63), anxiety (M = 1.33, SD = 0.78 vs. M = 0.94, SD = 0.68), and stress (M = 1.40, SD = 0.73 vs. M = 1.08, SD = 0.57); all comparisons were statistically significant (p < .05). Among participants classified as Type D, scores for depression (M = 1.28, SD = 0.73), anxiety (M = 1.36, SD = 0.76), stress (M = 1.44, SD = 0.69), and overall distress (M = 1.35, SD = 0.67) were all significantly higher than those of Non-Type D individuals (M = 0.69, SD = 0.56; M = 0.89, SD = 0.63; M = 1.01, SD = 0.52; M = 0.86, SD = 0.53, respectively), with all p-values < .001. Regression Analysis To explore associations, a hierarchical multiple regression was conducted to evaluate the extent to which Type D personality is associated with psychological distress after accounting for demographic variables and cardiovascular history. In Step 1, demographic factors (age, gender, education) and cardiac history were associated with 14.6% of the variance in distress, F(4, 141) = 6.05, p < .001. In Step 2, the addition of Type D personality was significantly associated with additional variance in distress, accounting for an additional 15.1% of the variance, ΔF(1, 140) = 29.64, p < .001. The final model was statistically significant, F(5, 140) = 14.87, p < .001, R² = .297. Type D personality showed a strong association with psychological distress (β = .46, p < .001), and cardiovascular history was also significantly associated with distress (β = .18, p = .008), after controlling for demographic variables. The mean score for the Negative Affectivity (NA) subscale was 12.1 (SD = 4.0), and for the Social Inhibition (SI) subscale was 11.3 (SD = 4.3), indicating moderate levels across the sample.

Conclusions:

The findings of this study confirm the hypothesis that Type D personality is associated with elevated levels of depression, anxiety, and stress. Participants with cardiovascular disease were more likely to report higher Type D scores and greater emotional distress compared to those without cardiac history. These results are consistent with existing literature suggesting that Type D personality increases vulnerability to psychological and physiological stressors that can exacerbate cardiovascular conditions [11,12,13]. Furthermore, participants with Type D personality traits, regardless of cardiac history, exhibited significantly higher levels of psychological distress than non-Type D participants. The strength and consistency of these group differences—confirmed through both t-tests and regression—highlight the clinical relevance of Type D personality in assessing psychological risk [12,15]. The use of validated measures such as the Depression Anxiety Stress Scales (DASS) helped ensure the reliability of psychological distress assessments in this study [11]. Regression analysis confirmed that Type D personality significantly predicts psychological distress even after controlling for demographic and medical variables. This supports the hypothesis that Type D traits are independently associated with distress and not merely a byproduct of illness status. These findings align with Denollet’s theoretical model of Type D personality as a risk factor for poor emotional and cardiac outcomes [8]. These results underscore the importance of incorporating psychological screening into cardiovascular care. Identifying patients with high psychological vulnerability can help clinicians implement early interventions, such as stress management training and tailored psychosocial support, potentially improving both emotional well-being and cardiac prognosis [16]. Our findings also reinforce the relevance of integrating psychological and behavioral health assessments into cardiac rehabilitation programs, as suggested by Chauvet-Gelinier and Bonin and echoed by recent clinical reviews [4,17,18]. Additionally, the association between chronic stress and cardiovascular morbidity is well established, and studies continue to demonstrate that unmanaged psychological distress significantly contributes to adverse cardiac events [14–16]. Chronic stress mechanisms—such as heightened autonomic arousal, systemic inflammation, and behavioral risk factors—may partially mediate the relationship between Type D traits and poor cardiovascular outcomes [14,15]. In line with Mols and Denollet’s assertion that early life experiences contribute to enduring personality patterns [12], our results underscore the necessity of adopting a lifespan approach to cardiovascular risk prevention that includes psychological factors. The strong association between Type D personality and distress in this study further demonstrates the need to incorporate personality assessment tools into standard cardiovascular evaluations. In summary, this study adds to the growing body of evidence suggesting that Type D personality traits may contribute to elevated psychological distress, particularly among individuals with cardiovascular disease. These findings point to the potential value of incorporating psychological assessments into cardiovascular care—especially for those identified with Type D characteristics—as a way to support both emotional well-being and clinical outcomes. However, further longitudinal research is needed to clarify causal relationships and to evaluate the effectiveness of targeted interventions in this population [13,19]. This study contributes a novel perspective by directly comparing psychological distress levels between individuals with and without cardiovascular disease, while simultaneously accounting for Type D personality traits. Unlike previous studies that often focus solely on cardiac populations, our approach clarifies the independent and additive effects of Type D personality across both clinical and non-clinical groups. By doing so, the study addresses a gap in the literature regarding whether Type D traits are primarily a consequence of chronic illness or represent a stable risk factor across health statuses. Furthermore, the integration of validated psychological instruments and rigorous regression analyses enhances the methodological robustness of our findings. This research thus advances understanding of the psychological dimensions of cardiovascular risk and supports the development of more personalized approaches to prevention and intervention. Author Contributions Conceptualization, KG; methodology, KG and YS; formal analysis, KG and YS , writing—original draft preparation, KG and YS, writing—review and editing, KG and YS. All authors have read and agreed to the published version of the manuscript. Funding This research received no external funding. Institutional Review Board (IRB) Statement The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Faculty of Social and Community Sciences, Ruppin Academic Center Informed Consent Statement Informed consent was obtained from all subjects involved in the study. Data Availability Statement The data that support the findings of this study are available from the corresponding author upon reasonable request. Conflicts of Interest The author declares no conflict of interest. Clinical Trial: NA