Toward a more systematic, cumulative, and applicable science of personality and health: lessons from type D personality.

The potential influence of personality characteristics on physical health generallyVand on cardiovascular disease, in particularVhas been a central topic in psychosomatic medicine, behavioral medicine, and health psychology for decades. In some instances, over time, research has produced a more refined understanding of psychosocial influences on health, as in the evolution of the Type A/B distinction (1) to a more specific focus on hostility, anger, and other components of the original construct (2,3). Several personality constructs seem to have reliable associations with later health (4,5). Yet, personality traits are sometimes introduced to the field with too little attention to their overlap with previously studied constructs, and they often fade from view when research turns elsewhere, impeding the development of a systematic and cumulative literature that could eventually support the development of risk-reducing interventions. A notable example of this general endeavor is the Type D (i.e., distressed) personality (6). Initially, a series of reports linked this combination of high levels of negative affectivity (NA) and social inhibition (SI) with the clinical course of coronary artery disease (CAD) and congestive heart failure (CHF) (7). Quantitative analyses of nine prospective studies in patients with cardiovascular disease indicate that Type D personality is associated with a greater than three-fold increased risk of adverse events (odds ratio = 3.7, 95% confidence interval = 2.7Y5.1). These effects of Type D personality seem to be distinct from depression and other aspects of psychological distress because, in some studies, Type D personality has independent associations with adverse cardiovascular outcomes. Plausible biologic and behavioral pathways that may account for the adverse effects of Type D personality have also been described (for a review, see Denollet et al. (7)). The concept of Type D personality has moved beyond scientific circles to receive considerable attention in the popular media. However, in this issue of Psychosomatic Medicine, Grande and colleagues (8) and Coyne and colleagues (9) report null findings regarding the association of Type D personality with mortality among persons with CHF and CAD, consistent with another recent report of null findings (10). Specifically, Grande et al. (8) report that Type D personality did not predict all-cause mortality in a sample of approximately 1000 German cardiac patients. Coyne et al. (9) similarly report that Type D personality did not predict mortality in a sample of more than 700 Dutch patients with heart failure. These two recent articles include sample sizes that are considerably larger than most of the prior, supportive studies; use a current and well-validated measure of Type D personality; and avoid data analytic flaws that have marred prior research. Multiple and methodologically strong failures to replicate widely cited findings compel a critical reexamination of research on Type D personality. The previous and current studies on Type D personality provide important lessons that can facilitate a more systematic, cumulative, and useful science of personality and cardiovascular disease. A central theme of these lessons is the need to make full use of conceptual models in all phases of research (11,12). The prior literature on Type D personality has gotten several of these key issues right, but other central issues are problematic.