Validity of the 15-item social inhibition questionnaire in outpatients receiving psychological or psychiatric treatment: The association between social inhibition and affective symptoms

OBJECTIVE

Social inhibition may promote symptoms of depression and anxiety in adults from an outpatient hospital population. The current work builds on a previously corroborated construct of social inhibition and examines the psychometric properties of this assessment tool and its predictive validity in the adult outpatient hospital population.

METHODS

A total of 350 adult outpatients receiving treatment at the department of Medical Psychology or Psychiatry completed measures of social inhibition and symptoms of anxiety (7-item Generalized Anxiety Disorder scale) and depression (9-item Patient Health Questionnaire). Factor analyses, reliability estimates, and regression analyses were used to replicate the robustness of the model of social inhibition, and the 15-item Social Inhibition Questionnaire (SIQ15).

RESULTS

In the current sample (N = 350; M_age = 45 years; 67.4% women), factor analyses confirmed the previously suggested three-factor model of social inhibition as measured by the SIQ15. The subscales of behavioral inhibition, interpersonal sensitivity and social withdrawal proved to be internally consistent (Cronbach's α between 0.87/0.95) and stable over time (test-retest reliability between r = 0.76/0.83). At baseline, interpersonal sensitivity and social withdrawal were associated with anxiety and depressive symptoms. At three months follow-up, only interpersonal sensitivity was related to depressive symptoms.

CONCLUSIONS

Social inhibition is associated with anxiety and depression at baseline and can be reliably assessed with the SIQ15 in an outpatient hospital population. The association of interpersonal sensitivity with depressive symptoms at three-month follow-up suggests an important aim for future research on the development of preventive methods for affective symptoms in socially inhibited outpatients.

Prevalence of anxiety and risk associated with ventricular arrhythmia in patients with an implantable cardioverter defibrillator

BACKGROUND

Anxiety has been associated with adverse clinical outcomes in patients who have received an implantable cardioverter defibrillator (ICD). However, results are inconclusive likely due to different measures being used to assess anxiety. Hence, the current study aims to examine the prevalence and the association between anxiety, ventricular tachyarrhythmia's (VTa's) and all-cause mortality, respectively.

METHODS

Patients who received an ICD for the first time were recruited from 6 Dutch referral hospitals as part of the WEBCARE trial. Patients filled in validated questionnaires (GAD-7, STAI-S, HADS-A, ANX4, ICDC, FSAS) to assess their baseline anxiety symptomatology. Logistic regression analysis and Cox Regression analysis were performed to examine the association between anxiety with 1) VTa's and 2) mortality, respectively.

RESULTS

A total of 214 Patients were included in the analysis with mean age 58.9 and 82.7% being male. The prevalence rates of anxiety varied depending on which questionnaire was used 12.4% (GAD-7), 17.5% (HADS-A), and 28.1% (STAI-S). (Cox) Regression analysis revealed that none of the anxiety measures was associated with VTa's or all-cause mortality in the current sample. Stratifying the sample by gender, the analysis showed that GAD-7, STAI-S, and ANX4 scores were associated with increased risk of VTa's but only in male patients.

CONCLUSIONS

Prevalence rates of anxiety varied depending on the measurement tool used. No significant association between anxiety and VTa's and all-cause mortality was observed in the total sample. GAD-7, STAI-S, and ANX4 were associated with increased risk for VTa's but only in male patients.

Personality traits, ventricular tachyarrhythmias, and mortality in patients with an implantable cardioverter defibrillator: 6 years follow-up of the WEBCARE cohort

OBJECTIVE

Risk stratification within the ICD population warrants the examining of the role of protective- and risk factors. Current study examines the association between Type D personality, pessimism, and optimism and risk of ventricular tachyarrhythmias (VTa's) and mortality in patients with a first-time ICD 6 years post implantation.

METHODS

A total of 221 first-implant ICD patients completed questionnaires on optimism and pessimism (Life Orientation Test) and Type D personality (Type D scale DS14) 10 to 14 days after implantation. VTa's and all-cause mortality 6 years post implant comprised the study endpoints.

RESULTS

Ninety (40.7%) patients had experienced VTa's and 37 (16.7%) patients died, 12 (5.4%) due to a cardiac cause. Adjusted logistic regression analysis showed that pessimism was significantly associated with increased risk of VTa's (OR = 1.09; 95% CI = 1.00-1.19; p = .05). Type D personality (OR = 1.05; 95% CI = 0.47-2.32; p = .91) and optimism (OR = 1.00; 95% CI = 0.90-1.12; p = .98) were not associated with VTa's. None of the personality types were associated with mortality.

CONCLUSION

Pessimism was associated with VTa's but not with mortality. No significant association with either of the endpoints was observed for Type D personality and optimism. Future research should focus on the coexistent psychosocial factors that possibly lead to adverse cardiac prognosis in this patient population.

Leukocyte telomere length and personality: associations with the Big Five and Type D personality traits

Backgrounds Accelerated cellular ageing, which can be examined by telomere length (TL), may be an overarching mechanism underlying the association between personality and adverse health outcomes. This 6-year longitudinal study examined the relation between personality and leukocyte telomere length (LTL) across time among adults with a wide age-range.

METHODS

Data from the Netherlands Study of Depression and Anxiety were used and included patients with a depression and/or anxiety disorder and healthy controls. Overall, 2936 persons (18-65 years, 66% female) had data on LTL at baseline and 1883 persons had LTL at 6-year follow-up. The Big Five personality traits (neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness) and Type D personality were assessed.

RESULTS

Neuroticism was negatively (B = -2.11, p = 0.03) and agreeableness was positively (B = 3.84, p = 0.03) related to LTL measured across two time points, which became just non-significant after adjusting for somatic health, lifestyle factors, and recent life stress (B = -1.99, p = 0.06; and B = 3.01, p = 0.10). Type D personality was negatively (B = -50.16, p < 0.01) related to LTL across two time points, which still remained statistically significant after full adjustment (B = -47.37, p = 0.01). Associations did not differ by age, gender, and current psychiatric status.

CONCLUSIONS

The Big Five traits high neuroticism and low agreeableness, and Type D personality were associated with shorter LTL measured across a 6-year period. Associations with the Big Five traits became non-significant after controlling for somatic health, lifestyle factors, and recent life stress, yet similar trends were observed. Type D personality remained independently associated with shorter LTL after full adjustment.

Sleep disturbance in patients with an implantable cardioverter defibrillator: Prevalence, predictors and impact on health status

Background:

Sleep disturbances are highly prevalent in patients with cardiac diseases and associated with poor health outcomes. However, little is known about sleep disturbance in patients with an implantable cardioverter defibrillator.

Aims:

We examined the prevalence and predictors of sleep disturbance and the impact on perceived health status in a Dutch cohort of implantable cardioverter defibrillator patients.

Methods:

Patients (n=195) enrolled in the Web-based distress program for implantable cardioverter defibrillator patients (WEBCARE) trial completed questionnaires at the time of implantable cardioverter defibrillator implantation, three, six and 12 months afterwards. Sleep disturbance was assessed with the corresponding item #3 of the Patient Health Questionnaire 9.

Results:

At baseline, 67% (n=130) reported sleep disturbance (cut off ≥1). One year later, the prevalence was 57% (n=112). Younger age (odds ratio=0.96, 95% confidence interval 0.92–0.99; p=0.012) and high negative affectivity/low social inhibition (odds ratio=4.47, 95% confidence interval 1.52–13.17; p=0.007) were associated with sleep disturbance at 12 months in adjusted analyses. Sleep disturbance was not associated with health status at 12 months. Charlson Comorbidity Index, anxiety, Type D personality and high negative affectivity/low social inhibition were associated with impaired health status at follow-up.

Conclusions:

Sleep disturbance was highly prevalent in patients with an implantable cardioverter defibrillator. Younger age and high negative affectivity predicted sleep disturbance 12 months post-implantation independent of other demographic, clinical, intervention and psychological covariates. Sleep disturbance was not associated with impaired health status at the 12-month follow-up.

Patient-reported health status prior to cardiac resynchronisation therapy identifies patients at risk for poor survival and prolonged hospital stays

Background

Patient-reported factors have largely been neglected in search of predictors of response to cardiac resynchronisation therapy (CRT). The current study aimed to examine the independent value of pre-implantation patient-reported health status in predicting four-year survival and cardiac-related hospitalisation of CRT patients.

Methods

Consecutive patients (N = 139) indicated to receive a first-time CRT-defibrillator at the University Medical Center Utrecht were asked to complete a set of questionnaires prior to implantation. The Kansas City Cardiomyopathy Questionnaire (KCCQ) was used to assess heart failure-specific health status. Data on patients’ demographic, clinical and psychological characteristics at baseline, and on cardiac-related hospitalisations and all-cause deaths during a median follow-up of 3.9 years were obtained from purpose-designed questionnaires and patients’ medical records.

Results

Results of multivariable Cox regression analyses showed that poor patient-reported health status (KCCQ score < 50) prior to implantation was associated with a 2.5-fold increased risk of cardiac hospitalisation or all-cause death, independent of sociodemographic, clinical and psychological risk factors (adjusted hazard ratio 2.46, 95 % confidence interval (CI) 1.30–4.65). Poor health status was not significantly associated with the absolute number of cardiac-related hospital admissions, but with the total number of days spent in hospital during follow-up (adjusted incidence rate ratio 3.20, 95 % CI 1.88–5.44).

Conclusions

Patient-reported health status assessed prior to CRT identifies patients at risk for poor survival and prolonged hospital stays, independent of traditional risk factors. These results emphasise the importance of incorporating health status measures in cardiovascular research and patient management. Heart failure patients reporting poor health status should be identified and offered appropriate additional treatment programs.

Personality subtypes and chest pain in patients with nonobstructive coronary artery disease from the TweeSteden Mild Stenosis study: mediating effect of anxiety and depression

BACKGROUND

Patients presenting with chest pain in nonobstructive coronary artery disease (CAD, luminal narrowing <60%) are at risk for emotional distress and future events. We aimed to examine the association of personality subtypes with persistent chest pain, and investigated the potential mediating effects of negative mood states.

METHODS

Any chest pain in the past month was the primary outcome measure reported by 523 patients with nonobstructive CAD (mean age 61.4 years, SD = 9.4; 48% men), who participate in the TweeSteden Mild Stenosis (TWIST) observational cohort. Personality was categorized into a 'reference group', a high social inhibition ('SI only'), a high negative affectivity ('NA only') and a 'Type D' (NA and SI) group. Negative mood states included symptoms of depression and anxiety (Hospital Anxiety and Depression Scale) and cognitive and somatic depression (Beck Depression Inventory). The PROCESS macro was used to examine the relation between personality subtypes and chest pain presence, with the negative mood states as potential mediators.

RESULTS

Persistent chest pain was present in 44% of the patients with nonobstructive CAD. Type D personality (OR = 1.91, 95% CI 1.24-2.95), but not the 'NA only' (OR = 1.48, 95% CI 0.89-2.44) or the 'SI only' (OR = 0.93, 95% CI 0.53-1.64) group was associated with chest pain, adjusted for age and sex. Negative mood states mediated the association between personality and chest pain.

CONCLUSIONS

Type D personality, but not negative affectivity or social inhibition, was related to chest pain in nonobstructive CAD, which was mediated by negative mood states.

Type D personality, suboptimal health behaviors and emotional distress in adults with diabetes: results from Diabetes MILES-The Netherlands

AIMS

Type D personality - defined as high negative affectivity (NA) and high social inhibition (SI) - has been associated with adverse cardiovascular prognosis. We explored the differential associations of Type D personality and its constituent components with health behaviors, emotional distress and standard biomedical risk factors as potential risk mechanisms in adults with diabetes.

METHODS

3314 Dutch adults with self-reported type 1 or 2 diabetes completed an online survey, including the DS14 Type D Scale. AN(C)OVAs and X(2) tests were used to compare participants scoring (i) low on NA and SI; (ii) high on SI only; (iii) high on NA only; (iv) high on NA and SI (Type D).

RESULTS

Participants with Type D personality (29%) were less likely to follow a healthy diet or to consult healthcare professionals in case of problems with diabetes management than those scoring high on neither or only one component. They also reported more barriers surrounding medication use, diabetes-specific social anxiety, loneliness and symptoms of depression and anxiety. There were no differences in standard biomedical risk factors (body mass index, blood pressure, cholesterol, HbA1c). After adjustment for demographics, clinical characteristics, NA, and SI in multivariable logistic regression analyses, Type D personality was independently associated with 2 to 3-fold increased odds of suboptimal health behaviors and over 15-fold increased odds of general emotional distress.

CONCLUSIONS

Type D personality was not related to standard biomedical risk factors, but was associated with unhealthy behaviors and negative emotions that are likely to have adverse impact on adults with diabetes.

Adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events: individual patient data meta-analysis

BACKGROUND

The association between depression after myocardial infarction and increased risk of mortality and cardiac morbidity may be due to cardiac disease severity.

AIMS

To combine original data from studies on the association between post-infarction depression and prognosis into one database, and to investigate to what extent such depression predicts prognosis independently of disease severity.

METHOD

An individual patient data meta-analysis of studies was conducted using multilevel, multivariable Cox regression analyses.

RESULTS

Sixteen studies participated, creating a database of 10 175 post-infarction cases. Hazard ratios for post-infarction depression were 1.32 (95% CI 1.26-1.38, P<0.001) for all-cause mortality and 1.19 (95% CI 1.14-1.24, P<0.001) for cardiovascular events. Hazard ratios adjusted for disease severity were attenuated by 28% and 25% respectively.

CONCLUSIONS

The association between depression following myocardial infarction and prognosis is attenuated after adjustment for cardiac disease severity. Still, depression remains independently associated with prognosis, with a 22% increased risk of all-cause mortality and a 13% increased risk of cardiovascular events per standard deviation in depression z-score.

Impact of type D personality on adherence to oral appliance therapy for sleep-disordered breathing

PURPOSE

Type D personality, defined as a combination of social inhibition and negative affectivity, has been associated with poor medication adherence and lower adherence to continuous positive airway pressure in patients with sleep-disordered breathing. Up to this date, the association of patient's personality with adherence with a mandibular advancement device (MAD) has not been studied. The purposes of this study were to examine the association between type D personality and poor adherence to MAD treatment and to examine the impact of type D personality on perceived side effects during this treatment.

METHODS

Eighty-two patients out of 113 patients with a known baseline type D scale who have started MAD treatment between June 2006 and December 2009 were included. Information about side effects and adherence were collected via a postal questionnaire. Thirty-three patients were using a monobloc MAD and 49 patients were using a duobloc MAD.

RESULTS

Forty-five percent of type D patients discontinued MAD treatment, whereas only 15 % of non-type D patients reported treatment discontinuation. The odds ratio for treatment discontinuation was 6.03 (95 % confidence interval 1.22-29.81; p = 0.027) for type D personality, adjusted for age, gender, MAD type (monobloc or duobloc), and decrease in apnea severity. In continuing MAD users, no significant difference in perceived side effects was reported between the personality types.

CONCLUSION

This is the first study to examine the relationship between type D personality and adherence to MAD treatment. Type D patients reported a significantly higher discontinuation rate when compared to patients without type D personality.

Suboptimal glycemic control in type 2 diabetes: a key role for anhedonia?

Recent studies examining the relationship between depression and glycosylated hemoglobin (HbA(1c)) concentrations in patients with type 2 diabetes have yielded mixed findings. One explanation may lie in the heterogeneity of depression. Therefore, we examined whether distinct features of depression were differentially associated with suboptimal glycemic control. Cross-sectional baseline data from a dynamic cohort study of primary care patients with type 2 diabetes from the Eindhoven region, The Netherlands, were analyzed. A total of 5772 individuals completed baseline measurements of demographic, clinical, lifestyle and psychological factors between 2005 and 2009. The Edinburgh Depression Scale was used to assess symptoms of depressed mood, anhedonia and anxiety. Suboptimal glycemic control was defined as HbA(1c) values ≥7%, with 29.8% of the sample (n=1718) scoring above this cut-off. In univariate logistic regression analyses, anhedonia was significantly associated with suboptimal glycemic control (OR 1.29, 95% CI 1.09-1.52), while both depressed mood (OR 1.04, 0.88-1.22) and anxiety (OR 0.99, 0.83-1.19) were not. The association between anhedonia and glycemic control remained after adjustment for the other depression measures (OR 1.33, 1.11-1.59). Alcohol consumption and physical activity met criteria for mediation, but did not attenuate the association between anhedonia and glycemic control by more than 5%. Although diabetes duration was identified as a confounder and controlled for, the association was still significant (OR 1.20, 1.01-1.43). Studying different symptoms of depression, in particular anhedonia, may add to a better understanding of the relationship between depression and glycemic control.

The course of depressive symptoms in primary care patients with type 2 diabetes: results from the Diabetes, Depression, Type D Personality Zuidoost-Brabant (DiaDDZoB) Study

AIMS/HYPOTHESIS

The aim of the study was to examine the course (incidence, recurrence/persistence) of depressive symptoms in primary care patients with type 2 diabetes and to identify significant predictors of these different course patterns.

METHODS

A cohort of 2,460 primary care patients with type 2 diabetes was assessed for demographic, clinical and psychological factors in 2005 and followed-up in 2007 and 2008. Depression was defined as a score of ≥ 12 on the Edinburgh Depression Scale. Multivariate logistic regression analyses were used to determine whether several depression-course patterns could be predicted by means of demographics, medical co-morbidities and psychological factors.

RESULTS

A total of 630 patients (26%) met the criterion for depression at one or more assessments. In the subgroup with no baseline depression, incident depression at follow-up was present in 14% (n = 310), while recurrence/persistence in those with baseline depression was found in 66% (n = 212).The presence of any depression was associated with being female, low education, non-cardiovascular chronic diseases, stressful life events and a self-reported history of depression. Incident depression was predicted by female sex, low education and depression history, while patients with a history of depression had a 2.5-fold increased odds of recurrent/persistent depression.

CONCLUSIONS/INTERPRETATION

Depression is common in primary care patients with type 2 diabetes, with one in seven patients reporting incident depression during a 2.5 year period. Once present, depression often becomes a chronic/recurrent condition in this group. In order to identify patients who are vulnerable to depression, clinicians can use questionnaire data and/or information about the history of depression.

Vital exhaustion and cardiovascular prognosis in myocardial infarction and heart failure: predictive power of different trajectories

BACKGROUND

We examined the different trajectories of vital exhaustion (VE) over a 12-month period and their impact on prognosis in a sample of myocardial infarction (MI) and chronic heart failure (CHF) patients.

METHOD

Consecutive MI (n=407) and CHF patients (n=297) were assessed at baseline, and at 3- and 12-month follow-up for symptoms of VE. Latent growth mixture modelling was used to examine the course of VE over time. The combined clinical endpoint was defined as cardiac hospital readmission or death.

RESULTS

Four distinct trajectories for VE were found: low VE, decreasing VE, increasing VE, and severe VE. Sex, marital status, left ventricular ejection fraction, psychotropic medication, sample group (CHF v. MI) and depressive symptoms were associated with VE, varying according to classes. The mean follow-up period was 25.3 months in which 34.7% of the patients experienced an event. Multivariate Cox regression showed that, compared with patients in the low VE class, patients in the increasing VE class [hazard ratio (HR)=1.16, 95% confidence interval (CI) 1.58-3.61, p=0.01], and the severe VE class (HR=1.69, 95% CI 1.31-2.64, p=0.02) had an increased risk for adverse cardiovascular events (i.e. cardiovascular hospital readmission or cardiovascular death). Decreasing VE was not related to adverse cardiovascular events (HR=0.97, 95% CI 0.66-1.69, p=0.81).

CONCLUSIONS

VE trajectories varied across cardiac patients, and had a differential effect on cardiovascular outcome. Increasing VE and severe VE classes were predictors of poor cardiovascular prognosis. These results suggest that identification of cardiac patients with an increased risk of adverse health outcomes should be based on multiple assessments of VE.

Symptom dimensions of post-myocardial infarction depression, disease severity and cardiac prognosis

BACKGROUND

Individual symptoms of post-myocardial infarction (MI) depression may be differentially associated with cardiac prognosis, in which somatic/affective symptoms appear to be associated with a worse cardiovascular prognosis than cognitive/affective symptoms. These findings hold important implications for treatment but need to be replicated before conclusions regarding treatment can be drawn. We therefore examined the relationship between depressive symptom dimensions following MI and both disease severity and prospective cardiac prognosis.

METHOD

Patients (n=473) were assessed on demographic and clinical variables and completed the Beck Depression Inventory (BDI) within the first week of hospital admission for acute MI. Depressive symptom dimensions were associated with baseline left ventricular ejection fraction (LVEF) and prospective cardiac death and/or recurrent MI. The average follow-up period was 2.8 years.

RESULTS

Factor analysis revealed two symptom dimensions--somatic/affective and cognitive/affective--in the underlying structure of the BDI, identical to previous results. There were 49 events attributable to cardiac death (n=23) or recurrent MI (n=26). Somatic/affective (p=0.010) but not cognitive/affective (p=0.153) symptoms were associated with LVEF and cardiac death/recurrent MI. When controlling for the effects of previous MI and LVEF, somatic/affective symptoms remained significantly predictive of cardiac death/recurrent MI (hazard ratio 1.31, 95% confidence interval 1.02-1.69, p=0.038). Previous MI was also an independent predictor of cardiac death/recurrent MI.

CONCLUSIONS

We confirmed that somatic/affective, rather than cognitive/affective, symptoms of depression are associated with MI severity and cardiovascular prognosis. Interventions to improve cardiovascular prognosis by treating depression should be targeted at somatic aspects of depression.

Depression and Type D personality represent different forms of distress in the Myocardial INfarction and Depression - Intervention Trial (MIND-IT)

BACKGROUND

We investigated whether depressive disorder and Type D personality refer to different forms of distress in the Myocardial INfarction and Depression - Intervention Trial (MIND-IT).

METHOD

A total of 1205 myocardial infarction (MI) patients were screened at 3, 6, 9 and 12 months post-MI; those with a Beck Depression Inventory (BDI) score 10 underwent the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Patients completed the DS14 measure of Type D personality at 12 months and were stratified to one of four subgroups: depressed/Type D, depressed/non-Type D, non-depressed/Type D, or non-distressed.

RESULTS

Two hundred and six (17%) patients were diagnosed with depression and 224 (19%) with Type D. Only 7% (n=90) had both forms of distress, and 60% of Type D patients were free of depression in the first year post-MI. Type D moderated the relationship between depressive and cardiac disorder. Depressed patients without Type D had the worst clinical status (left ventricular dysfunction, heart failure, Killip class 2) as compared to other patients, whereas depressed patients with a Type D personality did not differ in clinical status from non-distressed patients. Contrasting 'pure' Type D and depression subgroups showed that Type D patients without depression were less likely to have left ventricular dysfunction [odds ratio (OR) 0.47, 95% confidence interval (CI) 0.35-0.65, p<0.0001] than depressed patients without Type D.

CONCLUSIONS

Depression and Type D refer to different forms of distress in post-MI patients; most Type D patients display non-psychiatric levels of distress and Type D moderates the relationship between depressive and cardiac disorder. Different depression/Type D subgroups may be involved in the prediction of cardiac prognosis.

Reduced positive affect (anhedonia) predicts major clinical events following implantation of coronary-artery stents

OBJECTIVE

Emotional distress has been related to clinical events in patients with coronary artery disease, but the influence of positive affect (i.e. mood states such as activity, joy and cheerfulness) has received little attention. Therefore, we wanted to investigate the role of positive affect on clinical outcome after percutaneous coronary intervention (PCI) with stent implantation in these patients.

DESIGN

Prospective follow-up study. At baseline, patients from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry completed measures of positive affect, depression and anxiety post-PCI. Patients with reduced positive affect scored 1 SD below the mean score.

SETTING

University Hospital; Thoraxcenter of the Department of Cardiology.

SUBJECTS

874 patients (72% men; 62.2 +/- 10.9 years) from the RESEARCH registry. Main outcome measure. Death or myocardial infarction (MI) 2 years post-PCI.

RESULTS

At follow-up, there were 52 clinical events (deaths n = 27, MIs n = 25). Reduced positive affect and depression/anxiety were associated with poor prognosis, but reduced positive affect was the only independent predictor of events. The incidence of death/MI in adequate versus reduced positive affect patients was 4% (29/663) vs. 11% (23/211); HR = 2.55 (95% CI 1.46-4.34, P = 0.001), adjusting for clinical variables. Reduced positive affect and diabetes were independent prognostic factors, and patients with one (HR = 2.84, 95% CI 1.58-5.10) or both (HR = 5.61, 95% CI 2.25-13.99) of these factors had a higher risk when compared with nondiabetic patients with adequate positive affect, P < or = 0.003.

CONCLUSIONS

Reduced positive affect independently predicted death/MI following stent implantation, and improved risk stratification above and beyond diabetes.

Cardiac history, prior depression and personality predict course of depressive symptoms after myocardial infarction

BACKGROUND

Although many studies have focused on post-myocardial infarction (MI) depression, there is limited information about the evolution and determinants of depressive symptoms in the first year post-MI. Therefore we examined (1) the course of depressive symptoms during the first year post-MI and (2) the predictors of these symptom trajectories.

METHOD

To assess depressive symptoms, 287 patients completed the Beck Depression Inventory during hospitalization for MI, and 2, and 12 months post-MI. Personality was assessed with the Type-D scale during hospitalization. We used latent class analysis to examine the evolution of depressive symptoms over a 1-year period and multinomial logit regression analyses to examine predictors of these symptom trajectories.

RESULTS

The course of depressive symptoms was stable during the first year post-MI. Four groups were identified and classified as non-depressed [40%, intercept (IC) 2.52], mildly depressed (42%, IC 6.91), moderately depressed (14%, IC 13.73) or severely depressed (4%, IC 24.54). In multivariate analysis, cardiac history (log OR(severe) 2.93, p=0.02; log OR(moderate) 1.81, p=0.02; log OR(mild) 1.46, p=0.01), history of depression (log OR(severe) 4.40, p<0.001; log OR(moderate) 1.97, p=0.03) and Type-D personality (log OR(severe) 4.22, p<0.001; log OR(moderate) = 4.17, p<0.001; log OR(mild) 1.66, p=0.02) were the most prominent risk factors for persistence of depressive symptoms during the first year post-MI.

CONCLUSIONS

Symptoms of depression tend to persist during the first year post-MI. Cardiac history, prior depression and Type-D personality were identified as independent risk factors for persistence of depressive symptoms. The results of this study strongly argue for routine psychological screening during hospitalization for acute MI in order to identify patients who are at risk for chronicity of depressive symptoms and its deleterious effects on prognosis.

Impaired health status and invasive treatment in peripheral arterial disease: a prospective 1-year follow-up study

OBJECTIVE

It has been argued that health status and quality of life (QOL) should be taken into account in the treatment policy of patients with peripheral arterial disease (PAD). In cardiac patients, it has been shown that poor perceived health status is an independent predictor of mortality and hospitalization. We therefore examined (1) the role of health status, QOL, and clinical indices of disease severity as determinants of invasive treatment in patients with PAD and (2) the effect of invasive treatment on health status and QOL.

METHODS

At their first visit, patients completed the RAND 36-item Health Survey and World Health Organization Quality of Life assessment instrument questionnaires to assess health status and QOL, respectively. During the 1-year follow-up period, data concerning hospitalization were derived from the patients' medical files. Furthermore, patients completed the RAND 36 and the World Health Organization Quality of Life assessment instrument again at 1-year follow-up. The setting was a vascular outpatient clinic of a teaching hospital in Tilburg, The Netherlands; participants were 200 consecutive patients newly diagnosed with intermittent claudication, a common expression of PAD. Diagnosis was based on history, physical examination, treadmill walking distance, and ankle-brachial pressure indices. Main outcome measures were (1) invasive treatment of PAD that took place during the 1-year follow-up, derived from the patients' medical files, and (2) health status and QOL after 1 year of follow-up.

RESULTS

After 1 year of follow-up, 107 patients (53.5%) were event free, whereas 77 patients (38.5%) had been hospitalized for invasive treatment of PAD. Sixteen patients (8%) were hospitalized for other cardiovascular reasons. In a multivariate logistic regression model, age (odds ratio [OR], 0.95; 95% confidence interval [CI], 0.91-0.99; P = .024), pain-free walking distance (OR, 2.74; 95% CI, 1.05-7.17; P = .04), and physical functioning (OR, 4.46; 95% CI, 1.79-11.12; P = .001) were independent predictors of invasive treatment of intermittent claudication. After 1 year of follow-up, patients who were treated invasively experienced a significant improvement in their physical functioning ( P = .004), role limitations due to emotional problems ( P = .018), and bodily pain ( P = .026).

CONCLUSIONS

Patients with poor self-reported physical functioning, limited walking distance, and a younger age were likely to be treated invasively. The physician's clinical judgment about when to intervene adequately reflects the patient's own opinion about his or her health status. Invasive treatment led to a significant improvement in patients' health status. These findings indicate the effectiveness of the strategy to include patients' perceived physical functioning into the process of clinical decision-making.

Men deny and women cry, but who dies? Do the wages of "denial" include early ischemic coronary heart disease?

OBJECTIVES

In this study patients with documented ischemic coronary heart disease (ICHD; prior MI or CAD per catheterization) were tested for the association of various measures of emotional distress with Age at Initial Diagnosis.

METHODS

The measures were chosen because of a published track record at predicting mortality in this population. Females were oversampled to achieve equivalent numbers of each sex (n=50), and thus equivalent statistical power. In a subset of patients (38 males and 32 females), Spouse/Friend Ketterer Stress Symptom Frequency Checklists (KSSFCs) were received.

RESULTS

Females reported more depression and anxiety than males. However, spouses or friends reported more anger for males. Denial (spouse/friend minus self-ratings) was greater in males for all three scales of the KSSFC (Anger, P=.005; Depression, P=.024; Anxiety, P=.001). Although females showed the same trend, self and spouse or friend ratings of distress were significantly associated with Age at Initial Diagnosis only in males. When split at the sample mean on the Spouse/Friend KSSFC AIAI (Anger) scale, Age at Initial Diagnosis occurred 14.2 years earlier in males.

CONCLUSIONS

Use of a significant other in assessing psychosocial/emotional distress in males may confer greater accuracy, and therefore predictive power for clinical endpoints.

Perceived health following myocardial infarction: cross-validation of the Health Complaints Scale in Danish patients

With an ageing population and a decline in cardiac mortality rates, the number of patients with cardiac disease is increasing, which in turn poses a major challenge for secondary prevention. For this end, appropriate, sensitive, and validated instruments to assess health complaints and quality of life are required. The objectives of the current study were: (1) to cross-validate the Health Complaints Scale (HCS) in a Danish sample of patients with a first myocardial infarction (MI); and (2) to investigate whether perceived health, as measured by the HCS is related to cardiac disease severity. The HCS was originally developed in Belgian patients with coronary artery disease. One-hundred-and-twelve consecutive patients with a first myocardial infarction were assessed by means of a questionnaire four to six weeks post infarction. Clinical measures were sampled from medical records. The factor structure of the HCS and the internal consistency of the Somatic Complaints (alpha = 0.91) and Cognitive Complaints subscales (alpha = 0.94) were confirmed. The construct validity of the scale was confirmed against measures of psychopathology and personality. Patients scored significantly higher on the HCS Somatic and Cognitive scales as compared with self-reports of depression and anxiety (p < 0.0001). Health complaints were unrelated to severity of cardiac disease and rather reflected subjective perception of quality of life. These findings show that the HCS is a valid instrument that is equally applicable in Danish cardiac patients to monitor perceived health as a major component of quality of life.

Reducing emotional distress improves prognosis in coronary heart disease: 9-year mortality in a clinical trial of rehabilitation

BACKGROUND

The impact of treating emotional distress on prognosis in coronary heart disease (CHD) has not been documented convincingly. We tested the hypothesis that treatment-related changes in emotional distress may explain the beneficial effect of rehabilitation on prognosis.

METHODS AND RESULTS

In this nonrandomized clinical trial, 150 men with CHD participated in rehabilitation (n=78) or received standard medical care (n=72). There were no differences between rehabilitation and control patients with regard to left ventricular ejection fraction (LVEF) or standard care. End points were reduction in distress after 3 months and mortality after 9 years. At the end of the 3-month trial, 64 patients (43%) reported improvement and 22 (15%) reported deterioration in negative affect. Rehabilitation patients improved more (P=0.004) and deteriorated less (P=0.001) than control patients; rehabilitation was effective in reducing distress. After 9 years of follow-up, 15 patients had died (13 cardiac and 2 cancer deaths). Mortality was associated with LVEF </=50% (P=0.038) and deterioration in negative affect (P=0.007). Rate of death was 17% (12/72) for control patients versus 4% (3/78) for rehabilitation patients (P=0.009); rehabilitation was effective in reducing mortality. LVEF </=50% (OR 3.2; 95% CI 1.1 to 9.8; P=0.041) and rehabilitation (OR 0.2; 95% CI 0.1 to 0.7; P=0.016) were independent predictors of mortality. Rehabilitation warded off the deleterious effect of deterioration in negative affect on prognosis.

CONCLUSIONS

Deterioration in negative affect is associated with a high long-term mortality risk. Warding off deterioration in negative affect is a mechanism that may explain the beneficial effect of comprehensive rehabilitation on prognosis in patients with CHD.

Sensitivity and specificity of observer and self-report questionnaires in major and minor depression following myocardial infarction

This study evaluated screening abilities of self-report questionnaires for depression in first myocardial infarction (MI) patients. One month post-MI, 206 patients with first MI were screened for major and minor depression using the 90-item Symptom Check List (SCL-90), the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale (HADS), and the 17-item Hamilton Depression Rating Scale (Ham-D). The Structured Clinical Interview for DSM-IV criteria was used as the gold standard. Sensitivity and specificity for different cutoff points, using relative operating characteristics curves, were assessed. The internal consistency for all scales was good. When screening for major and minor depression, the optimal cutoff scores are lower than those for screening major depression only. The SCL-90, BDI, HADS, and Ham-D proved to have acceptable abilities for screening post-MI major and minor depression.

Screening for solid organ malignancies prior to heart transplantation

BACKGROUND

Prognosis of solid organ cancer in immunosuppressed hosts is generally dismal. Therefore, every effort to identify patients with asymptomatic carcinomas before transplantation should be encouraged.

METHODS

Sixty-seven patients referred for heart transplantation were examined adhering to the scheme proposed at the 24th Bethesda Conference. To increase the sensitivity of this work-up, the following items were added: tumor marker assays (prostate-specific antigen in males, carcino embryogenic antigen), abdominal ultrasound, CT scan of the abdomen and the thorax, mammography/echography of the breasts, PAP smear, colonoscopy if carcino embryogenic antigen abnormal or occult blood in stool, prostate echography if prostate-specific antigen abnormal or prostate hypertrophy.

RESULTS

Carcinoma was detected in 10 of the 67 patients; for 8 patients of this cancer group, transplantation was denied. Importantly, 9 of the 10 malignancies were detected by means of the diagnostic items that were added to the standard screening protocol. There were no significant differences between the cancer and the non-cancer group regarding mean age, sex, etiology of heart failure, and smoking history. Stratifying patients in younger (i.e., < or =54 years) and older (i.e., > or =55 years) age groups showed a significantly greater proportion of older patients in the cancer group (8/10=80%) compared to the non-cancer group (25/57=44%), P=0.04. After a mean follow-up of 34 months, 5 of the 36 transplanted patients developed a malignancy (4 skin carcinomas, 1 non-Hodgkin lymphoma). There have been no malignancy-related deaths until now.

CONCLUSION

The importance of a thorough screening program in the triage of candidates with preexisting malignancies, especially in an older patient population, is illustrated in this report.

Type D personality. A potential risk factor refined

OBJECTIVE

Acute and chronic psychological distress have been associated with coronary heart disease (CHD) but little is known about the determinants of distress as a coronary risk factor. Broad and stable personality traits may have much explanatory power; this article selectively focuses on negative affectivity (NA; tendency to experience negative emotions) and social inhibition (SI; tendency to inhibit self-expression in social interaction) in the context of CHD.

METHODS

The first part of this article reviews research on NA and SI in patients with CHD. The second part presents new findings on NA and SI in 734 patients with hypertension.

RESULTS

Accumulating evidence suggests that the combination of high NA and high SI designates a personality subtype ("distressed" type or type D) of coronary patients who are at risk for clustering of psychosocial risk factors and incidence of long-term cardiac events. Type D and its contributing low-order traits (dysphoria/tension and reticence/withdrawal) could also be reliably assessed in a community-based sample of patients with hypertension. This finding was replicated in men and women, and in Dutch- and French-speaking subjects. Type D hypertensives reported more depressive affect than their non type D counterparts.

CONCLUSIONS

There is an urgent need to adopt a personality approach in the identification of patients at risk for cardiac events. NA and SI are broad and stable personality traits that may be of special interest not only in CHD, but in other chronic medical conditions as well.

Inadequate response to treatment in coronary heart disease : adverse effects of type D personality and younger age on 5-year prognosis and quality of life

BACKGROUND

Improvement in treatment of patients with coronary heart disease (CHD) has caused longer survival but also an increase in the number of patients at risk for subsequent cardiac events and impaired quality of life (QOL). We hypothesized that chronic emotional distress confers an increased risk of poor outcome despite appropriate treatment.

METHODS AND RESULTS

This prospective study examined the 5-year prognosis of 319 patients with CHD. Baseline assessment included symptoms of depression/anxiety and distressed personality type (type D-ie, high negative affectivity and social inhibition). The main end points were cardiac death or nonfatal myocardial infarction and impaired QOL. There were 22 cardiac events (16 nonfatal); they were related to left ventricular ejection fraction (LVEF) </=50%, poor exercise tolerance, age </=55 years, symptoms of depression, and type D personality. Multivariate analysis yielded LVEF </=50% (OR, 3.9; P=0.009), type D personality (OR, 8.9; P=0.0001), and age </=55 years (OR, 2.6; P=0.05) as independent predictors of cardiac events. Convergence of these risk factors predicted the absence of the expected therapeutic response that was observed in 10% of the patients. When 2 or 3 risk factors occurred together, the rate of poor outcome was 4-fold higher (P=0. 0001). Estimates of medical costs increased progressively with an increasing number of risk factors. Smoking, symptoms of depression, and type D personality were independent predictors of impaired QOL.

CONCLUSIONS

Decreased LVEF, type D personality, and younger age increase the risk of cardiac events; convergence of these factors predicts nonresponse to treatment. Emotionally stressed and younger patients with CHD represent high-risk groups deserving of special study.

Personality and coronary heart disease: the type-D scale-16 (DS16)

Clinical diagnoses of depression, self-reported negative emotions, and personality traits have been associated with both the development and progression of coronary heart disease (CHD). This article focusses on negative affectivity (the tendency to experience negative emotions) and social inhibition (the tendency to inhibit self-expression in social interaction) in CHD patients. Two independent samples of patients with CHD were included in this study. Both empirical and internal-structural criteria were used to devise a brief self-report measure comprising an eight-item negative affectivity and an eight-item social inhibition scale in Sample 1 (N = 400). These scales were internally consistent (alpha = .89 and .82), stable over time (three-month test-retest reliability = .78 and .87) and were validated against standard personality scales. CHD patients with a "distressed" personality (Type-D) report high levels of negative affectivity and social inhibition; accordingly, this self-report measure was termed Type-D Scale-16 (DS16). Previous research showed that Type-D was associated with cardiac events and incidence of cancer in patients with CHD. Type-D as measured by the DS16 was associated with depressive affect and symptoms, stress, poor self-esteem, dissatisfaction with life, and low positive affect in Sample 2 (N = 100) of the present article. It is concluded that research on CHD should focus on affective disorder, specific negative emotions, and global personality traits, and that the DS16 is a practical, sound research tool that can be used to assess Type-D.

Personality and risk of cancer in men with coronary heart disease

BACKGROUND

There still is much debate with regard to the role of psychosocial factors in cancer. Evidence suggests that cancer and coronary heart disease (CHD) may have common causes. This study examined the role of pessimism, anxiety and personality in the development of cancer among men who had been diagnosed with CHD but were free of cancer at baseline.

METHODS

Two hundred and forty-six men who were treated for CHD, but were free of cancer, filled out psychological scales at baseline. Patients and their families were contacted after 6-10 years to determine the incidence of cancer.

RESULTS

At follow-up, 12 patients (5%) had been diagnosed with cancer (9 cancer deaths). Development of cancer was unrelated to cardiac pathology but was associated with age > or = 56 years, poor exercise tolerance, pessimism and anxiety. The rate of cancer was 8/60 = 13% for men with a distressed personality (type-D) and 4/186 = 2% for non-type-D men (P = 0.002); rate of cancer death was 10% and 2%, respectively (P = 0.007). Type-D refers to the interaction between high negative affectivity and high social inhibition. Regression analysis yielded older age (odds ratio 4.6, 95% CI 1.5-14.3) and type-D (odds ratio 7.2, 95% CI 2.9-18.1) as independent prognostic factors for cancer.

CONCLUSIONS

Type-D personality was a prognostic factor for the development of cancer in men with established CHD. Psychosomatic research should take a broad enough view of the specific and the global psychosocial variables that may play a role in both cancer and CHD.

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

BACKGROUND

Patients with myocardial infarction (MI) with a decreased left ventricular ejection fraction (LVEF) have a poor prognosis, but the role of emotional stress in prognosis is not known. We hypothesized that emotional stress in these patients (1) is unrelated to the severity of cardiac disorder, (2) predicts cardiac events, and (3) is a function of basic personality traits.

METHODS AND RESULTS

Eighty-seven patients with MI (age, 41 to 69 years) with an LVEF of < or =50% underwent psychological assessment at baseline. Patients and their families were contacted after 6 to 10 years (mean, 7.9 years); cardiac events were defined as cardiac death or nonfatal MI. Emotional distress was unrelated to the severity of cardiac disorder. At follow-up, 21 patients had experienced a cardiac event (13 fatal events). These events were related to LVEF of < or =30%, poor exercise tolerance, previous MI, anxiety, anger, and depression (all P< or =.02). Patients with a distressed personality (type D; ie, the tendency to suppress negative emotions) were more likely to experience an event over time compared with non-type D patients (P=.00005). Cox proportional hazards analysis yielded LVEF of < or =30% (relative risk, 3.0; 95% confidence interval, 1.2 to 7.7; P=.02) and type D (relative risk, 4.7; 95% confidence interval, 1.9 to 11.8; P=.001) as independent predictors. Anxiety, anger, and depression did not add to the predictive power of type D; these negative emotions were highly correlated and reflected the personality domain of negative affectivity.

CONCLUSIONS

Personality influences the clinical course of patients with a decreased LVEF. Emotional distress in these patients is unrelated to disease severity but reflects individual differences in personality. Clinical trials should take a broad view of the target of intervention; assessment of LVEF and personality may identify patients at risk.

Personality as independent predictor of long-term mortality in patients with coronary heart disease

BACKGROUND

Emotional distress has been related to mortality in patients with coronary heart disease (CHD), but little is known about the role of personality in long-term prognosis. We postulated that type-D personality (the tendency to suppress emotional distress) was a predictor of long-term mortality in CHD, independently of established biomedical risk factors.

METHODS

We studied 268 men and 35 women with angiographically documented CHD, aged 31-79 years, who were taking part in an outpatient rehabilitation programme. All patients completed personality questionnaire at entry to the programme. We contacted them 6-10 years later (mean 7-9) to find out survival status. The main endpoint was death from all causes.

FINDINGS

At follow-up, 38 patients had died; there were 24 cardiac deaths. The rate of death was higher for type-D patients than for those without type-D (23 [27%]/85 vs 15 [7%]/218; p < 0.00001). The association between type-D personality and mortality was still evident more than 5 years after the coronary event and was found in both men and women. Mortality was also associated with impaired left ventricular function, three-vessel disease, low exercise tolerance, and the lack of thrombolytic therapy after myocardial infarction. When we controlled for these biomedical predictors in multiple logistic regression analysis, the impact of type-D remained significant (odds ratio 4.1 [95% CI 1.9-8.8]; p = 0.0004). In this group of CHD patients, type-D was an independent predictor of both cardiac and non-cardiac mortality. Social alienation and depression were also related to mortality, but did not add to the predictive power of type-D.

INTERPRETATION

We found that type-D personality was a significant predictor of long-term mortality in patients with established CHD, independently of biomedical risk factors. Personality traits should be taken into account in the association between emotional distress and mortality in CHD.

Personality and mortality after myocardial infarction

Previous research showed: a) emotional distress is a risk factor for mortality after myocardial infarction (MI) and b) emotional distress is linked to stable personality traits. In this study, we examined the role of these personality traits in mortality after MI. Subjects were 105 men, 45 to 60 years of age, who survived a recent MI. Baseline assessment included biomedical and psychosocial risk factors, as well as each patient's personality type. After 2 to 5 (mean, 3.8) years of follow-up, 15 patients (14%) had died. Rate of death for patients with a distressed personality type (11/28 = 39%) was significantly greater than that for patients with other personality types (4/77 = 5%) (p < .0001). Patients with this personality type tend simultaneously to experience distress and inhibit expression of emotions. Low exercise tolerance, previous MI (p < .005), anterior MI, smoking, and age (p < .05) were also associated with mortality. A logistic regression model including these biomedical factors had a sensitivity for mortality of only 27%. The addition of distressed personality type in this model more than doubled its sensitivity. Of note, among patients with poor physical health, those with a distressed personality type had a five-fold mortality risk (p < .005). Consistent with the findings of other investigators, depression (p < .005), life stress, use of benzodiazepines (p < .01), and somatization (p < .05) were also related to post-MI mortality. These psychosocial risk factors were more prevalent in the distressed personality type than in the other personality types (p < .001-.05). Multiple logistic regression indicated that these psychosocial factors did not add to the predictive value of the distressed personality type. Hence, an important personality effect was observed despite the low power. This suggests that personality traits may play a role in the detrimental effect of emotional distress in MI patients.

Enhancing emotional well-being by comprehensive rehabilitation in patients with coronary heart disease

Since emotional distress is linked to poor prognosis in coronary patients, there is urgent need for research into interventions that may enhance emotional well-being in these patients. Cardiac rehabilitation aims to return the individual to optimal emotional function, but the psychological effect of this therapy still needs to be demonstrated. Hence, we examined the role of cardiac rehabilitation in enhancing emotional health. We examined 170 male patients with coronary heart disease, of whom 85 had participated in the outpatient rehabilitation programme of the University Hospital of Antwerp and 85 had received standard medical care only in two other hospitals. Rehabilitation and control patients were matched by medical category and tendency to experience distress. The Global Mood Scale, the Health Complaints Scale, and the Heart Patients Psychological Questionnaire were used to assess changes in emotional well-being over a 3-month period. These changes were significantly different as a function of cardiac rehabilitation (P<0.0001). Rehabilitation patients, but not control patients, reported a significant improvement in negative affect, positive affect, well-being , health and disability (P<0.001). At follow-up, differences in depression, tranquillizer use (P<0.05), and activity profile (P<0.01) confirmed that rehabilitation patients displayed more healthy behaviour than control patients. Patients not only improved more, but also deteriorated less as a function of rehabilitation. This therapy also had a positive effect on patients suffering minimal distress, which is at variance with previous research. These findings suggest that comprehensive rehabilitation may be an effective therapy for enhancing emotional well-being in patients with coronary heart disease.

Health complaints and outcome assessment in coronary heart disease

Research on coronary heart disease (CHD) lacks sensitive outcome measures. Health complaints, although subjective in nature, may provide information on the degree of recovery from CHD. The purpose of Study 1 was to identify common health complaints in a group of 535 men (mean age, 57.5 years) with CHD. In the weeks after a coronary event, they frequently reported somatic (e.g., chest pain, dyspnea, fatigue, sleep problems) and cognitive (e.g., concern about health and functional status) health complaints. Statistical analyses produced the Health Complaints Scale (HCS), which comprises 12 somatic and 12 cognitive complaints. Confirmatory factor analysis provided evidence for the model undergirding the HCS, and the somatic and cognitive scales of the HCS were found to have high internal consistency (alpha > or = .89), adequate test-retest reliability (r > or = .69), and good construct validity. Study 2 provided evidence for the idea that the HCS can be distinguished from standard scales of psychopathology. Statistical analyses in 266 men with CHD indicated that, compared to symptoms of psychopathology, the HCS scales displayed discrete factor loadings as well as higher scores at baseline and a normal clustering of scores. Important to note, HCS scores decreased in 60 subjects participating in cardiac rehabilitation (p < .0001) but not in 60 control subjects. Although research should not disregard psychological biases on symptom reporting, it is argued that health complaints need to be accurately assessed in CHD patients.

Sensitivity of outcome assessment in cardiac rehabilitation

I hypothesized that measures that match the theoretically prescribed effect of cardiac rehabilitation (i.e., enhancement of subjective health and well-being) are more appropriate to assess change than are measures of psychopathology. Study 1 examined the differential sensitivity to change of 3 measures in a sample of 162 men with coronary heart disease (CHD) who participated in cardiac rehabilitation. Ss reported less change on the State-Trait Anxiety Inventory and the Symptom Check List than on the Heart Patients Psychological Questionnaire, but in the absence of a control group it is difficult to known what caused this change. In Study 2, 60 men with CHD who participated in rehabilitation were compared with 60 men with CHD who received standard medical care alone. Rehabilitation Ss, but not control Ss, reported a decrease in disability and an increase in well-being as measured by the HPPQ. I concluded that sensitive measures may actually provide evidence for the psychological effect of cardiac rehabilitation.

Sensitivity of outcome assessment in cardiac rehabilitation

I hypothesized that measures that match the theoretically prescribed effect of cardiac rehabilitation (i.e., enhancement of subjective health and well-being) are more appropriate to assess change than are measures of psychopathology. Study 1 examined the differential sensitivity to change of 3 measures in a sample of 162 men with coronary heart disease (CHD) who participated in cardiac rehabilitation. Ss reported less change on the State-Trait Anxiety Inventory and the Symptom Check List than on the Heart Patients Psychological Questionnaire, but in the absence of a control group it is difficult to known what caused this change. In Study 2, 60 men with CHD who participated in rehabilitation were compared with 60 men with CHD who received standard medical care alone. Rehabilitation Ss, but not control Ss, reported a decrease in disability and an increase in well-being as measured by the HPPQ. I concluded that sensitive measures may actually provide evidence for the psychological effect of cardiac rehabilitation.

Biobehavioral research on coronary heart disease: where is the person?

This study examined the thesis that patients with coronary heart disease (CHD) comprise discrete personality subtypes and that identification of these subtypes may benefit biobehavioral research on CHD. Measures of Negative Affectivity, Social Inhibition, and Self-Deception were used to generate a personality taxonomy through cluster analysis in a sample of 405 men with CHD. This empirical taxonomy served as a basis for the development of a conceptual model which delineates hardy, distressed, inhibited, and repressive subtypes. Coronary proneness may differ across these subtypes to the extent that potential behavioral correlates of CHD were associated with subtype membership. Distressed individuals (characterized by elevated levels of Type A behavior, anger, hostility, and life stress) and inhibited individuals (characterized by the nonexpression of anger) may be particularly coronary prone. It is concluded that research should focus on the interaction of global traits that may define subtypes of patients with CHD.