41 SCIENTIFIC PUBLICATIONS International Journal of Psychology: Biopsychosocial Approach 2017 / 20 ISSN 1941-7233 (Print), ISSN 2345-024X (Online) https://dx.doi.org/10.7220/2345-024X.20.3 T YPE D PERSONALIT Y IN C ARDIOVASCUL AR PATIENTS AND GENER AL POPUL ATION: PRE VALENCE AND RE TROSPEC TIVE PERCEPTION OF STABILIT Y Justė Lukoševičiūtė1, Assoc. prof. Kastytis Šmigelskas1 Department of Health Psychology, Faculty of Public Health, Medical Academy, Lithuanian University of Health Sciences Abstract. Background and purpose. Type D personality is characterized by negative af- fectivity and social inhibition. This personality construct is linked to cardiovascular diseases and is considered as stable. However, there has been little research on preva- lence in non-clinical samples and on stability of this construct. The main aim of this study was to evaluate the prevalence and retrospective perception of stability of Type D personality in patients and general population. Methods. This was a cross-sectional study with a sample from general population (n=304) and cardiovascular patients (n=154). Type D was evaluated using DS14 questionnaire. Respondents were asked to assess their personal characteristics at the moment and how they felt 5 years ago. Items about health condition, lifestyle and sociodemographic characteristics were also included into questionnaire. Results. Type D personality was similarly prevalent in both study groups – 33.1% in cardiovascular patients and 35.9% in general popula- tion (p =.561). The prevalence of Type D based on retrospective assessment: during the last 5 years increased by 8.4% points in patients (p =.015) and by 0.4% points in comparison group (p =.472). In addition, Type D personality was associated with less healthy lifestyle in both study groups (p<.05) and also with a worse perceived health in comparison group (p<.001). Conclusions. Type D personality is similarly prevalent in general population and cardiovascular patients. However, this construct is consid- ered as less stable among the patients. Type D personality was associated with less healthy lifestyle and in part with worse perceived health. Keywords: negative affectivity, social inhibition, lifestyle, subjective health, health psychology. 1 Contacting author: Kastytis Šmigelskas. Address: Department of Health Psychology, Faculty of Public Health, Lithuanian University of Health Sciences. Tilžės g. 18, Kaunas LT-47181, Lithuania. E-mail: kastytis.smigelskas@lsmuni.lt; phone +370 37 242911. mailto:kastytis.smigelskas@lsmuni.lt Justė Lukoševičiūtė, Kastytis Šmigelskas 42 INTRODUC TION Cardiovascular disease (CVD) is the leading cause of death world- wide (WHO, 2014). In order to reduce the incidence and mortality of CVD it is important to establish not only medical but psychological causes as well. Type D personality is considered to be one of such risk factors and is associated with a short life expectancy in patients with coronary heart disease regardless of any biomedical risk factors (Denollet et al., 1996). The concept of Type D (“distressed”) personality is commonly used in medical psychology (Pedersen & Denollet, 2006). People, described as Type D personality, are characterised as having signs of negative af- fectivity (tendency to experience dysphoria, worry and irritability) and social inhibition (discomfort in social interactions, reticence and lack of social poise). Negative affectivity is an important factor in the assess- ment of subjective well-being and emotional distress (Denollet, 2005). Negative emotions are often associated with depression (Pedersen, et al., 2009), anxiety and fear to lose of control (Kupper & Denollet, 2014). While individuals with high social inhibition scores have a tendency to perceive the environment as threatening that is commonly related with anhedonia (Lussier & Loas, 2015), social anxiety (Kupper & Denollet, 2014), depression and alexithymia (Batsele et al., 2017). Type D personality construct is characteristic for 21% (Du et al., 2016) to 52% of cardiovascular patients (Moryś, Bellwon, Jeżewska, Ad- amczyk, & Gruchała, 2015). Whereas, the prevalence of Type D personal- ity among non-clinical samples is various, but generally considered to be lower than in patients. In the general population the prevalence of this personality type ranges from 13% (Conden, Leppert, Ekselius, & Åslund, 2013) to 40% (Horwood, Chamravi, & Tooley, 2015). Type D personality is described as a negative factor due to asso- ciations with poorer physical and mental health (Mols & Denollet, 2010), higher incidence of adverse clinical outcomes (Pedersen & Denollet, 2006) and lower scores of health-related quality of life (Staniute et al., 2015). Ac- cording to Ginting, van de Ven, Becker and Näring (2014), this personality type is also related with unhealthy lifestyle: a greater number of cigarettes, higher rates of alcohol and unhealthy food consumption, lower physical activity and weight control, and poor treatment adherence. This may partly explain a higher prevalence of Type D in clinical samples. 2017, 20, 41–60 p.International Journal of Psychology: A Biopsychosocial Approach 43 Personality is considered to be stable during all the lifespan (McCrae et al., 2000), but in terms of Type D personality and its stability, it is worth to note that research in this field is scarce and the results are inconsist- ent. The author of Type D personality construct states that both negative affectivity and social inhibition are broad and stable personality traits (Denollet, 2000). During the Type D Scale-14 (DS14) validation process and evaluating the stability of its individual dimensions, it was found that both dimensions of Type D remained stable over 3 months period and did not depend on the patient’s mood (Denollet, 2005). Several studies have shown that Type D is stable with the main per- sonality traits being inherited, which was confirmed in twin studies (Kup- per, Boomsma, De Geus, Denollet, & Willemsen, 2011). The Type D seems relatively stable in patients: Romppel, Herrmann-Lingen, Vesper and Grande (2012) revealed that the DS14 scale factorial structure remained stable throughout 6 years of assessment. In patients after myocardial in- farction the Type D was stable over the 18 months period, regardless of the mood changes and severity of disease (Martens, Kupper, Pedersen, Aquarius, & Denollet, 2007). In contrast, other researchers report findings suggesting the Type D personality change. This was demonstrated in samples with coronary syndrome (Ossola, De Panfilis, Tonna, Ardissino, & Marchesi, 2015), myo- cardial infarction (Conden, Rosenblad, Ekselius, & Åslund, 2014) and in CVD patients before and after cardiac surgery (Dannemman et al., 2010) with follow-up up to 12 months. Such ambiguous results suggest that the stability of Type D personality is not clear. To summarise the issues, described above it can be stated that the majority of Type D research is mainly focused on patient samples (es- pecially cardiovascular), while the research with general populations is rather scarce – and even when general population is investigated, there are specific strata of society, such as students (Williams et al., 2008), mili- tary staff (Rademaker, Van Zuiden, Vermetten, & Geuze, 2011) or elderly people (Kasai, Suzuki, Iwase, Doi, & Takao, 2013). The studies on common people without pre-selection (such as in Germany by Grande, Romppel, Glaesmer, Petrowski, & Herrmann-Lingen, 2010) are very rare. The stabil- ity of Type D was investigated even less, again, mainly addressing the clinical samples. Justė Lukoševičiūtė, Kastytis Šmigelskas 44 So, the main aim of our study was to evaluate the prevalence and stability of Type D personality in general and patient populations using a retrospective assessment. Due to time constraints we chose to as- sess the stability using not a longitudinal but cross-sectional approach, evaluating the subjective perception of Type D features on retrospective basis. In addition, we also wanted to compare the subjective health and lifestyle assessments depending on Type D personality, readdressing the findings in previous research on Type D. ME THODS Procedure and participants The study was conducted between October 2015 and January 2016 in Kaunas city, Lithuania. The study and its consent procedures were ap- proved by the Ethics Committee for Biomedical Research, Lithuanian University of Health Sciences. In total, 458 subjects participated in the study: 154 cardiovascular patients (response rate 91%) and 304 individuals of general popula- tion as comparison group (response rate 78%). The eligibility criteria for study sample were the age ≥18 years old, voluntary participation, abil- ity to communicate in Lithuanian, absence of cognitive disorientation or communicative disabilities. Detailed sociodemographic characteristics of the study sample by group are presented in Table 1. The group of patients consisted of in-patients at Department of Car- diology, the Hospital of Lithuanian University of Health Sciences (LSMU) Kauno klinikos. The patients had hypertension (51.3%), history of my- ocardial infarction (43.5%) or stroke (8.4%), with vascular thrombosis (20.1%), cardiac arrhythmia (23.4%), heart failure (7.1%) or other cardio- vascular diseases (26.6%). The comparison group was a quota sample (by age group and gen- der) of adult population in Kaunas city. More than a third (40.1%) of re- spondents reported being healthy, whereas other respondents had car- diovascular (30.6%), digestive (11.7%), endocrine and metabolic (10.2%), nervous (9.2%), allergic (7.9%), respiratory (5.8%), renal (5.2%) or other diseases (6.9%). 2017, 20, 41–60 p.International Journal of Psychology: A Biopsychosocial Approach 45 Table 1. Sociodemographic characteristics of study groups Patients (n=154) Comparison group (n=304) n % n % Age group 18–44 45–54 55–64 65–74 75–88 7 16 38 46 47 4.5 10.4 24.7 29.9 30.5 133 63 35 49 24 30.6 17.3 15.9 20.7 15.5 Mean±SD 67.0±11.80 46.8±18.94 Gender Women Men 60 94 39.0 61.0 175 129 57.6 42.4 Residence Rural Urban 52 102 33.8 66.2 36 268 11.8 88.2 Education level Lower than secondary Secondary Post-secondary 26 45 83 16.9 29.2 53.9 19 97 188 6.3 31.9 61.8 When comparing the study groups by sociodemographic indica- tors, it was found that patients group was older, having lower education, and prevailing male (61% compared to 42% of men among comparison group; p<.001). The study groups were considered to be appropriate without matching, since the primary aim was to reflect the real general population instead of matched by patients characteristics. MEASURES Type D personality was assessed using Type D (DS14) scale. This tool was developed by Denollet (2005) and established as valid and reliable instrument both in clinical samples (Svansdottir et al., 2012) and in gen- eral population (Grande et al., 2010). The Lithuanian version, used in this study, has been validated by Staniute and Bunevicius (2011). Permis- sion for use was obtained from one of the authors of Lithuanian version. It was shown that Lithuanian version of scale has good psychometric properties and good construct validity (Bunevicius et al., 2012). In addition, respondents were asked to assess their current health status on a 10-point scale (from 1 – “poor” to 10 – “excellent”) as well as Justė Lukoševičiūtė, Kastytis Šmigelskas 46 their lifestyle (from 1 – “very unhealthy” to 10 – “very healthy”). Sociode- mographic characteristics were also included in the questionnaire. DS14 scale consists of 14 items about personality traits: 7 items de- scribe negative affectivity (NA) and 7 items – social inhibition (SI). Type D personality was indicated when both subscales (NA and SI) scores were ≥10 (Denollet, 2005; Staniute & Bunevicius, 2011). The question- naire showed good internal consistency in this study (Cronbach’s α=.79 for negative affectivity and α=.74 for social inhibition), being very similar in patients (α=.80 and α=.73, respectively) and comparison group (α=.78 and α=.75, respectively). The respondents were asked to score on DS14 by assessing their cur- rent status and what they believe they used to be 5 years before. The lat- ter was considered as a subjective estimate of previous Type D profile to assess the retrospective perception of stability of the construct. Statistical analysis The data was analysed using IBM SPSS 20.0. In descriptive analysis, the variables were described using percentages and means±SD (stand- ard deviation). Inferential statistics included χ2 test, Fisher’s exact test, Student’s t-test, Mann-Whitney U test (for independent samples) as well as Student’s t-test for paired samples and binomial test (for paired com- parisons in current versus retrospective assessments). In data analysis, negative affectivity and social inhibition were analysed both as continu- ous and as dichotomous indicators with emphasis on the latter approach, based on Type D specific cut-offs of ≥10 pts (Denollet, 2005). The statisti- cal significance was set at p<.05. RESULTS Prevalence of Type D personality The study showed that based on a current assessment, the negative affectivity in patients was higher than in comparison group (11.7±7.03 and 10.1±5.96, respectively, p=.014), while social inhibition was non-sig- nificantly higher in patients than in comparison group (10.6±5.85 and 10.0±6.27, respectively, p=.309). Overall prevalence of Type D in patients and comparison group was similar (33.1% and 35.9%, respectively, p=.561). 2017, 20, 41–60 p.International Journal of Psychology: A Biopsychosocial Approach 47 Higher negative affectivity was slightly more common in patients (57.1% versus 50.7% in comparison group, p=.189), while social inhibi- tion – in comparison group (55.6% versus 49.4%, p=.206). Sociodemographic indicators – gender and residence (urban or rural) were not associated with Type D in both study groups, except that this personality type was more prevalent in female patients (45.0% compared to 25.5% in male patients; p=.012). However, the Type D prevalence by age group revealed different trends (Figure 1): while in cardiovascular pa- tients the prevalence was steadily increasing from 14% under 45 years of age to 38–39% above 65 years, in comparison group the pattern was rather unclear: though at the age from 45 to 74 years the trend was de- clining from 44 to 18%, but younger and older age groups did not follow this trend. Figure 1. Type D prevalence by age group among patients and comparison group Having given the numerous literature indicating that Type D is more prevalent in certain subgroups of people, we checked whether these trends occur in our study sample. We analysed patients and comparison group separately by health condition. The findings demonstrate that in our study there were virtually no health conditions that would be significantly associated with Type D. Justė Lukoševičiūtė, Kastytis Šmigelskas 48 Among cardiovascular patients, Type D tended to be more common in all disease groups, but that did not reach statistical significance levels (Table 2). Similar trends were observed regarding Type D dimensions, but again they did not reach statistical significance. Table 2. Prevalence of Type D and its dimensions among cardiovascular patients Condition Status n Type D (%) χ 2 p Nega- tive affecti- vity (%) χ 2 p Social inhibi- tion (%) χ 2 p Hypertension Present 79 36.7 .94 .331 64.6 3.64 .056 53.2 .94 .331 Absent 75 29.3 49.3 45.3 Myocardial infarction Present 67 34.3 .08 .779 64.2 2.40 .122 43.3 1.75 .186 Absent 87 32.2 51.7 54.0 Stroke Present 13 38.5 .18 .760 61.5 .11 .738 53.8 .12 .735 Absent 141 32.6 56.7 48.9 Vascular thrombosis Present 31 25.8 .94 .333 67.7 1.78 .182 38.7 1.76 .185 Absent 123 35.0 54.5 52.0 Cardiac arrhythmia Present 36 38.9 .71 .401 58.3 .03 .869 55.6 .72 .395 Absent 118 31.4 56.8 47.5 Heart failure Present 11 36.4 .06 1.000 63.6 .20 .759 45.5 .07 .789 Absent 143 32.9 56.6 49.7 Other CVD Present 41 34.1 .03 .870 61.0 .34 .563 53.7 .42 .520 Absent 113 32.7 55.8 47.8 Comorbid diseases Present 81 33.3 <.01 .952 56.8 .01 .926 50.6 .11 .741 Absent 73 32.9 57.5 47.9 The analysis in general population found some differences regard- ing Type D, though they were rare (Table 3). Here, the subjects who re- ported having nervous diseases had higher prevalence of Type D com- pared to other people (57% versus 33%; p=.014). All other conditions were non-significant for Type D. It can also be noted that negative af- fectivity was more common in patients with digestive and nervous dis- orders and significantly lower in people who did not report any health complaint (p<.05). 2017, 20, 41–60 p.International Journal of Psychology: A Biopsychosocial Approach 49 Table 3. Prevalence of Type D and its dimensions in comparison group Condition Status n Type D (%) χ 2 p Nega- tive affecti- vity (%) χ 2 p Social inhi- bition (%) χ 2 p Allergic disease Present 24 33.3 .07 .788 37.5 1.80 .179 50.0 .33 .566 Absent 101 36.1 51.8 56.1 Respiratory system Present 26 38.5 .08 .772 61.5 1.35 .246 42.3 2.03 .154 Absent 278 35.6 49.6 56.8 Digestive system Present 45 40.0 .40 .530 71.1 8.84 .003 46.7 1.70 .192 Absent 259 35.1 47.1 57.1 Nervous system Present 28 57.1 6.08 .014 78.6 9.61 .002 60.7 .33 .567 Absent 276 33.7 47.8 55.1 Endocrine system Present 31 48.4 2.36 .125 64.5 2.65 .103 58.1 .08 .770 Absent 273 34.4 49.1 55.3 Skeletal system Present 40 30.0 .69 .407 55.0 .35 .556 57.5 .07 .794 Absent 264 36.7 50.0 55.3 Cardio- vascular system Present 93 36.6 .03 .865 54.8 .94 .333 59.1 .68 .409Absent 211 35.5 48.8 54.0 Absence of diseases Yes 122 32.0 1.34 .247 43.4 4.24 .039 54.9 .04 .846 No 182 38.5 55.5 56.0 Retrospective perception of stability of Type D personality In order to define possible Type D change through 5 years, the study subjects were asked to rate Type D items for both today and 5 years ago. The changes were found that in patients there was increase in Type D (from 24.7% to 33.1%; p=.015) and negative affectivity (from 45.5% to 57.1%; p=.004), while in general population only the social inhibition has changed, decreasing from 60.9% to 55.6% (p<.001). Other changes in study groups were non-significant. In general, it can be concluded, that Type D subjectively was con- sidered as not stable within 5 years by 9.7% of patients and 13.5% of comparison group (χ2=1.34, p=.248), with negative affectivity being less stable than social inhibition (Figure 2). The comparison of patients by disease demonstrated, that different cardiovascular conditions were re- lated with similar retrospective perception of stability of Type D person- ality, except that stroke patients were more likely than others to report occurrence of Type D characteristics within the last 5 years. Here, 38% of Justė Lukoševičiūtė, Kastytis Šmigelskas 50 stroke patients could be considered as perceiving stable status of Type D while 62% reported previous absence of Type D features. Figure 2. Stability of Type D within 5 years: retrospective assessment of patients and comparison group Relations with subjective lifestyle and health In our study, Type D personality was related with lower scores for subjective lifestyle assessment in both study groups (Table 4). It was found that high scores on negative affectivity were related with less healthy lifestyle in both groups and high social inhibition score – only in the comparison group. Similarly, the distressed personality was also associated with poorer subjective health (Table 4). These findings indi- cate that Type D personality is an important factor for subjective lifestyle and health evaluation, even though the health conditions associate with Type D rather rarely. 2017, 20, 41–60 p.International Journal of Psychology: A Biopsychosocial Approach 51 Table 4. Lifestyle and subjective health assessment by groups of Type D, negative affectivity and social inhibition Patients Comparison group Lifestyle Subjective health Lifestyle Subjective health Type D Yes No t p 5.6±2.35 6.5±2.03 2.56 .012 4.8±2.14 5.5±2.01 1.86 .065 6.4±1.73 7.0±1.63 3.17 .002 6.6±1.94 7.4±1.73 4.01 <.001 Negative affectivity ≥10 pts <10 pts t p 5.9±2.34 6.7±1.87 2.26 .025 4.8±2.12 5.8±1.88 2.83 .005 6.5±1.69 7.1±1.63 3.42 .001 6.6±1.95 7.6±1.60 4.81 <.001 Social inhibition ≥10 pts <10 pts t p 5.9±2.19 6.6±2.13 1.96 .051 5.3±2.13 5.2±2.03 -.56 0.576 6.6±1.70 7.1±1.64 2.53 .012 7.0±1.78 7.3±1.96 1.10 0.273 DISCUSSION Type D personality is a psychological concept, mostly analysed in clinical samples. The prevalence of this personality type ranges depend- ing on sample characteristics – health condition, age, gender, country etc. However, the majority of the studies do not enrol people without obvious or specific health condition, making the research on Type D per- sonality predominantly based on health disorders. This creates the situa- tion where the prevalence of Type D in such samples is hard to compare with general population, even though it is largely accepted that Type D personality associates with worse physical and mental health (Versteeg, Spek, Pedersen, & Denollet, 2012). Regarding personality type, it is con- sidered as relatively stable concept, with existing proofs on stability (e.g. such personality traits as extraversion or conscientiousness) (Hampson & Goldberg, 2006). The Type D is also considered to be stable, though the evidence for that exists, but is scarce. Therefore, our study was not only targeted to assess the prevalence of Type D both in clinical sample and in general population, but also to address the stability of this concept using retrospective approach. Our study showed that Type D personality among both study groups was similarly prevalent. This is contradicting to previous findings since Justė Lukoševičiūtė, Kastytis Šmigelskas 52 among comparison group the Type D prevalence is usually lower than in patients (e.g. Mols & Denollet, 2010). Nonetheless, there are some studies where Type D prevalence in general population was found to be similar to the one, established in our study (Williams, Abbott, & Kerr, 2015). Some researchers suggest that it is not Type D that is related with worse health, but rather negative affectivity (Williams, O’Connor, Grubb, & O’Carroll, 2012), however, our study did not support this hypothesis either. More detailed analysis on specific subgroups of study sample re- vealed that the highest prevalence of Type D was found in subjects who reported having nervous system diseases (57%). This was similarly re- ported by Grande et al. (2004), who found the prevalence of Type D per- sonality in psychosomatic patients being 62%. Possibly, those patients experience more distress that links both to mental health impairment and Type D. In our study the Type D was more reported by women, which is found in the previous study as well (Staniute et al., 2015). Such gen- der differences may be due to women’s tendency to report increased anxiety and distress compared to men (Mommersteeg, Meissner, De- nollet, Aarnoudse, & Widdershoven, 2013). Comparing age groups, in our study the Type D personality was the most prevalent in patients, aged 65–74 years, while in comparison group the peak was observed in the eldest group – people, aged 75 years and older. These results are inconsistent with the previous research, where the highest preva- lence is mainly observed in young adults (33–38%) ( Williams et al., 2008; Šmitas & Perminas, 2015; Batsele et al., 2017) and during the older age groups it transforms to a decreasing trend (e.g. Wiltink et al., 2011). Nonetheless, some studies find high Type D prevalence rates in elder samples as well, such as 46% among elderly Japanese (Kasai et al., 2013). When it comes to the issue of Type D stability, we estimated Type D by asking the respondents to rate Type D items as they feel today and as they believe they used to be five years ago. In general population we found that the prevalence of this personality construct seems to be sta- ble, which is consistent with findings of Zohar (2016) in Israeli popula- tion. However, our findings, related with cardiovascular patients, were less consistent with the previous research. 2017, 20, 41–60 p.International Journal of Psychology: A Biopsychosocial Approach 53 Thus, we found that in patients the prevalence of Type D during 5 years increased from 25% to 33%. It is possible that this increase could be influenced by impaired health and subsequent increase of negative affectivity. According to Watson and Pennebaker (1989), health problems are likely to cause negative emotions, so it could be one of the reasons why negative affectivity has increased among patients but not in com- parison group. Of note, we found very unstable and negative perception of Type D change in stroke patients – 38% of stroke survivors reported being not a Type D personality both today and five years ago, while the rest (62%) shifted from having no Type D features towards being Type D personality. It is possible that retrospective Type D assessment could be influenced by patient’s medical condition, with amelioration of memo- ries in earlier life or pessimism in perceptions of current health status. Therefore, to our knowledge, this is the first study about stability of Type D personality in patients after stroke so this requires more research. The previous research in patients with acute coronary syndrome showed low stability for negative affectivity and Type D personality and suggested that DS14 questionnaire does not describe the fundamen- tal and permanent personality traits but shows emotional instability (Ossola et al., 2015). Loosman et al. (2017) study with dialysis patients also support that Type D personality is possibly more a state instead of a trait phenomenon. Kristofferzon, Lofmark and Carlsson (2007) claim that stressful situations or sudden health impairment (e.g. myocardial infarction) could have an effect on personality. However, some studies found that Type D personality in patients after myocardial infarction has remained stable over 18 months (Martens et al., 2007). Though our study showed that Type D prevalence does not differ in patients and general population, we found that Type D personality is associated with less healthy lifestyle in both study groups. Previous stud- ies are in line with this association (e.g. Ginting et al., 2014). Moreover, in comparison group the Type D was also related with worse perceived health. These findings in general population coincide with the previous cross-sectional study in the United Kingdom (Williams et al., 2015). This personality type has been associated with a poorer physical health status (Versteeg et al., 2012), musculoskeletal pain and psychosomatic symp- toms (Conden et al., 2013). It is counterfactual that people with Type D personality report worse lifestyle or health perceptions, but on the other Justė Lukoševičiūtė, Kastytis Šmigelskas 54 hand the sample of people with cardiovascular diseases report similar Type D features to general population. This issue could be addressed not in a cross-sectional study like ours, but rather in a longitudinal study. Since the stability issue in our study was approached in a retrospec- tive manner, our results should be interpreted with caution due to po- tential recall bias. The retrospective assessment may have affected our findings in a way that patients rating their status 5 years ago were assess- ing it in a less stressful way, suggesting that their current condition cur- rently is worse compared to that 5 years ago. Also, the five-year period can be interpreted differently between different age groups and future research needs to examine whether the age factor is an independent predictor in personality assessment. Therefore, since it was a retrospec- tive estimate, it does not provide direct evidence for the stability of per- sonality type. In our study, the comparison group was not matched which made the comparing of study groups relatively unbalanced. However, we chose this perspective in order to reflect the general population fore- most, and not to have a balance between the groups – by losing the natural variation within a general population through matching, we may bias the findings towards underestimate. Comparison group also included the people with certain health dis- orders, however, we tried to check for difference in subgroups analyses and we found that there were no major differences of Type D prevalence in comparison group considering specific diseases. Our rationale for choosing the retrospective measurement of per- sonality was due to the fact that it would be hardly possible to collect re- petitive data from the same individuals, especially from general popula- tion. This is not only restricted due to logistic reasons, but also may raise selection bias with less typical subjects keen to participate in the second measurement. To our knowledge, this is the first study to use such ap- proach for stability assessment of Type D personality – previous research has used retrospective approach with other personality indicators (e. g. Woodruff, 1983). Despite these limitations, our study has some strengths. First, the study included the comparison group designed through quota sam- pling to represent general population which had not been common in Type D research before. This gives a more realistic estimate of Type D 2017, 20, 41–60 p.International Journal of Psychology: A Biopsychosocial Approach 55 prevalence in society. Also, as far as we know, this study is the first to report the prevalence of Type D personality and its dimensions by differ- ent diseases groups. In addition, we analysed the prevalence of Type D in patients and comparison group by age group. This allows for a more clearly perception of the prevalence of Type D depending on the charac- teristics of study sample. Moreover, there has been little research done on the issue of stability of Type D personality, and it is one of the first studies to assess the stability of Type D personality using a retrospective approach. Some practical implications could be useful in health care, where professionals could identify the Type D patients and communicate more openly and actively. This could be effective to overcome high social in- hibition of patients with Type D patients who may be ashamed to ask about own health condition or treatment. Another way to help Type D patients could be psychosocial interventions that promote positivity and reduce the experience of negative emotions. Such approaches as psychoeducation, relaxation or additional attention may reduce the dis- tress level of these patients and improve their recovery. CONCLUSION It can be concluded that prevalence of Type D personality in gen- eral population and in cardiovascular patients is quite similar (33–36%). The retrospective assessment showed that general population in com- parison to CVD patients report more stable perceptions of personality in terms of Type D. In addition, Type D personality was associated with less healthy lifestyle in both study groups and also with a worse perceived health in comparison group. References Batsele, E., Denollet, J., Lussier, A., Loas, G., Vanden, E. S., Van de Borne, P., & Fantini- Hauwel, C. (2017). Type D personality: Application of DS14 French-version in general and clinical populations. Journal of Health Psychology, 22(8), 1075– 1083. doi: 10.1177/1359105315624499 Bunevicius, A., Staniute, M., Brozaitiene, J., Stropute, D., Bunevicius, R., Denollet, J. (2012). Type D (distressed) personality and its assessment with the DS14 in Justė Lukoševičiūtė, Kastytis Šmigelskas 56 Lithuanian patients with coronary artery disease. Journal of Health Psychology, 18(9), 1242–1251. doi: 10.1177/1359105312459098 Conden, E., Leppert, J., Ekselius, L., & Åslund, C. (2013). Type D personality is a risk factor for psychosomatic symptoms and musculoskeletal pain among adolescents: a cross-sectional study of a large population-based cohort of Swedish adolescents. BMC Pediatrics, 13(11), 1–9. doi: 10.1186/1471-2431-13-11 Conden, E., Rosenblad, A., Ekselius, L., & Åslund, C. (2014). Prevalence of Type D personality and factorial and temporal stability of the DS14 after myocardial infarction in a Swedish population. Scandinavian Journal of Psychology, 55(6), 601–610. doi: 10.1111/sjop.12162 Dannemann, S., Matschke, K., Einsle, F., Smucker, M. R., Zimmermann, K., Joraschky, P., … Köllner, V. (2010). Is Type–D a stable construct? An examination of Type-D personality in patients before and after cardiac surgery. Journal of Psychosomatic Research, 69, 101–109. doi: 10.1016/j.jpsychores.2010.02.008 Denollet, J., Sys, S. U., Stroobant, N., Rombouts, H., Gillebert, T. C., & Brutsaert, D. L. (1996). Personality as independent predictor of long-term mortality in patients with coronary heart disease. Lancet, 347(8999), 417–421. doi: 10.1016/S0140-6736(96)90007-0 Denollet, J. (2000). Type D personality: a potential risk factor refined. Journal of Psychosomatic Research, 49, 255–266. doi: 10.1016/S0022-3999(00)00177-X Denollet, J. (2005). DS14: Standard assessment of negative affectivity, social inhibition, and type D personality. Psychosomatic Medicine, 67(1), 89–97. doi: 10.1097/01.psy.0000149256.81953.49 Denollet, J. (2012). Type D or not type D: that‘s the question. The European Health Psychologist, 14(3), 58–63. Du, J., Zhang, D., Yin, Y., Zhang, X., Li, J., Liu, D., … Chen W. (2016). The personality and psychological stress predict major adverse cardiovascular events in patients with coronary heart disease after percutaneous coronary intervention for five years. Medicine, 95(15), e3364. doi: 10.1097/MD.0000000000003364 Ginting, H., van de Ven, M., Becker, E. S., & Näring, G. (2014). Type D personality is associated with health behaviors and perceived social support in individuals with coronary heart disease. Journal of Health Psychology, 21(5), 727–737. doi: 10.1177/1359105314536750 Grande, G., Jordan, J., Kümmel, M., Struwe, C., Schubmann, R., Schulze, F., ... Herrmann-Lingen, C. (2004). Evaluation der deutschen Typ-D-Skala (DS14) und Prävalenz der Typ-D-Persönlichkeit bei kardiologischen und psychosomatischen Patienten sowie Gesunden [Evaluation of the German Type D Scale (DS14) and prevalence of the Type D personality pattern in cardiological and psychosomatic patients and healthy subjects]. Psychotherapie, Psychosomatik, Medizinische Psychologie, 54(11), 413–422. doi: 10.1055/s-2004-828376 2017, 20, 41–60 p.International Journal of Psychology: A Biopsychosocial Approach 57 Grande, G., Romppel, M., Glaesmer, H., Petrowski, K., & Herrmann-Lingen, C. (2010). The type-D scale (DS14) – Norms and prevalence of type-D personality in a population-based representative sample in Germany. Personality and Individual Differences, 48, 935–939. doi: 10.1016/j.paid.2010.02.026 Hampson, S. E., & Goldberg, L. R. (2006). A first large-cohort study of personality-trait stability over the 40 years between elementary school and midlife. Journal of Personality and Social Psychology, 91(4), 763–779. doi: 10.1037/0022-3514.91.4.763 Horwood, S., Chamravi, D., Tooley, G. (2015). Examinating the prevalence of Type D personality in an Australian population. Australian Psychologist, 50(3), 212– 218. doi: 10.1111/ap.12089 Kasai, Y., Suzuki, E., Iwase, T., Doi, H., & Takao, S. (2013). Type D personality is associated with psychological distress and poor self-rated health among the elderly: A population-based study in Japan. Plos One, 8(10), e77918. doi: 10.1371/journal.pone.0077918 Kristofferzon, M. L., Lofmark, R., & Carlsson, M. (2007). Striving for balance in daily life: Experiences of Swedish women and men shortly after a myocardial infarction. Journal of Clinical Nursing, 16(2), 391–401. doi: 10.1111/j.1365-2702.2005.01518.x Kupper, N., Boomsma, D. I., De Geus, E. J. C., Denollet, J., & Willemsen, G. (2011). Nine- year stability of type D personality: contributions of genes and environment. Psychosomatic Medicine, 73, 75–82. doi: 10.1097/PSY.0b013e3181fdce54 Kupper, N., & Denollet, J. (2014). Type D personality is associated with social anxiety in the general population. International Journal of Behavioral Medicine, 21, 496–505. doi: 10.1007/s12529-013-9350-x Loosman, W. L., de Jong, R.W., Haverkamp, G. L. G., van den Beukel, T. O., Dekker, F. W., Siegert, C. E. H., & Honig, A. (2017). The stability of type D personality in dialysis patients. International Journal of Behavioral Medicine, 2017 Jun 28. doi: 10.1007/s12529-017-9667-y Lussier, A., & Loas, G. (2015). Relationship between type D personality and anhedonia: a dimensional study of university students. Psychological Reports: Mental and Physical Health, 116(3), 855–860. doi: 10.2466/09.02.PR0.116k27w2 Martens, E. J., Kupper, N., Pedersen, S. S., Aquarius, A. E., & Denollet, J. (2007). Type-D personality is a stable taxonomy in post-MI patients over an 18- month period. Journal of Psychosomatic Research, 63, 545–550. doi: 10.1016/j. jpsychores.2007.06.005 McCrae, R. R., Costa, P. T., Ostendorf, F., Angleitner, A., Hrebícková, M., Avia, M. D., … Smith, P. B. (2000). Nature over nurture: temperament, personality, and life span development. Journal of Personality and Social Psychology, 78(1), 173– 186. doi: 1O.1037//O022-3514.7S.1.173 Mols, F., & Denollet, J. (2010). Type D personality in the general population: a systematic review of health status, mechanisms of disease, and Justė Lukoševičiūtė, Kastytis Šmigelskas 58 work-related problems. Health and Quality of Life Outcomes 8(9), 1–10. doi: 10.1186/1477-7525-8-9 Mommersteeg, P., Meissner, A. G., Denollet, J., Aarnoudse, W., & Widdershoven, J. W. (2013). Women report increased anxiety, distress and poor general health status compared to men in patients with nonsignificant coronary artery disease; the TweeSteden Mild Stenosis TWIST study. European Heart Journal, 34, 5113–5113. doi: 10.1093/eurheartj/eht310.P5113 Moryś, J. M., Bellwon, J., Jeżewska, M., Adamczyk, K., Gruchała, M. (2015). The evaluation of stress coping styles and type D personality in patients with coronary artery disease. Kardiologia Polska, 73(7), 557–566. doi: 10.5603/ KP.a2015.0039 Ossola, P., De Panfilis, C., Tonna, M., Ardissino, D., & Marchesi, C. (2015). DS14 is more likely to measure depression rather than a personality disposition in patients with acute coronary syndrome. Scandinavian Journal of Psychology, 56(6), 685–692. doi: 10.1111/sjop.12244 Pedersen, S. S., & Denollet, J. (2006). Is type D personality here to stay? Emerging evidence across cardiovascular disease patient groups. Current Cardiology Reviews 2, 205–213. doi: 10.2174/157340306778019441 Pedersen, S. S., Yagensky, A., Smith, O. R. F., Yagenska, O., Shpak, V., & Denollet, J. (2009). Preliminary evidence for the cross-cultural utility of the type D personality construct in the Ukraine. The International Journal Of Medicine, 16, 108–115. doi: 10.1007/s12529-008-9022-4 Rademaker, A., van Zuiden, M., Vermetten, E., Geuze, E. (2011). Type D personality and the development of PTSD symptoms: A prospective study. Journal of Abnormal Psychology, 120(2), 299–307. doi: 10.1037/a0021806 Romppel, M., Herrmann-Lingen, C., Vesper, J. M., & Grande, G. (2012). Six year stability of Type-D personality in a German cohort of cardiac patients. Journal of Psychosomatic Research 72(2), 136–141. doi: 10.1016/j.jpsychores.2011.11.009 Šmitas, A., & Perminas, A. (2015). Studentų D tipo asmenybės ir jos komponentų sąsajos su sveikatai nepalankiu elgesiu [The links between student‘s type D personality, type D traits and their health risk behaviour]. Visuomenės sveikata [Public Health], 3(70), 68–74. Staniūtė, M., & Bunevičius, R. (2011). Asmenybės D tipo vertinimas naudojant DS14 klausimyną [Assessment of Type D personality using DS14 scale]. Biologinė psichiatrija ir psichofarmakologija [Biological Psychiatry and Psychopharmacology], 13(1), 36–37. Staniute, M., Brozaitiene, J., Burkauskas, J., Kazukauskiene, N., Mickuviene, N., & Bunevicius, R. (2015). Type D personality, mental distress, social support and health-related quality of life in coronary artery disease patients with heart failure: a longitudinal observational study. Health and Quality of Life Outcomes, 13(1), 1–11. doi: 10.1186/s12955-014-0204-2 2017, 20, 41–60 p.International Journal of Psychology: A Biopsychosocial Approach 59 Svansdottir, E., Karlsson, H. D., Gudnason, T., Olason, D. T., Thorgilsson, H., Sigtryggsdottir, U., … Denollet, J. (2012). Validity of Type D personality in Iceland: association with disease severity and risk markers in cardiac patients. Journal of Behavioral Medicine, 35, 155–166. doi: 10.1007/s10865-011-9337-5 Versteeg, H., Spek, V., Pedersen, S. S., & Denollet, J. (2012). Type D personality and health status in cardiovascular disease populations: A meta-analysis of prospective studies. European Journal of Cardiovascular Prevention & Rehabilitation, 19(6), 1373–1380. doi: 10.1177/1741826711425338 Watson, D., & Pennebaker, J.W. (1989). Health complaints, stress, and distress: Exploring the central role of negative affectivity. Psychological Review, 96(2), 234–254. doi: 10.1037/0033-295X.96.2.234 Williams, L., O‘Connor, R. C., Howard, S., Hughea, B. M., Johnston, D. W., Hay, J. L. (2008). Type-D personality mechanisms of effect: The role of health-related behavior and social support. Journal of Psychosomatic Research, 64, 63–69. doi: 10.1016/j.jpsychores.2007.06.008 Williams, L., O’Connor, R. C., Grubb, N. R., & O’Carroll, R. E. (2012). Type D personality and three-month psychosocial outcomes among patients post-myocardial infarction. Journal of Psychosomatic Research, 72, 722–726. doi: 10.1016/ j.jpsychores.2012.02.007 Williams, L., Abbott, C., & Kerr, R. (2015). Health behaviour mediates the relationship between Type D personality and subjective health in the general population. Journal of Health Psychology, 21(10), 2148–2155. doi: 10.1177/1359105315571977 Wiltink, J., Beutel, M. E., Till, Y., Ojeda, F. M., Wild, P. S., Munzel, T., ... Michal, M. (2011). Prevalence of distress, comorbid conditions and well being in the general population. Journal of Affective Disorders, 130, 429–437. doi: 10.1016/j. jad.2010.10.041 Woodruff, D. S. (1983) The role of memory in personality continuity: A 25  year follow-up. Experimental Aging Research: An International Journal Devoted to the Scientific Study of the Aging Process, 9(1), 31–34. doi: 10.1080/03610738308258417 World Health Organization. (2014). Global status report on noncommunicable diseases 2014. Retrieved from (2017, November 6) http://apps.who.int/iris/ bitstream/10665/148114/1/9789241564854_eng.pdf?ua=1 Zohar, A. H. (2016). Is type-D personality trait(s) or state? An examination of type-D temporal stability in older Israeli adults in the community. PeerJ, 4:e1690. doi 10.7717/peerj.1690 http://apps.who.int/iris/bitstream/10665/148114/1/9789241564854_eng.pdf?ua=1 http://apps.who.int/iris/bitstream/10665/148114/1/9789241564854_eng.pdf?ua=1 60 Justė Lukoševičiūtė, Kastytis Šmigelskas ASMENYBĖS D TIPAS TARP K ARDIOLOGINIŲ PACIENTŲ IR BENDROJOJE POPULIACIJOJE: PAPLITIMAS IR RE TROSPEK T Y VUSIS STABILUMO SUVOKIMAS Justė Lukoševičiūtė, Kast ytis Šmigelskas Lietuvos sveikatos mokslų universitetas Santrauka. Problema. Asmenybės D tipu apibūdinami žmonės, kurie pasižymi neigiamu afektu ir socialiniu varžymusi. Šis asmenybės konstruktas siejamas su širdies ir kraujagyslių sistemos ligomis ir laikomas pastoviu, nors tyrimų, vertinančių asmenybės D tipą neklinikinėse imtyse ir jo pastovumą, yra mažai. Pagrindinis šio tyrimo tikslas – įvertinti asmenybės D tipo paplitimą ir retrospektyviai įvertinti jo pastovumą tarp pacientų ir bendrojoje populiacijoje. Metodika. Vienmomentis tyrimas, kuriame daly- vavo 154 pacientai, sergantys širdies ir kraujagyslių sistemos ligomis, ir 304 lyginamo- sios grupės dalyviai. Asmenybės D tipas vertintas naudojant DS14 klausimyną, prašant respondentų įvertinti asmenybės savybes dabar ir kaip jautė prieš penkerius metus. Anketą taip pat sudarė klausimai apie sveikatos būklę, gyvenseną, socialines ir demo- grafines charakteristikas. Rezultatai. Asmenybės D tipas abiejose tyrimo grupėse buvo paplitęs panašiai – 33,1 proc. tarp pacientų ir 35,9 proc. bendrojoje populiacijoje (p = 0,561). Vertinant D tipo pastovumą retrospektyviai, paaiškėjo, kad šio asmenybės tipo paplitimas per penkerius metus padidėjo 8,4 proc. punkto pacientų grupėje (p = 0,015) ir 0,4 proc. punkto lyginamojoje grupėje (p = 0,472). Asmenybės D tipas taip pat buvo susijęs su mažiau sveika gyvensena abiejose tyrimo grupėse (p < 0,05), o lygi- namojoje grupėje – ir su prastesne subjektyviai vertinama sveikata (p < 0,001). Išvados. Asmenybės D tipas tarp širdies ir kraujagyslių sistemos ligų pacientų ir ben- drojoje populiacijoje yra paplitęs panašiai, tačiau šis reiškinys pacientų suvokiamas kaip mažiau stabilus. D tipas taip susijęs su mažiau sveika gyvensena ir iš dalies su prastesniu subjektyvios sveikatos įvertinimu. Reikšminiai žodžiai: neigiamas emocingumas, socialinis varžymasis, gyvensena, subjek- tyvi sveikata, sveikatos psichologija. Received: 30 09 2017 Accepted: 06 11 2017