Cardiovascular diseases and personality type

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INTRODUCTION

The high incidence and associated mortality rate of cardiovascular diseases (CVDs) remain a global public health concern [1]. CVDs account for approximately 17.9 million deaths worldwide each year [2]. In 2022, CVDs accounted for approximately 44% of the overall mortality structure of the Russian Federation (RF).¹ According to the Chief Cardiologist of the RF, E.V. Shlyakhto, “Reducing morbidity is one of the main priorities for improving health care systems worldwide.” Shlyakhto analyzed the current situation in the RF and revealed several challenges in cardiology care delivery, including insufficient and delayed identification of cardiovascular risk factors. To achieve the national health goal of decreasing mortality from CVDs, it is crucial to ensure long-term management of cardiovascular risk and promote a healthy lifestyle among the population [3].

Stratified medicine and a patient-centered approach are current trends in clinical practice [4]. The principles of patient-centered care include “the patient as an individual” and “the patient’s current life circumstances.” This approach to CVD prevention and treatment, which is recommended by international guidelines, involves patients collaborating with their physicians, improving satisfaction, efficacy, and therapy adherence [5].

A crucial component of primary and secondary prevention of CVDs is psychological intervention, including aspects related to professional and personal life. Psychosocial factors have a significant influence on the development of CVDs [6]. The relationship between psychological factors and the cardiovascular system is determined by the primary response to stress, the organism’s functional state, and its adaptive reserve capacity; this capacity enables rapid adjustment to acute stress but limits long-term adaptation under chronic stress [7]. Variability in personality traits determines stress vulnerability and shapes individual physical and psychological profiles [6].

This study aimed to review studies of the relationship between cardiovascular diseases and personality type. The review is intended for cardiologists and internists to improve awareness and understanding of this issue.

A review of publications was conducted in the PubMed and eLibrary.ru databases for the period from 1990 to 2024 using the following keywords: personality type, cardiovascular diseases, Type-D personality, myocardial infarction, and prognosis. This review summarizes and systematizes data from clinical studies and systematic reviews, excluding abstracts and publication summaries.

HISTORICAL CONTEXT OF THE PSYCHOSOMATIC APPROACH

The term psychosomatics was first introduced in the early 19th century by J. Heinroth (1818), and the concept of psychosomatic medicine was later proposed by F. Deutsch (1922). Initially, psychosomatic disorders were defined as nosological entities with an identified psychological component in their pathogenesis. Such conditions included hypertension (HTN), coronary artery disease (CAD), bronchial asthma, peptic ulcer, psoriasis, and others. Modern studies on behavioral and pathological personality traits demonstrated differences in susceptibility or resistance to somatic diseases among individuals with specific personality types [8]. H.F. Dunbar, the founder of the first theory of personality-specific psychosomatic predisposition, established the foundation for this field. According to her concept, psychological characteristics inherent to a given personality type have diagnostic and prognostic significance [9].

METHODS FOR ASSESSING PERSONALITY TYPE

To determine behavioral type (A, B, or AB), the Jenkins Activity Survey was used. This questionnaire was the basis for the Wasserman–Gumenyuk Personality Questionnaire, adapted for Russian-speaking respondents with consideration of cultural characteristics [10]. Type-D personality was identified when scores exceeded 10 on both the Negative Affectivity (NA) and Social Inhibition (SI) subscales of the DS-14 questionnaire.

PERSONALITY TYPES AND THEIR CHARACTERISTICS

M. Friedman and R. Rosenman (1959) differentiated two opposite personality Types—A and B—and were the first to identify a higher risk of CAD in individuals with Type A personality. Types A and B primarily describe behavioral patterns in stressful situations, and their influence on disease development is also observed under conditions of minimal novelty. The monograph “Type A Behavior and Your Heart” by M. Friedman and R. Rosenman was the first study to describe the relationship between behavior and the development of cardiovascular disease and introduced personality-based stratification (Type A or B). Subsequently, an intermediate personality type, namely, AB, was identified. Initially, research focused on Type A behavior, certain components of which (e.g., aggressiveness) may accelerate atherogenesis and negatively influence the course of heart disease, although its direct relationship with mortality was not established. Type A behavior, also called coronary-prone behavior, is an additional risk factor along with the five major factors: heredity, dyslipidemia, smoking, psychological stress, and hypertension [11].

A Type A personality is characterized by competitiveness, verbal aggressiveness, constant cognitive activity, ambition, decisiveness, high energy, and emotional tension, which together result in an inability to relax. Behaviorally, individuals with Type A personality often display rapid walking and eating, active gesturing, fast speech, and continuous engagement in tasks. Under stress, they exhibit conflict-prone behavior, ambition, irritability, and aggression toward competitors, along with exaggerated politeness.

Conversely, a Type B personality is manifested by pragmatism, rationality, emotional restraint, and a tendency toward latent dissatisfaction rather than open conflict. In individuals with Type B personality, prudence, friendliness, and contentment with their current situation enable them to objectively assess their abilities and adapt effectively. However, their lower self-demand often results in slower achievement of significant success, and their perceived age exceeds their biological age [12].

A Type AB personality combines emotional and behavioral stability, active and purposeful work capacity, a wide range of interests, and the ability to adapt to various circumstances by alternating intensive work with adequate rest.

Of particular interest is the concept of distressed personality (Type D), which was introduced by J. Denollet in 2000 [13]. Individuals with Type-D personality frequently experience negative emotions (NA) while simultaneously exhibiting SI, which is the suppression of emotional and behavioral responses in social interactions. This personality type is characterized by a critical attitude toward working conditions, a perceived imbalance between effort and reward, excessive competitiveness, and difficulties in relationships with supervisors and colleagues [14]. SI in individuals with Type-D personality is confirmed by low scores on social competence scales, fearfulness, and a tendency toward self-deception [15], distinguishing them from Type A personalities, who demonstrate heightened stress reactivity. Such behavior in individuals with Type-D personality may adversely influence the development and progression of the atherosclerotic process [16].

Hyperreactivity to stress and a tendency toward negative emotions are common to Types D and A personalities. However, patients with Type A personality tend to respond with hostility and anger, whereas those with Type-D personality respond with anxiety and worry. Notably, the negative impact on long-term prognosis in individuals with Type A personality can be minimized by taking responsibility for their own health [17]. Patients with Type-D personality generally experience a lack of social support and are reluctant to share negative emotions because of fear of disapproval. Therefore, a Type-D personality is most often characterized by emotional difficulties (a tendency toward depression, chronic tension, anger, and pessimism) and social difficulties (discomfort when interacting with unfamiliar people) [18].

INFLUENCE OF PERSONALITY TYPE ON CARDIOVASCULAR DISEASES

The association between Type A personality and CVDs is well established. The characterization of this personality type and its relationship with CAD facilitated the development of behavioral modification strategies. Using a comprehensive approach that included conflict resolution techniques, self-reflection, relaxation, group psychotherapy, and cognitive-social training, M. Friedman and R. Rosenman observed a decrease in hostility and other criteria characteristic of a Type A behavior [19].

Several studies have confirmed the association between Type A personality and CAD. In one such study, observation of 3200 healthy individuals over several years revealed a fivefold increase in the incidence of CAD among individuals with Type A personality [20]. Another study demonstrated that, compared with individuals with Type B personality, those with Type A personality exhibited higher blood pressure, more pronounced atherosclerosis and thrombosis, and a 5.5-fold higher rate of myocardial infarction [19].

The Western Collaborative Group Study, which is a 25-year follow-up study on cardiovascular disease incidence and mortality, found an increased risk of CAD among men with Type A personality [21]. The Framingham Study also showed a higher prevalence of CAD in both men and women with this personality type [22]. Medical history data indicate that angina pectoris, myocardial infarction, and stroke occurred more frequently in individuals with Type A behavior than in those with Types AB and B [23]. Hostility and anger are prognostic factors for cardiac rhythm disturbances, whereas components of Type A personality such as enthusiasm and competitiveness may accelerate atherosclerosis progression [24]. Research has demonstrated the rationale for using an individualized approach to identify patients predisposed to stress-related cardiovascular complications associated with specific behavioral types [18].

According to two independent meta-analyses of 25 studies, a Type-D personality is independently correlated with impaired physical and mental health in cardiac patients [25]. Studies have shown the adverse prognostic impact of Type-D personality in patients with CAD, classifying it as a chronic psychosocial risk factor for disease development and progression [26]. However, studies conducted in Germany have not confirmed the prognostic significance of Type-D personality in chronic heart failure [27]. A meta-analysis of 12 studies revealed that Type-D personality increases the mortality risk for patients with CAD [27].

In patients with stable CAD, prospective observation for at least 1 year indicated that Type-D personality was associated with a poorer prognosis. Among patients who had undergone coronary artery bypass grafting, it was linked to a higher incidence of cardiovascular events in the long term, and in those with chronic heart failure (CHF), it was associated with more frequent rehospitalizations [28, 29]. Moreover, in nonischemic CHF, no adverse prognostic effect of Type-D personality was identified (the DANISH study) [30]. Notably, differences in results depended on the nosological form and on the country where the study was conducted [18].

Multivariate logistic regression analysis showed that among individuals with Type-D personality, the risk of low physical activity was the highest (odds ratio = 3.12; p = 0.004). Physical inactivity, along with other unhealthy lifestyle factors and poor treatment adherence, may represent a link between Type-D personality and an unfavorable prognosis in cardiac patients [25]. Type-D personality has been shown to be associated with a higher number of complications and increased mortality among patients with CAD, myocardial infarction, CHF, and peripheral artery disease and with decreased quality of life and lower efficacy of pharmacologic and invasive interventions [18].

In the European HeartQoL Project, the prevalence of Type-D personality among patients was 35%–37% in Eastern and Southern Europe and 24%–27% in Northern and Western Europe [16]. In the Russian population, the prevalence of Type-D personality ranged from 14.3% to 31.8%, and among a cohort of patients with atherosclerosis of various localizations, the prevalence was 19.3% [16, 31].

In the multicenter KOMETA study (Clinical and Epidemiological Program for the Study of Psychosocial Risk Factors in Cardiology Practice in Patients with Arterial Hypertension and Coronary Artery Disease), Type-D personality was determined in 37.6% of outpatients with hypertension and CAD. Additionally, it was more commonly observed in patients with both hypertension and CAD than in those with hypertension alone (41.2% vs 35.8%; p < 0.01) [32].

Staniute et al. reported Type-D personality in 33.5% of patients with CAD [33]. In a prospective study of 977 patients (740 men and 237 women; mean age, 58.7 ± 9.4 years) who underwent coronary stenting, Type-D personality was found in 31.8% of participants. This type was more often associated with two or more previous myocardial infarctions (9% vs 4.5%; p = 0.006), but no association was found with CAD severity or outcomes of coronary stenting, including long-term results [31].

In another study, Type-D personality was observed in 32% of patients (n = 1018, including 764 men) with hemodynamically significant coronary artery stenoses who underwent urgent or elective percutaneous coronary intervention. Patients with Type-D personality were comparable to those with other personality types in terms of sex, age, and cardiovascular risk factors, except for a higher frequency of carbohydrate metabolism disorders (28.2% vs 22.1%; p = 0.047) and diabetes mellitus (25.3% vs 19.9%; p = 0.06). The authors more frequently observed ≥2 previous myocardial infarctions in these patients (17.6% vs 9.6%; p = 0.02), indicating that a Type-D personality is an additional risk factor for multifocal, hemodynamically significant coronary atherosclerosis [16].

In the ESSE-RF study (Kemerovo region), patients with Type-D personality more frequently exhibited coronary artery calcification, with a predominance of moderate and severe coronary calcium index (CI) values (10.3% and 12.5% vs 5.8% and 2.9%, respectively (p = 0.043 and p = 0.011). The severity of CI was higher in patients with Type-D personality than in those without Type-D personality (689.3 ± 53.7 vs 546.5 ± 47; p = 0.048). Differences in CI were observed in the left coronary artery, particularly in the left anterior descending artery (189.1 ± 12.5 vs 155.6 ± 16.7; p = 0.011) and circumflex branch (121.7 ± 30.6 vs 63.8 ± 21.7; p = 0.032). Multivariate analysis showed independent predictors of moderate and severe coronary calcification: Type-D personality (odds ratio [OR], 1.49; 95% confidence interval [CI], 2.01–2.29; p = 0.01), diabetes mellitus (OR, 1.28; 95% CI, 1.80–3.24; p = 0.02), and CAD (OR, 1.24; 95% CI, 1.01–1.53; p = 0.04) [34]. Multislice computed tomography coronary angiography in patients with Type-D personality but without CAD revealed a higher prevalence of atherosclerotic plaques (35% vs 23%; p = 0.03) [35].

Another study reported that a Type-D personality was more often associated with HTN (p = 0.033), CAD (p = 0.053), and cerebrovascular disease (p = 0.041) [31]. The development of HTN in these patients was attributed to a longer duration of increased blood pressure during stress, reflecting impaired adaptation [36].

Enatescu et al. reported a 19% prevalence of Type-D personality among hospitalized patients with CAD (n = 221; 131 men; mean age, 60 ± 10.2 years). This group exhibited a higher incidence of myocardial infarction (57.1% vs 34.6%; p = 0.007), a greater frequency of coronary artery occlusion (p < 0.001), decreased left ventricular systolic function (left ventricular ejection fraction, 47.4% ± 13.78% vs 51.7% ± 9.48%; p = 0.06), and decreased global longitudinal strain (−14.06% ± 5.65% vs −15.93% ± 4.82%; p < 0.001) [37].

Similar findings were obtained in a Russian study, wherein patients with chronic coronary syndrome and Type-D personality significantly more often had concomitant diabetes mellitus (35%) and diastolic dysfunction of the left and right ventricles [38]. Sumin et al. demonstrated an association between Type-D personality and smoking history, insufficient physical activity, overweight, obesity, and diabetes mellitus [25, 39]. Furthermore, Type-D personality has been associated with atherosclerotic plaque instability, which is characterized by a large lipid core, thin-cap fibroatheroma, and fibrous cap rupture [38, 40]. Another study reported a frequent development of atherosclerosis in stented arteries [41].

In a prospective study of patients with stable CAD, H.B. Leu found an association between Type-D personality and poorer prognosis [42]. Additionally, Kinash et al. (2024) reported that Type-D personality was more prevalent in patients with Type 2 myocardial infarction than in those with type 1 myocardial infarction (36.1% vs 28.3%; p < 0.05). The authors showed significantly increased subclinical levels of anxiety and depression; lower adherence to drug therapy among patients with Type-D personality [30 (43.4%) vs 9 (4.8%); p = 0.001], and a higher frequency of complications, all-cause mortality, and adverse cardiovascular events during long-term follow-up [28, 43].

The Rapamycin-Eluting Stent Evaluated at Rotterdam Cardiology Hospital study also demonstrated an association between Type-D personality and death or recurrent nonfatal myocardial infarction within 15 months among patients with rapamycin-eluting coronary stents [6]. The effect of Type-D personality on prognosis is believed to be mainly due to a combination of NA and SI. In patients with CHF, this personality type is characterized by higher resting heart rate, decreased stress reactivity, and frequent rehospitalizations [29]. In cases of concomitant CHF and chronic obstructive pulmonary disease, decreased quality of life and decreased forced expiratory volume in 1 second were observed [44].

Studies have shown that a Type-D personality allows for the prediction of an unfavorable course of CVD, providing opportunities to optimize therapeutic strategies and improve patient adherence to treatment [16]. Psychotherapy aimed at enhancing stress resilience and socialization appears to be appropriate complement to pharmacologic cardiologic therapy [15, 45]. In addition to improving compliance, a multimodal program designed to mitigate the prognostic impact of Type-D personality should include interventions that reinforce healthy lifestyle habits, structured physical exercise programs, stress management, communication and problem-solving training, and the development of coping strategies. In cases of anxiety–depressive disorders, pharmacologic and psychotherapeutic correction is recommended. Preliminary results of such programs demonstrate improvement in psychophysical status and quality of life among patients with CAD and Type-D personality [46].

A Type A personality is considered a risk factor for CAD [12, 47]. Moreover, a Type-D personality is regarded as a critical psychological marker of an unfavorable clinical course, which is characterized by a high likelihood of adverse cardiovascular outcomes and low quality of life [37, 48].

CONCLUSION

Based on the principles of stratified medicine, focus on personality type is justified, as it is associated with dissatisfaction with quality of life, delayed medical consultation, and low adherence to a healthy lifestyle and physician recommendations. A patient-centered approach should consider personality type. Studies aimed at improving the psychological status of patients, achieving regression of somatic disease, and enhancing survival among individuals with Type-D personality are ongoing. Future research should investigate the impact of personality traits on health, depending on life circumstances and clinical conditions. Increasing physician awareness of the role of personality characteristics and their influence on cardiac disorders will help identify the causes of patient maladaptation and improve the effectiveness of primary and secondary prevention. Targeted and timely psychotherapeutic correction may be beneficial in modifying the negative aspects of personality, which in turn may lead to decreased risk of adverse cardiovascular events, improved treatment adherence, and increased patient life expectancy.

ADDITIONAL INFORMATION

Author contributions: B.O.V.: conceptualization, investigation, scientific supervision, visualization, writing—original draft, writing—review & editing; M.E.I.: investigation, visualization, writing—original draft, writing—review & editing; Kh.E.V.: investigation, visualization, writing—original draft, writing—review & editing; P.A.A.: investigation, visualization, writing—original draft, writing—review & editing; V.I.Kh.: investigation, visualization, writing—original draft, writing—review & editing. All authors approved the version of the manuscript to be published and agree to be accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding sources: No funding.

Disclosure of interests: The authors declare no conflicts of interest related to this article.

Statement of originality: No previously published material (text, images, or data) was used in this work.

Data availability statement: The editorial policy regarding data sharing does not apply to this work, as no new data was collected or created.

Generative AI: No generative artificial intelligence technologies were used to prepare this article.

Provenance and peer review: This paper was submitted unsolicited and reviewed following the standard procedure. The peer review process involved two external reviewers, a member of the editorial board, and the in-house scientific editor.

 

¹ Health Care. Federal State Statistics Service. Available at: https://rosstat.gov.ru/folder/13721 Accessed on May 17, 2024.

About the authors

Olga V. Bulashova

Kazan State Medical University

Email: boulashova@yandex.ru
ORCID iD: 0000-0002-7228-5848
SPIN-code: 4211-2171

MD, Dr. Sci. (Medicine), Professor, Depart. of Propaedeutics of Internal Diseases named after Prof. S.S. Zimnitsky

Russian Federation, Kazan

Elza I. Mukhitova

City clinical hospital No. 7 named M.N. Sadykov

Author for correspondence.
Email: elza100487@mail.ru
ORCID iD: 0000-0002-0950-0277
SPIN-code: 8957-0513

Cardiologist, Cardiology Depart. 4

Russian Federation, Kazan

Elena V. Khazova

Kazan State Medical University; Hospital for War Veterans, Consultative Clinic

Email: hazova_elena@mail.ru
ORCID iD: 0000-0001-8050-2892
SPIN-code: 7013-4320

MD, Dr. Sci. (Medicine), Assistant Professor, Depart. of Propaedeutics of Internal Diseases Named after Professor S.S. Zimnitsky, therapist

Russian Federation, Kazan; Kazan

Alla A. Podolskaya

Kazan State Medical University; City clinical hospital No. 7 named M.N. Sadykov

Email: alla.podolsckaya@yndex.ru
ORCID iD: 0000-0002-9474-7601
SPIN-code: 1825-5493

MD, Cand. Sci. (Medicine), Assistant Professor, Depart. of Internal Diseases FSBEI, Cardiologist, Head, Cardiology Depart. 4

Russian Federation, Kazan; Kazan

Ildaria K. Valeeva

Kazan State Medical University

Email: valeeva.ildaria@yandex.ru
ORCID iD: 0000-0003-3707-6511
SPIN-code: 9818-5421

Dr. Sci. (Biology), Senior Research Associate, Tselni FSBEN

Russian Federation, Kazan

References

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