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1
A one-year prospective investigation of Type D personality and self-reported physical health
Authors: Sarah F. Allen PhD
a
, Mark A. Wetherell PhD
b
, & Michael A. Smith PhD
bc
a
Department of Health Sciences, Faculty of Science, University of York, UK. sarah.allen@york.ac.uk
b
Department of Psychology, Faculty of Health and Life Sciences, Northumbria University, UK
c
Faculty of Health and Medical Sciences, University of Western Australia, Australia
Running Head: Type D and Physical Health
Key words: Type D; health; physical symptoms; stress; anxiety.
Words: 6900
References: 79
Number of tables: 4
Number of figures: 1
Number of appendices: 1
Supplementary tables: 2
COI: No conflicts of interest.
Funding: The project was undertaken as part of a Northumbria University funded PhD studentship.
*Corresponding author: Dr Sarah F. Allen. Department of Health Sciences, Faculty of Science, University
of York, UK. sarah.allen@york.ac.uk. +44(0)1904321949
2
Abstract
Objective: Type D personality is characterised by negative affectivity and social inhibition, and is
often associated with poorer physical and psychological health. However, the underlying mechanisms
are unclear and the literature lacks longitudinal assessment. We aimed to prospectively examine the
relationships between Type D and physical symptoms, in addition to retrospective health.
Design: An online questionnaire-based study (N=535) with a one-year follow-up (N=160) was
conducted with healthy individuals (18-65years). Type D was assessed as a categorical and dimensional
construct.
Main Outcome Measures: Participants completed Type D scale-14, Hospital Anxiety and
Depression Scale, Cohen-Hoberman Inventory of Physical Symptoms and Perceived Stress Scale at both
phases. Retrospective health questions and Social Readjustment Rating Scale were completed at follow-
up.
Results: Type D was related to cardiac/sympathetic, metabolic, vasovagal, muscular, and
headache symptoms at baseline. At follow-up stressful events and anxiety mediated the relationships
between Type D and particular symptoms. Type Ds were more likely to report poorer health, and
increased minor illnesses, work absences, and medical-information-seeking.
Conclusions: Type D is associated with stress-related symptoms. Although the relationships are
primarily driven by NA, this supports the theory of a stress-related mechanism. These findings
contribute to the literature highlighting Type D as a risk factor for poor health.
3
Introduction
Type D personality is characterised by the interaction of negative affectivity (NA) and social
inhibition (SI) (Denollet, 2000). Type D individuals have the tendency to experience negative emotions
including dysphoria, anger, anxiety, hostility, and general distress across situations and time, whilst also
inhibiting the expression of these emotions in social situations due to fear of rejection or disapproval
(Denollet, 1998b; Mols & Denollet, 2010a).
Since its initial proposal the prognostic validity of the Type D construct has been demonstrated in
cardiac patient populations. However, there is accumulating evidence that Type D may be an important
risk factor for poor health in other illness groups (Mols & Denollet, 2010a), as well as in otherwise
‘healthy’ individuals (Smith et al., 2018; Williams & Wingate, 2012), that is, individuals who are free
from any chronic conditions. Existing research has established Type D as a predictor of poorer physical
health, including increased somatic symptoms, general health complaints and immune related illnesses
(Condén, Leppert, Ekselius, & Åslund, 2013; Stevenson & Williams, 2014; Williams & Wingate, 2012).
Early estimates suggest that Type D personality was prevalent in 20% of the general population
(Denollet, 2005). However, recent studies have estimated prevalence of up to 42.8% (Booth & Williams,
2015), which further exemplifies the importance of researching the health effects of Type D in ‘healthy’
populations
Type D has also been associated with increases in anxiety, depression, somatisation (Michal,
Wiltink, Grande, Beutel, & Brähler, 2011), maladaptive stress reactivity (Habra, Linden, Anderson, &
Weinberg, 2003; Howard & Hughes, 2013; Kelly-Hughes, Wetherell, & Smith, 2014; O’Leary, Howard,
Hughes, & James, 2013), dysfunctional coping strategies, lower social support (Williams & Wingate,
2012), and adverse health behaviours (Booth & Williams, 2015) in the general population. Accordingly,
these are all factors which may potentially mediate the relationship between Type D and physical health
(Howard, Hughes, & James, 2011; Williams & Wingate, 2012). The relationship between Type D and
health in the general population is beginning to receive more attention, and in a recent study, has been
found to be mediated by anxiety and perceived stress (Smith et al., 2018). However, prospective
4
examination is required to further understand the mechanisms underpinning the now well-documented
relationship.
Type D personality is traditionally assessed categorically, with individuals scoring above a
particular threshold on both SI and NA being classified as Type D (Denollet, 2005). Although this
approach is useful, it has also been criticised for not accurately representing the interactive effect of SI
and NA, and typologies generated from two continuous variables in this way, have been criticised
(Coyne et al., 2011). Consequently, Ferguson et al., (2009) has recommended that Type D may be better
conceptualised as a dimensional variable. Therefore, in line with previous studies (e.g. Stevenson &
Williams, 2014), Type D will be considered as both a categorical and a continuous variable within the
current study.
Given previous findings linking Type D to a range of health outcomes including; poor prognosis in
heart disease patients (Kupper & Denollet, 2007); cancer survivors (Mols, Denollet, Kaptein, Reemst, &
Thong, 2012) and other clinical populations (Mols & Denollet, 2010a) as well as increased physical
symptoms (Smith et al., 2018; Williams & Wingate, 2012), it appears necessary to assess the extent to
which Type D personality may predict physical health over time. Moreover, there is a notable lack of
longitudinal evidence to support the predictive value of Type D personality on health in the general
population. This makes it difficult to reliably infer cause and effect, and limits the capacity to investigate
potential mediating mechanisms (Maxwell & Cole, 2007). Therefore, a longitudinal assessment of the
associations between Type D personality and physical symptoms, in addition to aspects of general
health status and healthcare utilization, is warranted.
In light of the accumulating evidence with respect to the role of stress and distress in the Type D-
health relationship (e.g. Smith et al., 2018) this study will examine the potential mediating effects of
stress, anxiety and depression. The current study aims to contribute to our understanding of the
pathways underpinning the relationship between Type D personality and the manifestation of physical
symptoms. In light of the current Type D literature it is hypothesised that:
i) Type D personality will be linked to increased reporting of physical symptoms