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https://doi.org/10.15836/ccar2019.24

Differences in Personality Traits and the Influence of Personality Traits on the Development and Course of Coronary Heart Disease

Iva Žegura   ORCID icon orcid.org/0000-0001-9649-1948 ; University Psychiatric Hospital Vrapče, Zagreb, Croatia
Denis Bratko   ORCID icon orcid.org/0000-0002-2482-4413 ; University of Zagreb, Faculty of Humanities and Social Sciences, Zagreb, Croatia
Nataša Jokić- Begić ; University of Zagreb, Faculty of Humanities and Social Sciences, Zagreb, Croatia
Mario Ivanuša   ORCID icon orcid.org/0000-0002-6426-6831 ; Institute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia; University of Rijeka, Faculty of Medicine, Rijeka, Croatia

Puni tekst: engleski, pdf (342 KB) str. 24-33 preuzimanja: 282* citiraj
APA 6th Edition
Žegura, I., Bratko, D., Jokić- Begić, N. i Ivanuša, M. (2019). Differences in Personality Traits and the Influence of Personality Traits on the Development and Course of Coronary Heart Disease. Cardiologia Croatica, 14 (1-2), 24-33. https://doi.org/10.15836/ccar2019.24
MLA 8th Edition
Žegura, Iva, et al. "Differences in Personality Traits and the Influence of Personality Traits on the Development and Course of Coronary Heart Disease." Cardiologia Croatica, vol. 14, br. 1-2, 2019, str. 24-33. https://doi.org/10.15836/ccar2019.24. Citirano 27.11.2021.
Chicago 17th Edition
Žegura, Iva, Denis Bratko, Nataša Jokić- Begić i Mario Ivanuša. "Differences in Personality Traits and the Influence of Personality Traits on the Development and Course of Coronary Heart Disease." Cardiologia Croatica 14, br. 1-2 (2019): 24-33. https://doi.org/10.15836/ccar2019.24
Harvard
Žegura, I., et al. (2019). 'Differences in Personality Traits and the Influence of Personality Traits on the Development and Course of Coronary Heart Disease', Cardiologia Croatica, 14(1-2), str. 24-33. https://doi.org/10.15836/ccar2019.24
Vancouver
Žegura I, Bratko D, Jokić- Begić N, Ivanuša M. Differences in Personality Traits and the Influence of Personality Traits on the Development and Course of Coronary Heart Disease. Cardiologia Croatica [Internet]. 2019 [pristupljeno 27.11.2021.];14(1-2):24-33. https://doi.org/10.15836/ccar2019.24
IEEE
I. Žegura, D. Bratko, N. Jokić- Begić i M. Ivanuša, "Differences in Personality Traits and the Influence of Personality Traits on the Development and Course of Coronary Heart Disease", Cardiologia Croatica, vol.14, br. 1-2, str. 24-33, 2019. [Online]. https://doi.org/10.15836/ccar2019.24
Puni tekst: hrvatski, pdf (342 KB) str. 24-33 preuzimanja: 220* citiraj
APA 6th Edition
Žegura, I., Bratko, D., Jokić- Begić, N. i Ivanuša, M. (2019). Razlike u osobinama ličnosti i njihov utjecaj na razvoj i tijek koronarne bolesti srca. Cardiologia Croatica, 14 (1-2), 24-33. https://doi.org/10.15836/ccar2019.24
MLA 8th Edition
Žegura, Iva, et al. "Razlike u osobinama ličnosti i njihov utjecaj na razvoj i tijek koronarne bolesti srca." Cardiologia Croatica, vol. 14, br. 1-2, 2019, str. 24-33. https://doi.org/10.15836/ccar2019.24. Citirano 27.11.2021.
Chicago 17th Edition
Žegura, Iva, Denis Bratko, Nataša Jokić- Begić i Mario Ivanuša. "Razlike u osobinama ličnosti i njihov utjecaj na razvoj i tijek koronarne bolesti srca." Cardiologia Croatica 14, br. 1-2 (2019): 24-33. https://doi.org/10.15836/ccar2019.24
Harvard
Žegura, I., et al. (2019). 'Razlike u osobinama ličnosti i njihov utjecaj na razvoj i tijek koronarne bolesti srca', Cardiologia Croatica, 14(1-2), str. 24-33. https://doi.org/10.15836/ccar2019.24
Vancouver
Žegura I, Bratko D, Jokić- Begić N, Ivanuša M. Razlike u osobinama ličnosti i njihov utjecaj na razvoj i tijek koronarne bolesti srca. Cardiologia Croatica [Internet]. 2019 [pristupljeno 27.11.2021.];14(1-2):24-33. https://doi.org/10.15836/ccar2019.24
IEEE
I. Žegura, D. Bratko, N. Jokić- Begić i M. Ivanuša, "Razlike u osobinama ličnosti i njihov utjecaj na razvoj i tijek koronarne bolesti srca", Cardiologia Croatica, vol.14, br. 1-2, str. 24-33, 2019. [Online]. https://doi.org/10.15836/ccar2019.24

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Sažetak
According to the five personality traits (neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness), in accordance with the model by Costa and McCrae and the combinations
of facets within them, there is a differentiation of people who are more prone to experiencing positive emotions, are more optimistic, and have developed positive habits related to health, all of which contributes to their life satisfaction and the subjective feeling of wellbeing, and those individuals who are more prone to experiencing negative emotions, are pessimistic, possess negative habits related to health, and are less satisfied with life and report a reduced feeling of subjective wellbeing. The goal of the study was to investigate the relationship of protective and risk personality factors within the model by Costa and McCrae, psychosocial variables (the state of general wellbeing, behaviors related to healthy living, the level of the perception of the risk of developing disease), and the measurement of the state of the cardiovascular system in healthy individuals, patients with stable angina pectoris, and individuals with risk factors for coronary heart disease (CHD). The study participants (N=248) were individuals who were being tested in the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb. The participants were divided into three groups: a control group of healthy people, a control group of participants suffering from stable angina pectoris, and the study group of participants with risk factor for CHD. Contrary to expectations, it was shown that the three groups of participants did not differ according to personality traits. There is need for further research on the influence of protective and risk personality factors for the development of CHD, methodological improvements with the application of more sensitive personality measurements, and especially the relationship of positive and negative affect.

Ključne riječi
coronary heart disease; risk factors; five-factor model

Hrčak ID: 218123

URI
https://hrcak.srce.hr/218123

▼ Article Information



Introduction

Studies of the ways psychological factors may affect physical health show an obvious interaction of the physical and the psychological; the psychological processes and behavior may affect physical functions, and physical states may affect an individual’s thinking and actions (1). Health psychology and behavioral medicine follow the biopsychosocial model, according to which physical diseases are a result of biological, psychological, and social disorders. Nowadays, health psychology assumes that psychological factors may affect almost all diseases.

Coronary heart disease (CHD), or acute coronary syndrome (ACS), is the primary cause of morbidity and mortality in our civilization, and in developed countries it is considered a direct or indirect cause of a quarter of all deaths (2). CHD is also known as ischemic heart disease, degenerative coronary disease, and coronary insufficiency (3). These terms describe the conditions in which there is reduced blood supply in the heart muscle, which leads to its reduced oxygen and nutrient supply. A person experiences this as an attack of angina pectoris.

The newest study by Denellot et al shows that chronic negative feelings, whether they are part of type-A behavior or not, represent the greatest risk for the development of CHD and other physical illnesses in general (4-6). Individuals who have a chronic experience of one or more negative feelings such as depression, anxiety, or aggressive competitiveness are at greater risk of developing CHD (7, 8), as are those who experience the feelings of fatigue, rejection, defeat, social inhibition, or increased irritability, which is a state also known as vital exhaustion (9).

Acute and chronic psychological distress is tied to CHD, but little is known of the determinants of distress as a risk factor. It is possible that certain stable personality traits may explain the influence of distress on cardiovascular (CV) diseases as a potential risk factor. The focus of Johan Denollet’s study (4, 10, 11) on CV patients susceptible to distress is on negative feelings (an individual’s tendency towards feeling negative emotions) and social inhibition (tendency towards inhibiting emotions, attitudes, and opinions in social interaction, as well as avoiding and distrusting people from the one’s social environment).

Most studies on the link between personality risk factors and the frequency of CHD have been aimed at affect disorders, negative emotions, and social isolation. Depression and perceived low social support are often considered psychosocial factors with strongest ties to morbidity and mortality caused by CHD. In people who do not manifest a disease, evidence suggests that numerous stable personality traits represent the majority of the determinants of depression, psychological distress, stress, subjective mood, and the individual’s stability. Individual differences in personality and handling stressful situations are also tied with psychological distress in patients suffering from CHD.

Along with specific psychological risk factors, there is also the need to research personality in an early identification of those CV patients in whom there is risk of new events due to emotional stress. Evidence suggests that psychological stress factors tend towards mutual connection into clusters and that their clustering significantly increases risk of a CV event. Stabile personality traits may have a significant predictive value with regards to clustering risk factors in patients with CHD.

The aim of this study is to research the relationship of protective and risk personality trait factors in the development of CHD within the personality model by Costa and McCrae (12, 13) and the measurement of the condition of the CV system in healthy individuals, those with risk factors for the development of CHD, and those with diagnosed CHD. With regards to personality traits, it is expected that especially high neuroticism, low results on the dimensions of agreeableness, extraversion, openness to experience, and conscientiousness will be pronounced in individuals in whom there are somatic risk factors for the development of CHD and in those suffering from CHD (hypothesis 1 – H1). In other words, high neuroticism and low agreeableness will show a significant contribution to the explanation of the CHD variance. It is to be assumed that, according to personality traits, the greatest difference will be found between the group of healthy participants and those with diagnosed CHD in such a way that healthy participants will have more pronounced protective instead of risk personality factors in comparison with people with diagnosed CHD (hypothesis 2 – H2).

Participants and methods

The sample for this study was assembled during the day-to-day clinical work in the Institute for Cardiovascular Prevention and Rehabilitation in Zagreb for the purposes of gathering data for specialist cooperation in clinical psychology. The participants who undertook cardiologic testing participated voluntarily, with informed consent. The following was used: demographical data (age, sex), the frequency of risk factors for CHD, the state of the CV system (the result of ergometric testing), a questionnaire about general information, the NEO PI-R personality questionnaire and the revised NEO PI-R questionnaire (12). The participants were divided into three groups: those without risk factors or signs of CHD (Z group), those with CV risk factors and diagnosed CHD (K group), and those with confirmed CV risk factors, but without diagnosed CHD (R group). The criterion for the inclusion of participants in the Z group were the following: the risk factors for CHD were not confirmed, CHD was not diagnosed (good results of ergometric testing and laboratory values of biochemical blood tests according to expected medical criteria), and the absence of confirmed diagnoses of other physical chronic diseases. The participants included in the R group were selected according to the following criteria: the existence of CHD risk factors (abnormal results of ergometric testing and laboratory values of biochemical blood tests that deviate from the expected medical criteria), but no CHD. The participants in the R group were further divided on the basis of having two, three, or more risk factors (arterial hypertension, dyslipidemia, diabetes). The K group was constituded of participants who satisfied the following criteria: existence of CHD risk factors and diagnosed CHD (stable angina pectoris). One criterion for the inclusion of participants for all of the groups was the absence of diagnosed psychological illnesses and an age range of 18 to 65. Measurements of the medical condition and the status of the cardiovascular system included the variables of the ergometric finding and variables of laboratory values of biochemical blood test results.

The results were analysed using statistical methods and the statistical program SPSS 18. The level of statistical significance was set at 0.05.

Results

The study included 271 participants. 248 of those participants (148 men and 100 women) satisfied all the criteria and their results were included in further analysis. The Z group included 50 participants (30 men and 20 women), the K group included 86 participants (56 men and 30 women), and the R group was comprised of 112 participants (62 men and 50 women) (Table 1).

TABLE 1 Division of participants according to sex and groups.
K groupR groupZ groupTotal
Men566230148
Women305020100
All participants8611250248

The sample for this study is made up of older participants, which is to be expected since CHD is a disease of the older population (Table 2).

TABLE 2 Division of participants according to age groups.
≤3536-4041-4546-5051-5556-6061-65Total
K group1251112292686
R group611192523199112
Z group5886109450
All participants12213242455739248

The average age of the participants, expressed as an arithmetic mean, and the standard deviation are shown in Table 3. The groups of participants differed significantly with respect to age (F = 20.625, df = 2, p = 0.000).

TABLE 3 The average age of the participants according to groups of patients.
Arithmetic meanStandard deviation
K group55.947.04
R group49.448.44
Z group47.889.75
All51.388.91

In order to answer hypotheses H1 and H2, a discrimination analysis was performed on five personality factors according to the NEO PI-R personality questionnaire. Contrary to expectations, it was shown that the three groups of participants did not differ according to personality traits (Table 4). The discrimination analysis, which included the results of three groups of participants (healthy participants, those with the risk factor for the development of CHD, and patients with stable angina pectoris), resulted in a statistically insignificant discrimination analysis with the risk level of 0.05. In other words, according to the results shown by participants on the five factors in the NEO PI-R personality questionnaire, it is impossible to conclude which group they belong to (the healthy ones, those with somatic risk factors for CHD, those diagnosed with CHD). Since no significant difference was found between the participants on the basis of the group they belonged to according to the five-factor personality model, there was no additional analysis of each individual facet of personality factors. Therefore, it was shown that, according to personality traits, the three groups of participants (the healthy ones, those with a somatic risk factor for developing CHD) were identical.

TABLE 4 The results of the discrimination analysis according to the five-factor personality model for the groups of healthy participants, participants with the risk factor for developing CHD, and participants with diagnosed CHD – stable angina pectoris.
FunctionEigenvalues% explained variancesCanonical correlation coefficientWilks’ lambdaχ2dfp
10.4275.20.200.9513.46100.199
20.1424.80.120.993.3740.500

Discussion

The cardiovascular system is connected to experiencing emotions in a very complex way, and these connections may explain how and when personality dimensions may protect from the development of CHD or, on the other hand, represent risk factors for the development of CHD. Therefore, this study began with the hypothesis that, with regard to personality traits, it was to be expected that extremely high neuroticism, low results of the dimensions of agreeableness, extraversion, openness to experience, and conscientiousness would be pronounced in individuals with physical risk factors for the development of CHD and in those with stable angina pectoris. It was to be expected that, according to personality traits, the greatest difference would be between the group of healthy participants and those with diagnosed CHD, with the healthy participants having more pronounced protective factors than risk personality factors in comparison with participants with diagnosed CHD.

With respect to the main goal of this study, its results are in contrast with the usually consistent results from the existing literature on the topic of protective and risk personality factors for the development of CHD (6, 9, 14). Statistically insignificant discrimination analysis showed that, according to the results for the five factors of the NEO PI-R personality questionnaire shown by the participants, it is impossible to conclude which group these participants belong to.

In other words, the three groups of participants do not differ according to personality traints. Let us examine, in order, what may have led to such results. Firstly, there are the deficiencies of this study with respect to the sample. The group of healthy participants consists of people who attended cardiologic testing, and who did not show any CV risk factors, nor were they diagnosed with CHD. The group was comprised of 50 participants and this was the group with the smallest number of participants. One of the reasons why it was so difficult to find a sufficient number of healthy participants was that the study was performed in a cardiologic polyclinic. It can be assumed that a general practitioner already selected people who should undergo a specialist cardiologic examination and sent those who may have signs of CHD or may be under increased risk of CHD. This affected the selection of people who come for examination and who may be potential study participants, which probably “contaminated” the healthy group of participants. In order to improve the study, we may, for example, choose the student population as the group of healthy participants. On the other hand, this would mean that a significant amount of money would have to be spent on cardiologic examination in order to ensure measurements of the medical condition. Furthermore, this would also contribute to significant age gaps among the study participants – the student population would be significantly younger than other groups, and although CHD is increasingly diagnosed earlier, it is still more characteristic for advanced age and the older population.

This study used the NEO PI-R questionnaire by Costa and McCrae (12), and attempted to encompass the type D personality construct over five personality dimensions – neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness – in other words, the tendencies of an individual towards experiencing negative emotional states in contrast with individuals who have the pronounced personality trait of a tendency towards experiencing positive states.

In the area of behavioral medicine and health psychology, there are a series of scales intended for the examination of constructs such as behavior that contributes to the development of CHD, the health locus of control, the perception of risk of disease/treatment, type A behavior, type D personality. If NEO PI-R is used together with such scales, it may serve to improve the understanding of health psychology constructs, which often overlap. The scales intended for measuring various constructs may overlap and measure the same traits. Sometimes scales of different names measure the same construct, but this is not a rule. The correlation with NEO PI-R scales gives a reference point for the assessment of such scales. The information provided by NEO PI-R may explain the results on the other employed scales, which is of specific importance in the case of measuring perceived health or somatic complaints. For instance, various factors affect somatic complaints, and the most important determinants are the objective health status and neuroticism (15). Individuals report somatic symptoms due to objective reasons, because they really do have health problems that cause such symptoms, or because they are overly concerned for their health. Somatic difficulties are tied to psychological problems, and neuroticism is a good predictor for the tendency to claim somatic symptoms. By measuring neuroticism, it is possible to determine the probability that certain somatic complaints are actual disease indicators. However, it is more probable that somatic complaints indicate a health problem, and the probability is greater is the individual has low neuroticism results. More specifically, the results of the neuroticism scale should reveal individuals who have no disease and claim to have somatic difficulties, although they are actually healthy. For instance, neuroticism may overshadow the diagnosis of a CV disease. In the absence of objectivized CHD, a possible source of angina pectoris is significantly connected with the dimension of neuroticism, which represents a wide dimension of individual differences in the tendency to experience negative emotions, distress, and distress-related typical behavioral and cognitive patterns. Individuals who score higher on the neuroticism scale also report more frequently about pain and discomfort. Neuroticism has also been shown to be connected with an increased number of complains about the health condition, including chest pain and symptoms similar to angina, but it has not been shown to have a causal or etiological link with objective signs and pathophysiological results that indicate a disease, especially CHD (16). Similar results were found in the case of the hostility construct, which was shown to be connected with ACS, coronary death, and CHD. However, the measurements of the anger construct itself, which seems connected with hostility, were not related or were actually inversely related with the severity of heart disease (17). The five-factor model attempts to overcome this paradox by emphasizing the existence of two forms of hostility – angry hostility, which is part of neuroticism, and antagonistic hostility, which is part of agreeableness. Costa and McCrae show that antagonistic hostility is predictive for the onset of heart disease and that this emphasizes the need to find new models for psychosomatic diseases (15). Furthermore, as additional data and along with self-assessment, it would be wise to also collect assessment by close family members or partners for each personality domain, including agreeableness. This is very important in order to develop psychological treatment that increases agreeableness, or in case antagonism/agreeableness is a trait that is difficult to alter, individuals with this personality trait may be included in programs aimed at factors which are easier to change, such as smoking or arterial pressure.

On the other hand, we may assume that this examination of the evaluation of positive and negative affect using the five-factor model has shown to be too wide for examining specific mechanisms that may explain the connection between personality characteristics and emotional states. Due to this, it is possible to use specially created scales for the evaluation of positive and negative affect such as PANAS-X (18) or DS 14 (14, 19) and some other scales which may be used to examine, for instance, types of confrontation with stressful situations, the health control locus, etc. It would be interesting if these scales were applied together with the NEO PI-R questionnaire in order to obtain a better insight into whether questionnaire or adjective measures of mood provide a better prediction of mood, and what the relationships are with regards to the participant membership in the three groups in this study, with the examination of the results obtained from the group of participants with risk of developing CHD and those diagnosed with it being of primary importance. The research results show that adjective measures according to the five-factor model, after the control of effects of measure dimensions measured by the questionnaire, explain a fair portion of the variance of all measures of mood (20). Also, according to the study by Kardum et al (20), an additional variance explained by questionnaire measures after the control of effects of adjective measures of mood is almost negligible.

Studies on the structure of mood that are based on self-assessment show two dimensions of emotional states as basic ones: positive affect and negative affect (21). These constitute the evaluation aspect of emotional experience and are largely independent dimensions (22). Positive affect ranges from low excitement and absence of discomfort to high excitement and great discomfort. These dimensions are very useful in the practical sense of examining personalities, emotions, and in clinical practice, while also being useful in the theoretical sense. The main advantage of positive and negative affect is that they provide a better conceptual framework for the analysis of specific emotional states suggested in classic theories of emotion (23). Through its connection with numerous variables, they enable, for instance, the differentiation of anxiety and depression disorders (24) in situations where the surrounding variables are of different influence. Research suggests that these two variables are actually subjective indicators of two behavioral systems (25). The role of positive and negative affect in the determination of emotions may be compared with the dimensions of the five-factor model in determining personality (26). However, as we have already mentioned, this determination with the use of the five-factor model through specific facets of personality on each of the five large factors has advanced somewhat. A more detailed attempt to determine positive and negative affect is given by Watson and Tellegen (21). According to their model, positive and negative affect consist of several interrelated but very different dimensions of low-ranking emotions. According to them, the primary dimensions of negative affect are fear, sadness, guilt, hostility, shame, fatigue, and surprise, while the primary dimensions of positive affect are joy, self-confidence, attention, and calmness (26).

The DS 14 questionnaire was constructed on the same basis (6, 19), which is used to measure the type D personality construct in the general population, and the DS 16 questionnaire, constructed specifically for testing the type D personality on the population of CV patients (27). Both questionnaires consist of subscales intended for examining negative affect and social inhibition. An individual who scores highly on both scales can be said to have type D personality. The validation of type D personality in comparison with the five-factor personality model shows that negative effect is positively correlated with neuroticism, social inhibition correlates negatively with extraversion, and high negative affectivity and social inhibition are negatively correlated with conscientiousness (19). Most studies on type D personality are aimed at its prevalence and effects in the population of patients with various CV diseases, since the construct of type D personality was first described and further developed in this particular group of patients (27). These studies on CV patients have shown that type D personality is an independent predictor of negative health outcomes such as bad health status in general, repeated ACS, and increased risk of death (28-30). Taking into consideration the clinical relevance of test results on type D personality in the context of CV disorders, it is important to examine the potential importance of this construct for the general population. Since this study contains a group of healthy participants, it is important to examine what research shows about the frequency of type D personality and its effects in the healthy population.

Although type D personality has shown to predict the prognosis of the state of the CV system after taking into consideration clinical markers of disease severity (30), the possibility remains that such uncontrolled indicators of disease severity may lead to the onset of characteristics of type D in such studies. Studies of type D personality on individuals from the general population who seem healthy would enable a more direct test of the fact that type D is not merely an epiphenomenon caused by CV diseases. Moreover, type D personality is based on the average personality traits instead of psychopathological markers, which indicates that it should also be present in the general population (19) and that it has the opposite effect on the perceived health status reported by individuals from the general population.

Various studies show that individuals from the general population who have type D personality experience more symptoms of distress, depression, and anxiety in comparison with individuals who do not have type D personality (31-34). Increased vulnerability to mental problems in individuals with type D personality has also been found in patients with chronic pain syndrome (35), diabetics (36), and patients with CHD. (37) The existence of type D personality in people from the general population is also tied with a poorer health status. Individuals with type D personality report more somatic complaints (38) and a significantly lower health status in comparison with people who do not have type D personality (31). These findings correspond with the negative influence of type D personality on the somatic health status of CV patients. It has been shown that type D personality is an independent predictor of poorer health status and more cardiologic symptoms in CV patients (39). Patients with type D personality are under six times more risk of reporting reduced health status in comparison with a reference group of individuals who do not have type D personality (40). Type D personality is also a strong predictor of a bad outcome of CHD and a bad prognosis after ACS, and the risk of bad prognosis inherent in type D personality is similar to that of the traditional risk factors for CHD (30).

Conclusion

Statistically insignificant discrimination analysis has demonstrated that, given the results of the participants on the five factors according to the NEO PI-R personality questionnaire, we were unable to conclude which group they belong to (those who are healthy, those with physical risk factors for CHD, and those diagnosed with CHD), which is unexpected when we take into account existing studies and the hypothesis of this study. There is a need for further research of the influence of protective and risk personality factors for the development of CHD, especially the relation between positive and negative affect, which may help in the identification of risk groups and the creation and implementation of primarily preventive but also rehabilitation programs.

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