A “Type D” Personality: The Impact of Stress and Loneliness on Our HealthRobert Brooks, Ph.D.


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The headline on the October 3, 2005 cover of Newsweek read, “Forget Type A. Are You a ‘Type D’ Personality? Stress & Your Heart.” This issue of Newsweek contained several articles detailing the strong links between emotional and physical health, especially conditions that impacted on cardiovascular disease and heart attacks. The numerous research findings resonated with the ideas conveyed by Dr. Sam Goldstein and myself in our writings about a resilient lifestyle. These findings suggest that there are realistic steps that individuals can initiate to lead a healthier, more vibrant life.

In an article authored by Dr. Michael Miller, a Type D personality was identified as one prone to distress. Miller highlights the observations of cardiac patients by Belgium psychologist Johan Denollet. The latter noticed that some heart attack survivors were cheerful and optimistic even after sustaining extensive heart damage and enthusiastically engaged in rehabilitation programs. In contrast, other survivors, even those who had experienced a mild heart attack, displayed a more pessimistic outlook and avoided rehabilitation activities. Denollet was intrigued by the differences between these two groups and developed a 14-question personality test, labeled DS14, to measure levels of distress.

Miller writes, “The test defines overall distress in terms of two emotional states: ‘negative affectivity’ (worry, irritability, gloom) and ‘social inhibition” (reticence and a lack of self-assurance). It may sound more like a parlor game than a medical instrument—but in the research to date, it has been a surprisingly powerful predictor of cardiovascular health. High distress scores are strongly associated with both hypertension and coronary heart disease. And among people who already have heart conditions, those with the highest distress scores—the so-called Type D personalities—are less responsive to treatment and have a poorer quality of life. They are also more likely to die prematurely.”

One’s level of distress as measured by DS14 was found to have a profound impact on physical health. An earlier version of the test was administered to 300 people involved in a cardiac rehabilitation program in Antwerp. Within 10 years, 27% of Type D patients had died, primarily of heart disease or stroke, compared with 7% of those not identified as Type D. In a more recent study involving 875 patients who had received stents to open coronary arteries, Type D patients were more than four times as likely than non-Type D patients to experience a heart attack death within six to nine months of the procedure.

These findings contain major implications about our attitudes and lifestyle habits. Denollet emphasizes, “There are many Type D individuals who are living healthy lives and functioning quite well.” What factors contribute to their more positive outcome? Miller states, “A good marriage can be an antidote to social inhibition, especially if your partner’s ease with people compensates for your own discomfort. And even the most distress-prone person can learn through psychotherapy to cope with stress and beat back anxious thoughts. Even if you never fully conquer your distress, you can take practical steps to make it less toxic to your health. Exercise and a wholesome diet will reduce almost anyone’s risk of a heart attack. And lifestyle changes that protect your heart can improve your emotional state as well.” Evidently, an ongoing, dynamic relationship exists between our physical and emotional worlds.

In another article in the same Newsweek issue, Anne Underwood notes that physicians are finding that psychosocial variables pose far greater risks in physical conditions than previously realized. “Take depression. It at least doubles an otherwise healthy person’s heart-attack risk, says Dr. Michael Frenneaux, professor of cardiovascular medicine at the University of Birmingham in England. Hostility is an increasingly important risk factor, too. High hostility levels, as measured by a standard test, increased the chances of dying from heart disease by 29 percent in a large study of patients at Duke—and by more than 50 percent in people 60 and younger.”

If depression and anger can heighten medical risks, one can pose an important question: “Can strengthening positive emotions and an optimistic outlook help to diminish or prevent the occurrence of medical problems?” Underwood reports the findings of several studies that suggest a strong, affirmative answer to this question. Most importantly, these studies indicate there are reasonable, realistic steps each of us can take to lessen the probability of facing debilitating medical problems.

As an illustration, a feeling of optimism was related to slowing the progression of atherosclerosis. Psychologist Karen Matthews at the University of Pittsburgh followed 209 healthy, postmenopausal women for three years and found that those rated most optimistic had very little thickening in their carotid arteries—just 1 percent, versus as much as 6.5 percent in the pessimists. Underwood also notes, “Even laughter is starting to look like a cardiac elixir. In one recent study, Dr. Michael Miller (quoted earlier in this article) of the University of Maryland School of Medicine found that watching a funny movie for 15 minutes relaxed people’s peripheral arteries and increased blood flow for as long as 45 minutes afterward—comparable to the effect of aerobic exercise. He now recommends 15 minutes of hearty laughter daily as part of a healthy lifestyle.”

In my January, 2005 website article I highlighted a study reported in “The Positive Aging Newsletter” that offers further evidence of the beneficial effects of engaging in affirming activities. The study, conducted by psychologists Robert Emmons and Michael McCullough, evaluated 65 adults between the ages of 22 to 77 who suffered from forms of neuromuscular disease, such as post-polio condition. Participants were given a questionnaire on which to evaluate their daily experiences including their emotional experiences and well-being. In addition, half of the group was specifically asked to describe events in their day for which they were grateful.

The results indicated that those participants who reflected each day upon situations for which they were grateful reported “more sleep, better quality of sleep, greater optimism about the future, and a greater sense of connectedness to others. There was also a reduction in negative affect.” Emmons and McCullough conclude, “Gratitude and the actions stimulated by it, build and strengthen social bonds and friendships. . . . (It) leads them to feel loved and cared for by others. . . . Gratitude is also likely to build and strengthen a sense of spirituality. . . . It broadens the scope of cognition and enables flexible and creative thinking; it also facilitates coping with stress and adversity. Gratitude not only makes people feel good in the present, but it also increases the likelihood that people will function optimally and feel good in the future.”

The October, 2005 issue of Newsweek included an article by Dr. Dean Ornish, a clinical professor of medicine at the University of California in San Francisco and one of the world’s leading experts on preventing cardiovascular disease. Ornish contends, “Medicine today focuses primarily on drugs and surgery, genes and germs, microbes and molecules. Yet love and intimacy are at the root of what makes us sick and what makes us well. If a new medication had the same impact, failure to prescribe it would be malpractice. Connections with other people affect not only the quality of our lives but also our survival. Study after study find that people who are lonely are many times more likely to get cardiovascular disease than those who have a strong sense of connection and community.”

Ornish then offers a thought-provoking observation. “I’m not aware of any other factor in medicine—not diet, not smoking, not exercise, not genetics, not drugs, not surgery—that has a greater impact on our quality of life, incidence of illness and premature death. In part, this is because people who are lonely are more likely to engage in self-destructive behaviors. Getting through the day becomes more important than living a long life when you have no one else to live for.”

Ornish supports this statement by describing several studies. One was conducted at Yale and found that men and women who felt most loved and supported had substantially less blockage in their coronary arteries compared with those who did not feel loved. In another study undertaken by researchers at Case Western Reserve University, 10,000 married men were asked, “Does your wife show you her love?” The men who answered in the affirmative had significantly less angina. A third study at Duke examined men and women with heart disease and discovered that those who were single and had few, if any, friends were three times as likely to have died after five years as those who were married and had meaningful relationships.

Ornish emphasizes, “In all three studies, the protective effects of love were independent of other risk factors.” He concludes, “Awareness is the first step in healing. When we understand the connection between how we live and how long we live, it’s easier to make different choices. Instead of viewing the time we spend with friends and family as luxuries, we can see that these relationships are among the most powerful determinants of our well-being and survival. We are hard-wired to help each other. Science is documenting the healing values of love, intimacy, community, compassion, forgiveness, altruism, and service—values that are part of almost all spiritual traditions as well as many secular ones. Seen in this context, being unselfish may be the most self-serving approach to life, for it helps free both the giver and recipient from suffering, disease, and premature death. Rediscovering the wisdom of love and compassion may help us to survive at a time when an increasingly balkanized world so badly needs it.”

The genes we inherit certainly play an important role in our health. However, the studies described in this article offer ample proof that a person’s mindset and the behaviors that spring from this mindset are more important to our well-being than genes. Optimism, gratitude, love, and our connections to others serve to lessen or ward off physical diseases as well as pessimism and despair. The scientific evidence is very encouraging in terms of highlighting the many personal factors that are within our control to influence. The research data suggest that we all have untapped abilities to break free from negative emotions and engage in activities that harness and reinforce positive forces in our life—forces that contribute to our physical and emotional strength and our resilience.

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