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Distressed personality is associated with lower psychological well-being and life satisfaction, but not disability or disease activity in rheumatoid arthritis patients

Distressed personality is associated with lower psychological well-being and life satisfaction,... Clin Rheumatol (2012) 31:661–667 DOI 10.1007/s10067-011-1905-0 ORIGINAL ARTICLE Distressed personality is associated with lower psychological well-being and life satisfaction, but not disability or disease activity in rheumatoid arthritis patients Kim Klaassen & Ivan Nyklíček & Simone Traa & Ron de Nijs Received: 18 April 2011 /Revised: 5 December 2011 /Accepted: 5 December 2011 /Published online: 22 December 2011 The Author(s) 2011. This article is published with open access at Springerlink.com Abstract The distressed personality type (“type D person- Keywords Disease activity Distressed (type D) . . . ality”) has been shown to be associated with low quality of personality Mindfulness Quality of life Rheumatoid life and higher morbidity and mortality in various patient arthritis Well-being groups. Because the role of type D personality is unknown in patients with rheumatoid arthritis (RA), the aim of the present study was to investigate the association of type D Introduction personality with aspects of quality of life and disease activ- ity in RA patients. In addition, a potential buffering effect by Rheumatoid arthritis (RA) is the most common chronic accepting mindfulness was examined. Participants were 147 autoimmune arthritis [1, 2]. The disease generally follows patients between 22 and 87 years of age. Patients completed aremitting–flaring course of inflammation and pain and relevant questionnaires at home and the disease activity leads to increasing functional disability [1, 2]. Patients con- score was determined. After controlling for potentially con- fronted with the diagnosis of RA have to change their way founding variables, multivariate analyses of covariance of living [3] and they experience psychological distress showed an association of type D personality with a lower more often than people in the general population [4]. The satisfaction with life (p<0.001) and a lower psychological disease requires adaptation and involves many future uncer- well-being (p<0.001), but not disease activity in RA tainties because it cannot be cured. Therefore quality of life patients. Although mindfulness was associated with a higher in this population is recognised as a very important treat- satisfaction with life (p00.02) and positive mood (p00.01), ment outcome [5]. The evaluation of this quality depends it did not diminish the unfavourable associations between not only on the disease activity. Individuals can vary greatly type D and well-being. In conclusion, although type D in their psychological adaptation to the disease and this is personality is related with lower well-being, it does not not always explained by variations in inflammatory activity seem to be associated with disability or disease activity in [6]. Patients with a comparable clinical picture and time RA patients. since their diagnosis can evaluate their quality of life quite differently. This means that other factors than only the medical parameters may be responsible for these differen- K. Klaassen I. Nyklíček (*) ces. An emerging area of explanation of individual differ- Center of Research on Psychology in Somatic disease (CoRPS), Department of Medical Psychology, Tilburg University, ences in quality of life and physical functioning in medical PO Box 90153, 5000 LE, Tilburg, The Netherlands patients in general involve relatively stable individual dis- e-mail: [email protected] positions such as personality [7]. There is only little research regarding the relation be- S. Traa Department of Medical Psychology, Máxima Medical Centre, tween personality and the individual differences in quality Eindhoven, The Netherlands of life and physical functioning in rheumatoid arthritis patients. Optimism and the tendency to hold greater positive R. de Nijs outcome expectancies have been found to be related to Regional Rheumatic Center ZO-Brabant, Eindhoven, The Netherlands better psychological well-being in RA patients [8]. 662 Clin Rheumatol (2012) 31:661–667 Optimism may have a positive impact on physical health as been reported to enhance quality of life [23–25] and de- well, optimistic patients report fewer symptoms [9]. Patients crease pain or coping with pain [26, 27] in various clinical with negative affectivity (the tendency to experience nega- and non-clinical samples. In addition, preliminary data sug- tive mood states across situations and one of the compo- gest that mindfulness is associated with psychological well- nents of type D personality, see below) are reported to show being in fibromyalgia patients [28] and that mindfulness- lower health satisfaction scores [10]. RA patients in general based interventions may decrease T cell production of pro- report higher levels of negative affectivity compared to the inflammatory cytokines [29] which may be beneficial in RA general population [3, 11]. Negative affectivity is associated patients. with more negative emotions, including more symptoms of Therefore, the aim of the study was to investigate the anxiety and depression, which are known to affect quality of association of the distressed personality type (type D per- life unfavourably [12]. sonality) with aspects of quality of life, including psycho- Psychological characteristics have been found to be im- logical well-being, life satisfaction and disability, as well as portant determinants of functioning in other chronic dis- disease activity in rheumatoid arthritis patients and the po- eases. The distressed personality type (type D personality) tentially buffering effect of mindfulness. The hypotheses are has been identified as an important explanatory factor of that (a) type D patients report lower levels of these aspects individual differences in quality of life and also clinical of quality of life compared with non-type D patients, while outcomes in various patient groups, ranging from chronic (b) they show a more severe disease activity; (c) mindful- pain patients to patients with malignant melanoma [13]. ness buffers the effects mentioned in hypotheses (a) and (b). Type D personality refers to patients who frequently expe- rience negative emotions across situations (are high in neg- ative affectivity) in combination with a tendency not to Method express affect to others (termed social inhibition) [7, 14, 15]. Most type D personality research has been performed Patients and procedure in patients with cardiovascular diseases [7, 16], in which patients with a type D personality have been found not only Participants were recruited in the Regional Rheumatic Center to have an increased risk of psychological distress, but also ZO-Brabant, Eindhoven, the Netherlands, and were provided adverse clinical health status [7, 14, 17] and impaired qual- with information about the study by the rheumatologist. The ity of life [18]. Type D personality is also associated with a study complied with the Helsinki Declaration on human sub- high risk of cardiac events, such as myocardial infarction jects; the protocol being approved by the Medical Ethics [15, 19] and a threefold increased risk of a cardiac death in Committee of the Máxima Medical Center, Eindhoven, the cardiac patients [14, 17]. In addition, type D personality has Netherlands. been found to be associated with enhanced levels of pro- Inclusion criteria were a diagnosis of rheumatoid arthri- inflammatory cytokines TNF-α and its receptors [20], tis, starting treatment with methotrexate or a TNF-α antag- which are important disease parameters in RA [21]. onist (for a substudy not reported on here) and sufficient While the role of type D personality in cardiac and some understanding of written and spoken Dutch language. All other somatic patients has been found, the role of this patients had to be included within 4 weeks after start with psychological characteristic in rheumatoid arthritis patients this medication. The exclusion criteria were age ≥90 years, is unknown. Given its relations with psychological well- chronic severe psychiatric conditions (e.g. psychosis or a being, quality of life and levels of pro-inflammatory cyto- personality disorder) and any infections during last week. If kines in other patient samples, type D personality may be an the latter condition was the case, but was very temporary important factor in rheumatoid patients as well. (such as common cold), we aimed to postpone the inclusion In addition, mindfulness may be hypothesised to be a by 1 or 2 weeks, depending on the duration of the condition. buffering factor concerning the negative consequences of After explanation of the study, patients were asked to type D personality on aspects of quality of life and perhaps complete a questionnaire at home and to send it back within even physical health status. Mindfulness is commonly de- 1 week. In the case of refusal, a short questionnaire with fined as the state of being attentive to and aware of what is general variables such as gender, age, marital status, level of taking place in the present with an open and accepting (non- education and the time since diagnosis was attached to be judgemental) attitude. This quality of attention to the present able to compare participants with nonparticipants. Data moment has been claimed to buffer adverse consequences of were collected from 162 individuals: 147 participants negative emotions, which are strongly present in type Ds, by (91%) who completed questionnaires and 15 nonpartici- (a) identification and letting go of ruminative thoughts about pants (9%). None of the patients refused to provide the the past or future and (b) mental and bodily relaxation [22]. general data. Indeed, mindfulness-based psychological interventions have Clin Rheumatol (2012) 31:661–667 663 The disease activity score was measured by the rheuma- about the past week: “Are you able to…” perform a partic- tologist and had to be determined within a month before and ular task. The responses are scored on a four-point Likert a month after the questionnaire was completed. Average scale ranging from 0 (without any difficulty) to 3 (unable to time between patients' completion of the questionnaire and do) [31]. The Dutch version has good reliability: Cronbach's measurement of disease activity score was 5.6±9.6 days. α was between 0.85 and 0.95 in previous research [32] and 0.89 in this sample. Materials The Dutch version of the Satisfaction with Life Scale [33] is a brief questionnaire consisting of five items using Questionnaires a seven-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). It measures how satisfied patients are Type D personality was measured using the 14-item type with their present life. This questionnaire has an adequate D Scale (DS14) [15]. This questionnaire consists of construct validity and internal consistency: Cronbach's α of two subscales, negative affectivity and social inhibition, of 0.87 in previous research [33] and 0.92 in this study. seven items each. Items are scored on a five-point Likert The Dutch Global Mood Scale [34] consists of ten pos- scale ranging from 0 (false) to 4 (true). A cutoff score of ≥10 itive and ten negative mood terms. The patients have to on both scales is conventionally used to classify subjects as answer on a five-point Likert scale ranging from 0 (not at having type D personality. In previous research on the Dutch all) to 4 (extremely), the extent to which they have experi- version, the test–retest reliability over a 3-month period was enced each mood state lately. This questionnaire has ade- 0.72 and 0.82 for negative affectivity and social inhibition, quate construct validity and good internal consistency respectively, and the internal consistency (Cronbach's α) (Cronbach's α of 0.90 in previous research) [34] and Cron- was 0.88 and 0.86, respectively. Evidence for construct bach's α of 0.93 and 0.88 for negative and positive affect, validity is also provided [15]. In this sample, the internal respectively in this study. consistency was 0.83 for both subscales. The Dutch Symptoms of Anxiety and Depression [35] Mindfulness was assessed by means of the Freiburg scale consists of four items which are scored on a five-point Mindfulness Inventory-short-form (FMI-s) [30]. The FMI- Likert scale ranging from 0 (not at all) to 4 (very much). The s consists of 14 items and is regarded as an index of overall questionnaire is a reliable and brief index of mixed anxiety– mindfulness, including the aspects of attention to external depression symptoms. In this sample the Cronbach's α was and internal (proprioceptive and psychological) phenomena 0.85. Also in previous research, the scale had good internal in the present moment, accepting self-reflection and a non- consistency (Cronbach's α of 0.86) and validity [35]. reacting stance. These items are scored on a four-point Finally a questionnaire was employed for assessing differ- Likert scale ranging from 1 (rarely) to 4 (almost always). ent sociodemographic control variables, such as age, gender, The original FMI-s has shown good construct validity and education level (low0lower than midlevel vocational educa- internal consistency (Cronbach's α of 0.86) [30]. Because tion; high is at least midlevel vocational education) and mar- no Dutch translation was available at the start of the study, ital status (having a partner or not). The medical control the second author (IN) translated the FMI-s into Dutch variables time since diagnosis and treatment (methotrexate together with Drs. M. van der Lee and C. Völker (Helen or a TNF-α antagonist) were obtained from medical records. Dowling Institute, the Netherlands) and Dr. M. Schroevers (Groningen University, Netherlands), one of which is a Disease activity score native German speaker, using the standard back-translation method. Because of this new translation, we carefully tested The Disease Activity Score (DAS-28) [2] is originally a the internal consistency in the present sample, resulting in a Dutch instrument that indicates how active the RA is at a satisfactory Cronbach's α of 0.79. certain moment. The DAS-28 consists of four parts: (a) the Various instruments were used to measure different amount of swollen joints and (b) the amount of tender joints aspects of quality of life. The Health Assessment Question- as determined by the rheumatologist, (c) a general health naire [31] has been validated in groups of patients with a assessment on a visual analogue scale (VAS) (from 1–100) wide variety of rheumatic diseases, including rheumatoid obtained from the patient on self-evaluated disease severity arthritis, and measures the degree of disability. We used the and (d) erythrocyte sedimentation in the blood. The DAS-28 standard Dutch version [32], which consists of 20 items in score can be calculated using the formula; DAS-2800.54(√ eight categories which represent a comprehensive set of number of tender joints)+0.065 (number of swollen joints)+ functional activities (dressing and grooming, arising, eating, 0.33 (Ln erythrocyte sedimentation)+0.0072 (VAS score). walking, hygiene, reach, grip and common daily activities). This total score is a number between 0 and 10, indicating the These questions are part of the disability index score, with- amount of disease severity. This composite measure has out including questions regarding aids and devices and ask shown adequate validity [2, 36]. 664 Clin Rheumatol (2012) 31:661–667 Statistical analysis unstandardized β coefficient0−0.20, η 00.05), positively with life satisfaction (F [1,124]06.33, p00.01, unstandard- All analyses were performed using SPSS software. First ized β00.15, η 00.05), but also positively with disability participants and nonparticipants were compared on age, ratings (F [1,124]04.09, p00.05, unstandardized β00.01, gender, education, marital status and time since diagnosis η 00.03). Women reported a higher disability than men (F using independent sample t tests or chi-square tests. [1,124]05.99, p00.02, η 00.05) and reported more symp- The main analyses were multivariate analyses of covari- toms of anxiety and depression (F [1,124]08.66, p00.01, ance (MANCOVA) to examine associations between type D η 00.07). Longer time since diagnosis was associated with personality (independent variable) and the outcome varia- higher disability scores (F [1, 124]06.67, p00.01, unstan- bles. Separate analyses were performed for the cluster of dardized β00.002, η 00.05), but fewer symptoms of anxiety psychological variables (negative affect, positive affect, and depression (F [1,124]04.19, p00.04, unstandardized symptoms of anxiety and depression, health status and sat- β0−0.01, η 00.03). There were no significant associations isfaction with life) and for the cluster of disease activity between educational level and treatment condition and well- variables (swollen joints, tender joints, level of erythrocyte being or quality of life (p>0.10). sedimentation and VAS). In addition, the association be- Type D patients differed significantly from non-type D tween type D, mindfulness and total DAS-28 was examined patients on the omnibus test of the combined dependent using a separate univariate analysis of covariance. Finally, variables of aspects of quality of life (F [5,118]07.54, p< the type D by mindfulness interaction was explored on all 0.001, η 00.24), while controlled for age, sex, education, outcome variables to examine the potential buffer effect by treatment and time since diagnosis. Patients with a type D mindfulness. An α level of 0.05 was used in all analyses. In personality reported a lower psychological well-being than addition, all analyses were controlled for age, gender, edu- non-type D patients. They showed more symptoms of anx- cation level, time since diagnosis and treatment condition iety and depression (F [1,122]017.37, p<0.001, η 00.13), (methotrexate versus TNF-α). more negative affect (F [1,122]06.52, p00.01, η 00.05) and less positive affect (F [1,122]09.10, p00.003, η 0 0.07) (Table 2). Type D patients also reported a lower Results satisfaction with life than non-type D patients (F [1,122]0 25.44, p<0.001, η 00.17), but there was no significant Participants had a higher educational level than individuals difference regarding the disability score (F [1,122]00.34, who did not participate in the study: 87 (59.6%) versus 3 p00.56, η 00.003). (20.0 %) patients had at least midlevel vocational education When mindfulness was added to the model, the interac- (χ [1]07.12, p00.008). The nonparticipants did not differ tion effect of type D by mindfulness was not significant in from participants (all p>0.10) regarding age (57.4±11.3 vs the omnibus test (F [5,117]00.86, p00.51, η 00.01) or in 57.2±10.7 years), gender (81 (55.1%) vs 10 (66.7%) wom- univariate analyses (all p>0.10). Mindfulness did show a en), marital status (117 (80.1%) vs 11 (73.3%) having a significant omnibus main effect on the combined dependent partner), treatment (116 (78.9%) vs 10 (66.7%) having variables of aspects of quality of life (F [5,117]02.71, p0 methotrexate) or time since diagnosis (51.6±101.6 vs 42.4± 0.02, η 00.11). Univariate analyses showed that mindful- 54.7 months). ness was positively associated with positive affect (F Due to occasional missing data on the questionnaire data, [1,121]09.14, p00.003; unstandardized β coefficient0 analyses on questionnaire data were based on 141 patients, 0.35, η 00.05) and satisfaction with life (F [1,121]05.58, of whom 43 (30.5%) had a type D personality and 98 p00.02; unstandardized β00.24, η 00.05), but no associations (69.5%) were not type Ds, which is comparable to previous were found with the other variables. findings in cardiac patients [15]. Patients with a type D personality did not differ from non-type Ds regarding Disease activity all sociodemographic and background medical variables (Table 1). Type D patients did score lower on mindfulness Due to 42 missing values on the disease activity score, the compared with non-type D patients (35.0±5.7 vs 38.4±6.5; t number of participants in the analyses on disease activity [139]02.94, p00.004). was limited to 105. None of the covariates showed a signif- icant association with disease activity (all p>0.10). Type D Aspects of quality of life patients did not differ from non-type D patients on the combined dependent variables of disease activity in the Several covariates showed significant associations with omnibus test (F [4, 100]00.81, p00.52, η 00.02). Also in some aspects of quality of life. Age was negatively associ- univariate tests on the separate DAS components and total ated with negative affect (F [1,124]06.56, p00.01; DAS-28, no effects were obtained on erythrocyte sedimentation, Clin Rheumatol (2012) 31:661–667 665 Table 1 Characteristics of Type D personality (N043) Non-type D personality (N098) tor χ patients with rheumatoid arthritis with and without Age 54.9 (11.2) 58.4 (11.3) 1.70 distressed (type D) personality: means (SD) or numbers (%) Higher education 27 (62.8%) 59 (60.2%) 0.01 Female sex 25 (58.1%) 54 (55.1%) 0.00 Having a partner 32 (74.4%) 83 (84.7%) 0.75 TNF-alpha antagonist 7 (16.3%) 23 (23.5%) 0.69 Higher education—at least Months since diagnosis 33.3 (72.3) 60.0 (111.7) 1.68 midlevel vocational education Mindfulness 35.0 (5.7) 38.4 (6.5) 2.94* *p<0.01 swollen joints, tender joints, VAS and total DAS-28 (all p> buffering effects by mindfulness were obtained. Although 0.10). Also mindfulness and the type D by mindfulness inter- the interaction effect between type D and mindfulness on action did not show significant effects: omnibus test (F [4, erythrocyte sedimentation was in the expected direction and 2 2 93]00.38, p00.82, η 00.02 and F [4, 93]01.45, p00.22, η 0 significant, the simple effects within type D and non-type D 0.06, resp.) and univariate tests (p>0.10), except for erythro- groups were not. Because this may have been due to the cyte sedimentation (F [1, 96]04.00, p00.048, η 00.04). Post- small subgroup sample sizes as a result of missing sedimen- hoc analyses revealed a nonsignificant tendency for mindful- tation values, it may be fruitful for future studies to examine ness to be associated with lower erythrocyte sedimentation in this interaction effect in a larger sample. All in all, these type D, but not in non-type D, individuals (r0−0.19, N032 present results suggest that type D personality may be an type D, p>0.10 versus r00.11, N078 non-type D, p>0.10). important psychological characteristic associated with psy- chological well-being and life satisfaction, but not with reported disability or objective disease indicators, in RA Discussion patients. The association between type D and lower psychological The main aim of the present study was to examine the well-being and aspects of quality of life has been found earlier in several studies in cardiovascular patients [7, 18]. association of the distressed (type D) personality with aspects of quality of life, including psychological well- In these patients, a relation was also found between type D personality and enhanced levels of pro-inflammatory cyto- being, life satisfaction, and disability, as well as the disease activity in RA patients. In multivariate analyses, in which kines [20] and self-evaluated cardiac symptoms [15, 18]. The association between type D personality and disease various potentially confounding variables were controlled, type D patients reported lower positive mood, higher nega- activity was not found in the present sample of RA patients. tive affect, more symptoms of anxiety and depression and First, one should note that in contrast to cardiovascular lower general satisfaction with life compared to non-type D patients, all RA patients use some form of anti-inflammatory patients. No associations were found between type D per- medication. Nevertheless, the lack of associations with reported disability and objective disease indicators may be sonality and disability or disease activity scores. Also no Table 2 Type D personality in a a Type D (N031/43) Non-type D (N074/98) relation to psychological well-being, quality of life and Quality of life disease activity: means (and standard errors) from a Life satisfaction 20.94 (1.00)* 27.12 (0.68)** MANCOVA analysis Disability score 1.13 (0.10) 1.06 (0.07) Psychological well-being VAS visual analogue scale of Positive affect 16.91 (1.22)* 21.38 (0.82)** self-perceived disease severity, Negative affect 16.72 (1.43)** 12.26 (0.97)* DAS-28 disease activity score-28 Anxiety and depression 5.56 (0.48)* 3.12 (0.33)** *p<0.05; **p<0.01 Disease activity The higher N concerns self-report data, the lower N Swollen joints 6.09 (0.94) 7.08 (0.61) concerns disease activity; Tender joints 5.53 (0.86) 6.61 (0.56) analyses were controlled for age, VAS 55.96 (4.81) 50.27 (3.13) gender, education level, time Erythrocyte sedimentation 27.88 (4.06) 28.43 (2.64) since diagnosis and treatment condition (methotrexate or TNFα Total DAS-28 4.77 (0.25) 4.70 (0.16) antagonist) 666 Clin Rheumatol (2012) 31:661–667 due to the fact that these involve either ratings of ability to involved correlational data gathered at one time point, pre- perform rather concrete and specific behaviours—in case of cluding any possible conclusions along causal lines. Sec- the disability index—or mainly ratings by rheumatologists in ond, missing values in the disease activity score, especially combination with physiological parameters, both of which are regarding the erythrocyte sedimentation, resulted in reduced less or not at all influenced by the subjective interpretation by power of analyses on this outcome. In addition, it was not the patient as compared to the psychological variables used in possible to obtain erythrocyte scores at the same time point this study. It is known that type D personality is especially as the other data, introducing a small time gap between the associated with a gloomy view of life, as reflected by associ- assessment times, being 5.5 days on average, potentially ations with all kinds of psychological symptoms and low decreasing the effect size. ratings of subjective satisfaction with quality of life [13, 18]. A merit of the study is the high response rate. Ninety-one Why mindfulness did not buffer these associations is diffi- percent of patients asked to participate completed the ques- cult to explain. One possibility is the fact that patients with a tionnaires, resulting in adequate generalisability of the pres- type D personality scored significantly lower on mindfulness ent results to the RA population from which the participants compared to non-type Ds. Perhaps their lower mindfulness were drawn. scores prevented mindfulness to be able to buffer any effects In conclusion, the present study showed associations of the on psychological well-being. Another possibility is that the distressed (type D) personality with subjective indices of instrument used to measure mindfulness in this study is of a aspects of quality of life, such as psychological well-being too global nature as mindfulness has been conceptualised as a and life satisfaction in RA patients, but not with disability or multidimensional construct [37]. Perhaps specific mindful- objective indices of disease activity. Future research including ness skills, such as accepting one's thoughts and feelings prospective follow-up assessments is needed to be able to help without judgement or having a nonreactive stance towards to draw conclusions along causal lines. If the present results these internal phenomena may be more directly associated are confirmed and extended in future studies, interventions with various aspects of psychological well-being [37] and may be designed to meet the needs of patients with a type D with type D personality than a general mindfulness measure. personality, as outlined above. One may speculate if an intervention aimed at the enhance- ment of specific mindfulness skills may be useful to increase Acknowledgements The authors would like to thank Dr. Eveline Bicknese, Dr. Frans Hoogwegt and Dr. Anton Westgeest of Máxima psychological well-being in type D patients, as such mindful- Medical Center Eindhoven for their cooperation in providing the ness interventions have been found to enhance psychological context necessary for conducting the present study. well-being, satisfaction with life and coping with pain in various patient populations [23-26, 28, 29]. Alternatively, it Disclosures None. has been suggested that more patient-tailored interventions may be needed for type D patients to benefit from psycholog- Open Access This article is distributed under the terms of the Crea- ical interventions [38]. Dependent on the specific problems tive Commons Attribution Noncommercial License which permits any and needs of an individual patient, such an intervention may noncommercial use, distribution, and reproduction in any medium, apply a combination of approaches aimed at enhancing coping provided the original author(s) and source are credited. skills related to either the negative affectivity or social inhibi- tion component of type D, or both. Such approaches may include cognitive–behavioural therapy or mindfulness-based References cognitive therapy for the enhancement of mood and interper- sonal therapy and assertiveness training for feeling more 1. Symmons D, Turner G, Webb R, Asten P, Barrett E, Lunt M, Scott comfortable in social situations, including the context of in- D, Silman A (2002) The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century. Rheumatology teraction with health care providers [38]. Because such spe- (Oxford) 41:793–800 cific interventions for type D patients do not exist yet, despite 2. van Riel PL, van Gestel AM, van de Putte LB (1996) Development the fact that this personality type is associated with decreased and validation of response criteria in rheumatoid arthritis: steps psychological well-being and satisfaction with life, the clini- towards an international consensus on prognostic markers. Br J Rheumatol 35(Suppl 2):4–7 cian is advised to (a) routinely screen for type D personality 3. Krol B (1996) Quality of life in rheumatoid arthritis patients: the using the simple and brief 14-item DS-14 questionnaire [15] relation between personality, social support and depression [un- and (b) offer these patients the possibility for a conversation published dissertation]. Groningen University, Groningen with a psychologist, who may assess in more depth the risk of 4. Pincus T, Griffith J, Pearce S, Isenberg D (1996) Prevalence of self-reported depression in patients with rheumatoid arthritis. Br J psychological problems in these patients, and possibly offer Rheumatol 35:879–883 them specific psychological treatment. 5. Chou CY, Brauer DJ (2005) Temperament and satisfaction with This study has a number of limitations which must be health status among persons with rheumatoid arthritis. Clin Nurse considered when interpreting the results. First, the analyses Spec 19:94–100 Clin Rheumatol (2012) 31:661–667 667 6. Curtis R, Groarke A, Coughlan R, Gsel A (2005) Psychological 23. Carlson LE, Speca M, Patel KD, Goodey E (2003) Mindfulness- stress as a predictor of psychological adjustment and health status based stress reduction in relation to quality of life, mood, symp- in patients with rheumatoid arthritis. Patient Educ Couns 59:192–198 toms of stress, and immune parameters in breast and prostate 7. Denollet J, Vaes J, Brutsaert DL (2000) Inadequate response to cancer outpatients. Psychosom Med 65:571–581 treatment in coronary heart disease: adverse effects of type D 24. Nyklíček I, Kuijpers KF (2008) Effects of mindfulness-based personality and younger age on 5-year prognosis and quality of stress reduction intervention on psychological well-being and life. Circulation 102:630–635 quality of life: is increased mindfulness indeed the mechanism? 8. Treharne GJ, Lyons AC, Booth DA, Kitas GD (2007) Psycholog- Ann Behav Med 35:331–340 ical well-being across 1 year with rheumatoid arthritis: coping 25. Witek-Janusek L, Albuquerque K, Chroniak KR, Chroniak C, resources as buffers of perceived stress. Br J Health Psychol Durazo-Arvizu R, Mathews HL (2008) Effect of mindfulness 12:323–345 based stress reduction on immune function, quality of life and 9. Andersson G (1996) The benefits of optimism: a meta-analytic coping in women newly diagnosed with early stage breast cancer. review of the Life Orientation Test. Pers Indiv Diff 21:719–725 Brain Behav Immun 22:969–981 10. Hagglund KJ, Haley WE, Reveille JD, Alarcon GS (1989) Predicting 26. Grossman P, Tiefenthaler-Gilmer U, Raysz A, Kesper U (2007) individual differences in pain and functional impairment among Mindfulness training as an intervention for fibromyalgia: evidence patients with rheumatoid arthritis. Arthritis Rheum 32:851–858 of postintervention and 3-year follow-up benefits in well-being. 11. Suurmeijer TPBM, Van Sonderen FLP, Krol B, Doeglas DM, Van Psychother Psychosom 76:226–233 Den Heuvel WJA, Sanderman R (2005) The relationship between 27. Kingston J, Chadwick P, Meron D, Skinner TC (2007) A pilot personality, supportive transactions and support satisfaction, and randomized control trial investigating the effect of mindfulness mental health of patients with early rheumatoid arthritis. Results from practice on pain tolerance, psychological well-being, and physio- the Dutch part of the EURIDISS study. Soc Indicat Res 73:179–197 logical activity. J Psychosom Res 62:297–300 12. Watson D, Pennebaker JW (1989) Health complaints, stress, and 28. Veehof MM, Ten Klooster PM, Taal E, Westerhof GJ, Bohlmeijer distress: exploring the central role of negative affectivity. Psychol ET (2011) Psychometric properties of the Dutch Five Facet Mind- Rev 96:234–254 fulness Questionnaire (FFMQ) in patients with fibromyalgia. Clin 13. Mols F, Denollet J (2010) Type D personality among noncardio- Rheumatol 30:1045–1054 vascular patient populations: a systematic review. Gen Hosp Psy- 29. Carlson LE, Speca M, Patel KD, Faris P (2007) One year pre–post chiatry 32:66–72 intervention follow-up of psychological, immune, endocrine and 14. Denollet J, Sys SU, Stroobant N, Rombouts H, Gillebert TC, blood pressure outcomes of mindfulness-based stress reduction Brutsaert DL (1996) Personality as independent predictor of (MBSR) in breast and prostate cancer outpatients. Brain Behav long-term mortality in patients with coronary heart disease. Lancet Immun 21:1038–1049 347:417–421 30. Walach H, Buchheld N, Buttenmüller V, Kleinknecht N, Schmidt S 15. Denollet J (2005) DS14: standard assessment of negative affectiv- (2006) Measuring mindfulness: the Freiburg Mindfulness Inven- ity, social inhibition, and type D personality. Psychosom Med tory. Pers Indiv Diff 40:1543–1555 67:89–97 31. Bruce B, Fries JF (2003) The Stanford Health Assessment Ques- 16. Pedersen SS, Denollet J (2006) Is type D personality here to stay? tionnaire: a review of its history, issues, progress, and documenta- Emerging evidence across cardiovascular disease patient groups. tion. J Rheumatol 30:167–178 Curr Cardiol Rev 2:205–213 32. Boers M, Jacobs JW, van Vliet Vlieland TP, van Riel PL (2007) 17. Schiffer AA, Pedersen SS, Widdershoven JW, Hendriks EH, Winter Consensus Dutch health assessment questionnaire. Ann Rheum JB, Denollet J (2005) The distressed (type D) personality is Dis 66:132–133 independently associated with impaired health status and in- 33. Arrindell WA, Meeuwesen L, Huyse FJ (1991) The Satisfaction with creased depressive symptoms in chronic heart failure. Eur J Life Scale (SWLS): psychometric properties in a non-psychiatric Cardiovasc Prev Rehabil 12:341–346 medical outpatients sample. Pers Indiv Diff 12:117–123 18. Pedersen SS, Denollet J (2003) Type D personality, cardiac events, 34. Denollet J (1993) Emotional distress and fatigue in coronary heart and impaired quality of life: a review. Eur J Cardiovasc Prev disease: the Global Mood Scale (GMS). Psychol Med 23:111–121 Rehabil 10:241–248 35. Denollet J (2006) Recognizing increased risk of depressive comor- 19. Denollet J, Pedersen SS, Vrints CJ, Conraads VM (2006) Useful- bidity after myocardial infarction: looking for 4 symptoms of ness of type D personality in predicting five-year cardiac events anxiety-depression. Psychother Psychosom 75:346–352 above and beyond concurrent symptoms of stress in patients with 36. Prevoo ML, van 't Hof MA, Kuper HH, van Leeuwen MA, van de coronary heart disease. Am J Cardiol 97:970–973 Putte LB, van Riel PL (1995) Modified disease activity scores that 20. Denollet J, Conraads VM, Brutsaert DL, De Clerck LS, Stevens include twenty-eight-joint counts. Development and validation in a WJ, Vrints CJ (2003) Cytokines and immune activation in systolic prospective longitudinal study of patients with rheumatoid arthri- heart failure: the role of type D personality. Brain Behav Immun tis. Arthritis Rheum 38:44–48 17:304–309 37. Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L (2006) 21. Ackermann C, Kavanaugh A (2007) Tumor necrosis factor as a Using self-report assessment methods to explore facets of mind- therapeutic target of rheumatologic disease. Expert Opin Ther fulness. Assessment 13:27–45 Targets 11:1369–1384 38. Pelle AJ, Van den Broek KC, Denollet J (in press) Interventions in 22. Blackledge JT, Hayes SC (2001) Emotion regulation in acceptance the context of the distressed (type D) personality. In: Dornelas AE and commitment therapy. J Clin Psychol 57:243–255 (ed). Stress proof the heart. Springer, New York http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Clinical Rheumatology Pubmed Central

Distressed personality is associated with lower psychological well-being and life satisfaction, but not disability or disease activity in rheumatoid arthritis patients

Klaassen, Kim; Nyklíček, Ivan; Traa, Simone; de Nijs, Ron
Clinical Rheumatology , Volume 31 (4) – Dec 22, 2011
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0770-3198
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10.1007/s10067-011-1905-0
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Clin Rheumatol (2012) 31:661–667 DOI 10.1007/s10067-011-1905-0 ORIGINAL ARTICLE Distressed personality is associated with lower psychological well-being and life satisfaction, but not disability or disease activity in rheumatoid arthritis patients Kim Klaassen & Ivan Nyklíček & Simone Traa & Ron de Nijs Received: 18 April 2011 /Revised: 5 December 2011 /Accepted: 5 December 2011 /Published online: 22 December 2011 The Author(s) 2011. This article is published with open access at Springerlink.com Abstract The distressed personality type (“type D person- Keywords Disease activity Distressed (type D) . . . ality”) has been shown to be associated with low quality of personality Mindfulness Quality of life Rheumatoid life and higher morbidity and mortality in various patient arthritis Well-being groups. Because the role of type D personality is unknown in patients with rheumatoid arthritis (RA), the aim of the present study was to investigate the association of type D Introduction personality with aspects of quality of life and disease activ- ity in RA patients. In addition, a potential buffering effect by Rheumatoid arthritis (RA) is the most common chronic accepting mindfulness was examined. Participants were 147 autoimmune arthritis [1, 2]. The disease generally follows patients between 22 and 87 years of age. Patients completed aremitting–flaring course of inflammation and pain and relevant questionnaires at home and the disease activity leads to increasing functional disability [1, 2]. Patients con- score was determined. After controlling for potentially con- fronted with the diagnosis of RA have to change their way founding variables, multivariate analyses of covariance of living [3] and they experience psychological distress showed an association of type D personality with a lower more often than people in the general population [4]. The satisfaction with life (p<0.001) and a lower psychological disease requires adaptation and involves many future uncer- well-being (p<0.001), but not disease activity in RA tainties because it cannot be cured. Therefore quality of life patients. Although mindfulness was associated with a higher in this population is recognised as a very important treat- satisfaction with life (p00.02) and positive mood (p00.01), ment outcome [5]. The evaluation of this quality depends it did not diminish the unfavourable associations between not only on the disease activity. Individuals can vary greatly type D and well-being. In conclusion, although type D in their psychological adaptation to the disease and this is personality is related with lower well-being, it does not not always explained by variations in inflammatory activity seem to be associated with disability or disease activity in [6]. Patients with a comparable clinical picture and time RA patients. since their diagnosis can evaluate their quality of life quite differently. This means that other factors than only the medical parameters may be responsible for these differen- K. Klaassen I. Nyklíček (*) ces. An emerging area of explanation of individual differ- Center of Research on Psychology in Somatic disease (CoRPS), Department of Medical Psychology, Tilburg University, ences in quality of life and physical functioning in medical PO Box 90153, 5000 LE, Tilburg, The Netherlands patients in general involve relatively stable individual dis- e-mail: [email protected] positions such as personality [7]. There is only little research regarding the relation be- S. Traa Department of Medical Psychology, Máxima Medical Centre, tween personality and the individual differences in quality Eindhoven, The Netherlands of life and physical functioning in rheumatoid arthritis patients. Optimism and the tendency to hold greater positive R. de Nijs outcome expectancies have been found to be related to Regional Rheumatic Center ZO-Brabant, Eindhoven, The Netherlands better psychological well-being in RA patients [8]. 662 Clin Rheumatol (2012) 31:661–667 Optimism may have a positive impact on physical health as been reported to enhance quality of life [23–25] and de- well, optimistic patients report fewer symptoms [9]. Patients crease pain or coping with pain [26, 27] in various clinical with negative affectivity (the tendency to experience nega- and non-clinical samples. In addition, preliminary data sug- tive mood states across situations and one of the compo- gest that mindfulness is associated with psychological well- nents of type D personality, see below) are reported to show being in fibromyalgia patients [28] and that mindfulness- lower health satisfaction scores [10]. RA patients in general based interventions may decrease T cell production of pro- report higher levels of negative affectivity compared to the inflammatory cytokines [29] which may be beneficial in RA general population [3, 11]. Negative affectivity is associated patients. with more negative emotions, including more symptoms of Therefore, the aim of the study was to investigate the anxiety and depression, which are known to affect quality of association of the distressed personality type (type D per- life unfavourably [12]. sonality) with aspects of quality of life, including psycho- Psychological characteristics have been found to be im- logical well-being, life satisfaction and disability, as well as portant determinants of functioning in other chronic dis- disease activity in rheumatoid arthritis patients and the po- eases. The distressed personality type (type D personality) tentially buffering effect of mindfulness. The hypotheses are has been identified as an important explanatory factor of that (a) type D patients report lower levels of these aspects individual differences in quality of life and also clinical of quality of life compared with non-type D patients, while outcomes in various patient groups, ranging from chronic (b) they show a more severe disease activity; (c) mindful- pain patients to patients with malignant melanoma [13]. ness buffers the effects mentioned in hypotheses (a) and (b). Type D personality refers to patients who frequently expe- rience negative emotions across situations (are high in neg- ative affectivity) in combination with a tendency not to Method express affect to others (termed social inhibition) [7, 14, 15]. Most type D personality research has been performed Patients and procedure in patients with cardiovascular diseases [7, 16], in which patients with a type D personality have been found not only Participants were recruited in the Regional Rheumatic Center to have an increased risk of psychological distress, but also ZO-Brabant, Eindhoven, the Netherlands, and were provided adverse clinical health status [7, 14, 17] and impaired qual- with information about the study by the rheumatologist. The ity of life [18]. Type D personality is also associated with a study complied with the Helsinki Declaration on human sub- high risk of cardiac events, such as myocardial infarction jects; the protocol being approved by the Medical Ethics [15, 19] and a threefold increased risk of a cardiac death in Committee of the Máxima Medical Center, Eindhoven, the cardiac patients [14, 17]. In addition, type D personality has Netherlands. been found to be associated with enhanced levels of pro- Inclusion criteria were a diagnosis of rheumatoid arthri- inflammatory cytokines TNF-α and its receptors [20], tis, starting treatment with methotrexate or a TNF-α antag- which are important disease parameters in RA [21]. onist (for a substudy not reported on here) and sufficient While the role of type D personality in cardiac and some understanding of written and spoken Dutch language. All other somatic patients has been found, the role of this patients had to be included within 4 weeks after start with psychological characteristic in rheumatoid arthritis patients this medication. The exclusion criteria were age ≥90 years, is unknown. Given its relations with psychological well- chronic severe psychiatric conditions (e.g. psychosis or a being, quality of life and levels of pro-inflammatory cyto- personality disorder) and any infections during last week. If kines in other patient samples, type D personality may be an the latter condition was the case, but was very temporary important factor in rheumatoid patients as well. (such as common cold), we aimed to postpone the inclusion In addition, mindfulness may be hypothesised to be a by 1 or 2 weeks, depending on the duration of the condition. buffering factor concerning the negative consequences of After explanation of the study, patients were asked to type D personality on aspects of quality of life and perhaps complete a questionnaire at home and to send it back within even physical health status. Mindfulness is commonly de- 1 week. In the case of refusal, a short questionnaire with fined as the state of being attentive to and aware of what is general variables such as gender, age, marital status, level of taking place in the present with an open and accepting (non- education and the time since diagnosis was attached to be judgemental) attitude. This quality of attention to the present able to compare participants with nonparticipants. Data moment has been claimed to buffer adverse consequences of were collected from 162 individuals: 147 participants negative emotions, which are strongly present in type Ds, by (91%) who completed questionnaires and 15 nonpartici- (a) identification and letting go of ruminative thoughts about pants (9%). None of the patients refused to provide the the past or future and (b) mental and bodily relaxation [22]. general data. Indeed, mindfulness-based psychological interventions have Clin Rheumatol (2012) 31:661–667 663 The disease activity score was measured by the rheuma- about the past week: “Are you able to…” perform a partic- tologist and had to be determined within a month before and ular task. The responses are scored on a four-point Likert a month after the questionnaire was completed. Average scale ranging from 0 (without any difficulty) to 3 (unable to time between patients' completion of the questionnaire and do) [31]. The Dutch version has good reliability: Cronbach's measurement of disease activity score was 5.6±9.6 days. α was between 0.85 and 0.95 in previous research [32] and 0.89 in this sample. Materials The Dutch version of the Satisfaction with Life Scale [33] is a brief questionnaire consisting of five items using Questionnaires a seven-point Likert scale ranging from 1 (strongly disagree) to 7 (strongly agree). It measures how satisfied patients are Type D personality was measured using the 14-item type with their present life. This questionnaire has an adequate D Scale (DS14) [15]. This questionnaire consists of construct validity and internal consistency: Cronbach's α of two subscales, negative affectivity and social inhibition, of 0.87 in previous research [33] and 0.92 in this study. seven items each. Items are scored on a five-point Likert The Dutch Global Mood Scale [34] consists of ten pos- scale ranging from 0 (false) to 4 (true). A cutoff score of ≥10 itive and ten negative mood terms. The patients have to on both scales is conventionally used to classify subjects as answer on a five-point Likert scale ranging from 0 (not at having type D personality. In previous research on the Dutch all) to 4 (extremely), the extent to which they have experi- version, the test–retest reliability over a 3-month period was enced each mood state lately. This questionnaire has ade- 0.72 and 0.82 for negative affectivity and social inhibition, quate construct validity and good internal consistency respectively, and the internal consistency (Cronbach's α) (Cronbach's α of 0.90 in previous research) [34] and Cron- was 0.88 and 0.86, respectively. Evidence for construct bach's α of 0.93 and 0.88 for negative and positive affect, validity is also provided [15]. In this sample, the internal respectively in this study. consistency was 0.83 for both subscales. The Dutch Symptoms of Anxiety and Depression [35] Mindfulness was assessed by means of the Freiburg scale consists of four items which are scored on a five-point Mindfulness Inventory-short-form (FMI-s) [30]. The FMI- Likert scale ranging from 0 (not at all) to 4 (very much). The s consists of 14 items and is regarded as an index of overall questionnaire is a reliable and brief index of mixed anxiety– mindfulness, including the aspects of attention to external depression symptoms. In this sample the Cronbach's α was and internal (proprioceptive and psychological) phenomena 0.85. Also in previous research, the scale had good internal in the present moment, accepting self-reflection and a non- consistency (Cronbach's α of 0.86) and validity [35]. reacting stance. These items are scored on a four-point Finally a questionnaire was employed for assessing differ- Likert scale ranging from 1 (rarely) to 4 (almost always). ent sociodemographic control variables, such as age, gender, The original FMI-s has shown good construct validity and education level (low0lower than midlevel vocational educa- internal consistency (Cronbach's α of 0.86) [30]. Because tion; high is at least midlevel vocational education) and mar- no Dutch translation was available at the start of the study, ital status (having a partner or not). The medical control the second author (IN) translated the FMI-s into Dutch variables time since diagnosis and treatment (methotrexate together with Drs. M. van der Lee and C. Völker (Helen or a TNF-α antagonist) were obtained from medical records. Dowling Institute, the Netherlands) and Dr. M. Schroevers (Groningen University, Netherlands), one of which is a Disease activity score native German speaker, using the standard back-translation method. Because of this new translation, we carefully tested The Disease Activity Score (DAS-28) [2] is originally a the internal consistency in the present sample, resulting in a Dutch instrument that indicates how active the RA is at a satisfactory Cronbach's α of 0.79. certain moment. The DAS-28 consists of four parts: (a) the Various instruments were used to measure different amount of swollen joints and (b) the amount of tender joints aspects of quality of life. The Health Assessment Question- as determined by the rheumatologist, (c) a general health naire [31] has been validated in groups of patients with a assessment on a visual analogue scale (VAS) (from 1–100) wide variety of rheumatic diseases, including rheumatoid obtained from the patient on self-evaluated disease severity arthritis, and measures the degree of disability. We used the and (d) erythrocyte sedimentation in the blood. The DAS-28 standard Dutch version [32], which consists of 20 items in score can be calculated using the formula; DAS-2800.54(√ eight categories which represent a comprehensive set of number of tender joints)+0.065 (number of swollen joints)+ functional activities (dressing and grooming, arising, eating, 0.33 (Ln erythrocyte sedimentation)+0.0072 (VAS score). walking, hygiene, reach, grip and common daily activities). This total score is a number between 0 and 10, indicating the These questions are part of the disability index score, with- amount of disease severity. This composite measure has out including questions regarding aids and devices and ask shown adequate validity [2, 36]. 664 Clin Rheumatol (2012) 31:661–667 Statistical analysis unstandardized β coefficient0−0.20, η 00.05), positively with life satisfaction (F [1,124]06.33, p00.01, unstandard- All analyses were performed using SPSS software. First ized β00.15, η 00.05), but also positively with disability participants and nonparticipants were compared on age, ratings (F [1,124]04.09, p00.05, unstandardized β00.01, gender, education, marital status and time since diagnosis η 00.03). Women reported a higher disability than men (F using independent sample t tests or chi-square tests. [1,124]05.99, p00.02, η 00.05) and reported more symp- The main analyses were multivariate analyses of covari- toms of anxiety and depression (F [1,124]08.66, p00.01, ance (MANCOVA) to examine associations between type D η 00.07). Longer time since diagnosis was associated with personality (independent variable) and the outcome varia- higher disability scores (F [1, 124]06.67, p00.01, unstan- bles. Separate analyses were performed for the cluster of dardized β00.002, η 00.05), but fewer symptoms of anxiety psychological variables (negative affect, positive affect, and depression (F [1,124]04.19, p00.04, unstandardized symptoms of anxiety and depression, health status and sat- β0−0.01, η 00.03). There were no significant associations isfaction with life) and for the cluster of disease activity between educational level and treatment condition and well- variables (swollen joints, tender joints, level of erythrocyte being or quality of life (p>0.10). sedimentation and VAS). In addition, the association be- Type D patients differed significantly from non-type D tween type D, mindfulness and total DAS-28 was examined patients on the omnibus test of the combined dependent using a separate univariate analysis of covariance. Finally, variables of aspects of quality of life (F [5,118]07.54, p< the type D by mindfulness interaction was explored on all 0.001, η 00.24), while controlled for age, sex, education, outcome variables to examine the potential buffer effect by treatment and time since diagnosis. Patients with a type D mindfulness. An α level of 0.05 was used in all analyses. In personality reported a lower psychological well-being than addition, all analyses were controlled for age, gender, edu- non-type D patients. They showed more symptoms of anx- cation level, time since diagnosis and treatment condition iety and depression (F [1,122]017.37, p<0.001, η 00.13), (methotrexate versus TNF-α). more negative affect (F [1,122]06.52, p00.01, η 00.05) and less positive affect (F [1,122]09.10, p00.003, η 0 0.07) (Table 2). Type D patients also reported a lower Results satisfaction with life than non-type D patients (F [1,122]0 25.44, p<0.001, η 00.17), but there was no significant Participants had a higher educational level than individuals difference regarding the disability score (F [1,122]00.34, who did not participate in the study: 87 (59.6%) versus 3 p00.56, η 00.003). (20.0 %) patients had at least midlevel vocational education When mindfulness was added to the model, the interac- (χ [1]07.12, p00.008). The nonparticipants did not differ tion effect of type D by mindfulness was not significant in from participants (all p>0.10) regarding age (57.4±11.3 vs the omnibus test (F [5,117]00.86, p00.51, η 00.01) or in 57.2±10.7 years), gender (81 (55.1%) vs 10 (66.7%) wom- univariate analyses (all p>0.10). Mindfulness did show a en), marital status (117 (80.1%) vs 11 (73.3%) having a significant omnibus main effect on the combined dependent partner), treatment (116 (78.9%) vs 10 (66.7%) having variables of aspects of quality of life (F [5,117]02.71, p0 methotrexate) or time since diagnosis (51.6±101.6 vs 42.4± 0.02, η 00.11). Univariate analyses showed that mindful- 54.7 months). ness was positively associated with positive affect (F Due to occasional missing data on the questionnaire data, [1,121]09.14, p00.003; unstandardized β coefficient0 analyses on questionnaire data were based on 141 patients, 0.35, η 00.05) and satisfaction with life (F [1,121]05.58, of whom 43 (30.5%) had a type D personality and 98 p00.02; unstandardized β00.24, η 00.05), but no associations (69.5%) were not type Ds, which is comparable to previous were found with the other variables. findings in cardiac patients [15]. Patients with a type D personality did not differ from non-type Ds regarding Disease activity all sociodemographic and background medical variables (Table 1). Type D patients did score lower on mindfulness Due to 42 missing values on the disease activity score, the compared with non-type D patients (35.0±5.7 vs 38.4±6.5; t number of participants in the analyses on disease activity [139]02.94, p00.004). was limited to 105. None of the covariates showed a signif- icant association with disease activity (all p>0.10). Type D Aspects of quality of life patients did not differ from non-type D patients on the combined dependent variables of disease activity in the Several covariates showed significant associations with omnibus test (F [4, 100]00.81, p00.52, η 00.02). Also in some aspects of quality of life. Age was negatively associ- univariate tests on the separate DAS components and total ated with negative affect (F [1,124]06.56, p00.01; DAS-28, no effects were obtained on erythrocyte sedimentation, Clin Rheumatol (2012) 31:661–667 665 Table 1 Characteristics of Type D personality (N043) Non-type D personality (N098) tor χ patients with rheumatoid arthritis with and without Age 54.9 (11.2) 58.4 (11.3) 1.70 distressed (type D) personality: means (SD) or numbers (%) Higher education 27 (62.8%) 59 (60.2%) 0.01 Female sex 25 (58.1%) 54 (55.1%) 0.00 Having a partner 32 (74.4%) 83 (84.7%) 0.75 TNF-alpha antagonist 7 (16.3%) 23 (23.5%) 0.69 Higher education—at least Months since diagnosis 33.3 (72.3) 60.0 (111.7) 1.68 midlevel vocational education Mindfulness 35.0 (5.7) 38.4 (6.5) 2.94* *p<0.01 swollen joints, tender joints, VAS and total DAS-28 (all p> buffering effects by mindfulness were obtained. Although 0.10). Also mindfulness and the type D by mindfulness inter- the interaction effect between type D and mindfulness on action did not show significant effects: omnibus test (F [4, erythrocyte sedimentation was in the expected direction and 2 2 93]00.38, p00.82, η 00.02 and F [4, 93]01.45, p00.22, η 0 significant, the simple effects within type D and non-type D 0.06, resp.) and univariate tests (p>0.10), except for erythro- groups were not. Because this may have been due to the cyte sedimentation (F [1, 96]04.00, p00.048, η 00.04). Post- small subgroup sample sizes as a result of missing sedimen- hoc analyses revealed a nonsignificant tendency for mindful- tation values, it may be fruitful for future studies to examine ness to be associated with lower erythrocyte sedimentation in this interaction effect in a larger sample. All in all, these type D, but not in non-type D, individuals (r0−0.19, N032 present results suggest that type D personality may be an type D, p>0.10 versus r00.11, N078 non-type D, p>0.10). important psychological characteristic associated with psy- chological well-being and life satisfaction, but not with reported disability or objective disease indicators, in RA Discussion patients. The association between type D and lower psychological The main aim of the present study was to examine the well-being and aspects of quality of life has been found earlier in several studies in cardiovascular patients [7, 18]. association of the distressed (type D) personality with aspects of quality of life, including psychological well- In these patients, a relation was also found between type D personality and enhanced levels of pro-inflammatory cyto- being, life satisfaction, and disability, as well as the disease activity in RA patients. In multivariate analyses, in which kines [20] and self-evaluated cardiac symptoms [15, 18]. The association between type D personality and disease various potentially confounding variables were controlled, type D patients reported lower positive mood, higher nega- activity was not found in the present sample of RA patients. tive affect, more symptoms of anxiety and depression and First, one should note that in contrast to cardiovascular lower general satisfaction with life compared to non-type D patients, all RA patients use some form of anti-inflammatory patients. No associations were found between type D per- medication. Nevertheless, the lack of associations with reported disability and objective disease indicators may be sonality and disability or disease activity scores. Also no Table 2 Type D personality in a a Type D (N031/43) Non-type D (N074/98) relation to psychological well-being, quality of life and Quality of life disease activity: means (and standard errors) from a Life satisfaction 20.94 (1.00)* 27.12 (0.68)** MANCOVA analysis Disability score 1.13 (0.10) 1.06 (0.07) Psychological well-being VAS visual analogue scale of Positive affect 16.91 (1.22)* 21.38 (0.82)** self-perceived disease severity, Negative affect 16.72 (1.43)** 12.26 (0.97)* DAS-28 disease activity score-28 Anxiety and depression 5.56 (0.48)* 3.12 (0.33)** *p<0.05; **p<0.01 Disease activity The higher N concerns self-report data, the lower N Swollen joints 6.09 (0.94) 7.08 (0.61) concerns disease activity; Tender joints 5.53 (0.86) 6.61 (0.56) analyses were controlled for age, VAS 55.96 (4.81) 50.27 (3.13) gender, education level, time Erythrocyte sedimentation 27.88 (4.06) 28.43 (2.64) since diagnosis and treatment condition (methotrexate or TNFα Total DAS-28 4.77 (0.25) 4.70 (0.16) antagonist) 666 Clin Rheumatol (2012) 31:661–667 due to the fact that these involve either ratings of ability to involved correlational data gathered at one time point, pre- perform rather concrete and specific behaviours—in case of cluding any possible conclusions along causal lines. Sec- the disability index—or mainly ratings by rheumatologists in ond, missing values in the disease activity score, especially combination with physiological parameters, both of which are regarding the erythrocyte sedimentation, resulted in reduced less or not at all influenced by the subjective interpretation by power of analyses on this outcome. In addition, it was not the patient as compared to the psychological variables used in possible to obtain erythrocyte scores at the same time point this study. It is known that type D personality is especially as the other data, introducing a small time gap between the associated with a gloomy view of life, as reflected by associ- assessment times, being 5.5 days on average, potentially ations with all kinds of psychological symptoms and low decreasing the effect size. ratings of subjective satisfaction with quality of life [13, 18]. A merit of the study is the high response rate. Ninety-one Why mindfulness did not buffer these associations is diffi- percent of patients asked to participate completed the ques- cult to explain. One possibility is the fact that patients with a tionnaires, resulting in adequate generalisability of the pres- type D personality scored significantly lower on mindfulness ent results to the RA population from which the participants compared to non-type Ds. Perhaps their lower mindfulness were drawn. scores prevented mindfulness to be able to buffer any effects In conclusion, the present study showed associations of the on psychological well-being. Another possibility is that the distressed (type D) personality with subjective indices of instrument used to measure mindfulness in this study is of a aspects of quality of life, such as psychological well-being too global nature as mindfulness has been conceptualised as a and life satisfaction in RA patients, but not with disability or multidimensional construct [37]. Perhaps specific mindful- objective indices of disease activity. Future research including ness skills, such as accepting one's thoughts and feelings prospective follow-up assessments is needed to be able to help without judgement or having a nonreactive stance towards to draw conclusions along causal lines. If the present results these internal phenomena may be more directly associated are confirmed and extended in future studies, interventions with various aspects of psychological well-being [37] and may be designed to meet the needs of patients with a type D with type D personality than a general mindfulness measure. personality, as outlined above. One may speculate if an intervention aimed at the enhance- ment of specific mindfulness skills may be useful to increase Acknowledgements The authors would like to thank Dr. Eveline Bicknese, Dr. Frans Hoogwegt and Dr. Anton Westgeest of Máxima psychological well-being in type D patients, as such mindful- Medical Center Eindhoven for their cooperation in providing the ness interventions have been found to enhance psychological context necessary for conducting the present study. well-being, satisfaction with life and coping with pain in various patient populations [23-26, 28, 29]. Alternatively, it Disclosures None. has been suggested that more patient-tailored interventions may be needed for type D patients to benefit from psycholog- Open Access This article is distributed under the terms of the Crea- ical interventions [38]. Dependent on the specific problems tive Commons Attribution Noncommercial License which permits any and needs of an individual patient, such an intervention may noncommercial use, distribution, and reproduction in any medium, apply a combination of approaches aimed at enhancing coping provided the original author(s) and source are credited. skills related to either the negative affectivity or social inhibi- tion component of type D, or both. Such approaches may include cognitive–behavioural therapy or mindfulness-based References cognitive therapy for the enhancement of mood and interper- sonal therapy and assertiveness training for feeling more 1. Symmons D, Turner G, Webb R, Asten P, Barrett E, Lunt M, Scott comfortable in social situations, including the context of in- D, Silman A (2002) The prevalence of rheumatoid arthritis in the United Kingdom: new estimates for a new century. Rheumatology teraction with health care providers [38]. Because such spe- (Oxford) 41:793–800 cific interventions for type D patients do not exist yet, despite 2. van Riel PL, van Gestel AM, van de Putte LB (1996) Development the fact that this personality type is associated with decreased and validation of response criteria in rheumatoid arthritis: steps psychological well-being and satisfaction with life, the clini- towards an international consensus on prognostic markers. Br J Rheumatol 35(Suppl 2):4–7 cian is advised to (a) routinely screen for type D personality 3. Krol B (1996) Quality of life in rheumatoid arthritis patients: the using the simple and brief 14-item DS-14 questionnaire [15] relation between personality, social support and depression [un- and (b) offer these patients the possibility for a conversation published dissertation]. Groningen University, Groningen with a psychologist, who may assess in more depth the risk of 4. Pincus T, Griffith J, Pearce S, Isenberg D (1996) Prevalence of self-reported depression in patients with rheumatoid arthritis. Br J psychological problems in these patients, and possibly offer Rheumatol 35:879–883 them specific psychological treatment. 5. Chou CY, Brauer DJ (2005) Temperament and satisfaction with This study has a number of limitations which must be health status among persons with rheumatoid arthritis. Clin Nurse considered when interpreting the results. First, the analyses Spec 19:94–100 Clin Rheumatol (2012) 31:661–667 667 6. Curtis R, Groarke A, Coughlan R, Gsel A (2005) Psychological 23. Carlson LE, Speca M, Patel KD, Goodey E (2003) Mindfulness- stress as a predictor of psychological adjustment and health status based stress reduction in relation to quality of life, mood, symp- in patients with rheumatoid arthritis. Patient Educ Couns 59:192–198 toms of stress, and immune parameters in breast and prostate 7. Denollet J, Vaes J, Brutsaert DL (2000) Inadequate response to cancer outpatients. Psychosom Med 65:571–581 treatment in coronary heart disease: adverse effects of type D 24. Nyklíček I, Kuijpers KF (2008) Effects of mindfulness-based personality and younger age on 5-year prognosis and quality of stress reduction intervention on psychological well-being and life. Circulation 102:630–635 quality of life: is increased mindfulness indeed the mechanism? 8. Treharne GJ, Lyons AC, Booth DA, Kitas GD (2007) Psycholog- Ann Behav Med 35:331–340 ical well-being across 1 year with rheumatoid arthritis: coping 25. Witek-Janusek L, Albuquerque K, Chroniak KR, Chroniak C, resources as buffers of perceived stress. Br J Health Psychol Durazo-Arvizu R, Mathews HL (2008) Effect of mindfulness 12:323–345 based stress reduction on immune function, quality of life and 9. Andersson G (1996) The benefits of optimism: a meta-analytic coping in women newly diagnosed with early stage breast cancer. review of the Life Orientation Test. Pers Indiv Diff 21:719–725 Brain Behav Immun 22:969–981 10. Hagglund KJ, Haley WE, Reveille JD, Alarcon GS (1989) Predicting 26. Grossman P, Tiefenthaler-Gilmer U, Raysz A, Kesper U (2007) individual differences in pain and functional impairment among Mindfulness training as an intervention for fibromyalgia: evidence patients with rheumatoid arthritis. Arthritis Rheum 32:851–858 of postintervention and 3-year follow-up benefits in well-being. 11. Suurmeijer TPBM, Van Sonderen FLP, Krol B, Doeglas DM, Van Psychother Psychosom 76:226–233 Den Heuvel WJA, Sanderman R (2005) The relationship between 27. Kingston J, Chadwick P, Meron D, Skinner TC (2007) A pilot personality, supportive transactions and support satisfaction, and randomized control trial investigating the effect of mindfulness mental health of patients with early rheumatoid arthritis. Results from practice on pain tolerance, psychological well-being, and physio- the Dutch part of the EURIDISS study. Soc Indicat Res 73:179–197 logical activity. J Psychosom Res 62:297–300 12. Watson D, Pennebaker JW (1989) Health complaints, stress, and 28. Veehof MM, Ten Klooster PM, Taal E, Westerhof GJ, Bohlmeijer distress: exploring the central role of negative affectivity. Psychol ET (2011) Psychometric properties of the Dutch Five Facet Mind- Rev 96:234–254 fulness Questionnaire (FFMQ) in patients with fibromyalgia. Clin 13. Mols F, Denollet J (2010) Type D personality among noncardio- Rheumatol 30:1045–1054 vascular patient populations: a systematic review. Gen Hosp Psy- 29. Carlson LE, Speca M, Patel KD, Faris P (2007) One year pre–post chiatry 32:66–72 intervention follow-up of psychological, immune, endocrine and 14. Denollet J, Sys SU, Stroobant N, Rombouts H, Gillebert TC, blood pressure outcomes of mindfulness-based stress reduction Brutsaert DL (1996) Personality as independent predictor of (MBSR) in breast and prostate cancer outpatients. Brain Behav long-term mortality in patients with coronary heart disease. Lancet Immun 21:1038–1049 347:417–421 30. Walach H, Buchheld N, Buttenmüller V, Kleinknecht N, Schmidt S 15. Denollet J (2005) DS14: standard assessment of negative affectiv- (2006) Measuring mindfulness: the Freiburg Mindfulness Inven- ity, social inhibition, and type D personality. Psychosom Med tory. Pers Indiv Diff 40:1543–1555 67:89–97 31. Bruce B, Fries JF (2003) The Stanford Health Assessment Ques- 16. Pedersen SS, Denollet J (2006) Is type D personality here to stay? tionnaire: a review of its history, issues, progress, and documenta- Emerging evidence across cardiovascular disease patient groups. tion. J Rheumatol 30:167–178 Curr Cardiol Rev 2:205–213 32. Boers M, Jacobs JW, van Vliet Vlieland TP, van Riel PL (2007) 17. Schiffer AA, Pedersen SS, Widdershoven JW, Hendriks EH, Winter Consensus Dutch health assessment questionnaire. Ann Rheum JB, Denollet J (2005) The distressed (type D) personality is Dis 66:132–133 independently associated with impaired health status and in- 33. Arrindell WA, Meeuwesen L, Huyse FJ (1991) The Satisfaction with creased depressive symptoms in chronic heart failure. Eur J Life Scale (SWLS): psychometric properties in a non-psychiatric Cardiovasc Prev Rehabil 12:341–346 medical outpatients sample. Pers Indiv Diff 12:117–123 18. Pedersen SS, Denollet J (2003) Type D personality, cardiac events, 34. Denollet J (1993) Emotional distress and fatigue in coronary heart and impaired quality of life: a review. Eur J Cardiovasc Prev disease: the Global Mood Scale (GMS). Psychol Med 23:111–121 Rehabil 10:241–248 35. Denollet J (2006) Recognizing increased risk of depressive comor- 19. Denollet J, Pedersen SS, Vrints CJ, Conraads VM (2006) Useful- bidity after myocardial infarction: looking for 4 symptoms of ness of type D personality in predicting five-year cardiac events anxiety-depression. Psychother Psychosom 75:346–352 above and beyond concurrent symptoms of stress in patients with 36. Prevoo ML, van 't Hof MA, Kuper HH, van Leeuwen MA, van de coronary heart disease. Am J Cardiol 97:970–973 Putte LB, van Riel PL (1995) Modified disease activity scores that 20. Denollet J, Conraads VM, Brutsaert DL, De Clerck LS, Stevens include twenty-eight-joint counts. Development and validation in a WJ, Vrints CJ (2003) Cytokines and immune activation in systolic prospective longitudinal study of patients with rheumatoid arthri- heart failure: the role of type D personality. Brain Behav Immun tis. Arthritis Rheum 38:44–48 17:304–309 37. Baer RA, Smith GT, Hopkins J, Krietemeyer J, Toney L (2006) 21. Ackermann C, Kavanaugh A (2007) Tumor necrosis factor as a Using self-report assessment methods to explore facets of mind- therapeutic target of rheumatologic disease. Expert Opin Ther fulness. Assessment 13:27–45 Targets 11:1369–1384 38. Pelle AJ, Van den Broek KC, Denollet J (in press) Interventions in 22. Blackledge JT, Hayes SC (2001) Emotion regulation in acceptance the context of the distressed (type D) personality. In: Dornelas AE and commitment therapy. J Clin Psychol 57:243–255 (ed). Stress proof the heart. Springer, New York

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Clinical Rheumatology – Pubmed Central

Published: Dec 22, 2011

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