Letter to the Editor Received: March 8, 2011 Accepted after revision: June 22, 2011 Published online: February 2, 2012
Psychother Psychosom 2012;81:118–120 DOI: 10.1159/000330215
Type D Personality and Alexithymia among Psychiatric Outpatients John S. Ogrodniczuka , Carlos Sierra Hernandeza , Ingrid Sochtingb, Anthony S. Joycea , William E. Pipera a
Department of Psychiatry, University of British Columbia, Vancouver, B.C., and b Department of Psychiatry, Richmond Hospital, Richmond, B.C., Canada
Individuals with ‘distressed’ (type D) personality tend to harbor negative emotions and engage in pervasive withdrawal or avoidance of social contact or communication [1, 2]. Originally developed to study the role of personality traits in outcomes among cardiovascular patient populations [3], interest in the construct expanded and its value has since been confirmed in several other patient populations, demonstrating associations with poor physical and mental health and poor self-management of disease [4]. One mechanism that might explain the link between type D personality and poor health outcomes is maladaptive affect regulation. The developers of the type D construct argue that ‘it is not the experience of negative emotions per se, but rather the chronic psychological distress that results from holding back negative emotions, that is likely to affect … health’ [5, pp 583]. A great deal of evidence supports the connection between difficulties with affect regulation and poor physical and mental health [6, 7]. One construct that has received attention within this literature is alexithymia, generally understood as a trait deficit in the cognitive processing of emotional experience, such that individuals have limited capacity to symbolize emotions and elaborate upon emotional experience [8]. Individuals with alexithymia have difficulties identifying and expressing feelings, distinguishing emotions from bodily sensations, and have an externally orientated style of thinking. They are often beset by diffuse negative affect and are socially avoidant, dull, and less emotionally attached to others [9]. It has been found to be associated with poor health outcomes in a variety of populations [10–12]. Authors have speculated that the characteristics of alexithymic individuals reflect the type D personality profile [13]. However, we are not aware of any published reports on the association between these constructs, a shortcoming in the literature recently highlighted by others [10]. To this end, the present study examined the association between type D personality and alexithymia among a psychiatric outpatient sample, a population expected to report high levels of both personality characteristics [14, 15].
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Participants (n = 68) were consecutively admitted patients to the Core Program of the Richmond Mental Health Outpatient Services, a psychotherapy service that receives referrals from family physicians and community mental health agencies. Diagnostic assessments were not performed for this study. However, diagnoses provided by the referring sources indicated that 70% of subjects presented with a depressive disorder and 20% presented with an anxiety disorder. Participants’ average age was 42.5 years (SD = 10.5, range = 19–61). Seventy-three percent were women. Forty percent were married or living with a partner, 73% were educated beyond high school, 88% reported receiving previous psychiatric treatment, but fewer (18%) had a history of psychiatric hospitalization. Ethics approval for the study was received and subjects participated with informed voluntary written consent. The type D personality scale (DS14) is a 14-item scale comprised of two subscales: a 7-item subscale which measures negative affectivity (NA), and a 7-item subscale measuring social inhibition (SI) [1]. Participants who score highly on both NA and SI using a cutoff point of 610 on both scales are classified as having a type D personality. The Toronto Alexithymia Scale 20 [16] is a 20-item scale composed of three subscales. It provides an overall score for alexithymia, as well as subscores for each of the three core factors of alexithymia: difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking. The Beck Depression Inventory (BDI-II) [17] was used to control for depressive symptom severity due to the potential confounding effect of depression on the assessment of alexithymia and type D personality [18]. Analysis of covariance was performed to examine the association between a designation of type D personality and alexithymia. Depressive symptoms (BDI score) served as a covariate. Given recent findings suggesting that type D may be more appropriately treated as a dimensional construct [19], we also calculated partial correlations (controlling for depressive symptoms) to assess the association between type D (NA ! SI) and alexithymia. Finally, partial correlations were calculated to assess the associations between the components of type D personality and alexithymia, while controlling for depressive symptom severity. Among the 68 participants, 56 (82.4%) were classified as having type D personality by using the recommended cutoff point of 610 on both NA (mean = 20.82; SD = 4.69) and SI (mean = 19.41; SD = 4.76) subscales.
This work was conducted in the Department of Psychiatry, Richmond Hospital, Richmond, B.C., Canada.
Table 1. Associations between alexithymia and type D personality
Alexithymia
Type D (categorical) type D
non-type D
F
p
Total score Difficulty identifying feelings Difficulty describing feelings Externally oriented thinking
62.1 (10.1) 24.5 (4.6) 17.4 (4.4) 20.2 (4.6)
48.7 (9.8) 20.8 (7.1) 12.4 (4.0) 15.5 (4.6)
12.22 1.81 8.88 10.84
0.001 0.184 0.004 0.002
Alexithymia
Type D (dimensional) overall score
negative affectivity
social inhibition
0.40 (p = 0.001) 0.22 (p = 0.079) 0.26 (p = 0.033) 0.41 (p = 0.001)
0.34 (p = 0.006) 0.38 (p = 0.002) 0.20 (p = 0.109) 0.17 (p = 0.186)
0.39 (p = 0.001) 0.14 (p = 0.251) 0.30 (p = 0.015) 0.42 (p = 0.000)
Total score Difficulty identifying feelings Difficulty describing feelings Externally oriented thinking
Control variable in all analyses = Beck Depression Inventory total score.
Patients with type D personality presented with higher overall alexithymia, greater difficulties describing feelings, and more externally oriented thinking (table 1). Difficulty identifying feelings did not differ between those with or without type D designation. Table 1 also shows that type D was significantly correlated with overall alexithymia, difficulty describing feelings, and externally oriented thinking. We also found that NA was significantly associated with difficulty identifying feelings. SI was significantly associated with difficulty describing feelings and externally oriented thinking. Type D patients were more alexithymic than non-type D patients. They had greater difficulties communicating their feelings and a stronger propensity to engage in externally oriented thinking. Furthermore, the proclivity to negative affect (one type D feature) was associated with difficulties identifying one’s feelings. The tendency for SI (another type D feature) was associated with difficulties describing feelings and externally oriented thinking. Given the high prevalence of both alexithymia and type D characteristics in this psychiatric outpatient sample, and the strong association between the two constructs, it is tempting to speculate on the role that they might play in affecting the adaptive functioning of such patients. However, the correlational nature of our study precludes conclusions about causality. Since the basic tenet of type D personality is that not so much the experience of negative emotions per se is responsible for poor health outcomes, but rather the way individuals cope with such emotions, a key question then is about the specific kind of emotion regulation strategies employed by type D persons that could contribute to their poor health. It is proposed that type D persons engage in emotion suppression to regulate their negative emotions, i.e. the willful avoidance of expressing negative emotions – presumably to avoid social confrontation or negative social evaluation [1]. However, emotion suppression, as measured by the DS14, is operationalized mostly on a behavioral level in the form of SI. Thus, many of the scale’s items, like ‘I am a closed kind of
Letter to the Editor
person’ and ‘I would rather keep other people at a distance’, do not allow for distinguishing the particular emotion regulation strategies underlying type D personality [20]. In a careful review of constructs related to emotional expression, Garssen [21] argued that the emotion regulation strategy of type D persons is reflective of anxious defensiveness (inhibiting the expression of negative emotions that one is fully aware of), but distinctly different from repression (denial of the awareness of and lack of expression of negative emotion). Our findings add to the understanding of emotion regulation associated with type D. For instance, our finding of an association between negative affect and difficulty identifying feelings suggests that while type D persons may be aware of their negative emotions, their awareness may be more a vague perception of distress rather than a clear appreciation of the precise nature of the distressing emotions. Furthermore, our finding that SI was associated with difficulty describing feelings suggests that the socially avoidant behavior of type D persons may be related to a difficulty with articulating their emotional experiences to others. Finally, the association between SI and externally oriented thinking may suggest that the anxious defensiveness of type D mentioned by Garssen [21] manifests as a tendency to focus on external events rather than internal thoughts and feelings. Limitations include the use of self-report assessment of alexithymia, its cross-sectional design, and modest sample size. Future research should attempt to use more objective measures by independent assessors, such as the Toronto Structured Interview for Alexithymia [22] or the alexithymia module of the Diagnostic Criteria for Psychosomatic Research [23], and a longitudinal design. This study is the first to identify an association between type D personality and alexithymia. The affect regulation tendencies of type D personality appear to correspond to features of alexithymia. Future research should consider evaluating the effectiveness of interventions aimed at improving emotion expression deficits, which may improve the health status of type D patients.
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References 1 Denollet J: DS14: standard assessment of negative affectivity, social inhibition, and type D personality. Psychosom Med 2005;67:89–97. 2 Sher L: Type D personality: the heart, stress, and cortisol. QJM 2005; 98:323–329. 3 Pedersen SS, Denollet J: Type D personality, cardiac events, and impaired quality of life: a review. Eur J Cardiovasc Prev Rehabil 2003;10: 241–248. 4 Mols F, Denollet J: Type D personality among noncardiovascular patient populations: a systematic review. Gen Hosp Psychiatr 2010; 32: 66–72. 5 Denollet J, Sys SU, Brutsaert DL: Personality and mortality after myocardial infarction. Psychosom Med 1995;57:582–591. 6 Aldao A, Nolen-Hoeksema S, Schweizer S: Emotion-regulation strategies across psychopathology: a meta-analytic review. Clin Psychol Rev 2010;30:217–237. 7 Nykliček I, Vingerhoets A, Zeelenberg M: Emotion Regulation and Well-Being. New York, Springer Science, 2011. 8 Taylor GJ, Bagby RM: New trends in alexithymia research. Psychother Psychosom 2004;73:68–77. 9 Vanheule S, Inslegers R, Meganck R, Ooms E, Desmet M: Interpersonal problems in alexithymia: a review; in Lysakker P, Dimaggio GC (eds): Metacognition in Severe Adult Disorders. London, Routledge, 2010, pp 161–176. 10 Grabe HJ, Schwahn C, Barnow S, Spitzer C, John U, Freyberger HJ, Schminke U, Felix S, Völzke H: Alexithymia, hypertension and subclinical atherosclerosis in the general population. J Psychosom Res 2010;68:139–147. 11 Taylor GJ, Taylor-Allan HL: Applying emotional intelligence in understanding and treating physical and psychological disorders: what we have learned from alexithymia; in Bar-On R, Maree JG, Elias MJ (eds): Educating People to Be Emotionally Intelligent. Westport, Praeger Publishers/Greenwood, 2007, pp 211–223. 12 Lumley MA, Beyer J, Radcliffe A: Alexithymia and physical health problems: a critique of potential pathways and a research agenda; in Vingerhoets A, Nyklíček I, Denollet J (eds): Emotion Regulation: Conceptual and Clinical Issues. New York, Springer Science, 2008, pp 43– 68. 13 Topciu RA, Zhao X, Tang W, Heisel MJ, Talbot NL, Duberstein PR: Childhood sexual abuse and personality differentiating high and low alexithymia in a depressed population. Psychother Psychosom 2009;78: 385–387.
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14 Kunst MJJ, Bogaerts S, Winkel FW: Type D personality and posttraumatic stress disorder: a cross-sectional exploration. Clin Psychol Psychother 2011;18:13–22. 15 Taylor GJ, Parker JDA, Bagby RM, Acklin MW: Alexithymia and somatic complaints in psychiatric out-patients. J Psychosom Res 1992;36: 417–424. 16 Bagby RM, Parker JDA, Taylor GJ: The twenty-item Toronto Alexithymia Scale. I. Item selection and cross validation of the factor structure. J Psychosom Res 1994;38:23–32. 17 Beck A, Steer R, Brown G: The Beck Depression Inventory Manual, ed 2. San Antonio, Psychological Corporation, 1996. 18 Lumley MA: Alexithymia and negative emotional conditions. J Psychosom Res 2000;49:51–54. 19 Ferguson E, Williams L, O’Connor RC, Howard S, Hughes B, Johnston DW, Allan, JL, O’Connor DB, Lewis CA, Grealy MA, O’Carroll RE: A taxometric analysis of type D personality. Psychosom Med 2009; 71: 981–986. 20 Grande G, Glaesmer H, Roth M: The construct validity of social inhibition and the type-D taxonomy. J Health Psychol 2010;15:1103–1112. 21 Garssen B: Repression: finding our way in the maze of concepts. J Behav Med 2007;30:471–481. 22 Bagby RM, Taylor GJ, Parker JDA, Dickens SE: The development of the Toronto Structured Interview for Alexithymia: item selection, factor structure, reliability and concurrent validity. Psychother Psychosom 2006;75:25–39. 23 Fava GA, Freyberger HJ, Bech P, Christodoulou G, Sensky T, Theorell T, Wise TN: Diagnostic criteria for use in psychosomatic research. Psychother Psychosom 1995;63:1–8.
Dr. John Ogrodniczuk Department of Psychiatry, University of British Columbia Suite 420-5950, University Boulevard Vancouver, BC V6T 1Z3 (Canada) Tel. +1 604 822 8034, E-Mail ogrodnic @ interchange.ubc.ca
Letter to the Editor
