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Type “D” for distressed

Type “D” for distressed

(This article was first printed in the August 2005 issue of the Harvard Heart Letter. For more information or to order, please go to

A newly coined personality type could signal a higher risk for heart disease.

Do you sweat the small stuff, see the glass as half empty, have trouble making friends, and keep your feelings bottled up inside? That combination could be particularly hard on your heart.

For more than a decade, researchers in the Netherlands have been looking into a connection between what they call type D personality and different aspects of heart disease. If their findings hold up elsewhere, type D could prove to be a significant contributor to heart disease. Then again, if the hoopla around Type A personality was any indication, it could end up on the scrap heap of faded ideas.

The D stands for distressed, says psychologist Johan Denollet, of Tilburg University in the Netherlands, who has led research in this area. Type D people tend to be anxious, irritable, and insecure. They keep an eye out for trouble rather than pleasure. They want to be liked by others — don’t we all? — and go to great lengths to avoid saying or doing things that others might not like. As a result, they are often tense and inhibited around others.

To see how you stack up, try the type D questionnaire below, which was published in the January–February 2005 issue of Psychosomatic Medicine.

D and the heart

Dr. Denollet and his colleagues have looked at the impact of type D personality on the heart from various angles. Their first report, in 1996, included 286 men and women who had enrolled in a cardiac rehabilitation program. Each filled out a personality questionnaire at the start of the three-month program. Almost one-third fit the type D pattern.

Eight years later, the researchers tracked down the participants to find out who had died and who was still alive. Among those classified as type D, 27% had died, compared with just 7% of the non-Ds. Most of the deaths were due to heart disease or stroke.

Since then, type D personality has been linked with

  • early death
  • increased risk for developing cardiovascular problems after a heart attack
  • poorer response to proven treatments for heart disease
  • increased chances of sudden cardiac arrest.

In another report, a different Dutch team followed almost 900 men and women who had received a drug-releasing stent to hold open a blocked coronary artery. After just nine months, 5.6% of those with type D personalities had a heart attack or died of heart disease, compared with 1.3% of the others.

What’s the connection? No one really knows. People with type D personalities seem to have more highly activated immune systems and more inflammation, which could mean more damage to blood vessels in the heart and throughout the body. They also tend to have exaggerated blood pressure and other reactions to stress.

Another possibility is that type D is a catchall for depression, anxiety, and poor social connections, each of which has been linked with heart disease.

Tempest in a teapot?

The connection between personality types and disease doesn’t have a very good track record. Remember type A, the hard-driving, competitive type who couldn’t relax? Beginning in the late 1950s, a flurry of reports indicated that type A people were more likely to develop heart disease than type Bs (those who were more relaxed and less competitive). In 1981, a national panel of experts concluded that type A behavior was a bona fide risk factor for heart disease. The idea eventually imploded under the weight of several large studies that found no connection between type A personality and heart disease.

The research wasn’t a waste, though. It got people thinking about how emotion, mood, behavior, and social factors might affect the heart. Later work helped identify elements of type A behavior that might actually protect the heart (like the drive to succeed and the dedication to make healthy changes) and those that might harm it (like anger and hostility).

The notion that there was a cancer personality — dubbed type C — knocked around for a while, but it, too, has been largely discredited.

More work to be done

It is still too early to tell if type D personality will stand the test of time or follow types A, B, and C into obscurity. Researchers still need to define the type D personality more carefully. They also must see if the connection holds true in larger studies in various countries and populations.

That said, it looks as though Dr. Denollet is onto something. Instead of focusing on individual elements such as depression, anxiety, hostility, and social isolation, using broad personality traits may be a faster or more efficient way to identify people at higher-than-average risk of heart disease.

The problem with this approach is that it’s easier to change a particular trait, such as hostility, or a mood, such as depression, than it is to change a personality type. But as Dr. Denollet says, this is just the beginning of the research process, not the end.

The D-Scale 14

According to Dr. Denollet and his colleagues, this brief questionnaire accurately identifies type D individuals.

Below are a number of statements that people often use to describe themselves. Read each one and circle the appropriate number next to that statement to indicate your answer. There are no right or wrong answers: Your own impression is the only thing that matters.


1=rather false


3=rather true


1) I make contact easily when I meet people

0 1 2 3 4

2) I often make a fuss about unimportant things

0 1 2 3 4

3) I often talk to strangers

0 1 2 3 4

4) I often feel unhappy

0 1 2 3 4

5) I am often irritated

0 1 2 3 4

6) I often feel inhibited in social interactions

0 1 2 3 4

7) I take a gloomy view of things

0 1 2 3 4

8) I find it hard to start a conversation

0 1 2 3 4

9) I am often in a bad mood

0 1 2 3 4

10) I am a closed kind of person

0 1 2 3 4

11) I would rather keep people at a distance

0 1 2 3 4

12) I often find myself worrying about something

0 1 2 3 4

13) I am often down in the dumps

0 1 2 3 4

14) When socializing, I don’t find the right things to talk about

0 1 2 3 4

˝Negative affectivity˝ scale: Add scores for questions 2, 4, 5, 7, 9, 12, and 13

˝Social inhibition˝ scale: Add scores for questions 1*, 3*, 6, 8, 10, 11, and 14

(*For scoring questions 1 and 3, if you circled 0, enter 4; if 1, enter 3; if 2, enter 2; if 3, enter 1; if 4, enter 0.)

You qualify as a type D personality if you scored 10 or higher on both negative affectivity and social inhibition scales.

(This article was first printed in the August 2005 issue of the Harvard Heart Letter. For more information or to order, please go to

The Harvard Health Letter is your monthly guide to heart health

Harvard Heart Letter

If you’re concerned about heart disease, you need expert information and advice you can trust. The Harvard Heart Letter, from Harvard Medical School, is your monthly advisory on the latest developments in heart health, new treatments, prevention, and research breakthroughs. Read more »