Type D Personality Mediates the Relationship Between Remembered Parenting and Perceived Health Krista C. van den Broek, Ph.D., Kim G. Smolderen, Ph.D. Susanne S. Pedersen, Ph.D., Johan Denollet, Ph.D.
Background: Type D personality (a joint tendency to experience negative emotions and inhibit self-expression) has been associated with adverse outcomes across cardiovascular diseases, but little is known about its association with remembered parenting. Objective: The authors sought to investigate the association between Type D personality, remembered parenting, and perceived health outcomes. Method: Adults from the general Dutch population (N⫽662) completed the Remembered Relationship with Parents (RRP) scale, the DS14 (which assesses Type D personality), the Short-Form Health Survey, the Beck Depression Inventory, and the Hospital Anxiety and Depression Scale. Results: Type D personality was associated with adverse remembered parenting, and both were related to poor perceived health. Importantly, Type D mediated the relationship between adverse remembered parenting and adverse perceived health outcomes. Discussion: When developing interventions for Type D personality, it may be important to take adverse childhood experiences into account. (Psychosomatics 2010; 51:216 –224)
T
he “distressed” (Type D) personality is an emerging risk factor across cardiovascular disease, including ischemic heart disease, heart failure, peripheral arterial disease, and cardiac arrhythmias.1–3 Type D personality is a stable personality constellation, referring to the tendency to experience increased negative emotions (high negative affectivity), paired with the tendency to inhibit self-expression in social interactions (high social inhibition).1 Type D personality has been associated with an increased risk of emotional distress,4 –6 impaired health-related quality of life,4,7,8 and cardiac events/mortality.9,10 Suggested pathways for the relationship between personality and adverse health outcomes are immune activation,11 dysfuncReceived October 4, 2007; revised January 15, 2008; accepted February 5 , 2008. From the CoRPS–Center of Research on Psychology in Somatic diseases, Tilburg University, Tilburg, The Netherlands. Send correspondence and reprint requests to Johan Denollet, Ph.D., CoRPS–Center of Research on Psychology in Somatic diseases, Dept. of Medical Psychology and Neuropsychology, Tilburg University, P.O. Box 90153, 5000 LE Tilburg, The Netherlands. e-mail:
[email protected] © 2010 The Academy of Psychosomatic Medicine
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tional stress reactivity,12 disturbances in cortisol regulation,13 and inadequate self-management behaviors.14,15 Knowledge of the mechanisms involved in personality development is important, especially in the case of Type D personality, since this trait is associated with an increased risk of adverse health outcomes. The characteristics of Type D may in part be attributed to genetic factors. A recent study showed that the heritability for Type D was 52%.3 Regarding environmental factors, relationships with parents while growing up may be of importance, with particular dysfunctional parenting styles leading to more emotional instability. Although there is a paucity of studies on the relationship between parenting styles and personality, there is evidence to suggest that repeated experiences of criticism and rejection in childhood may lead to the development of negative affectivity.16 Parental overprotection and relative lack of parental care/love have been associated with neuroticism in later adult life.17–20 In turn, neuroticism has been shown to mediate the relationship between parenting Psychosomatics 51:3, May-June 2010
van den Broek et al. styles and mental health.17,18 Moreover, in highly sensitive individuals, an adverse childhood environment was related to adult shyness;16 that is, the fear of negative social evaluations and discomfort in social contact, which are closely related to the Social Inhibition component of Type D personality. Importantly, inadequate caregiving and other forms of adverse childhood experiences may have enduring influences on mental and even physical health in adulthood.21 Most studies on adverse parenting and adult mental health have focused on depression, including adolescent,22 postnatal,23 lifetime,24 –26 and adult27 depression. Other studies have also found significant associations between parenting and anxiety.28,29 Also, adverse childhood experiences have been related to somatic diseases, including cardiovascular disease,30 –32 lung disease,31 cancer,33,34 liver disease,31 and an overall increased mortality risk.35 Furthermore, research shows that adverse childhood experiences can result in altered cardiovascular and neurohormonal responses to stress,36 –38 as well as poor self-rated health31 and increased symptom-reporting.39 Collectively, evidence suggests that both inadequate caregiving and Type D personality may be related to physical and emotional health outcomes. Poor parenting styles may enhance the risk of developing a Type D personality, which in turn may increase the risk of poor health outcomes. Hence, Type D personality may mediate the relationship between recollections of a dysfunctional relationship with parents and poor adult physical and mental health outcomes, as shown in the mediational model presented in Figure 1. The present study was designed to investigate the relationship between Type D personality FIGURE 1.
Mediational Model of Remembered Relationship With Parents and Perceived Health Outcomes, With Type D Personality as Mediating Variable
Type D Personality
(a)
Remembered Relationship with Parents
(c)
(b)
Perceived Health Outcomes
Outcomes refer to Short-Form-36 subscales and Beck Depression Inventory/Hospital Anxiety and Depression Scale depression and anxiety symptoms.
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and recollections of a poor relationship with parents. Therefore, the aims were to examine 1) whether Type D personality is associated with recollections of the relationship with parents as being dysfunctional; 2) the association between recollections of relationship with parents and perceived health; and 3) whether Type D personality mediates the link between recollections of the relationship with parents and perceived physical and emotional health outcomes. METHOD Participants and Design The participants in this cross-sectional study were middle-aged adults from the general Dutch population. Most participants lived in North Brabant, a province in the south of the Netherlands. Different age (range: 30 – 80 years) and sex-ratio groups were evenly represented in the sample. Exclusion criteria were cognitive impairment, the presence of severe psychopathological (e.g., psychosis, suicidal ideation) or invalidating somatic comorbidities (e.g., cancer), and insufficient knowledge of the Dutch language. Participants were contacted in person by psychology students from Tilburg University, who provided them with the questionnaires. The research assistants explained the purpose and the anonymous nature of the study. The study was approved by the local ethics committee; it was conducted to conform to the Helsinki Declaration. All participants gave written informed consent. Remembered Relationship With Parents The Remembered Relationship with Parents (RRP10) scale was used to assess recollections of the relationship with parents.27 This self-report instrument retrospectively assesses caregiving processes with emphasis on empathic parenting. Respondents are asked to describe the relationship with their parents, while growing up, on a 5-point Likert scale from 0 (False) to 4 (True). The RRP10 consists of two subscales, Alienation and Control. Alienation (5 items) reflects memories of the child’s feelings of alienation from parents (e.g., “I often felt that my parents did not understand me;” and “I was very closed toward my parents.”), and Control (5 items) represents memories of a controlling parenting style (e.g., “My parents worried that I could not take care of myself;” and “My parents were overprotective.”). High scores on both parenting scales indicate worse remembered relationships with parents while growing up. Remembered alienation and control http://psy.psychiatryonline.org
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Type D Personality, Parenting, and Health were assessed with reference to the father and mother separately. Because of its brevity (only 10 items) and its nonpathological focus, the RRP10 is suitable for use in nonpsychiatric populations and in epidemiological and clinical research. As previously demonstrated in this sample, the RRP10 has a sound factor structure, good internal consistency (Cronbach’ alpha⫽0.83– 0.86), and convergent validity with the Parental Bonding Instrument.27,40 Type D Personality The DS14 was used to assess Type D personality.1 The DS14 consists of two 7-item subscales. The Negative Affectivity subscale assesses the tendency to experience negative emotions (e.g., “I am often in a bad mood.”), and the Social Inhibition subscale assesses the tendency to inhibit self-expression in social interaction (e.g., “I often feel inhibited in social interactions.”). Items are rated on a 5-point Likert scale from 0 (False) to 4 (True). A standardized cutoff of ⱖ10 on both subscales indicates a Type D personality. The use of this cutoff to quantify Type D personality was confirmed in a study using item-response theory.41 The DS14 has sound psychometric properties, with Cronbach’ ␣s of 0.88 and 0.86, indicating a high level of internal consistency, and factor loadings ranging from 0.62 to 0.82, showing good factorial validity.1 The Cronbach ␣ values for the Negative Affectivity scale and for the Social Inhibition scale in our study were 0.85 and 0.88, respectively. Furthermore, construct validity was confirmed against the NEO-Five Factor Inventory, with Negative Affectivity and Social Inhibition correlating 0.68 and – 0.59/– 0.65 with Neuroticism and Extraversion, respectively, indicating that these traits were related, although not identical.1 Also, divergent validity between Type D personality and measures of negative affect has been shown, with studies showing a predictive value for adverse outcomes of Type D personality above and beyond symptoms of anxiety and depression.10 Moreover, a recent study confirmed the stability of Type D personality during the course of 18 months in patients after myocardial infarction.42 This study also showed that Type D classification was not affected by changes in mood status. Health Status The 36-item Short-Form Health Survey (SF–36) was used to assess health status.43 The SF–36 comprises eight subdomains: 1) limitations in physical activities because of health problems; 2) limitations in social activities be218
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cause of physical or emotional problems; 3) limitations in usual role activities because of physical problems; 4) bodily pain; 5) general mental health (psychological distress and well-being); 6) limitations in usual role activities because of emotional problems; 7) vitality (energy and fatigue); and 8) general health perceptions.43 Given that the response categories are different across items, standardized scoring algorithms are applied; items are summed together within a domain to obtain scale scores. This outcome is then divided by the range of scores, and raw scores are transformed to a scale ranging from 0 to 100.44 A high score on the SF–36 represents good health status, with a high score on bodily pain indicating absence of pain. Internal consistency and test–retest reliability estimates in general population surveys are high; the SF–36 has also been validated in the Netherlands, with acceptable psychometric properties (mean Cronbach’s ␣: 0.84).45 The mean Cronbach’s ␣ for the SF–36 subscales in our sample was also satisfactory (0.80).
Symptoms of Depression/Anxiety Symptoms of depression and anxiety were evaluated with the Beck Depression Inventory (BDI)46 and the Hospital Anxiety and Depression Scale (HADS);47 these measures are often used in research on patients with somatic diseases, such as coronary artery disease.48 –50 The BDI is a 21-item, self-report instrument that measures the presence and severity of depressive symptoms and has good psychometric properties, with a Cronbach’s ␣ of 0.81 in nonpsychiatric subjects.51 We found a Cronbach ␣ of 0.82 for our sample. The 7-item HADS–Depression and HADS–Anxiety subscales also have good validity and internal consistency (Cronbach’s ␣: 0.80 – 0.93).52 In this study, Cronbach’s ␣ values for the Anxiety and Depression subscales were acceptable (␣: 0.73 and 0.77, respectively).
Demographics Information about sex, age, education level, and marital status was obtained from the participants. Low education, as an indicator of socioeconomic status, and marital status (having no partner) are generally associated with higher levels of psychiatric morbidity and having more disabilities.53,54 Marital status was defined as having a partner or not, and low education was scored as having secondary education or less. Psychosomatics 51:3, May-June 2010
van den Broek et al. Statistical Analysis Baseline characteristics of the sample, stratified by sex, were compared by chi-square test for dichotomous variables; the Student’s t-test was used for continuous variables. The Student’s t-tests were also used to examine the relationship between Type D personality and remembered relationships with parents. In multivariable linearregression analyses, the independent effect of Type D personality on remembered parenting was tested, adjusting for demographic variables (age, sex, having no partner, and low education). Before investigating whether Type D mediated the relationship between remembered parenting and perceived health outcomes (SF–36, BDI, HADS), we examined whether the assumptions underlying the mediation model according to Baron and Kenny55 were fulfilled: 1) the remembered relationship with parents had to be associated with the mediator Type D personality; 2) the remembered relationship with parents had to be related to perceived health outcomes; and 3) Type D personality had to be associated with the health outcomes, adjusted for remembered parenting (see Figure 1). Type D personality was considered a mediator if it accounted for the relationship between remembered parenting and perceived health outcomes.55 The assumptions for mediation were tested with a series of linear-regression analyses. For the relationship between remembered parenting (continuous scores) and the mediator Type D personality, we performed a logisticregression analysis. To allow for a more direct test of the mediation effect, we used Sobel tests.56,57 The percentages of the part of the total effect (Path B in Figure 1) explained by the mediator were calculated by dividing the unstandardized  coefficient of the indirect effect (Path A*C) by the unstandardized  coefficient of the total effect. Sobel tests, which are products of coefficient tests for the mediating-variable effect, are used to test the significance of the mediating-variable effect by dividing the estimate of the mediating-variable effect by its standard error (SE) and comparing this value to a standard normal distribution. In contrast with causal step methods (e.g., the Baron and Kenny approach), Sobel tests are less prone to Type I errors and have more statistical power to detect mediation.55–57 Because SPSS for Windows does not have the ability to directly test the mediation effect, Sobel tests were performed with an SPSS macro by Preacher and Hayes58 (http://www.comm.ohio-state.edu/ahayes/sobel. htm). SPSS for Windows, Version 14.0.1., was used for all other analyses. Psychosomatics 51:3, May-June 2010
RESULTS Of the 709 included participants, 47 were excluded from analyses because of missing data on self-report measures. Hence, analyses were based on 93% of participants (N⫽662; 48% men; mean age: 54.2 [standard deviation {SD}]: 14.0 years). Baseline characteristics of the total sample and stratified by sex are presented in Table 1. Women were more likely to have no partner, a lower educational level, and a Type D personality than were men. Also, women reported lower mean scores on physical functioning, social functioning, mental health, and vitality, and experienced more depressive symptoms than their male counterparts.
Type D Personality and Remembered Parenting Participants with a Type D personality reported significantly more alienation and control in the remembered relationship with their parents than non-Type Ds (Figure 2). In multivariable analyses with remembered parenting as dependent variable and Type D personality, age, sex, having no partner, and low educational level as independent variables, Type D personality was associated with more remembered alienation from parents (⫽7.5; p ⬍0.0001) and control by parents (⫽5.1; p ⬍0.0001) while growing up. None of the demographic variables were related to parenting style in the multivariate analyses, except having a low educational level, which was associated with more remembered control by parents (⫽2.3; p⫽0.008).
Remembered Parenting, Type D Personality, and Perceived Health Both remembered alienation from parents and control by parents were significantly associated with poor perceived health outcomes as measured by the SF–36, except for the subscale Bodily Pain (Table 2). Participants with poor remembered relationships with their parents also experienced more symptoms of depression and anxiety. Point-biserial correlations between Type D personality and SF–36 subscales were significant, except for the subscale Bodily Pain, indicating that “Type Ds” reported an impaired subjective health status, as compared with nonType Ds. Also, Type Ds experienced more symptoms of depression and anxiety. http://psy.psychiatryonline.org
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Type D Personality, Parenting, and Health Test of the Mediational Model
parental alienation (odds ratio [OR]: 1.1; 95% confidence interval [CI]: 1.07–1.12; p ⬍0.0001) and control (OR: 1.1; 95% CI: 1.05–1.10; p ⬍0.0001). Linear-regression analyses indicated that both parenting styles were associated with poor perceived health (all significant at p ⬍0.0001, except Bodily Pain). Type D personality was associated with all perceived health outcomes when controlling for
Next, we tested the hypothesis that Type D personality mediated the relationship between remembered parenting and perceived health outcomes (Figure 1). The assumptions underlying the mediational model were all confirmed: Type D personality was associated with both TABLE 1.
Characteristics of the Total Sample Total (N ⴝ 642)
Men (N ⴝ 307)
Women (N ⴝ 335)
p
54.2 (14.0) 87 (13.6) 61 (19.9)
53.9 (13.9) 30 (9.8) 61 (19.9)
54.5 (14.1) 57 (17.0) 111 (33.1)
NS 0.007 ⬍0.0001
14.3 (9.5) 12.1 (9.0) 116 (18.1)
14.0 (9.3) 12.0 (8.9) 45 (14.7)
14.6 (9.6) 12.2 (9.1) 71 (21.2)
NS NS 0.032
85.2 (19.9) 86.4 (18.6) 79.3 (34.0) 87.1 (24.1) 79.1 (14.7) 70.2 (16.9) 51.5 (13.6) 69.5 (18.8)
87.3 (21.1) 89.0 (19.3) 81.5 (35.7) 88.6 (29.3) 81.4 (14.9) 72.6 (17.0) 51.0 (14.5) 69.8 (19.3)
83.3 (21.1) 84.0 (19.3) 77.2 (35.7) 85.7 (29.3) 76.9 (14.9) 68.0 (17.0) 52.0 (14.5) 69.3 (19.3)
0.011 0.001 NS NS ⬍0.0001 ⬍0.0001 NS NS
6.1 (5.4) 4.9 (3.2) 4.3 (3.1)
5.1 (4.7) 4.4 (3.2) 4.4 (3.0)
7.0 (5.9) 5.3 (3.3) 4.2 (3.1)
⬍0.0001 ⬍0.0001 NS
Independent variables Demographics Age, years No partner, N (%) Less education, N (%) RRP10 subscales Alienation from parents Control by parents Type D, N (%) Dependent variables Health status Physical Functioning Social Functioning Role–Physical Role–Emotional Mental Health Vitality Bodily Pain General Health Depression/Anxiety Depression (BDI) Depression (HADS) Anxiety (HADS)
Data are presented as mean (standard deviation), unless otherwise specified. “Less education” is defined as secondary school or lower; RRP10: Remembered Relationship with Parents scale; Physical Functioning, Social Functioning, Role–Physical, Role–Emotional Mental Health, Vitality, Bodily Pain, and General Health scales are from the SF–36 Short-Form Health Survey;43 BDI: Beck Depression Inventory;46 HADS: Hospital Anxiety and Depression Scale.47
FIGURE 2.
Type D Personality Versus Non-Type D Personality Subjects on Parental Relationship Dimensions of Alienation and Control Non-type D (N=526)
25 SD 8.3
SD 9.2
10
Mean Score
Mean Score
20 15
SD 8.7
20
Type D (N=116)
15
SD 8.8
10 5
5 0
0 Alienation From Parents p
