Type D personality in adults

This study is one of the first steps in our research concerning Type D personality. Its goal is to explain the Type D personality concept, to present the psychometric qualities of the DS14 scale for diagnosing Type D personality, to summarize the results of the latest international review studies on Type D, the results of studies carried out in Slovakia, and to report findings from research on a sample of adult residents of Slovakia.

The concept of Type D personality (distress), characterized by high negative affectivity and simultaneously high social inhibition, was introduced into psychology in 1995 by Johan Denollet. The construct is the result of research conducted on patients with coronary heart disease. The term distress refers to a distinct personality configuration identifying individuals who tend to experience emotional and interpersonal difficulties that can affect physical health (Denollet, Sys, & Brutsaert, 1995). Type D personality was derived from existing personality theories and empirical evidence that included cluster and factor analyses (Pedersen & Denollet, 2003).

Negative affectivity (NA) refers to a stable tendency to experience negative emotions (Denollet, 1998a, 2000, 2005; Pedersen & Denollet, 2003, 2006), in other words the tendency to experience dysphoric moods, anxiety, and irritability (Denollet, 2005). Social inhibition (SI) refers to a stable tendency to suppress the expression of emotions and behavior in social interactions (Denollet, 1998a, 2000, 2005; Pedersen & Denollet, 2003, 2006). In other words, social inhibition means discomfort in social interactions, a lack of social assertiveness, and a tendency to avoid confrontation in social situations, leading to non-expression (Denollet, 2005). From a cognitive perspective, Type D personalities often tend to brood and view things in a negative, pessimistic light. From an affective perspective, depressive mood symptoms are often accompanied by other negative emotions such as anxiety and anger (Denollet, 2000). Individuals who score highly on both scales are simultaneously referred to as Type D personalities (Denollet, 1998a, 2000, 2005; Pedersen & Denollet, 2003, 2006).

For the diagnosis of Type D personality, a combination of several methods was initially used, with the aim of determining the most suitable item combination. In 1998 Johan Denollet developed the DS16 questionnaire, drawing from an item pool originating from MMPI-2 (Minnesota Multiphasic Personality Inventory) and items created specifically to detect Type D personality. The DS16 scale consisted of 16 items, 8 for the negative affectivity subscale and 8 for the social inhibition subscale. In a sample of 400 people, it was confirmed that the scales are internally consistent (Cronbach's alpha: 0,89 (NA); 0,82 (SI)) and stable over time (test-retest reliability after 3 months: 0,78 (NA); 0,87 (SI)) (Denollet, 1998a).

The validity of the Type D personality construct and the DS16 scale was examined in Denmark in a group of patients after myocardial infarction (N=112) and a control group of healthy individuals (N=115). The prevalence of Type D personality was 24% in patients after myocardial infarction and 25% in healthy individuals. The study confirmed the two-factor structure of the DS16 scale and also the internal consistency of the subscales (Cronbach's alpha: 0,83 (NA); 0,76 (SI)). Comparison of both groups confirmed that Type D may be an indicator of general emotional distress. Type D personalities scored higher than non-Type D individuals on indicators of depression, anxiety, post-traumatic stress disorder symptoms, and avoidance. The results indicate that the Type D personality construct is applicable among Danish patients with heart disease (Pedersen & Denollet, 2004).

A revision of the DS16 scale yielded the DS14 scale currently in use (Denollet, 2005). DS14 consists of 14 items covering two subscales. The NA subscale includes 7 items covering the tendency to experience dysphoria, anxiety concerns, and irritability. The SI subscale consists of 7 items dealing with social discomfort, reserve, and lack of social engagement. Psychometric qualities of the scale were examined in a sample of 3813 participants (2508 from the general population, 573 cardiology patients, and 732 patients with hypertension), who completed DS14 (121 of them completed the scale twice) and 275 individuals also completed the NEO-FFI. All items loaded on their corresponding factor between 0,62 and 0,82. The NA and SI scales are internally consistent (Cronbach's alpha = 0,88 (NA); 0,86 (SI)), stable over a three-month period (r = 0,72 (NA); r = 0,82 (SI)), and independent of mood and health status. Twenty-one percent of the general population showed Type D versus 28% of patients with cardiovascular disease and 53% of patients with hypertension. In conclusion, DS14 is a short psychometric instrument for measuring negative affectivity and social inhibition that can be easily incorporated into research (Denollet, 2005).

The adequacy of the German version of DS14 was examined by Grande et al. (2004) on 2421 individuals, including cardiovascular and psychosomatic patients and healthy workers. Internal consistency was 0,87 for the negative affectivity subscale and 0,86 for the social inhibition subscale. The prevalence of Type D personality was 25% among cardiovascular patients, 62% among psychosomatic patients, and 32,5% among healthy workers. The German study concluded that DS14 is a valid and reliable instrument, though the prognostic validity of the model requires further research (Grande et al., 2004).

Psychometric qualities of the Hungarian version of DS14 were examined in a sample of 12 653 people. Purebl and colleagues (Purebl et al., 2006) found that 4 items lowered the quality of the questionnaire, so these items were removed and the scale was reduced to 10 items. The psychometric properties of the reduced version appear sufficient (Cronbach's alpha: 0,87 (NA); 0,84 (SI)). Factor analysis confirmed the two-factor structure of the Hungarian version, which is suitable for detecting Type D personality (Purebl et al., 2006).

A validation study of the Italian version of DS14 conducted in 145 patients with heart disease confirmed its validity (Cronbach's alpha: 0,82 (NA); 0,80 (SI)) and also indicated that Type D is a predictor of psychological distress (Schiffer et al., 2006).

In the study conducted by Pedersen et al. (2009), which focused on psychometric qualities of the Ukrainian version of DS14, 250 healthy Ukrainian students participated; they completed DS14, the Eysenck Personality Questionnaire, an anxiety-focused questionnaire, and the Beck Depression Inventory. The prevalence of Type D personality was 22,4%. The study confirmed the two-factor structure and validity of DS14. The subscales were internally consistent (Cronbach's alpha: 0,86 (NA); 0,71 (SI)) and stable over 4 weeks (r=0,85 (NA), r=0,63 (SI)). Type D personalities had significantly higher scores than non-Type D personalities on anxiety (p<0,001), depressive symptoms (p<0,001), negative affectivity (p<0,001), and lower scores on positive affectivity (p<0,001). The results indicate that the Ukrainian version of DS14 is a valid and reliable instrument, although additional research is also needed (for example in groups of patients with heart disease) (Pedersen et al., 2009).

In the early studies it was hypothesized that Type D personality is a predictor of cardiovascular disease. Studies (Denollet et al., 1996, 1998, 2000; Pedersen & Denollet, 2003) examining the association between cardiovascular disease and Type D personality confirmed this relationship, showing that people with Type D personality have a fourfold higher risk of heart disease and death from such diseases than those without Type D, independently of other risk factors. It was also shown that Type D personality is a prognostic factor for the development of cancer in people with coronary heart disease (Denollet, 1998b).

Recent review studies on Type D personality indicate the following: in the general population, the presence of Type D has a negative effect on mental health (more symptoms of depression, anxiety, post-traumatic stress disorder, mental distress, poorer coping, less social support) and physical health (more health complaints, poorer health, more flu-like illnesses) (Mols & Denollet, 2010b). In patients with non-cardiovascular diseases (studies included, for example, patients with chronic pain, asthma, sleep apnea, vertigo, melanoma), Type D personality was associated with a higher number or more painful health complaints, greater perception of negative emotions (e.g., depression and anxiety), and had a detrimental effect on health-related behavior (poor treatment adherence and significantly reduced effort during diagnostic testing) (Mols & Denollet; 2010a).

Next we turn to research on Type D personality conducted in Slovakia. Selko and Dubayová (2006) tested 60 patients after myocardial revascularization and 170 university students (control group). The authors expected high levels of negative affectivity and social inhibition in patients, but were surprised by the high values in the control group of young healthy university students. Gender differences in NA and SI scores were similarly in the patient group and the control group in favor of women (Selko, Dubayová, 2006).

In our survey (Ďurka, 2006), 102 psychology university students aged 18 to 30 participated. Students obtained the following results: negative affectivity 8,75 (men - 7,85; women - 8,89), social inhibition 10,57 (men - 9,92; women - 10,66). Comparison of men and women did not show a significant difference in any subscale (negative affectivity and social inhibition). We identified 24 students as Type D personalities (23,5%). The fact that almost every fourth student was identified as a Type D personality, that is, a person who has a stable tendency to experience negative emotions and at the same time suppress their expression, indicates the need to shape psychology students also in their personality dimension (Ďurka, 2006).

In the survey we conducted in 2007, 77 teachers from primary schools in the districts of Michalovce and Sobrance participated (Ďurka, 2007). On the negative affectivity scale they achieved an average score of 10,84, and on the social inhibition scale an average score of 9,75. Of the total 77 teachers, we identified 22 teachers as Type D personalities (28,57%). The fact that roughly three in ten teachers have times when they feel negative emotions and simultaneously suppress expression of these emotions in social interactions is alarming. In percentage terms, the highest proportion of Type D personalities appeared in the group of teachers aged 21 to 30 years (42,11%); we assume this is due to the relative inexperience of these younger teachers. Perhaps high expectations of themselves, their colleagues, and children at school bring them situations of frustration and stress that they cannot manage effectively. A high prevalence of Type D personalities is also seen in teachers aged 41 to 50 years, at 39,13%. We believe this is due more to their home situation: their children are already in adolescence and are leaving for secondary or university education, often staying in hostels; these are joyful yet stressful situations that, together with stressful teaching work, place high demands on their mental resources and can easily overwhelm them. The lowest prevalence of Type D personalities is among teachers aged 31 to 40, which we explain by the fact that these individuals already have stable family and professional circumstances. They already have their own apartment (or house), partner, children, steady job, and are still relatively young. These (and of course other) factors positively help them cope with problems, frustrations, and stressful situations (Ďurka, 2007).

To examine correlations among mental health, stress, and sense of humor, we conducted a survey in 2008 with 41 teachers from the Košice Region (Ďurka, 2010). Comparison with the results of the previous study (Ďurka, 2007), which included a sample of 77 teachers, does not indicate significant changes in the negative affectivity scale (10,84 in 2007 and 10,22 in 2008) and social inhibition scale (9,75 in 2007 and 9,15 in 2008). In the 2007 study, we identified 28,57% of teachers as Type D personalities; in this study this value is somewhat higher (36,6%). If the finding that nearly three in ten teachers are Type D personalities was considered alarming (Ďurka, 2007), we are now raising the warning finger even higher and noting that it is not only necessary but essential to do something to improve teachers’ mental and overall health. These results are not altered by the fact that teachers obtained an average score of 12,41 on the mental health questionnaire. This score indicates minor difficulties in dealing with everyday problems, and thus fairly good mental health.

In the teachers’ group there is a significant negative relationship between the Type D subscales (negative affectivity, social inhibition) and mental health, meaning that the higher the negative affectivity (or social inhibition), the worse the mental health. This means that higher stress is associated with poorer health. The negative relationship is also present between Type D subscales and sense of humor, meaning that the higher the negative affectivity (or social inhibition), the lower the sense of humor, i.e., the greater the stress and the poorer the use of humor as a coping tool; however, this relationship is not significant. The relationship between sense of humor and mental health is positive, but it is not significant; this does not confirm Miller’s (2003) findings, which report a significant relationship between these variables.

Teachers who are not Type D personalities scored higher average scores on the sense of humor questionnaire than teachers with Type D personality. Although this difference is not significant, it suggests that humor is a good mechanism for coping with stress. Teachers who are not Type D personalities also scored significantly lower average scores on the mental health questionnaire than teachers who are Type D personalities, indicating that better stress coping leads to better mental health (Ďurka, 2010).

Sample The study involved 295 respondents, 92 men (31,2%) and 203 women (68,8%) aged 18 to 71 (mean age 35,36 years, SD=10,78). We divided respondents into the following age groups: up to 20 years (N=24), 21 to 30 years (N=91), 31 to 40 years (N=83), 41 to 50 years (N=71), and over 50 years (N=26). Frequencies of men and women in each age group are summarized in table no. 1 (appendix no. 2).

Method We used the DS14 scale, whose author is Johan Denollet and which was published in 2005 in the journal Psychosomatic Medicine (Denollet, 2005). The scale consists of 14 items that load on two subscales. The Negative Affectivity (NA) subscale has 7 items and the Social Inhibition (SI) subscale also has 7 items. On both scales scores can range from 0 to 28. A person is considered a Type D personality if they score 10 or more on both scales (the negative affectivity scale and the social inhibition scale). We translated the scale together with my colleague Mário Schwarz in March 2006. The DS14 scale was included in the appendices (Appendix no. 1). We used SPSS 15 for statistical analyses.

Results Prevalence of Type D personality in the research sample

The prevalence of Type D personality in our sample is 105 people (35,6% of all respondents), of whom 27 were men (29,3% of the total number of men) and 78 were women (38,4% of the total number of women). We did not find a significant difference between men and women in the prevalence of Type D personalities (Pearson Chi-Square=2,275; p=0,131). In the age group up to 20 years, we identified 12 persons as Type D personalities from 24 individuals (50% within the age group), in the group aged 21 to 30 years we labeled 36 of 91 as Type D (39,6%), in the group aged 31 to 40 years 23 of 83 (27,7%), in the group aged 41 to 50 years 25 of 71 (35,2%), and in the group over 51 years we identified 9 of 26 as Type D (34,6%). The prevalence of Type D personality by age group is summarized in table no. 2 (appendix no. 2). No significant differences were found among age groups in the prevalence of Type D personalities (Pearson Chi-Square=5,063; p=0,281).

We also compared men and women within each group based on Type D prevalence. In the group up to 20 years, we identified 2 men out of 7 (28,57%) and 10 women out of 17 (58,82%) as Type D; a comparison between men and women could not be performed because the total number of people in the group is less than 40 (N=24 in our case), and expected cell frequencies are smaller than 5. In the 21 to 30 group, we labeled 9 men out of 27 (33,33%) and 27 women out of 64 (42,19%) as Type D; no significant sex difference was found (Pearson Chi-Square=0,623; p=0,430). In the 31 to 40 group, 9 of 28 men (21,43%) and 17 of 55 women (30,91%) were classified as Type D, with no significant difference between groups (Pearson Chi-Square=0,832; p=0,362). In the following age group (41-50 years), we labeled 6 of 21 men (28,57%) and 19 of 50 women (38%) as Type D, and no significant difference between groups was found (Pearson Chi-Square=0,576; p=0,448). In the group over 50 years, we identified 4 of 9 men (44,44%) and 5 of 17 women (29,41%) as Type D; comparison by sex could not be performed because the total group size is less than 40 (N=26 in our case) and expected cell frequencies are smaller than 5.

Comparison of groups based on negative affectivity and social inhibition subscales

In the negative affectivity subscale, respondents achieved an average score of 10,69 (SD=5,62); compared with the cut-off score (cut off=10), a significant difference was observed (t(294)=2,114; p=0,035*). In the social inhibition subscale, they achieved an average score of 10,16 (SD=5,30); compared with the cut-off score, no significant difference was found (t(294)=0,516; p=0,606).

In the negative affectivity subscale, men achieved an average score of 9,75 (SD=5,09), women an average score of 11,12 (SD=5,80). Comparison of men and women based on average scores in the negative affectivity subscale shows a significant difference between groups (t(198,670)=-2,045; p=0,042*; while Levene's test indicated that variances of both variables were not equal, F=4,594; p=0,033).

In the social inhibition subscale, men achieved an average score of 10,74 (SD=5,70), women an average score of 9,90 (SD=5,11). Comparison of men and women based on average scores in the social inhibition subscale did not show a significant difference between groups (t(293)=1,266; p=0,207; while Levene's test indicated that variances of both variables are equal, F=1,788, p=0,182).

Before comparing individual age groups on the basis of the negative affectivity and social inhibition subscales (the resulting values for each age group are in table no. 3, appendix no. 2), we had to decide whether to use parametric or non-parametric tests. In the groups with smaller sample sizes than 30 (the up-to-20 and over-50 groups), we tested normality for the variables negative affectivity and social inhibition. The Shapiro-Wilk normality test confirmed normal distribution for negative affectivity in both groups (SW(24)=0,961; p=0,457 in the up-to-20 group and SW(26)=0,954; p=0,291 in the over-50 group). For social inhibition, normality was confirmed in the up-to-20 group (SW(24)=0,957; p=0,378), while in the over-50 group normality was not confirmed (SW(26)=0,932; p=0,087). Based on the normality test, we used a parametric One-Way ANOVA for comparing age groups on the negative affectivity variable. We used the same statistical test for comparison on the social inhibition variable, with the difference that we excluded the over-50 group from testing because it did not meet normality assumptions. For comparison of the over-50 group with the other age groups, we used the non-parametric Mann-Whitney U test.

Comparison of individual age groups on the negative affectivity variable (see table no. 4, appendix no. 2 for results) showed a significant difference between the group up to 20 years and the group from 31 to 40 years (p=0,025), between the 21 to 30 group and the 31 to 40 group (p=0,016), and between the 31 to 40 group and the 41 to 50 group (p=0,019*). No significant differences in negative affectivity were found among the remaining groups.

Comparison of individual groups on the social inhibition variable (results in table no. 5, appendix no. 2) did not show significant differences. Comparison of the over-50 group with the other age groups using the Mann-Whitney U test did not show significant differences. Mann-Whitney U test results: comparison of the over-50 group and the up-to-20 group (U=270,00; p=0,413), comparison of the over-50 group and the 21 to 30 group (U=1023,50; p=0,295), comparison of the over-50 group and the 31 to 40 group (U=897,00; p=0,194), and comparison of the over-50 group and the 41 to 50 group (U=719,50; p=0,097).

Discussion

The prevalence of Type D personality in our study is 35,6%. Although not significant, a higher prevalence is observed in women (38,4%) than in men (29,3%). Mols and Denollet (2010a) report a prevalence of 13%–24% in their review study of Type D in normative populations. Compared with this finding, a 35,6% prevalence in our sample appears high, which may be conditioned by the fact that the survey was conducted among a general population of adult citizens of Slovakia, while we did not assess either current health status or prior illnesses of respondents (this is a limitation of this study).

The highest prevalence of Type D personalities was observed in the group up to 20 years (50%) and in the group from 21 to 30 years (42,11%), while in the group from 41 to 50 years prevalence was 39,13% and in the group over 50 years it was 28,57%. The lowest prevalence was recorded in the group from 31 to 40 years, at 4,76%. Results from the survey on teachers (Ďurka, 2010) show the same distribution of Type D personality prevalence across age groups as in the present study: the highest prevalence in the 21 to 30 age group, then the 41 to 50 group, then the over 50 group, and the lowest in the 31 to 40 group.

Respondents scored 10,69 on average on negative affectivity and 10,16 on social inhibition. In negative affectivity, women scored significantly higher than men; in social inhibition, men scored higher than women (the difference between groups is not significant). These results are in line with findings by Johan Denollet (Denollet, 2005). Selko and Dubayová (2006) also report higher negative affectivity scores in women than men, but in social inhibition they found the opposite result (higher scores in favor of women).

Comparison of age groups based on the negative affectivity subscale indicated significant differences between the 31 to 40 group and the other groups (up to 20, 21 to 30, and 41 to 50), while other differences were not significant. Comparison of age groups based on the social inhibition subscale did not reveal significant differences.

The lowest prevalence of Type D personality in the 31 to 40 group and the significantly lower negative affectivity scores compared with younger and older age groups are explained by the fact that in the two most important life domains, namely family and work, these individuals have already reached relative stability. In other words, these people have achieved something in both family and working life. In working life they already have higher positions than people under 30, who are only beginning to work, and it should also be noted that they are still young and not yet thinking about retirement as those over 50. In family life, they rely on their life partner, have children, and also own housing, which is not yet typically the case for those under 30. We consider it necessary to state that this explanation is not the only possible one and may not be correct.

How can we help people with Type D personality? First, it is important to recognize that Type D personality is not itself a mental illness; it is only a predisposition to illness. According to Vinaya Joshi, the key to success is stress management rather than stress elimination. Among the techniques that help people deal with everyday stress, he includes physical exercise, massage, (relaxation) breathing, psychological techniques (hobbies, social support, reframing seemingly unsolvable situations, and others), and stress relief through the senses (Joshi, 2007).

According to Debbie Mandel (2006), someone who does not want to become a Type D personality should follow these guidelines:

• They should take responsibility for their life. Improve things where things are lacking, or change the environment for the better. Learn to accept loss.
• They should express themselves honestly, while being attentive to how others receive their words. Communication is two-way. Try to listen more, because important information can sometimes be learned that may help.
• Keep their needs in balance with the needs of the people with whom they live. If a person knows what makes them happy, they can make others happy too. Find something positive in them and say it; this can activate positive energy in others. Positive energy will be reflected back.
• A person can also learn from criticism. They should spend time with people who do not always agree with them. Listen to their thoughts and suggestions, and avoid the need to always be right.
• Do not allow emotional needs to run their life. Try to leave the comfort zone and seek change. Emotional safety can function as a cage.
• Do not let anger determine the future. Old wounds consume energy and prevent progress. (Mandel, 2006).

Research on Type D personality is currently very popular. As Fred (2002) notes, current evidence suggests that Type D has replaced Type A as the dominant personality risk factor for coronary heart disease. There are also critics who argue that Denollet adds a new concept to an area already crowded with similar constructs (Lasperance and Frasure-Smith, 1996). Whether the Type D personality model will escape a similar fate as the previous A, B, and C models will only be shown in the future.

Author: Mgr. Róbert Ďurka, PhD. Literature: Denollet, J. (1998a). Personality and coronary heart disease: The Type-D Scale-16 (DS16). Annals of Behavioral Medicine, 20, 209 - 215. Denollet, J. (1998b). Personality and risk of cancer in men with coronary heart disease. Psychological Medicine, 28(4), 991 - 995. Denollet, J. (2000). Type D personality: A potential risk factor refined. Journal of Psychosomatic Research, 49, 255 - 266. Denollet, J. (2005). DS14: Standard assessment of negative affectivity, social inhibition, and type D personality. Psychosomatic Medicine, 67(1), 89 – 97. Denollet, J., & Brutsaert, D.L. (1998). Personality, disease severity, and the risk of long-term cardiac events in patients with decreased ejection fraction after myocardial infarction. Circulation, 97, 167 - 173. Denollet, J., Sys, S.U., & Brutsaert, D.L. (1995). Personality and mortality after myocardial infarction. Psychosomatic Medicine, 57, 582 - 591. Denollet, J., Sys, S.U., Stroobant, N., Rombouts, H., Gillebert, T.C. & Brutsaert, D.L. (1996). Personality as independent predictor of long-term mortality in patients with coronary heart disease. Lancet, 347, 417 - 421. Denollet, J., Vaes, J., & Brutsaert, D.L. (2000). Inadequate response to treatment in coronary heart disease: Adverse effects of type D personality and younger age on 5-year prognosis and quality of life. Circulation, 102(6), 630-635. Ďurka, R. (2006). Osobnosť typu D. In Selko, D., Psychológia zdravia – Rok 1? (84 -91). Bratislava: Mauro. Ďurka, R. (2007) Osobnosť typu D u pedagógov. In Selko, D., Psychická odolnosť a psychológia zdravia (106 - 114). Bratislava: Mauro. Ďurka, R.: Mentálne zdravie, stres a zmysel pre humor u pedagógov (2010). In Lovaš, L., Gajdošová, B., & Kováčová Holevová, B. (Eds.). Psychologia Cassoviensis 2008 (207 - 212). Košice: Univerzita Pavla Jozefa Šafárika. Fred, H. L.(2002) To be B or not to be B – Is that the question? Texas Heart Institute Journal, 29(1), 1 - 2. Grande, G., Jordan, J., Kümmel, M., Struwe, C., Schubmann, R., Schulze, F., Unterberg, C., von Känel, R., Kudielka, B.M., Fischer, J., & Herrman-Lingen, C. (2004). Evaluation der deutschen typ-D-skala (DS14) und prävalenz der typ-D-persönlichkeit bei kardiologischen und psychosomatischen patienten sowie gesunden. Psychotherapie, Psychosomatik, Medizinische Psychologie, 54(11), 413 - 423. Lesparence, F., & Frasure-Smith, N. (1996). Negative emotions and coronary heart disease: Getting to the heart of the matter. Lancet, 347(8999), 414 - 415. Joshi, V.(2007). Stres a zdraví. Praha: Portál. Mandel, D. (2006) Are you a Type D Personality? Here`s the antidote [online] [cit. 2006-02-26]. Available from WWW: http://www.turnonyourinnerlight.com/TypeD.html. Miller, D. M. (2003). The correlation between sense of humor and mental health. [online] [cit. 2008-10-01]. Available from WWW: http://clearinghouse.missouriwestern.edu/manuscript/405.asp. Mols, F., & Denollet, J. (2010a). Type D personality among noncardiovascular patient populations: A systematic review. General Hospital Psychiatry, 32(1), 66 - 72. Mols, F., & Denollet, J. (2010b). Type D personality in the general population: a systematic review of health status, mechanisms of disease, and work-related problems. Health and Quality of Life Outcomes, 8(1), 1 - 10. Pedersen, S.S., & Denollet, J. (2003). Type D personality, cardiac events, an impaired quality of life: A review. European Journal Of Cardiovascular Prevention And Rahabilitation, 10(4), 241 - 248. Pedersen, S.S., & Denollet, J. (2004). Validity of the Type D personality construct in Danish post-MI patients and healthy controls. Journal of Psychosomatic Research, 57, 265 - 272. Pedersen, S.S., & Denollet, J. (2006). Is Type D personality here to stay? Emerging evidence across cardiovascular disease patient groups. Current Cardiology Reviews, 2, 205 - 213. Pedersen, S.S., Yagensky, A., Smith, O.R.F., Yagenska, O., Shpak, V., & Denollet, J. (2009). Preliminary evidence for the cross-cultural utility of the type D personality in the Ukraine. Int. J. Behav. Med., 16, 108 - 115. Purebl, G., Rózsa, S., Danis, I., & Kopp, M. (2006). A D-típusu személyiség skála pszichometriai jellemzői reprezentatív vizsgálat alapján. Mentálhigiéné és Pszichosomatika, 7(3), 225 - 230. Selko, D., & Dubyová, T., (2006). Typ D a riziko kardiovaskulárnych ochorení v „zdravej populácii“. In Selko, D., Psychológia zdravia – Rok 1? (92 - 100). Bratislava: Mauro. Schiffer, A.A.J., Pavan, A., Pedersen, S.S., Gremigni, P., Sommaruga, M., & Denollet, J. (2006). Type D personality and cardiovascular disease: Evidence and clinical implications. Minerva Psichiatrica, 47(1), 79 - 87.

Type D personality in adults / Róbert Ďurka, 2011. In: Cesty psychologie a psychologie cest: 28th Psychological Days: 8–10 September 2010, Olomouc / ed. Daniel Heller, Pavel Michálek. - Praha: PEF ČZU v Praze, 2011. - ISBN 978-80-213-2193-9, pp. 532-543. The text was also published as an abstract. In Cesty psychologie a psychologie cest: 28th Psychological Days, 8–10.9.2010: program and abstracts of contributions. Olomouc: Faculty of Arts, Palacký University Olomouc, 2010, p. 45. - ISBN 978-80-213-2193-9.