Evidence for a cognitive bias of interpretation toward threat in individuals with a Type D personality more

J Behav Med DOI 10.1007/s10865-011-9351-7 Evidence for a cognitive bias of interpretation toward threat in individuals with a Type D personality Delphine Grynberg • Yori Gidron • Johan Denollet Olivier Luminet • Received: August 7, 2010 / Accepted: April 25, 2011 Ó Springer Science+Business Media, LLC 2011 Abstract Biological and behavioral mediators link Type D personality with a poor prognosis in heart disease. However, the mediator role of cognitive biases is still unknown. This study tested whether Type D individuals exhibit an interpretative bias for ambiguous social situations. For this aim we examined Type D and non-Type D individuals’ evaluations of written social situations that varied in terms of situations’ clarity (clear, ambiguous) and social judgment (neutral, negative). A convenience sample of 42 young, healthy adults rated each situation in relation to the difficulty of formulating a verbal response, anticipated distress, and perceived threat, and they completed the Type D personality scale (DS14; Denollet, 2005). Results showed an interpretation bias among Type D individuals, as they rated ambiguous or neutral situations as significantly more distressing compared to non-Type D individuals. Only clearly negative situations were rated similarly by Type D and non-Type D individuals. The discussion suggests that this interpretation bias in Type D individuals would increase their vulnerability to perceived stress. Keywords Type D personality Á Interpretation Bias Á Social Judgment Á Ambiguity Á Threat Introduction The role of psychological factors in coronary heart disease has been extensively investigated in the past two decades (see reviews by Chida & Steptoe, 2009; Kuper et al., 2002; Rozanski et al., 1999). Studies examining the possible role of psychological factors in the aetiology of coronary heart disease included hostility (e.g., Barefoot et al., 1994; Dembroski et al., 1989) and more recently ´ depression (e.g., Frasure-Smith & Lesperance, 2010). Many studies have demonstrated the prognostic role of negative emotions, primarily depression, in patients with coronary heart disease (see review by van Melle et al., 2004), though some reviews qualify these conclusions (Nicholson et al., 2006). In contrast, relatively little work has been done on broader personality factors in relation to aetiology or prognosis in coronary heart disease. Focusing on personality may be important because some traits involve differences in feeling emotional distress (e.g., Denollet & Brutsaert, 1998), which can in turn affect coronary heart disease progression (Denollet et al., 2006; Stansfeld et al., 2002). Denollet and colleagues have conducted systematic work on the prognostic role of the Type D personality in coronary heart disease. Type D individuals are characterized by both elevated Negative Affectivity and Social Inhibition (Denollet, 2005). Negative Affectivity relates to dysphoric sensations as well as worry, and Social Inhibition is associated with inhibition of emotional and behavioral expression during social interactions. In several prospective studies, cardiovascular and coronary heart disease patients with a Type D personality were found to have poorer prognosis, independent of established prognostic factors (e.g., Denollet et al., 1996; Denollet & Brutsaert, 1998). Recently, two meta-analytic reviews also D. Grynberg (&) Á O. Luminet ´ Research Institute for Psychological Sciences, Universite Catholique de Louvain, Louvain-la-Neuve, Belgium e-mail: delphine.grynberg@uclouvain.be Y. Gidron Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium J. Denollet CoRPS—Center of Research on Psychology in Somatic Diseases, Tilburg University, Tilburg, The Netherlands 123 J Behav Med confirmed that Type D personality was associated with an increased risk of poor cardiovascular outcomes, with a mean odds ratio ranging between 3.2 and 3.7 for major adverse cardiac events (Denollet et al., 2010; O’Dell et al., in press). In their review, O’Dell and colleagues (in press) concluded that Type D is a promising construct, and that more research is warranted for further improving our understanding of the relationships between Type D and important cardiovascular outcomes. Whereas some preliminary work has pointed at the possible biological mediators of these relationships (such as, for example, elevated tumor-necrosis factor alpha and its receptors; Conraads et al., 2006; Denollet et al., 2003), little work has focused on possible psychological mediators. One study recently found that poor communication with health professionals was associated with Type D personality (Schiffer et al., 2007), possibly pointing at a behavioral mediator between Type D personality and coronary heart disease prognosis. However, it is also possible that cognitive processes partly underlie this personality profile and its detrimental prognostic effects. In its initial conceptualization, Type D individuals were thought to fear social judgment and the subsequent anxiety it can provoke (Denollet, 2000). By avoiding social situations via Social Inhibition, chances of experiencing subsequent distress are reduced. This reduced distress may negatively reinforce their social withdrawal and social inhibition. It is possible that the Social Inhibition and Negative Affectivity of Type D individuals are related to cognitive biases in interpreting social situations as more distressing or threatening than they really are. Such cognitive biases may be particularly apparent in socially ambiguous situations, where interpretation biases may exist when individuals ‘‘read’’ into a situation implications that may not be present. Such interpretation processes have been found in social phobia (e.g., Amir et al., 1998), which is highly pertinent to Type D personality. Several studies indeed suggest that cognitive bias might be responsible for the initiation (Clark, 2001; Heeren et al., submitted) and maintenance of social anxiety (Amir et al., 2008; Schmidt et al., 2009). However, no previous studies have focused on cognitive bias during social interactions among individuals with a Type D personality. Daily social interactions may include varying degrees of social judgment (neutral, positive or negative), but their perception may also depend on the level of clarity in which such judgments are presented. In this case, social judgment refers to the potential neutral or negative judgment of the other partners in a social interaction, whereas clarity refers to the availability of knowledge about the intentions of others. Socially ambiguous situations could be construed by highly sensitive individuals as distressing or threatening because the absence of information about the intentions leaves room for interpretation biases to occur. Whereas both level of clarity and social judgment showed to have effect on interpretation biases (e.g., Voncken et al., 2003) we suggest that their effects might interact. Therefore, the purpose of the present study was to test main effects of social judgment and situation clarity and their interaction effects on participants’ interpretation bias of social scenarios in Type D and non Type D individuals. We hypothesized that Type D personality, social judgment and situation clarity will each influence the difficulty formulating a verbal response, anticipated distress and perceived threat in simulated social scenarios. In line with an interpretation bias, we hypothesized that Type D individuals would respond with greater difficulty formulating a verbal response, and show greater anticipated distress and perceived threat than non-Type D individuals to socially ambiguous situation and more particularly to ambiguous but non-judgmental situations, because such situations are more open to interpretation. Method Participants Eighty-one participants were recruited on the campus of the catholic University of Louvain-la-Neuve through posted advertisements. From this sample, 42 participants were selected according to their Type D characteristics. Individuals were classified as having a Type D personality based on the previously published cut-off score (i.e., C10 on both the Negative Affectivity and Social Inhibition scales of the DS14; Denollet, 2005). In the present study, a third of the participants fulfilled the criterion for having a Type D personality. The prevalence of Type D personality is twenty percent in the general population, and more than fifty percent among hypertensive patients (Denollet, 2005). Whereas in most epidemiological studies, Type D individuals are contrasted with all the remaining participants in a clinical sample, it was thought that for the purpose of an experimental study testing thought processes, it was more suitable to contrast Type D individuals (i.e., C10 on Negative Affectivity and Social Inhibition) with individuals who were clearly non-Type-D (i.e., \10 on Negative Affectivity and Social Inhibition). These individuals are less likely to experience negative emotions and are less likely to be inhibited during social interactions. Within the selected sample, there were 88% women, and the mean (SD) age was 23.46 (6.99) years. The Type D group was composed of 24 participants (23 female) with a mean age 123 J Behav Med of 22.52 years (SD = 5.21), and the non-Type D group was composed on 18 participants (14 female) with a mean age of 24.67 years (SD = 8.78). The non-Type D group differed significantly from the Type D group on both Negative Affectivity (M = 5.27 (Range = 0–9); M = 14.92 (Range = 10–25); P \ .001) and Social Inhibition (M = 6.06 (Range = 2–9); M = 15.17 (Range = 10–22); P \ .001). Participants were paid 7 Euros for taking part in the study, which was part of a larger study on social cognition. Materials Participants read sixteen written scenarios depicting daily social interactions that varied along two dimensions, namely social judgment (neutral, negative) and clarity (clear, ambiguous). Each scenario fulfilled one of the four following conditions: (1) ambiguous- negative: (e.g., ‘‘You go to a birthday party, and some people look at each other and start whispering when they see you come in’’); (2) ambiguous-neutral (e.g., ‘‘You go to a birthday party and a person you don’t know nods his head to you’’); (3) clearnegative (e.g., ‘‘You have been dismissed for a serious offence’’): (4) clear-neutral; ‘‘You are in the train and the ticket inspector asks for your ticket’’). Thirty-four scenarios were pre-tested by independent judges (seven Ph.D. students) who rated the scenarios on their relevance to this group of participants (students), and the degree to which each scenario was socially negative and clear. The sixteen scenarios with the most consistent ratings were selected for the present study: four clear-neutral; four clear-negative, four ambiguous-neutral and four ambiguous-negative. The average intraclass correlation coefficients for all conditions (ICC, Shrout & Fleiss, 1979) was .79 with a median of .93, which indicates excellent interrater reliability (Bartko, 1966). A closer inspection of the material motivated us to remove the results of one scenario (i.e., from the ‘‘clear negative’’ combination) that depended too much on participants’ age. There are thus fifteen sentences in total. Sentences were presented in the same randomized order to all participants. Type D personality was assessed with the DS14 questionnaire (Denollet, 2005). It includes seven items assessing Negative Affectivity (tendency to experience negative emotions; e.g., ‘‘I am often down in the dumps’’) and seven items assessing Social Inhibition (tendency to inhibit selfexpression during social interaction; e.g., ‘‘I am a closed kind of person’’). Participants rated their agreement with each item on a 5-point Likert scale. The internal consistencies of these factors were .88 and .86, respectively. The high correlation between Negative Affectivity and neurot- icism and between Social Inhibition and introversion support the construct validity of the questionnaire (Denollet, 2005), and the DS14 has been demonstrated to be stable over time (Martens et al., 2007). Design and procedure This study employed a quasi-experimental mixed design. Participants read and rated each scenario in relation to three dependent variables (a) the difficulty in formulating a verbal response (i.e., Would it be difficult for you to say something in this situation, if you wanted to (0 = not difficult, 10 = very difficult)); (b) the distress they anticipated feeling (i.e., If you were in this situation, what would be the level of your distress (0 = no distress; 10 = highly distressful)), and (c) their perceptions of threat (i.e., To what extent do you find this situation threatening (0 = not threatening; 10 = extremely threatening)). Finally, participants completed the Type D personality scale. Statistical analysis Repeated measures analyses of variance (ANOVA) were used to evaluate the separate effects of Type D personality, clarity and social judgment on difficulty in formulating a verbal response, anticipated distress and perceived threat. Univariate ANOVAs were then used to test the simple effects of interactions between social judgment, clarity and personality on the three outcomes. Results Table 1 depicts the means scores of participants’ difficulty formulating a verbal response, anticipated distress and perceived threat in response to each of the four types of social situations. Main and interaction effects of Type D personality Across all situations, Type D individuals presented overall greater difficulties in formulating a verbal response (F(1, 40) = 7.89, P = .008, partial eta2 = .165), more anticipated distress (F(1, 40) = 18.42, P \ .001, partial eta2 = .315), and greater perceived threat (F(1, 40) = 19.44, P \ .001, partial eta2 = .327) than non-Type D individuals (Figs. 1, 2, 3). The significant interaction between Type D and clarity on difficulty in formulating a verbal responses (F(1, 40) = 5.50, P = .024, partial eta2 = 121) and anticipated distress 123 J Behav Med Table 1 Means (standard deviations) of participants’ difficulty formulating a verbal response and ratings of distress and perceived threat in daily situations, as a function of situations’ clarity and judgment and participants’ personality Personality Difficulty formulating a verbal response Non-Type D Clear, neutral Clear, negative Ambiguous, neutral Ambiguous, negative 10 8 6 4 2 0 -2 Clear Neutral Clear Negative Non-Type D Type D Anticipated distress Non-Type D 0.49 (0.66) 7.83 (1.58) 0.68 (0.91) 4.82 (1.93) Type D 2.04 (1.35) 8.47 (1.48) 2.64 (1.56) 6.86 (1.64) Perceived threat Non-Type D 0.15 (0.32) 6.54 (2.31) 0.29 (0.45) 3.74 (2.18) Type D 1.29 (1.08) 8.07 (1.38) 1.82 (1.33) 5.84 (1.86) Type D 1.62 (1.21) 5.75 (2.30) 2.75 (1.99) 5.84 (2.24) 0.35 (0.63) 5.15 (2.67) 0.92 (0.80) 4.14 (2.20) Difficulty Formulating a Verbal Response * *** we found a three-way Type D 9 clarity 9 judgment interaction on anticipated distress (F(1, 40) = 4.62, P = .038, partial eta2 = .104). Testing the interpretation bias hypothesis *** Ambiguous Neutral Ambiguous Negative Situations Fig. 1 Effects of Type D personality, clarity and social judgment on difficulty formulating a verbal response. The error bars represent the standard deviation of the mean 10 8 6 4 2 0 Clear Neutral Clear Negative Ambiguous Neutral Ambiguous Negative Non-Type D Type D *** *** *** Situations Fig. 2 Effects of Type D personality, clarity and social judgment on anticipated distress. The error bars represent the standard deviation of the mean 10 8 6 4 2 0 -2 Clear Neutral Clear Negative Non-Type D Type D * *** ** *** Ambiguous Neutral Ambiguous Negative Situations To test the interpretation bias hypothesis, we chose to examine the Type D 9 clarity interaction for negative and neutral judgments separately, as we suspected that the interaction between Type D and clarity should be more sensitive to individual differences than the interaction between Type D and social judgment. This is based on the reasoning that it would be harder for all participants to differentiate ambiguous from clear situations (‘‘Clarity’’), than to differentiate neutral from negative situations (‘‘Social Judgment’’). In socially negative situations, Type D significantly interacted with clarity (F(1, 40) = 11.90, P = .001, partial eta2 = .229). In negative and ambiguous situations, Type D individuals reported more anticipated distress than non-Type D individuals (F(1,41) = 13.76, P = .001, partial eta2 = .256), whereas in negative and clear situations, Type D personality had no effect on anticipated distress (F(1,41) = 1.81, P = .19). In socially neutral situations, Type D did not interact with clarity (F(1, 40) = 2.70, P = .11), such that Type D individuals presented higher levels of anticipated distress in both clear (F(1,41) = 20.11, P \ .001, partial eta2 = .334) and ambiguous (F(1,41) = 22.43, P \ .001, partial eta2 = .359) situations, than non-Type D individuals. Hence, there was a stable Type D effect on anticipated distress in socially neutral situations, as clarity of the situation did not interact with Type D personality in these situations. Fig. 3 Effects of Type D personality, clarity and social judgment on perceived threat. The error bars represent the standard deviation of the mean. *P \ .05; **P \ .01; ***P \ .001 Feeling of Threat Anticipated Distress (F(1, 40) = 14.10, P = .001, partial eta2 = .261) showed that the Type D effect was mostly significant in ambiguous situations, whereas Type D effects were weaker or non significant in clear situations1 (see Figs. 1, 2). Moreover, In ambiguous situations Type D individuals reported greater difficulties in formulating a verbal response and more anticipated distress than non-Type D individuals (respectively F(1, 41) = 10.80, p = .002, partial eta2 = .213; F(1, 41) = 22.37, P \ .001, partial eta2 = .359). In clear situation these effects were respectively F(1,41) = 3.68, p = .06, partial eta2 = .084; F(1,41) = 10.90, p = .002, partial eta2 = .214). 1 123 J Behav Med Differential sensitivity to situational cues The source of the three-way Type D 9 clarity 9 judgment interaction on anticipated distress was in the absence of an effect of Type D personality in social situations that are clearly negative as opposed to a significant Type D effect in all other social situations. In fact, Type D individuals reported significantly more anticipated distress than nonType D individuals in neutral, ambiguous as well as negative situations. Moreover, the effect of clarity in negative situations had only an effect size of .216 (F(1, 47) = 12.71, P = .001) among Type D individuals whereas it attained an effect size of .436 among non-Type D individuals (F(1,35) = 26.28, P \ .001). This contrast of effect sizes supports the differential sensitivity to situational cues and further highlights the interpretation bias observed among Type D individuals. Discussion To the best of our knowledge, this is the first study testing the cognitive bias of interpretation of Type D personality. It was hypothesized that beyond biological and psychological mediators which have been associated with Type D personality so far, a more cognitive process (interpretation bias) might also be associated with this personality, which could partly explain the poorer prognosis observed in Type D cardiac patients. It was expected that ambiguous social situations, which provide room for interpretation (i.e., ambiguous and especially neutral ambiguous situations) would elicit in Type D individuals higher ratings of cognitive (i.e., perceived threat) and affective (i.e., anticipated distress) responses would be associated with reduced assertiveness (i.e., difficulty formulating a verbal response). Supporting the lack of sensitivity to situational cues in Type D individuals, although both groups presented less distress and less perceived threat in negative ambiguous situations than in negative clear situations, analyses showed that the decrease was much stronger among nonType D individuals than among Type D individuals. This contrast highlights thus the hypothesized interpretation bias among Type D individuals. Additionally, personality interacted with clarity such that mainly in ambiguous situations, did Type D individuals present higher rating of anticipated distress, perceived greater threat and reported difficulty formulating a verbal response than non-Type D individuals. Because an ambiguous situation is characterized by the possibility to infer into a situation implications that may not be present, those results show that Type D individuals report more negative responses than non-Type D individuals when a situation is open to interpretation. This supports thus the hypothesis that Type D individuals are more prone to an interpretation bias. Such ambiguous situations have been found in many studies to yield greater distress in various contexts such as job-uncertainty (e.g., Paulsen et al., 2005), perhaps since people cannot adequately prepare for, or mentally represent, such events. Also, the effects of interpretation biases on subsequent emotional distress are receiving increasing attention (e.g., Amir et al., 2005). In this study, socially anxious participants reported more anticipated negative feeling in ambiguous social situations than control participants. This confirms our findings that ambiguity may create an interpretation bias associated with higher reports of negative affects. Limitations and strengths This study has a number of limitations. First, the study would benefit from having a more representative sample, by including people of different ages as well as more male participants. Furthermore, the sample was relatively small, even if it was statistically satisfactory. Second, there are methodological limitations. We used simulated written scenarios, with single-items as a measure of each of the three dependant variables, and did not include observational methods to document how individuals actually behave in real situations. Future studies should combine self-report with observational methods to evaluate participants’ actual responses to more realistic daily social events. The strengths of this study included the clear theoretical framework and rationale of the experimental design and the within-subject design that increased the statistical power. Moreover, we have included distinctly different facets of social situations and new findings about the cognitive underpinnings of Type D personality. Interpretation bias Type D individuals reported higher anticipated distress than non Type D individuals for all possible social scenarios, except for clearly negative social situations. Thus, as long as events are negative and ambiguous, or simply neutral, Type D individuals may react to them more negatively than non-Type D individuals in real life. Our result are consistent with an interpretation bias in Type D individuals, as they reported more anticipated distress to events that are either ambiguous and/or neutral in general. Whereas non-Type D individuals showed greater sensitivity to the precise nature of the situation, Type D individuals were less sensitive to such changes in social cues. 123 J Behav Med Implications for stress research A subtle social experimental stressor may be used to uncover effects of cognitive bias among Type D individuals on their physiological stress reactivity. One possibility would be to include more ambiguity, and room for interpretation in the Trier Social Stress Test (Kirschbaum et al., 1993). This test is the most frequently used test for inducing social stress in the lab but includes an evaluation task of unambiguously negative social situations only. Clinical implications Higher perceived threat and feeling of distress during ambiguous situations might explain how Type D personality may be associated with an increased vulnerability to stress-related cardiovascular events in patients with coronary heart disease. Longitudinal studies should address the prognostic role of these interpretation biases by examining their impact on the development and progression of coronary heart disease in Type D individuals. Therapeutic efforts aimed at helping Type D individuals in medical settings may need to focus on altering negative interpretations of ambiguous social situations in order to help them to cope in a more adaptive way with daily challenges. These cognitive interventions could be based on the ones already validated for socially anxious participants (Beard & Amir, 2008; Murphy et al., 2007). These findings highlight the cognitive underpinnings of Type D personality, thereby extending the current literature demonstrating possible biological (Conraads et al., 2006; Denollet et al., 2003) and behavioral (Schiffer et al., 2007) correlates of this personality profile. In sum, future studies would need to use an observational paradigm to replicate and substantiate the present findings. Furthermore, future interventions may need to include teaching Type D individuals how to evaluate more accurately socially neutral situations. Reappraising threat in neutral situations would constitute the first step to possibly reducing their initial negative responses. clearly negative situations, which support the hypothesis of an interpretation bias of daily social events. Acknowledgments This study was supported by grants 1.1.233.09 from the Belgian National Funds for Scientific Research (FNRS-FRS) to Delphine Grynberg (Research Fellow). This study was supported by grants 1.5.175.06 and 1.5.148.10 from the Belgian National Fund for Scientific Research granted to Olivier Luminet (Senior Research associate). This research was also supported by a Joined Research Grant (ARC 06/11-337) from the Belgian French Community to Olivier Luminet, and by a VICI grant (#453-04-004) from the Netherlands Organization for Scientific Research to Johan Denollet. We thank Betty Chang for her help in improving the manuscript. Appendix Clear negative 1. 2. You have been dismissed for a serious offence. You explain to your colleagues that you are late for the meeting because your train was twenty minutes late. They tell you that it is unacceptable and ask you to not participate anymore in these meetings. You receive a mail from a friend, who tells you that he was very disappointed by your aggressive behavior at his party, and that he does not want to see you ever again. 3. Ambiguous negative 1. You go to a birthday party, and some people look at each other and start whispering when they see you come in. You explain to your colleagues that you are late for the meeting because your train was twenty minutes late. They listen to your explanation and then take a coffee break. You are going to a club, and the doorman refuses to let you in. Someone enters in your classroom and firmly declares that the headmaster wants to see you immediately. 2. 3. 4. Clear neutral 1. You are in the train and the ticket inspector asks for your ticket. You explain to your colleagues that you are late for the meeting because your train was twenty minutes late. They tell you that there is no problem. You walk in the street and a person points out to you that your laces are undone. You call a friend to ask him to go to the cinema with other friends, but he tells you that he can not come because he is with his mother, whom he has not seen for a while. Conclusion 2. Overall, two important findings emerged in relation to the cognitive underpinnings of Type D personality. First, Type D individuals have greater difficulty in formulating a verbal response, and also exhibit more anticipated distress and perceived threat during ambiguous social situations, than non-Type D individuals. Second, Type D individuals reported much more anticipated distress than non-Type D individuals in neutral or ambiguous situations, but not in 3. 4. 123 J Behav Med Ambiguous neutral 1. 2. 3. You go to a birthday party and a person you don’t know nods his head to you. You go to the bookshop and the bookseller sells you a newspaper without the TV guide. You pass your colleague in the street and after having looked at you, he starts walking more quickly and then crosses the street. You are going to the cinema and the usherette does not give you the program. 4. References Amir, N., Beard, C., & Bower, E. (2005). Interpretation bias and social anxiety. 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