Personality and cardiovascular risk: Association between hypertension and affective temperaments—a cross-sectional observational study in primary care settings

Abstract

Background: Affective temperaments can be considered the subclinical manifestations of affective disorders, which have a bidirectional relationship with cardiovascular diseases.

Objectives: Aim of this study was to assess the role of affective temperaments in primary hypertension, which is the leading risk factor of cardiovascular morbidity and mortality.

Methods: In total, 251 consecutive patients, including 179 patients being treated for primary hypertension with anti-hypertensives, with chronic disorders without diagnosed depression were enrolled in a primary care setting. Patients completed the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A). Lifestyle-related risk factors, chronic diseases including cardiovascular complications were also recorded. Logistic regression analysis was used to determine the relationship of affective temperaments and lifestyle-related risk factors on hypertension.

Results: Dominant cyclothymic temperament—with instability and rapid mood swings as main characteristics—had a significant association with hypertension (P = 0.006) even after the adjustment of correlation for known risk factors such as age, diabetes mellitus and obesity (OR: 11.88, 95%CI: 1.27–111.17). This association remained significant after controlling for the family wise error rate. The obtained adjusted P value was 0.024 at a 0.05 error rate.

Conclusion: Results indicate that dominant cyclothymic affective temperament may be an additional risk factor in cardiovascular morbidity, and it may be worthy of further assessment to identify patients at risk and formulate a more individualized treatment approach.

Keywords::

• anxiety
• depression
• somatization
• general practice/family medicine
• heart and circulation
• prevention

KEY MESSAGE:

• Personality traits are important moderators of chronic somatic conditions including hypertension.

• Affective temperaments determine individual emotional reactions for environmental stimuli and can be expressed on five scales: hyperthymic, depressive, cyclothymic, irritable and anxious.

• Cyclothymic temperament shows an association with hypertension independently of age, diabetes mellitus and obesity.

INTRODUCTION

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality worldwide (1). It affects a dominant part of Western population and is responsible for up to one third of deaths (2). Major depression is an established independent risk factor of CVD exerting its effects within a bidirectional relationship. Its’ prevalence is three times higher in patients with heart disease, and every fifth cardiac patient develops major depression (3–5). Moreover, bipolar disorder is also associated with increasing cardiovascular morbidity and mortality, especially in women (6–8). This could be related to the fact that bipolar disorder is associated with markedly increased prevalence of obesity, smoking and hypertension (9–11).

Beside traditional risk factors, personality can affect vulnerability to and prognosis of cardiovascular disorders (CVD). Anxiety, hostility and type D personality—among other psychosocial risk factors—contribute to the development, clinical course and prognosis of CVD through unhealthy lifestyle, increased healthcare utilization and low adherence to behaviour-change recommendations or cardiac medications according to the European Guidelines on cardiovascular disease prevention in clinical practice (12).

Temperament is regarded as the inherited part of personality and represents the biologically stable core of emotional reactivity (13,14). Affective temperaments can be measured on five temperament scales by the Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) (15). Hyperthymic temperament is characterized by upbeat, over- confident and over-energetic traits while depressive is self-denying, striving to live in harmony with others and sensitive to suffering. Anxious temperament can be best explained by exaggerated worries especially toward family members. Cyclothymic temperament shows affective instability with rapid mood shifts and intense emotions, while irritable temperament incorporates sceptical and critical traits (14,16).

All individuals have their own characteristic temperament profile determining their emotional response to environmental stimuli. Affective temperaments are also responsible—in their natural mixture—for cultural characteristics on a national level (14,17).

However, dominant affective temperaments, temperaments on their extremes, are regarded as the subclinical manifestations or even precursors of major affective disorders (18). According to extensive research, dominant affective temperaments contribute to the development, symptom formation, clinical expression, course and prognosis of depression (18).

Behavioural risk factors are preponderant in cardiovascular disorders, and personality patterns and temperaments can be considered as moderators instead of causes of specific diseases (19,20). Specific affective temperaments and their relationship with different somatic disorders may contribute to the formulation of more effective prevention and better treatment planning in a psychosomatic approach.

The aim of this study was to establish the possible relationship between dominant affective temperaments and hypertension and examine their influence independently of other known risk factors of hypertension in primary care patients free of any affective disorders.

METHODS

Patients

In a cross-sectional design, patients were collected twice weekly in three separated primary care practices (average of 1500 patients in the catchment area of each, with a daily turnover of 20–40 patients) between February and June 2011. Inclusion criteria included patients older than 18 years, with known and medically treated primary hypertension and non-hypertensive age and gender-matched controls were also collected. Exclusion criteria were secondary hypertension, the presence of ICD-10 depressive or bipolar disorders or antidepressant/mood stabilizer treatment at the time of the study and blood pressure more than 139/89 mmHg during the baseline blood pressure measurement in the normotensive control group. Two patients were excluded because they declined to fill in the questionnaires. Patients received thorough oral and written explanation of the study. Data on sociodemographic characteristics, physical activity and addictive behaviour was collected and trained personnel undertook physical examination (blood pressure, pulse rate, height, weight, waist circumference measurements). Medical history (with special attention to cardiovascular complications and depression) as well as data on current medication was extracted from medical documentation or electronic medical record of patients by GPs. Data of 302 consecutively investigated primary hypertensive (n = 212) and non-hypertensive (n = 90) chronically ill patients were collected. Thirty-three persons from the hypertensive group and 15 from the control group were excluded due to ICD-10 depressive or bipolar disorders or antidepressant/mood stabilizer treatment at the time of the study and another three persons from the control group because of blood pressure higher than 139/89 mmHg at the baseline measurement. The final sample consisted of 179 primary hypertensive and 72 non-hypertensive patients who completed the questionnaires. Prior to involvement, all participating patients gave written informed consent. The study has been approved the competent ethical committee (TUKEB 842/PI/2011) and was carried out in accordance with the tenets of the Declaration of Helsinki.

Measures

A self-administered questionnaire was used to assess sociodemographic characteristics (age, gender and education) and lifestyle factors (tobacco use, physical activity and BMI). Data on chronic illnesses (year and origin of hypertension; cardiovascular and cerebrovascular disorders, kidney disease, peripheral artery disease, diabetes mellitus, depression and information about other chronic medical conditions) and current medication was collected from certified medical record or electronic medical documentation of patients by GPs.

TEMPS-A. The Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) is a 110-item instrument, which was developed to measure affective temperaments on depressive, cyclothymic, hyperthymic, irritable and anxious subscales, requiring ‘yes’ (score 1) or ‘no’ (score 0) answers (15). TEMPS-A is used to assess the point scores of each subscale and also to measure the presence of the dominant form of affective temperaments by taking the mean of the subscale and adding up two standard deviations to it. Those reaching the mean + 2 SD level or higher on each subscale have dominant affective temperament (score 1) while below this level score 0. The self-report questionnaire is translated to more than 30 languages and validated in several countries worldwide. It was validated in Hungarian in 2006 and showed good internal consistency and moderate correlations with the Beck Depression Inventory (BDI), Temperament and Character Inventory (TCI) and the NEO Personality Inventory-Revised (NEO-PI-R) in a normative sample of clinically well Hungarian persons (n = 1132), (21,22).

Statistical analyses

As scientific evidence support the non-linear association between age, BMI and cardiovascular disorders, we dichotomized our related data splitting age at 60 years based on that the prevalence of hypertension is more than twice among people older than 60 years compared to people younger than 60 years (23). We applied the WHO established categories for BMI and used the 25 kg/m² lower border of increased body weight as cutting point (24). Affective temperaments can also be measured as interval scales or can be dichotomized. We used the categorical scale for analysis in this study. Chi-square or Fisher's exact tests were applied for the assessment of group differences in categorical variables (gender, obesity, tobacco use, regular physical activity and most common chronic conditions of the sample in hypertensive and normotensive patients). Independent samples t-tests were used for the assessment of gender differences in age and to examine the age difference between hypertensive and normotensive patients. Binary logistic regression was used to examine the association between hypertension and age, education, physical activity, tobacco use, being overweight or obese, diabetes mellitus and dominant affective temperaments. The outcome variable was the presence or absence of hypertension. The predictor of main interest was the prevalence of dominant affective temperaments, and the model was adjusted for age, obesity and diabetes mellitus. To control for the family-wise error rate, we applied multiple comparison tests developed for generalized linear models (glm) to dominant affective temperaments simultaneously (25,26). Univariate analyses were performed using SPSS version 19.0. R Version 15.1 was applied for logistic regression.

RESULTS

Baseline characteristics of the sample

The sample consisted of 251 cases. Statistical analysis was carried out based on the data of 179 primary hypertensive patients (102 females, 77 males, mean age ± SD: 62 ± 14 years mean SBP: 137.2 ± 13.1 mmHg, mean DBP: 82.1 ± 9.9 mmHg) and 72 normotensive control patients (48 females, 24 males; mean age ± SD: 51 ± 15 years mean SBP: 121.2 ± 11.2 mmHg mean DBP: 75.9 ± 8.9 mmHg). Mean duration of hypertension (± SD) in the sample was 13 years (± 9 years). Most common chronic disorders in the whole sample were musculoskeletal disorders (36.1%), dyslipidaemia (25.5%), gastrointestinal diseases (25.5%) and diabetes mellitus (22.8%).

Table 1 shows the distribution of demographic background characteristics, lifestyle-related risk factors, and most common chronic conditions for the hypertensive and normotensive patients. Hypertensive patients were significantly more obese and older than patients were in the normotensive group, with higher prevalence of diabetes mellitus (P < 0.0001, respectively). Gender differences, tobacco use, the level of physical activity and the prevalence of other common chronic conditions were non-significant between hypertensive patients and normotensives.

Table 1. Prevalence of socio-demographic factors, lifestyle-related hypertension risk factors and most common chronic disorders of 251 chronically ill primary care patients in Hungary.

	Hypertensive patients n = 179 n (%)	Normotensive patients n = 72 n (%)	P value
Older age (≥ 60 years)	101 (56)	22 (31)	< 0.0001
Female	102 (57)	48 (67)	0.157
Education in years
8 years	38 (21)	11 (15)	0.291
12 years	81 (45)	28 (39)
> 12 years	57 (32)	32 (44)
Increased BMI^a	135 (75)	32 (44)	< 0.0001
Smokers (%)	28 (16)	16 (22)	0.324
Regular physical activity^b	35 (20)	17 (25)	0.426
Diabetes mellitus (Missing data = 1)	54 (30)	3 (4)	< 0.0001
Musculoskeletal conditions^c	56 (36)	22 (37)	0.916
Dyslipidemia^c	44 (28)	11 (18)	0.136
Gastrointestinal disorders^c	45 (29)	10 (17)	0.066

^aIncreased BMI: > 25 kg/m².

^bRegular physical activity: 30 min aerobic exercise daily or more than once weekly.

^cMissing data: 35, hypertensives: n = 156, normotensives: n = 60.

To assess the predictive role of lifestyle-related risk factors on hypertension in our sample, we conducted binary logistic regression, and found that older age (> 60 years) (OR: 4.3; 95% CI: 2.2–8.9; P < 0.0001) increased BMI (> 25kg/m²) (OR: 4.6; 95% CI: 2.3–9.6; P < 0.0001), and diabetes mellitus (OR: 5.2; 95%CI: 1.9–18.5, P = 0.003) predicted hypertension while the effects of regular physical activity, smoking status and gender were not larger than could be due to the chance in these data (P > 0.05).

Measuring dominant affective temperaments of the whole sample (scoring more than mean + 2 SD on any specific subscale); we found that 58 patients (23%) showed dominant affective temperaments. Comparing rates of dominant affective temperaments between hypertensive and non-hypertensive control patients, we found that the prevalence of cyclothymic temperament was significantly higher in the hypertensive than in the non-hypertensive control group (12.8% versus 4.2%, P = 0.041).

Relationship between hypertension and dominant affective temperaments adjusted for older age > 60 years, diabetes mellitus and overweight/obesity BMI > 25 kg/m²

Table 2 provides an analysis of the associations between age older than 60 years, BMI greater than 25 kg/m² diabetes mellitus and dominant affective temperaments (depressive, cyclothymic, irritable and anxious) to the prevalence of hypertension. We excluded dominant hyperthymic temperament because we had only three positive observations out of 251. Results show that obesity (P < 0.0001), older age (P < 0.0001) and diabetes mellitus (P = 0.0006) was positively associated with hypertension as it was found in the first model (data shown in Table 2). Dominant cyclothymic temperament also increased the odds of hypertension significantly (P = 0.006). To control for the family-wise error rate, we applied a multiple test developed for generalised linear models (glm) to the four types of affective temperaments simultaneously and obtained that dominant cyclothymic temperament was significantly related to hypertension at a 0.05 family-wise error rate (25,26). The obtained adjusted P value was 0.024.

Table 2. Relationship between the prevalence of hypertension and age, overweight/obesity, diabetes mellitus and dominant depressive, cyclothymic, irritable and anxious affective temperaments, among 251 chronically ill primary care patients in Hungary (multivariable logistic regression).

	Adjusted OR	95% CI^a	P value*
Intercept	0.253	0.12–0.51	0.0002
Age (> 60)	4.687	2.34–9.95	< 0.0001
BMI > 25 kg/m2	6.222	3.06–13.30	< 0.0001
Diabetes mellitus	7.023	2.53–25.22	0.0006
Dominant depressive temperament	2.759	0.26–29.24	0.6982
Dominant cyclothymic temperament	11.885	1.27–111.17	0.0236
Dominant irritable temperament	0.388	0.06–2.47	0.5560
Dominant anxious temperament	1.649	0.35–7.71	0.8587

^aAge, overweight/obesity and diabetes mellitus were considered as independent risk factors for hypertension; confidence intervals and P values were determined independently with error rate of 0.05. Dominant affective temperaments were tested simultaneously and corrected for 5% family-wise error rate (FVER). In case of dominant affective temperaments, multiplicity-adjusted P value is significant at the 0.05 level.

DISCUSSION

Main findings

Our results indicate that marked dominant cyclothymic temperament (scoring more than mean + 2 SD on the cyclothymic subscale) is significantly related to primary hypertension independently from age, obesity and diabetes mellitus. Moreover, the 10.4% prevalence of marked dominant cyclothymic temperament in our primary hypertensive patients is significantly higher than the same rate in the non-hypertensive patient control group (4.2%) and the 4.2% frequency of dominant cyclothymic temperament in the Hungarian normative validation sample (21).

Limitations

To study the association between hypertension and temperaments, we used a heterogeneous real-practice population with relatively small sample size. The control group was younger and suffered from less chronic illnesses than the hypertensive group. The slightly lower dyslipidaemia/diabetes mellitus ratio (1.12) in our sample comparing to the dyslipidaemia/diabetes ratio (1.49) of the representative Hungarian sample of the Eurostat Health and Life Expectancy Survey can be explained by the older patient population with more cardiovascular disorders and rigorous follow up of diabetic patients in primary care in Hungary. The cross-sectional nature of the investigation prevents drawing causal relationship and long-term conclusions.

Interpretation

The role of cyclothymic temperament is especially important in the symptom formation, clinical course and prognosis of affective disorders (18). Cyclothymic temperament has instability as main characteristic expressed in mood, self-esteem and socialization. Mood lability or instability, energy-activity and daydreaming, were three factors distinguishing those patients who converted from major depressive disorder to bipolar II disorder from those who remained unipolar in an 11-year longitudinal study (28). Cyclothymic temperament is associated with bipolar II disorder; it is related to worse prognosis of depression with more residual symptoms as well as suicidal behaviour (18). Based on its evolutionary origin, however, the intense emotions, keen perceptions and the romantic nature of cyclothymic temperament also enhance fitness and adaptation, hence cyclothymic temperament along with its genetic background persisted throughout evolution (16). Apart from its pathoplastic role in affective illnesses, cyclothymic temperament is also the most important predictive factor of atypical major depression with somatic symptoms, among them appetite and weight gain (27).

The relationship of metabolic and cardiovascular disorders with bipolarity was first introduced by Kretschmer, and later supported by further research reporting that hypertension was over-represented in bipolar affective and anxious patients but not in schizophrenic ones (29,30). Moreover, bipolar disorder is associated with significantly increased prevalence of obesity, smoking and hypertension, which develops more than a decade earlier in bipolar patients than in unipolar major depression or in non-depressed controls (9–11). Our results indicate the role of affective temperaments in the background of cardiovascular symptom formation, and extend the above association between affective and cardiovascular pathology also on the domain of mental health. This known association between cardiovascular risk and affective temperaments can be incorporated into the preventive and screening models of cardiovascular morbidity.

Implication for clinical practice

Since the focus of medicine switched from the treatment of acute illnesses to chronic comorbid conditions, optimal health care should centre on the patient instead of the disease to make treatment more effective and less harmful (31). In this context, the role of psychosocial factors in facilitating, sustaining or modifying the course of a disease should attract interest. The relative weight of psychosocial factors may vary from illness to illness or from one individual to another (32). Temperament profile strongly influences individual responses to environmental stimuli (16,17). Affective temperaments may play an important role in determining patients who are at greater risk of developing risky health behaviours or certain disorders. The assessment of temperamental profile may provide an excellent opportunity for individualized preventative care, thus enhancing the quality of life in the long-term, and may help in defining possible intervention point in reversing or decreasing the impact of already evolved risk factors and preventing the development of further ones.

Conclusion

Our results indicate the association of dominant cyclothymic temperament with hypertension independently of older age, obesity and diabetes mellitus in a chronically ill Hungarian primary care patient population. The relative stability of temperaments throughout life makes this finding relevant in detecting patients at high risk of the complications of hypertension and support more individualized care of patients.

ACKNOWLEDGEMENTS

The authors are indebted to all participating patients and GPs’ for their contribution. Xenia Gonda is a recipient of the Bolyai János fellowship of the Hungarian Academy of Sciences.

Declaration of interest: The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.