Psychological Distress in Patients with Chronic Coronary Syndrome: Features of Coping Strategies and Cognitive Appraisal in Depression and Type D Personality

Introduction

Psychosocial stress is a recognized risk factor for the development and progression of cardiovascular disease [1-4]. Psychosocial stressors may precipitate either acute episodes of psychological distress (e.g., anxiety, depression) or induce chronic stress that contributes to the development of enduring personality traits [1, 5]. In recent years, increasing attention has been paid to the Type D (distressed) personality construct, which is characterized by a predisposition to the psychological distress. This personality type is characterized by the combination of negative affectivity (a tendency to experience negative emotions) and social inhibition (the suppression of self-expression in social interactions) [6].

Individuals with Type D personality are not only more vulnerable to depressive reactions, but this personality construct itself has been identified as an independent risk factor for coronary artery disease (CAD) [7], with significant clinical and prognostic implications. Among CAD patients, Type D personality has been associated with poorer quality of life [8], reduced adherence to medical therapy [9], a higher prevalence of multifocal atherosclerosis [10], and the maintenance of unhealthy lifestyle behaviors [11]. Consequently, the adverse prognostic impact of Type D personality in CAD has been confirmed in individual studies [12-14] and in a recent meta-analysis [15].

Depression, another extensively studied psychosocial factor, shares many adverse effects with Type D personality. However, important distinctions exist. For example, in patients with chronic heart failure (CHF), the prognostic relevance of Type D personality has not been demonstrated, in contrast to its established role in coronary heart disease [15]. Depression, in turn, has a well-documented negative effect on prognosis in both coronary heart disease and CHF [16, 17]. Moreover, a wide spectrum of treatment approaches is available for patients with CHF and depression, including pharmacological therapy [18] and non-pharmacological interventions such as physical exercise, cognitive-behavioral therapy (CBT), and educational activities [19, 20].

First, this personality type is believed to be a stable trait that remains consistent during long-term observation [21], possibly with genetic underpinnings [22]. Second, pharmacological treatments used for depressive disorders are unlikely to be used for individuals with Type D personality. Accordingly, cognitive-behavioral interventions remain the principal therapeutic option. However, studies evaluating CBT for Type D personality have yielded inconsistent findings [23,24]. Some investigations failed to reduce the prevalence of Type D personality among CAD patients [25], while others reported reductions in depressive symptoms in individuals with Type D personality but not in those without it [26].

These mixed results may be attributable to an inappropriate focus of behavioral interventions. Instead of attempting to modify the personality type itself, interventions should target the ways in which individuals with Type D personality appraise and respond to everyday stressors – processes shaped by their cognitive appraisal [27] and coping strategies [28]. Accordingly, recent studies have begun to explore coping mechanisms in Type D individuals [29] and their potential role in mediating the clinical and prognostic implications of this personality construct [14, 30]. Nevertheless, such studies remain limited, and cultural or national factors may further influence coping and appraisal processes.

Because the development of specific coping strategies is preceded by cognitive appraisal of stressors, it is essential to examine tools that assess perceptions of challenging life situations in patients with varying degrees of psychological distress. These considerations formed the rationale for the present investigation. The aim of this study was to examine the relationships among cognitive appraisal, coping strategies, Type D personality, and depression levels in patients with chronic coronary syndrome.

Methods

Study design and participants

This study included patients who underwent elective percutaneous coronary intervention (PCI) at the Research Institute of Complex Issues of Cardiovascular Diseases. Participants were recruited from December 2020 to October 2021 and from December 2023 to October 2024.

Inclusion criteria were as follows: diagnosis of chronic coronary syndrome requiring myocardial revascularization, ability to complete psychological questionnaires accurately, and provision of written informed consent. Exclusion criteria included a recent acute coronary syndrome (<6 months), the presence of severe comorbid pathology or psychiatric disorders, and withdrawal of consent at any study stage.

Initially, 480 patients aged 33-81 years undergoing elective PCI were screened. After applying the inclusion and exclusion criteria, 209 patients were enrolled in the final analysis. Clinical, laboratory, and instrumental data, as well as medical history, were obtained from medical records. The study protocol was approved by the local ethics committee of the institution and conformed to the principles of the Declaration of Helsinki. All participants provided written informed consent.

Preoperative clinical, anamnestic, laboratory, and instrumental characteristics were assessed. Psychological evaluation included assessment of Type D personality, anxiety and depression levels, coping strategies, and cognitive appraisal of stressful life situations (Figure 1). A detailed description of the psychological assessment methodology has been published previously [19].

Figure 1. Flowchart of patients’ selection. CAD, coronary artery disease; PCI, percutaneous coronary intervention.

DS-14 questionnaire

Type D personality was assessed using a validated Russian-language version of the DS-14 questionnaire [30]. The questionnaire consists of 14 items covering two subscales – Negative Affectivity (NA) and Social Inhibition (SI) – each containing 7 items. High scores indicate a greater tendency to experience negative emotions and to inhibit emotional expression in social interactions, contributing to increased psycho-emotional distress.

Each item is rated on a 5-point Likert scale. A total score of ≥10 on both subscales indicates the presence of Type D personality. The DS-14 has been shown to be a valid and reliable measure of NA and SI in Russian samples [30]. In the current study, Cronbach’s α was 0.78 for NA and 0.74 for SI, confirming satisfactory internal consistency of the Russian version of DS14.

Hospital Anxiety and Depression Scale

Depression and anxiety were evaluated using the Hospital Anxiety and Depression Scale (HADS), translated and adapted into Russian. The questionnaire comprises 14 items forming two subscales – Anxiety (A) and Depression (D) – each rated on a 4-point scale (0-3). Higher scores reflect greater symptom severity. Subclinical anxiety or depression was defined as ≥ 8 points.

The Russian version demonstrated high internal consistency (Cronbach’s α=0.90 overall; 0.86 for anxiety; 0.84 for depression). Patients were categorized into two groups: those with subclinical or clinical depression (≥ 8 points) and those without (<8 points). Subsequent analyses compared cognitive appraisal and predominant coping strategies between patients with and without Type D personality or depression (Figure 1).

Coping strategies questionnaire

Coping strategies were assessed using the Ways of Coping Questionnaire (WCQ), designed to evaluate cognitive and behavioral responses to stress. The Russian-adapted version was used [31], demonstrating acceptable reliability (Cronbach’s α=0.78 overall; range 0.75-0.81). The instrument includes 50 items describing possible reactions to stressful situations, rated as “never”, “rarely”, “sometimes”, or “often.”

Mean scores were calculated across eight scales: confrontive coping, distancing, self-controlling, seeking social support, accepting responsibility, escape-avoidance, planful problem solving, and positive reappraisal [19]. These reflect both adaptive and maladaptive coping tendencies. Each strategy was further classified as rarely, moderately, or frequently used based on individual scores.

Cognitive appraisal questionnaires

Cognitive appraisal of stressful situations was evaluated using the questionnaire Cognitive Assessment of a Difficult Life Situation [32]. A detailed description of this questionnaire has been provided earlier [19]. The tool generates mean scores across eight scales describing individual perceptions of challenging events: (1) general features of difficult situations; (2) lack of control of the situation; (3) ambiguity (unclearness) of the situation; (4) need for rapid and active response; (5) decision-making difficulty (dilemma); (6) difficulty predicting the situation; (7) negative emotions; (8) threat for the future. The following model fit indices were observed: RMSEA=0.044; CFI=0.910; χ²=912.899; df=378 [32].

The second instrument, Types of Orientations in Difficult Life Situations (TODS) [33], assessed individual patterns of orientation in stressful situations. It identifies responses contributing to or mitigating psychological distress. Adaptive orientations include assertiveness (striving for difficulties), diligence (orientation toward high work intensity), vigilance (attention to threat signals), and focus on opportunities. Maladaptive orientations involve focus on losses, orientation towards obstacles, rejection, conservation of resources (inaction), and neglecting problems (carelessness). Model fit indices were satisfactory (RMSEA=0.049; CFI=0.900; χ²=3068.835; df=1171) [33].

Based on average scores across scales, predominant cognitive appraisals and orientations were determined for each participant. These patterns were subsequently compared between CAD patients with and without psychological distress (presence vs absence of Type D personality and/or depression).

Statistical analyses

Statistical analyses were performed using SPSS Statistics 17.0 (IBM Corp., the USA). Normality of quantitative variable distributions was assessed with the Kolmogorov–Smirnov test. Non-normally distributed data were presented as medians (Me) with interquartile ranges (25th-75th percentiles).

Group comparisons were conducted using the Mann–Whitney U test for continuous variables and the chi-square (χ²) test for categorical variables. Factors associated with Type D personality and subclinical depression were examined using multiple binary logistic regression (Forward Stepwise LR method). Two regression models were tested for each outcome: Model 1 included WCQ variables, and Model 2 included TODS variables. A p-value < 0.05 was considered statistically significant.

Results

Clinical and demographic characteristics of the comparison groups

Patients were divided into groups according to two classification criteria:

1. presence (n=76) or absence (n=133) of Type D personality;

2. presence of subclinical or clinical depression (HADS≥8; n=53) or its absence (HADS<8; n=156).

Clinical and demographic characteristics are presented in Table 1. In both comparisons, male patients predominated. Diabetes mellitus was more frequent among individuals with Type D personality (30.7%) compared to those without it (17.6%; p=0.029). No statistically significant differences were found in laboratory or instrumental parameters between the groups. According to coronary angiography, single-vessel disease predominated across the cohort (75.6%).

Table 1. Clinical and demographic characteristics of study groups with and without Type D personality or depression

Distribution of coping strategies according to the WCQ

Analysis of coping strategies using the WCQ (Figure 2) showed that patients with depression scored significantly lower on the positive reappraisal scale compared with non-depressed patients (p=0.03). No other statistically significant differences in coping strategies were observed between the depression groups.

Figure 2. Distribution of coping strategies according to the WCQ questionnaire in groups with coronary heart disease with the presence/absence of the type D or depression.

* р=0,03.

The frequency distribution of specific coping strategies among patients with CAD stratified by Type D personality and depression status is presented in Table 2.

Table 2. Coping strategies in groups with and without Type D personality or depression according to the Ways of Coping Questionnaire

Patients without Type D personality less frequently employed escape–avoidance (p=0.014), accepting responsibility (p=0.021), and self-controlling (p=0.003) strategies compared with Type D individuals.

Moderate use of confrontive coping (p=0.041) and accepting responsibility (p=0.009) was more typical among Type D patients.

In contrast, among patients with depression rare use of confrontive coping was more common (30.2 % vs 11.5 %, p=0.001), while, for non-depressed patients, moderate use of the strategy was more typical (62.8 % vs 43.4 %, p=0.013).

Results of cognitive appraisal questionnaires

In individuals exhibiting psychological distress, the predominant cognitive appraisal dimension was ambiguity of the situation (median=17.0 for Type D patients; median=17.5 for depressed patients).

Patients with Type D personality scored significantly higher on lack of situation control (p=0.003) and ambiguity of the situation (p=0.026). Patients with depression more frequently reported difficulty in decision-making (p=0.043) (Table 3).

Table 3. Cognitive appraisal in groups with and without Type D personality or depression according to the Cognitive Assessment of a Difficult Life Situation questionnaire

Regarding types of orientation in difficult situations, non-Type D personality patients most commonly demonstrated striving for difficulties (p=0.013). Conversely, Type D patients exhibited significantly higher levels of orientation toward obstacles (p=0.009), focus on losses (p<0.001), and resource conservation (p=0.019) than those without Type D personality.

Patients with depression showed significantly lower levels of striving for difficulties (p<0.001), attention to threat signals (p=0.038), and focus on opportunities (p<0.001), while demonstrating higher focus on losses (p=0.039), compared to non-depressed patients (Table 4).

Table 4. Cognitive appraisal in groups with and without Type D personality or depression according to the Types of Orientations in Difficult Life Situations questionnaire

Psychological status

Results from the DS-14 and HADS questionnaires across the cohort are presented in Table 5. Patients with Type D personality exhibited significantly higher anxiety (p<0.001) and depression (p<0.001) scores than non-Type D individuals. Similarly, depressed patients demonstrated higher levels of negative affectivity (p<0.001) and social inhibition (p=0.044) compared with those without depression.

Table 5. Psychological status of groups with and without Type D personality or depression

Binary logistic regression: associations of psychological factors with Type D personality and depression

Binary logistic regression analysis (Table 6) identified the following independent associations:

Type D personality was positively associated with moderate use of the accepting responsibility coping strategy (B=1.423; p=0.004) and inversely associated with positive reappraisal (B=-0.107; p=0.045).

Table 6. Association of psychological factors with the presence of Type D personality or depression according to logistic regression analysis

Depression was positively associated with rare use of confrontive coping (B=2.261; p=0.001) and higher reliance on self-controlling (B=0.199; p=0.001), while inversely related to positive reappraisal (B=-0.138; p=0.008) and rare use of distancing (B=-1.462; p=0.037).

Regarding cognitive appraisal variables, Type D personality was independently associated with higher lack of situation control (B=0.099; p=0.007) and rejection (B=0.116; p=0.001). Depression was associated with greater threat for the future (B=0.127; p=0.026) and inversely associated with striving for difficulties (B=-0.093; p=0.023) and focus on opportunities (B=-0.160; p=0.008).

Discussion

In this study, patients with CAD and depression exhibited lower scores on the Positive reappraisal coping scale, while no significant differences were found among patients with Type D personality. When analyzing the frequency of coping strategy use, both Type D and depressed patients demonstrated a predominance of maladaptive strategies. In terms of cognitive appraisal, individuals with Type D personality were more likely to perceive stressful situations as uncontrollable and ambiguous, to focus on losses, and to display rejection and inaction in challenging circumstances.

These findings were somewhat unexpected. Previous studies have more consistently reported maladaptive coping strategies among individuals with Type D personality. For instance, the predominance of Escape–avoidance coping was observed both in healthy individuals with Type D personality [34,35] and in CAD patients [36]. Similarly, the maladaptive strategy Acceptance-resignation was reported among healthy participants [35] and CAD patients [36]. In CAD cohort, additional coping features such as Shifting responsibility [37], infrequent use of Confrontation [36] and Planning [37] were also identified. Before cardiac surgery, Type D patients demonstrated a significantly greater tendency toward helplessness and a less frequent use of optimistic coping strategies [38].

Differences in reported coping patterns may be caused by the use of different assessment tools and scales, as well as to cultural factors. For instance, the Acceptance-resignation coping pattern has been described specifically among Chinese patients, who often perceive stress as uncontrollable, demonstrate reluctance to seek medical help and low treatment adherence [39]. In contrast, our results align with those of Moryś et al., who also failed to detect a clear preference for any specific coping style among CAD patients with Type D personality [40]. In addition, in our recently published study, Type D personality was associated with one-year adverse outcomes after PCI, while no associations were found with coping strategies [19].

Given that the adoption of certain coping strategies is preceded by cognitive appraisal of stressful situations, it is reasonable to assume that group differences (Type D vs non-Type D; with vs without depression) may be more clearly reflected in cognitive appraisal scales than in coping measures.

Research on cognitive appraisal in individuals with Type D personality remains limited, and findings are inconsistent. This inconsistency likely stems from variations in clinical context and methodological design. For example, cognitive appraisals of threat and challenge were found to mediate the relationship between Type D personality and the frequency of major adverse cardiovascular events (MACE) within one year after PCI in CAD patients [36]. Another cohort with post-PCI MACE demonstrated low baseline scores for Negative emotions and Future Prospects on cognitive appraisal measures [19]. Among elderly Type D patients, negative appraisals of illness were linked to poorer self-care abilities [41].

The present study provides further evidence that both Type D personality and depression are characterized by unproductive cognitive appraisals of stress, which hinder effective problem-solving. In contrast to Type D personality, coping research in depression has a long tradition. A recent meta-analysis by Muñoz-Cruz et al. [42] demonstrated a robust association between dysfunctional coping strategies and clinically significant depressive symptoms, while adaptive strategies such as Acceptance and Positive reappraisal were consistently linked to fewer depressive symptoms. Another recent study confirmed that greater use of adaptive coping strategies was associated with lower depression scores, whereas maladaptive strategies correlated with higher anxiety and depression [43]. It has also been suggested that when negative external or internal stimuli exceed an individual’s cognitive appraisal capacity, the risk of developing depression increases [44].

Coping-based approaches play an important role in the treatment of depression. Studies show that individuals with depression tend to use strategies such as self-acceptance (e.g., recognizing and accepting one’s feelings, accepting one’s present self, hold onto hope), activity (e.g., recreational activities, exercise, volunteering), reduction of stressors and symptoms (e.g., avoidance of triggers, medical consultation), and seeking interpersonal support from family members, friends, and peers [45]. Depression management often incorporate cognitive-behavioral therapy (CBT) [22, 23], which emphasizes Cognitive reappraisal techniques [46-48].

Our findings indicate that Type D personality and depression are associated with distinct cognitive appraisal patterns. Depression was marked by a lower tendency toward active engagement (manifested as difficulty in decision-making, lack of desire for challenges, and reduced focus on opportunities), while Type D personality was characterized by passive observation (focus on losses and obstacles, conservation of resources, and lack of control). Therefore, CBT programs for individuals with Type D personality should be designed in accordance with these personality-specific cognitive features. As demonstrated in this study, therapeutic approaches should consider not only patients’ predominant coping strategies but also their underlying cognitive appraisals of stress.

This study has several limitations. First, psychological status was assessed via self-report questionnaires, which inherently introduce a degree of subjectivity. Second, the study was conducted in a single center, limiting the replication of findings. Third, the cross-sectional design does not allow to assess the cause-and-effect relationships between the clinical and psychological indicators. Finally, Type D personality was evaluated dichotomously rather than as continuous scores of its subcomponents or their interaction. This approach may overestimate its prognostic impact [49]. Nevertheless, recent research in patients with CAD supports the adverse prognostic significance of both dichotomous and interaction-based assessments of Type D personality [20, 50]. Thus, either approach may be valid for evaluating the "Type D effect"; in the present study, we chose the dichotomous method for its utility.

Conclusion

In patients with CAD and comorbid depression, lower scores were observed on the Positive reappraisal coping scale, while no significant differences were detected among individuals with Type D personality. However, differences in cognitive appraisal of stressful situations were more pronounced in the Type D group. These patients more frequently perceived situations as uncontrollable and ambiguous, demonstrated a tendency to focus on losses, and exhibited avoidance and inaction in difficult circumstances. When designing behavioral intervention programs for patients with CAD, we suggest considering both the patients’ cognitive appraisals of their difficulties and the predominant coping strategies they employ to manage stress.

Financing

The work was supported by the Comprehensive Basic Research Program of the SB RAS within the framework of the basic research topic of the Research Institute of Complex Problems of Cardiovascular Diseases No. 0419-2022-0002 “Development of innovative models for managing the risk ofdeveloping diseases of the circulatory system, taking into account comorbidity based on the study offundamental, clinical, epidemiological mechanisms and organizational technologies for providing medical carein the industrial region of Siberia”.

Conflict of interest

All authors declare no conflict of interest

Ethical approval

All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

AI or AI-Assisted Technologies

The authors did not use AI or AI-assisted technologies in the preparation of this manuscript.