CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2010;8:220 –222
BRIEF COMMUNICATION
Personality Traits and Impaired Health-Related Quality of Life in Patients
With Functional Gastrointestinal Disorders
STEPHANIE L. HANSEL, SARAH B. UMAR, TISHA N. LUNSFORD, LUCINDA A. HARRIS, JOHN K. DIBAISE, and
MICHAEL D. CROWELL
Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona
BACKGROUND & AIMS: Negative affectivity and social
isolation (Type D personality) are personality traits associated
with poor health-related quality of life (HRQoL). We hypothe-
sized these traits would be associated with impaired HRQoL
and increased gastrointestinal symptom severity in functional
gastrointestinal disorders. METHODS: Data were collected
from patients undergoing breath testing. Patients completed
the Type D Scale-14, Gastrointestinal Symptoms Severity
Index and Short-Form Health Survey 12. RESULTS: Of 230
patients evaluated, 37% met criteria for Type D personality.
Type D was associated with a decreased Mental Component
score on the Short-Form Health Survey 12 (mean differ-
ence ⫽ ⫺8.29; 95% confidence interval, 5.2–11.4; P ⬍ .001).
On the Gastrointestinal Symptoms Severity Index, severity of
symptoms was significantly higher in Type D patients com-
pared with non Type D patients (P ⬍ .001). CONCLU-
SIONS: Type D personality was associated with de-
creased perceived HRQoL and reporting of more severe
gastrointestinal symptoms. Type D personality construct
may be an important consideration when assessing
HRQoL outcomes. Consideration of personality traits
could improve risk stratification in research and clinical
practice in this patient group.
F unctional gastrointestinal disorders (FGIDs) are common
and have profound effects on health-related quality of life
(HRQoL).1 Personality traits such as neuroticism, emotional
hypersensitivity, maladaptive stress coping, and aggression have
been shown to play a role in FGIDs.2–7 Interestingly, negativism,
aggression and neuroticism have also been shown to be associ-
ated with poorer HRQoL and therapeutic outcomes to both
psychological and pharmacological treatments.8
Negative affectivity (NA) and social inhibition (SI) are 2
personality traits that have been associated with inadequate
stress coping, increased anxiety, and depression in coronary
artery disease and hypertension.9 Individuals with both of these
traits have been labeled as distressed or Type D personality.9
Type D personality has been associated with noncardiac chest
pain, decreased HRQoL, and poorer clinical outcomes in car-
diac patients.9 –11 Few data have reported on the inter-relation-
ship between personality traits, treatment outcomes, and
HRQoL in FGIDs. We hypothesized that Type D personality
trait may be prevalent in patients with FGIDs, and might play
a role in patients’ reporting of symptoms and diminished sense
of well-being (HRQoL).
Methods
Data were collected from 230 consecutive adult pa-
tients undergoing glucose hydrogen breath testing for GI
symptoms at a tertiary clinic between January and December
2007. The Mayo Clinic Institutional Review Board approved
the protocol.
Questionnaires
The Type D Scale-14 (DS-14) was developed to assess
NA, SI, and Type D Personality in a standardized fashion. It
consists of 14 questions. Type D personality was determined by
standardized cutoff ⱖ10 on the scales of NA and SI. This
instrument has excellent reliability and validity.9
The Gastrointestinal Symptoms Severity Index (GISSI) is a
multidimensional instrument designed to measure the fre-
quency, severity, and bothersomeness of individual GI symp-
toms and to provide subscale scores for interrelated symp-
tom clusters. The final validated questionnaire includes 22
items plus the 4 pelvic symptoms specific to females.12 Pa-
tients were classified into FGID subgroups using GISSI sub-
scale.
The Medical Outcomes Survey (MOS) Short Form-12 v2
(SF-12v2) is a shortened version of the Short Form-36 used to
measure health outcomes and functional status. The Physical
Component Scale (PCS) and Mental Component Scale (MCS)
have been found to summarize the 8 subscales of the original
Short Form-36 with 85% of the reliable variance.13
Statistical Analysis
Statistical comparisons were planned a priori to address
the primary hypotheses. Multivariable logistic regression and
analyses of covariance were used to evaluate the relationship
between Type D personality and decreased HRQoL while con-
trolling for age, gender, and severity of GI symptoms. Following
Abbreviations used in this paper: CI, confidence interval; DS-14, Type
D Scale-14; FGIDs, functional gastrointestinal disorders; GI, gastroin-
testinal; GISSI, Gastrointestinal Symptoms Severity Index; HRQoL,
health-related quality of life; MCS, Mental Component Scale; NA,
negative affectivity; OR, odds ratio; PCS, Physical Component Scale;
SF-12v2, Medical Outcomes Survey (MOS) Short Form-12 v2; SI, social
inhibition.
© 2010 by the AGA Institute
1542-3565/10/$36.00
doi:10.1016/j.cgh.2009.10.008
February 2010 PERSONALITY TRAITS AND IMPAIRED HRQOL IN FGID 221

Table 1. Pairwise Comparison of SF-12v2 Controlling for Age, Gender, and GI Symptom Severity
SF-12v2 component scores Type D (95% CI) Non type D controls (95% CI) Mean difference 95% CI P valuea

MCS 38.31 (35.91–40.71) 46.60 (44.75–48.44) 8.29 5.19–11.38 ⬍.001

PCS 36.01 (33.50–38.53) 38.34 (36.46–40.32) 2.37 ⫺0.87–5.62 .150
SF-12v2 subscales
Physical function 36.71 (34.05–39.37) 42.16 (40.12–44.20) 5.45 2.01–8.88 .002
Role physical 34.85 (32.42–37.29) 38.43 (36.56–40.29) 3.57 0.44–6.71 .026
Bodily pain 35.30 (32.79–37.80) 39.52 (37.61–41.44) 4.23 1.00–7.46 .011
Vitality 39.09 (36.91–41.26) 43.45 (41.78–45.12) 4.36 1.55–7.17 .002
Social function 34.13 (31.49–36.76) 40.96 (38.94–42.98) 6.83 3.44–10.23 ⬍.001
Role emotional 37.25 (34.60–39.90) 45.11 (43.08–47.14) 7.86 4.45–11.28 ⬍.001
Mental health 37.89 (35.62–40.15) 46.46 (44.73–48.20) 8.57 5.66–11.49 ⬍.001
General health 36.82 (34.36–39.28) 40.01 (38.12–41.89) 3.19 0.02–6.36 .049
aThe overall experiment-wise alpha was maintained at P ⬍ .05 using Bonferroni adjustments for multiple comparisons.

analysis of overall group differences on the total scores at P ⱕ
.05, alpha levels were adjusted using the Bonferroni correction
for multiple comparisons.
Point and interval estimates are reported for all descriptive
data and presented as means (SD) or proportions and their 95%
confidence interval (CI). Results of univariate and multivariate
logistic regression are presented as odds ratios (OR) and 95%
confidence intervals (CI). All analyses were completed using
SPSS v15.0 statistical software (Chicago, IL).
Results
Of the 230 patients evaluated, 85 (37%) met criteria for
Type D personality. The Type D cases tended to be younger
than controls (54 [17] vs 58 [16] years respectively; P ⫽ .042),
but no other significant differences were found between the
groups in demographics characteristics. The indications for
breath testing were similar between Type D and control
patients and included bloating, diarrhea, and abdominal
pain. A positive hydrogen breath test was identified in 10.4%
of the total sample. There was no significant association
between Type D personality and the finding of a positive
hydrogen breath test.
Effects of Type D Personality on
Health-Related Quality of Life
Compared with non Type D patients, Type D patients
scored significantly higher on NA (6.2 [4.5] vs 16.2 [4.1]; P ⬍
.001) and SI (8.9 [3.4] vs 14.5 [3.3]; P ⬍ .001) subscales of the
DS-14. A significant negative correlation was noted between NA
and the MCS of the SF-12v2 (⫺0.60; P ⬍ .001), but not the PCS.
A moderate negative association was noted between SI and the
MCS (⫺0.25; P ⬍ .001), but only a marginal association was
noted with the PCS. Moderate, significant positive correlations
were noted between NA and GI symptoms on the GISSI (0.18 –
0.29; P ⬍ .01), but not between symptoms and SI.
As shown in Table 1, Type D patients scored significantly
lower (worse) on multiple subscale scores and the Mental Com-
ponent scale of the SF-12v2 after controlling for demographic
characteristics and severity of GI symptoms compared with
FGID. The adjusted odds ratio for a poor mental component
scale score was 3.32 (95% CI, 1.82– 6.06, P ⬍ .001) times as high
in FGID patients high on Type D personality trait than non
Type D patients. The differences between Type D patients and
non Type D patients on the PCS were not statistically signifi-
cant after adjusting for age, gender, and severity of GI symp-
toms, although a trend was still noted (OR, 1.82, 95% CI,
0.98 –3.40; P ⫽ .06).
Effects of Type D Personality on
Symptom Severity
Symptom severity scores were significantly higher in
Type D patients on all subscales of the GISSI compared with
the non Type D patients even after controlling for potential
confounders (Table 2). Small negative correlations were
noted between symptom severity scores and the MCS. Sig-
nificant negative correlations were noted between the severity
of symptom subscales and PCS that ranged from ⫺0.25 to ⫺
0.44 (P ⬍ .05). Logistic regression showed small but statis-
tically significant associations between dyspepsia (OR, 1.02;
95% CI, 1.001–1.03; P ⫽ .003) and diarrhea (OR, 1.01; 95%
CI, 1.00 –1.02; P ⫽ .047) subscales scores and decreased
physical component score. No significant associations were
found between symptom severity and the mental component
score.

Table 2. Pairwise Comparison on the Subscales of the GISSI Controlling for Age and Gender
GISSI subscales Type D (95% CI) Non type D controls (95% CI) Mean difference 95% CI P valuea

Abdominal pain, discomfort 58.18 (53.15–63.20) 45.21 (41.37–49.04) 12.97 6.62–19.31 ⬍.001
Constipation, difficult defecation 34.53 (29.21–39.85) 22.60 (18.54–26.66) 11.93 5.21–18.66 ⬍.001
Diarrhea 41.54 (35.44–47.64) 29.71 (25.05–34.37) 11.83 4.12–19.55 .003
Dyspepsia 41.75 (35.68–47.81) 30.24 (25.61–34.88) 11.50 3.84–19.17 .003
GERD 25.73 (21.53–29.93) 18.66 (15.46–21.87) 7.07 1.76–12.37 .009

GERD, gastroesophageal reflux disorder.

aTheoverall experiment-wise alpha was maintained at P ⬍ .05 using Bonferroni adjustments for multiple comparisons.
222 HANSEL ET AL
Discussion
These results confirm our primary hypothesis that a
clinically meaningful subset of patients with FGIDs test posi-
tive for the Type D personality trait. We found that 37% of
FGID patients in our study sample met the criteria for Type D
personality. These patients did not differ from those not meet-
ing the criteria for Type D personality regarding demographics
or indication for testing except for being slightly younger. A
subset of patients with FGIDs appear to display subclinical
levels of emotional distress that might be attributable to higher
levels of Type D personality traits. The presence of these traits
may be associated with increased perception of disease severity
and decreased perceived global HRQoL, which may adversely
affect assessment of treatment outcomes.
The current findings supported our second hypothesis and
showed that patients with Type D personality reported signif-
icantly higher severity of symptoms than those patients without
Type D personality on all subscales of the GISSI. The observa-
tion of increased symptom severity across all subscales of the
GISSI suggests global differences in perception of symptom
severity in Type D patients rather than higher acuity.
Finally, these data supported the hypothesis that Type D
patients with FGIDs would report higher levels of impaired
HRQoL compared with patients without Type D personality.
Patients with Type D personality scored significantly lower on
all subscales of the SF-12v2 indicating more impaired or poorer
perceived HRQoL. After adjusting for age, gender, and symp-
tom severity, Type D remained a significant predictor only for
the MCS score. Consistent with these results, symptom severity
was negatively correlated with the PCS, but not with the MCS.
Together, these observations support the hypothesis that Type
D patients with FGID perceive their HRQoL to be worse than
FGID patients without Type D personality traits, and that the
primary decrement is related to negative emotions and aberrant
social function.
The present study has several limitations. Patients undergo-
ing breath testing for GI symptoms at a tertiary clinic were
studied and may have resulted in oversampling of FGID sub-
groups. Community studies could provide additional insight
into the role of Type D personality traits in FGID patients. The
SF-12 was used because of its widespread use and its validated
subscales, and because these scales have been reported to be
reduced in FGID patients. Studies are needed on the impact of
Type D traits on condition-specific quality of life in FGIDs.
Psychological distress was not assessed in this study because
our aim was to evaluate personality traits that have been shown
to be stable over time. Additional studies are needed to evaluate
the interactions among Type D personality traits, symptom
severity, quality of life, and psychological states.
In conclusion, Type D personality was prevalent in patients
with FGIDs and associated with more severe upper and lower
GI symptoms than non Type D patients. Furthermore, Type D
personality trait was associated with decreased perceived
HRQoL. Thus, Type D personality may be an important con-
sideration when planning treatment of patients with FGIDs
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 8, No. 2
and when assessing HRQoL outcomes. Consideration of per-
sonality traits may allow for improved risk stratification in
research and clinical practice in this patient group. Further
studies are needed to evaluate whether FGID patients with Type
D personality trait show greater dissatisfaction with medical
interventions, are less compliant with medical therapy, and
have inferior therapeutic outcomes.
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Reprint requests
Address requests for reprints to: Michael D. Crowell, PhD, Division of
Gastroenterology and Hepatology, 13400 East Shea Boulevard, Scotts-
dale, Arizona 85259. e-mail: crowell.michael@mayo.edu; fax: (480)
301-6737.
Conflict of interest
The authors disclose no conflicts.