Type D Personality Is Associated With Depressive Symptoms and Clinical Activity in Inflammatory Bowel Disease

Sebastian Bruno Ulrich Jordi; Federica Botte; Brian Matthew Lang; Thomas Greuter; Niklas Krupka; Bianca Auschra; Philipp Schreiner; Michael Christian Sulz; Luc Biedermann; Roland von Känel; Gerhard Rogler; Stefan Begré; Benjamin Misselwitz


Aliment Pharmacol Ther. 2021;54(1):53-67. 

In This Article

Abstract and Introduction


Background: Inflammatory bowel disease (IBD) can be exacerbated by stress and depression. Type D personality, characterised by high negative affectivity and social inhibition, represents a vulnerability towards stressors and is associated with adverse outcomes in coronary heart disease.

Aims: To assess the prevalence of Type D personality in IBD patients and investigate potential associations with disease course.

Methods: We tested for associations between Type D (Type D Scale-14), depressive symptoms (Hospital Anxiety and Depression Scale's depression subscore ≥11) and recurrent IBD amongst Swiss IBD cohort patients. We built regression models for cross-sectional and Cox proportional hazards models for time-to-event analyses. IBD disease course was assessed by the future occurrence of active disease (Crohn's Disease Activity Index ≥150/Modified Truelove & Witts activity index ≥10) and several IBD-relevant endpoints.

Results: Amongst 2275 patients (1005 ulcerative colitis, 1270 Crohn's disease), 672 (29.5%) had Type D. Type D was a significant risk factor for future active disease (adjusted hazard ratio, aHR: 1.60, corrected P value, q = 0.007) and predicted the future presence of depressive symptoms (aHR: 3.30, P < 0.001). The combination of Type D and depressive symptoms further increased the risk for active disease (aHR: 3.98, q < 0.001). However, Type D associated depressive symptoms seemed to be the main contributor to this effect as Type D's predictive power decreased considerably in models corrected for depressive symptoms (aHR: 1.32, CI: 0.97–1.79, q = 0.292).

Conclusions: Type D personality's prevalence amongst IBD patients was comparable with its prevalence in the general population. Type D was strongly associated with depressive symptoms and showed modest independent associations with IBD prognosis.


Inflammatory bowel diseases (IBD) include the subtypes Crohn's disease (CD), ulcerative colitis (UC) and IBD unclassified (IBDu). They affect over 2 million Europeans and 1.5 million North Americans with an increasing incidence worldwide.[1] The exact pathogenesis of IBD remains incompletely understood, but likely includes interactions between environmental factors, the gut microbiota as well as immunological and genetic parameters.[2–4]

IBD course is characterised by periods of quiescent disease which are disrupted by flare-ups that are difficult to predict. Stress, depression and anxiety have been associated with IBD[4] and depression and anxiety have been shown to be triggers of clinical recurrence.[5,6] It is unclear which IBD patients are particularly vulnerable to stress, depression and anxiety.

Type D (distressed) personality (Type D) identifies individuals with difficulties adapting to stress.[7] Type D is characterised by a tendency to experience negative affectivity combined with social inhibition.[8] Individuals with high negative affectivity more frequently experience negative feelings such as dysphoria, anxiety and irritability. Individuals with high social inhibition show reduced expression of emotions and behaviours in social interactions because of fear of disapproval. Socially inhibited individuals tend to feel timid, tense and insecure when with others.[8] Type D is usually assessed via the validated Type D Scale-14. The Type D Scale-14 contains only 14 items and is well-suited as an efficient tool in clinical and research settings.[8]

Type D is a well-established risk factor for adverse outcomes in coronary heart disease.[9–11] In a meta-analysis of over 5000 coronary heart disease patients, Type D significantly increased the risk for mortality and non-fatal myocardial infarction (odds ratios [OR] >1.5).[9] Type D describes a personality constellation, predisposing to stress and depression[12] and as such constitutes a fundamentally different concept from depression.

Both, Type D and depression, have been associated with immune activation and increased levels of inflammatory biomarkers such as tumour necrosis factor (TNF) and C-reactive protein (CRP).[13–16]

The prevalence of Type D in the general population is 20%-30%.[17] Research has demonstrated temporal stability of personality traits with only rare substantial changes[18] in long-term observational studies[19–22] and a genetic component has been described.[12,19] Nevertheless, the risk for Type D might be affected by critical life events.[23,24]

Studies showed that depression negatively affects the IBD course and is associated with clinical recurrence.[5,25] But while there is comprehensive evidence for the associations between the depression and deterioration of IBD, the role of Type D, has not been examined yet and could add novel aspects to our understanding of IBD.

We used data from the Swiss IBD cohort study[26] to explore the relationship between Type D and IBD course regarding the hazard of experiencing active disease, new extraintestinal manifestations or clinical recurrence using well-established clinical composite endpoints.[5,6] We further analysed whether depressive symptoms and Type D act as independent or mutually enforcing predictors of deteriorating IBD course.