Heart failure and cardiomyopathies Open Heart: first published as 10.1136/openhrt-2015-000312 on 5 February 2016. Downloaded from Stress-coping skills and neuroticism in apical ballooning syndrome (Takotsubo/ stress cardiomyopathy) Dawn C Scantlebury,1 Daniel E Rohe,2 Patricia J M Best,1 Ryan J Lennon,3 Amir Lerman,1 Abhiram Prasad1,4 To cite: Scantlebury DC, ABSTRACT et al KEY QUESTIONS Rohe DE, Best PJM, . Introduction: Apical ballooning syndrome (ABS) is Stress-coping skills and typically associated with an antecedent stressful neuroticism in apical What is already known about this subject? situation. Affected patients have been reported to have ballooning syndrome ▸ Patients with apical ballooning syndrome (ABS) (Takotsubo/stress higher frequencies of premorbid affective disorders. We have been found to have a higher prevalence of cardiomyopathy). Open Heart hypothesised that patients with ABS would have affective disorders which are associated with 2016;3:e000312. elevated levels of neuroticism (tendency to experience high neuroticism (trait anxiety). This raises the doi:10.1136/openhrt-2015- negative affect) and greater vulnerability to stress. question of whether a specific personality profile 000312 Methods: In this cross-sectional study, all active renders a subject prone to the development of participants in the Mayo Clinic ABS prospective follow- ABS. A recent study suggests a high prevalence up registry were invited to complete the third edition of of ‘type D’ personality, which may be charac- the NEO Personality Inventory (NEO-PI-3). The NEO-PI- terised by high neuroticism, but the ‘type D’ per- 3 is the universally accepted measure of the ‘Five- sonality is not a universally accepted personality ▸ Additional material is Factor Model’ of personality. Inventory responses were construct. available. To view please visit scored using the NEO-PI-3 computer program and the the journal (http://dx.doi.org/ data were compared with US normative sample used in What does this study add? 10.1136/openhrt-2015- standardisation of the inventory. Significance was set ▸ We found that patients with ABS do not demon- 000312). at 0.0014 to account for multiple comparisons. strate high levels of neuroticism, and thus do not seem to have a personality characterised by Received 29 June 2015 Results: Of 106 registry participants approached, 53 Revised 24 December 2015 completed the inventory. There was no difference in a predisposition to affective disorders. http://openheart.bmj.com/ Accepted 8 January 2016 age, gender, time from ABS diagnosis, type of Additionally, there has been no study to date antecedent stressor (emotional, physical or none) or that has systematically assessed personality pro- severity of initial illness between the responders and files of patients with ABS. This study addresses non-responders. Responders had mean Neuroticism this gap in the literature. T-scores of 48.0±10.6 (95% CI 45.1 to 50.9); p=0.18, How might this impact on clinical practice? when compared with the normal mean of 50. There ▸ The association of ABS with stressful situations, was also no significant difference in the facet scale of especially psychologically stressful situations, Vulnerability: 46.9±8.4 (44.6 to 49.2), p=0.038, at might tempt clinicians into assuming an under- α =0.0014. lying ‘neurotic’ personality and presume poor on September 28, 2021 by guest. Protected copyright. Conclusions: Contrary to our hypothesis, patients stress-coping skills. Our study refutes this, sug- 1 Division of Cardiovascular with ABS do not manifest higher levels of neuroticism gesting excessive stress exposure as the likely Diseases, Department of and do not have greater vulnerability to stress than the predominant causal variable. Attention should Internal Medicine, Mayo general population. These findings have implications focus on evaluating and mitigating stressors in Clinic, Rochester, Minnesota, for the clinicians’ perception of, and approach to, USA patients with a prior history of ABS. The demon- patients with ABS. 2Department of Psychiatry stration that individuals developing ABS have, in and Psychology, Mayo Clinic, general, a personality profile that lies within the Rochester, Minnesota, USA limits of normal may promote accurate clinician 3Department of Health perceptions and improve clinician–patient Sciences Research, Mayo INTRODUCTION relationships. Clinic, Rochester, Minnesota, USA Apical ballooning syndrome (ABS), also 4Cardiovascular and Cell known as Takotsubo or stress cardiomyop- Sciences Institute, athy/syndrome, is a reversible cardiomyop- artery disease is typically absent. ABS is pre- St. George’s University of athy typically characterised by transient dominantly diagnosed in postmenopausal London, London, UK systolic dysfunction of the mid and apical women and is preceded by an acute physical segments of the left ventricle.1 The clinical or emotional stress trigger in greater than Correspondence to 2 Dr Abhiram Prasad; presentation of ABS mimics an acute myocar- two-thirds of patients. Purported patho- [email protected] dial infarction, but obstructive coronary physiological mechanisms underlying ABS Scantlebury DC, Rohe DE, Best PJM, et al. Open Heart 2016;3:e000312. doi:10.1136/openhrt-2015-000312 1 Open Heart Open Heart: first published as 10.1136/openhrt-2015-000312 on 5 February 2016. Downloaded from include altered β adrenergic signalling in the presence universally used inventory of normal personality.13 It has of elevated catecholamine levels3 and impaired vascular become the standard inventory that measures the responses to stress.4 Five-Factor Model (FFM) and provides a systematic Aside from physiological factors, patients diagnosed with assessment of emotional, interpersonal, experiential, ABS may have a psychosocial predisposition to ABS. They attitudinal and motivational styles. According to the are more likely to have a premorbid diagnosis of a chronic FFM, the five major domains (also called factors) of per- anxiety disorder compared with age-matched and gender- sonality are neuroticism, extraversion, openness, agree- matched acute coronary syndrome and general population ableness and conscientiousness.14 For clarity of – controls.5 7 They are more likely to have a family history of presentation, when a personality factor is being discussed, anxiety or depression and more likely to report social stres- that is, neuroticism, the word is not capitalised. sors such as being divorced and isolated.5 Intriguingly, However, when a domain (factor) or facet scale of the patients with ABS appear to have a higher frequency of NEO-PI-3 is discussed, the scale title is capitalised, that is, migraine and Raynaud’s phenomenon.8 ABS, migraine Neuroticism, Vulnerability, etc. In addition, the and Raynaud’s share similarities with female predomin- NEO-PI-3 measures six underlying facets for each of the ance, precipitation by triggers, altered vascular reactivity five domains. Taken together, the five domain scales and and increased likelihood of affective disorders.9 Of note, 30 facet scales of the NEO-PI-3 facilitate a comprehen- patients with migraine and Raynaud’s who have no diagno- sive and detailed assessment of normal adult personality. sis of affective disorders, appear to have elevated levels of The NEO-PI-3 is self-administered, requires a sixth grade neuroticism, a normal personality trait defined as a propen- reading level, uses a five-point Likert scale format, and sity to experience negative affect that is expressed as ner- has 240 personality and 3 validity items. vousness and insecurity.10 11 Elevated levels of neuroticism The focus of this study was on the neuroticism are found in patients with chest pain syndromes in the domain. This domain contrasts adjustment and emo- absence of coronary disease, and in those with increased tional stability with maladjustment and identifies indivi- cardiovascular mortality.12 The association of neuroticism duals who are prone to psychological distress and with migraine, Raynaud’s and other cardiovascular diseases maladaptive-coping responses. The six facets of the led us to postulate that ABS might be associated with ele- Neuroticism scale are Anxiety (prone to worry, fearful, vated levels of neuroticism. Thus, our hypothesis was that apprehensive), Angry hostility (tendency to experience patients with ABS would manifest a personality profile char- anger and related states such as frustration and bitter- acterisedbyhighneuroticism,comparedwiththatofthe ness), Depression (prone to feelings of guilt, sadness, general population. Our secondary hypothesis was that par- and loneliness), Self-consciousness (sensitive to ridicule, ticipants’ vulnerability to stress would be significantly prone to feelings of inferiority), Impulsiveness (inability greater than in the general population. to control cravings and urges) and Vulnerability (diffi- culty coping with stress). http://openheart.bmj.com/ PATIENTS AND METHODS Feedback Participants The NEO-PI-3 was mailed to participants with a letter The Mayo Clinic Institutional Review Board approved explaining the purpose of the study. In order to encourage the study protocol. Participants gave signed consent to participation, participants were offered the option of participate in the study. This cross-sectional study utilised receiving the results of their testing in the form of the participants in the Mayo Clinic ABS Registry who are NEO-PDR Individual Planning Report (NEO-PDR; prospectively diagnosed with ABS at the time of presen- http://www4.parinc.com/WebUploads/samplerpts/NEO