Do coping strategies mediate the association between Type D personality and quality of life among people with multiple sclerosis?

Abstract

The aim of this study is to explore whether different coping strategies are able to mediate the association between Type D personality and quality of life. We collected information from 156 consecutive patients (response rate: 72.9%; 75.0% women; median age: 40 ± 3 years). Patients completed the Type D Scale-14, the Coping Self-Efficacy Scale and the Short-Form Health Survey for measuring physical and mental quality of life. The mediating effect of coping was analysed using correlations, linear regressions and the Sobel z-test. In the mental quality of life, all three studied coping strategies mediated the association between Type D personality and quality of life.

Keywords

chronic disease coping mental component of quality of life multiple sclerosis physical component of quality of life Type D

Introduction

Multiple sclerosis (MS) is a chronic neurological disease causing dysfunctions which can be manifested in a wide range of symptoms, including fatigue, balance impairments, sleep problems and pain (Newland et al., 2012). Besides these physical symptoms, psychological symptoms are common as well, including depression, anxiety, low self-esteem or somatisation (Sarisoy et al., 2013). All of these symptoms affect health-related quality of life (HRQoL) in both the physical component summary (PCS) and mental component summary (MCS) domains (Shawaryn et al., 2002). Given its unpredictable course (Park et al., 2013), the experience of MS can be highly subjective, taking into account not only objective symptoms but also the personality of patients. The reactions of patients to the diagnosis can vary from frustration to the feeling that their identity has been assaulted (Koffman et al., 2013).

In the past, various diseases were associated with different personality types, for example, Type A personality (Bram et al., 1982; Dimsdale et al., 1978). Type D personality was later described as a type in which negative affectivity (NA) and social inhibition (SI) are prominent (Denollet, 1998, 2000). NA is manifested in high levels of distress and dissatisfaction regardless of the time or situation, even when a person is not threatened by a stressful situation. It can be said that in general, people with the NA trait tend to focus on the negative side of things (Watson and Pennebaker, 1989). SI is a more passive trait describing stable tendencies to inhibit behaviour and emotional response during social interaction (Denollet, 2005). Type D personality has been found to be associated with poorer health status and independently tied to symptoms of depression and anxiety in various health-threatening conditions (Mols et al., 2012; Schoormans et al., 2012; Starrenburg et al., 2013) and it has been shown to have an effect on physical (PCS) and mental (MCS) quality of life in patients with MS and Parkinson’s disease (Dubayova et al., 2013).

Symptoms of MS and the diagnosis itself threaten to change a person’s everyday habits and bring disarray into the life of patients who find themselves facing all kinds of issues resulting from their disease. To manage such a situation, one requires functional coping strategies (Goretti et al., 2010). Patients, while dealing with their condition, engage in various coping strategies (Kara and Acikel, 2012; Lode et al., 2007) which do not have the same effect on the patient’s well-being (Sullivan et al., 1997). Multiple studies have focused on the effect of different coping strategies on quality of life. Some studies indicate that problem-focused coping is the most adaptive (Crooks et al., 2011; Goretti et al., 2010); in others, a lesser reliance on avoidance coping was found to be more adaptable (Mackay and Pakenham, 2012), and some came to the conclusion that coping focused on stopping unpleasant emotions and thoughts has its place in dealing effectively with chronic conditions as well (Harmell et al., 2011; Mikula et al., 2014). Adequate coping strategies also seem to differ between patients with different diagnoses, such as when laryngectomised patients, for example, use an active coping more often than MS patients, while MS patients utilise more coping by suppression and so on (Aarstad et al., 2011).

Both Type D personality and coping seem to be associated with HRQoL, and although personality traits are relatively stable over time (Mommersteeg and Pouwer, 2012), coping seems to have its own independent influence on quality of life in patients with a chronic disease. Previous studies suggested that coping has a potential to mediate relationship between Type D and perceived severity of the disease especially in cardiovascular patients (Middel et al., 2014; Williams and Wingate, 2012; Yu et al., 2011), but research in field of MS is scarce (Dubayova et al., 2013); thus, the aim of this study was to thus analyse the associations between Type D personality and HRQoL in MS patients and to explore whether this association is mediated by the different coping strategies used by patients with MS. Type D was chosen for its inclusion of social (SI) and emotional (NA) scales, which would provide us with more complex picture of HRQoL than tool only assessing depression or anxiety would.

Methods

Participants

MS patients from region of Eastern Slovakia who met the McDonald criteria (Polman et al., 2005) were asked to participate in the study (n = 214). Out of these, 58 patients (60.3% women) refused to participate (response rate: 72.9%), and the exclusion criteria were applied to the rest. These were as follows: the presence of a psychiatric diagnosis, the score on the Mini-Mental State Examination (MMSE) <24, pregnancy and the inability to speak Slovak. The final sample (N = 156) had a median age of 40 ± 3 years and consisted of 75.0 per cent women. There were no statistically significant differences between respondents and non-respondents in terms of gender and age.

Procedure

Data collection for this cross-sectional study took place between September 2010 and June 2013. Filling in self-report questionnaires, a semi-structured interview and a neurological examination were the parts of the data collection. The invitation letter, the informed consent form, the non-response sheet and the questionnaires were sent to participants’ homes by postal mail. After 2 weeks, patients were reminded about the questionnaires by a phone call, and their neurological examination and interview were scheduled at the same time. These were performed at the Neurology Outpatient Clinic. The neurological examination was carried by a single neurologist, and a trained interviewer conducted the semi-structured interview.

The Local Ethics Committee approved the study before it started. Each patient provided a signed informed consent form prior to the study.

Measures

Type D

The presence of Type D personality among patients with MS was assessed using the Type D Scale-14 (DS14) (Denollet, 2005). It consists of 14 items used to build two scales – NA and SI, each consisting of seven items. Patients assessed their personality on a 5-point Likert scale with anchor points ranging from 0 = false to 4 = true. The score on both scales can range from 0 to 28, with a higher score indicating higher inclination to NA or SI. A cut-off score of 10 was set in both scales as the point when subjects would be considered as Type D (Denollet, 2005). In our sample, Cronbach’s alpha was 0.89 for NA, 0.84 for SI and 0.89 for Type D. We treated Type D as a continuous variable.

Coping self-efficacy

Coping self-efficacy (CSE) was measured using the 26-item CSE Scale developed specifically for chronically ill populations (Chesney et al., 2006). The CSE is a prerequisite for using actual coping strategies, as patients need to be sure that they can perform coping actions before they act upon them. Therefore, in this article, we treat the terms coping and coping self-efficacy as equivalent because both concepts are closely tied to each other. In this questionnaire, patients were asked to respond to the following question: ‘When things are not going well for you, or when you’re having problems, how confident or certain are you that you can do the following’. Respondents then answered on an 11-point scale. The instrument included three subscales representing self-efficacy for the use of ‘problem-focused coping’ strategies (ranging from 0 to 120), ‘emotion-focused coping’ which means ability to get support from friends and family (ranging from 0 to 50) and the ‘ability to stop unpleasant emotions and thoughts’ (ranging from 0 to 90). A higher score indicates a higher ability to cope with the situation described in the question (Chesney et al., 2006). In our sample, Cronbach’s alpha was 0.94 for problem-focused coping, 0.86 for coping focused on getting support and 0.93 for stopping unpleasant emotions and thoughts.

HRQoL

HRQoL was assessed using the 36-item Short-Form (SF-36) health survey (Ware and Sherbourne, 1992). Various aspects of HRQoL are covered in eight scales, which then can be summarised into two main components. The subscales included in the questionnaire are as follows: (1) physical functioning (10 items), (2) role limitation due to physical health (four items), (3) bodily pain (two items), (4) general mental health (five items), (5) social functioning (two items), (6) psychological distress and well-being (five items), (7) role limitations due to emotional problems (three items) and (8) vitality, energy or fatigue (four items). Two summary scores are calculated, namely, a PCS and an MCS. In addition, one question is designed to measure changes in health status over the past year. All item scores are coded and transformed into a scale of 0 (poor health) to 100 (optimal health). The component summary scores are normalised to a general population mean of 50 and a standard deviation of 10. A higher score indicates better HRQoL in both dimensions. In our sample, Cronbach’s alpha was 0.92 for the PCS and 0.93 for the MCS.

Sociodemographic and clinical variables

For the description of our study population, we used the Expanded Disability Status Scale (EDSS) score as a measure of functional disability in MS patients (scoring from 0.0 to 10.0), with an increasing score indicating more severe disability (Kurtzke, 1983). Information on the clinical course of MS was retrieved from medical records. The age (treated as continuous variable) of patients along with the information on gender and education (elementary, secondary and university) were asked during the interview.

Statistical analyses

First, descriptive analyses of the study variables were carried out. Next, correlations and a series of linear regression analyses were carried out in order to calculate the figures for mediations. Finally, the Sobel z-test was used to examine the mediating effects of the three different coping strategies on the association of Type D and both components of quality of life in MS patients. Statistical analyses were performed in IBM SPSS 20 and MedGraph (Jose, 2013).

Results

A basic description of the study population is given in Table 1 (N = 156). The median age of MS respondents was 40 years, and the sample consisted of 75.0 per cent women. The median EDSS score was 3, and the median disease duration was 6 years. The majority of patients (68%) belonged to relapse-remitting clinical course. Majority of the sample scored below cut-off score of 10 in Hospital Anxiety and Depression Scale–Depression (HADS-D) questionnaire for depressive symptoms (85.5%) (Table 1).

Table 1.

Description of the study population (N = 156).

Variables	N (%)	Median	95% CI	Range
Age (years)	156	40.0	37–43	18–61
Gender
Male	39 (25.0%)
Female	117 (75.0%)
Education
Elementary	6 (3.8%)
Secondary	113 (72.4%)
University	37 (23.7%)
Disease duration (years)		6	5–8	1–28
MS course
CIS	19 (12.4%)
RRMS	104 (68.0%)
SPMS	30 (19.6%)
EDSS		3	2.5–3.5	1.0–8.0
HADS-D⩽10	133 (85.3%)
HADS-D > 10	23 (14.7%)
Type D
Negative affectivity		12	10–14	0–28
Social inhibition		10	9–12	1–24
Coping
Problem		83.5	77–87	22–120
Emotion		35.0	33–38	3–50
Stopping		63.0	58–67	4–90
Quality of life
PCS		38.1	35.1–40.4	16.0–60.0
MCS		43.1	38.9–47.8	17.3–69.8

CIS: clinically isolated syndrome; RRMS: relapse-remitting multiple sclerosis; SPMS: simple progressive multiple sclerosis; EDSS: Expanded Disability Status Scale; HADS-D: Hospital Anxiety and Depression Scale–Depression; PCS: physical component summary; MCS: mental component summary; CI: confidence interval.

Missing values: EDSS: 9.6 per cent, disease duration: 3.2 per cent, MS course: 1.9 per cent.

Before we proceeded with the mediations, we prepared the data, starting with correlations, which showed us that PCS was not correlated with other studied variables, while MCS was correlated significantly. Coping strategies intercorrelated significantly. Finally, Type D correlated significantly with all of the studied variables except for PCS (Table 2).

Table 2.

Correlations between the variables under study.

	HRQoL		Coping
	PCS	MCS	Problem focused	Emotion focused	Stopping^a
MCS	0.079
Problem focused	0.091	0.476 *
Emotion focused	0.099	0.448 *	0.852 *
Stopping^a	0.039	0.512 *	0.875 *	0.840 *
Type D	−0.090	−0.428*	−0.428*	−0.475*	−0.484*

HRQoL: health-related quality of life; PCS: physical component summary; MCS: mental component summary.

Coping focused on stopping unpleasant emotions and thoughts

Values in bold are significant at p<.05.

Next, we performed a series of linear regressions between the studied variables, thus preparing data for the mediations. The outcomes of the analyses showed that while in the PCS there is no mediation between the studied variables, in the MCS partial mediations in all three types of coping were present (Table 3).

Table 3.

The mediating effect of coping on the association between Type D and PCS and MCS.

	Type D
	PCS		MCS
Coping	Sobel z value	Indirect effect	Sobel z value	Indirect effect (%)
Problem-focused coping	−0.72		−3.70*	35.9
Emotion-focused coping	−0.79		−3.37*	34.3
Coping focused on stopping unpleasant emotions and thoughts	−0.05		−4.11*	45.0

PCS: physical component summary; MCS: mental component summary

The indirect effect is shown only when significant.

Values in bold are significant at p<.05.

In the MCS, the indirect mediating effect of all three coping strategies was significant. The indirect effect was 35.9 per cent for problem-focused coping, 34.3 per cent for emotion-focused coping and 45.0 per cent for coping focused on stopping unpleasant emotions and thoughts. A detailed model of how all of the studied coping strategies mediate the association between Type D and MCS is depicted in Figure 1, showing the mediating effect of coping strategies.

Figure 1.

The mediating effect of the studied coping strategies on the association between Type D and MCS.

Discussion

The aim of this study was to examine whether coping mediates the association between Type D personality and HRQoL in patients with MS. No association between Type D and PCS was present in our results, possibly resulting from the objective nature of PCS as a reflection of adverse inflammatory processes in the brain tissue or other physical impairments, possibly being present (Marrie et al., 2012). This may be also a reason for PCS and MCS not being correlated in our sample. While PCS taps physical symptoms which are measured by EDSS, MCS may be intact between the attacks of the disease and be more dependent on mental factors, rather than physical.

In MCS, there seems to be much more space for coping to mediate the association between Type D personality and HRQoL. MCS seems much more likely to be swayed by coping than its physical counterpart (Poppe et al., 2012). Coping seems to be a variable associated with MCS regardless of the specific type of coping. The mental domain seems to have the capacity for the self-helping tendencies of patients, and although PCS can be only occasionally altered by psychological instruments, MCS responds well to various protective efforts (Hopman et al., 2009; Trojan et al., 2012). While personality traits are considered to be rather stable over time, MCS can be possibly altered by coping (Mikula et al., 2014; Poppe et al., 2012).

Strengths and limitations

Among the strengths of this study are the high response rate (72.9%) and the consecutive way of collecting data. Some limitations should be noted, however. Patients with a lower disease severity were more likely to participate in the study, while patients with a higher disability were more likely to refuse to participate. Also, although the women-to-men ratio in MS is 2:1, in the study sample the ratio was somewhat higher (75.0% women), so the results may better explain relationship between the studied variables in women than in men. In addition, due to the cross-sectional design, any causal relationships drawn from our results should be interpreted with caution.

Implications

These results suggest that there is an association between Type D and MCS and that this association is partially mediated by different coping strategies; no such effect was found with regard to PCS. With coping as a mediator between Type D and MCS, one can alter coping strategies in order to mediate this association resulting in a better MCS. Although we believe Type D personality traits are considered to be fairly stable, coping strategies can actively be modified and thus be of great use in diminishing the adverse effects of Type D on MCS by educating patients. Various coping strategies, especially those focused on stopping unpleasant emotions and thoughts, can be used in people with high levels of NA or SI. Coping can also be beneficial for physicians, relatives and caretakers of patients with MS. MS clubs and self-help or peer groups could include this information into educational programmes and encourage patients to use problem-focused coping, emotion-focused coping as well as coping focused on stopping unpleasant emotions and thoughts, especially when Type D personality traits are present. Therapists can also work with coping, experiment with different strategies and analyse which seem to be most appropriate for different patients. Future research is needed, though, especially longitudinal studies that would shed more light on the causality of the associations between the studied variables.

Footnotes

Acknowledgements

The authors wish to thank the people with multiple sclerosis who participated in this study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Slovak Research and Development Agency under contract APVV-0220-10 (50%) and by the project Medipark-Kosice (50%) supported by the Operational programme Research and Development (Contract No. OPVaV/12/2013).

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