The Relationship between Type D Personality and Primary Narrow Angle &amp; Primary Angle Closure Glaucoma

doi:10.21203/rs.3.rs-2354734/v1

Purpose: To investigate the relationship of type D personality and primary narrow angle and primary angle closure glaucoma.

Methods: A cross-sectional study was performed in 110 patients with primary narrow angle admitted to the Department of Ophthalmology, the First Affiliated Hospital of China Medical University from June to October 2021. Among them, 49 patients had a history of glaucoma attack or visual field changes, and 61 patients had no history of glaucoma attack and visual field changes. Forty-nine age-related cataract patients with normal anterior chamber depth were included as control group. The demographic characteristics and ophthalmic examination results were collected, and all subjects were evaluated by type D scale-14, self-rating anxiety scale and self-rating depression scale.

Results: There were 60 subjects (54.5%) had type D personality in primary narrow angle patients, and 5 subjects (10.2%) in control group; in primary narrow angle group, 37 patients (75.5%) had type D personality among primary angle closure glaucoma patients, and 23 patients (37.7%) in patients without history of glaucoma attack or visual field changes. The results of ordered logistic regression analysis showed that type D personality increased the risk of angle-closure glaucoma and primary narrow angle (OR=5.730，95%CI 2.596-12.648，p<0.001).

Conclusions: TDP and anxiety are significantly associated with PACG, TDP has a certain correlation with PNA.

Primary angle-closure glaucoma

type D personality

primary narrow angle

history of glaucoma attack

Glaucoma is the leading cause of irreversible blindness in the world^[1], the prevalence of glaucoma was increasing with the aging of the population. In 2020, there was 76 million glaucoma patients all over the world for people aged 40–80. It was predicted that by 2040 the number will increase to 111.8 million^[2]. Primary glaucoma is divided into primary angle-closure glaucoma (PACG) and primary open angle glaucoma (POAG). Globally, Asians has the highest prevalence of PACG^[2], among which 60% are women^[3]. Elevated intraocular pressure (IOP) and positive family history are the main risk factors of PACG^[4]. According to progression, PACG could be divided into three states: primary narrow angle (PNA), primary angle-closure (PAC) and PACG^[5]. PNA refers to the shallow anatomical anterior chamber depth (ACD). PAC refers to PNA accompanied by angle closure. PACG is PAC accompanied glaucoma attack, which is manifested as rapidly IOP increased, eye pain and headache^[6].

Simultaneously, glaucoma is also recognized as an ophthalmic physical and mental disease^[7]. A review summarized previous studies on the personality characteristics of glaucoma patients^[8], which concluded that glaucoma patients had a certain degree of negative personality. But the relationship between specific personality characteristics and glaucoma is not clear. Type D personality (TDP) was a kind of “sad personality”, which was composed of two dimensions, negative affectivity (NA) and social inhibition (SI)^[9]. NA refers to the persistent negative emotion^[10]. SI refers to personal emotional inhibition or unwillingness to contact society^[11]. People with TDP often had serious negative emotions and were prone to sadness and loneliness^[12]. However, no study has explored the relationship of TDP and PNA/PACG.

Therefore, in order to explore the relationship of TDP and PNA/PACG, provide evidence to the prevention and treatment of glaucoma, we performed this study.

2.1. Ethical Approval

This cross-sectional study received ethical approval of the Ethics Committee of the First Affiliated Hospital of China Medical University. Meanwhile, the subjects included in this study signed informed consent.

2.2. Research Objects

In this study, 110 PNA patients admitted to the ophthalmology department of the first affiliated hospital of China Medical University from June to October 2021 were included as the case group, including 49 cases with glaucoma attack history or visual field changes and 61 cases without glaucoma attack history. Forty-nine age-related cataract patients with normal anterior chamber depth were included as control group.

Inclusion criteria of case group: ①ultrasound biomicroscopy showed narrow angle or angle closure; ②subjects voluntarily accepted various psychological and personality characteristics surveys and signed informed consent. Inclusion criteria of control group: ①age-related cataract patients with normal anterior chamber depth diagnosed by ophthalmologic examination; ②subjects voluntarily accepted various psychological and personality characteristics surveys and signed informed consent. Exclusion criteria: ①other acute ophthalmic diseases (such as scleritis, conjunctivitis, keratitis or uveitis) or chronic ophthalmic diseases; ②high myopia; ③drug or alcohol dependence; ④severe mental disorders and severe diseases of other systems; ⑤diabetes.

2.3. Research Tools

The research investigation consisted of five questionnaires: ①Census Table of Demographic Characteristics, ②Record table of eye examination results, ③Type D Scale-14 (DS14), ④Self-rating Anxiety Scale (SAS), ⑤Self-rating Depression Scale (SDS).

Information on demographic characteristics included age, gender, educational level, monthly household income, smoking, drinking, hypertension, sleep quality, living conditions and course of disease. Ophthalmic examination results included IOP by Non-contact tonometer (Equipment information: Topcon, Japan). With 21 mmHg as the cut-off value, an IOP greater than or equal to 21 mmHg was considered an uncontrolled IOP.

DS14 table was developed to evaluate TDP with high reliability^[13]. DS14 includes 14 items, NA and SI dimensions are assessed by 7 items separately, each item consists of 5 levels of options, the score is based on the Likert Scale (0-4 points)^[13]. If both NA and SI scores are greater than or equal to 10, the subject could be recognized as TDP^[14].

SAS and SDS are used to assess the mood disorders of anxiety and depression respectively^[15], the assessment items of the two scales are both composed of 20 questions, each of which has 4 answers (even/no, sometimes, often, continuously), based on the Likert Scale (1-4 points)^[16]. At present, the cutoff value of the scale in China was based on the general population rather than the clinical validity, so it was not easy to determine the cutoff value^[17]. But a large number of studies were using SAS and SDS for psychological assessment in glaucoma researches^[18].

2.4. Statistical Analysis

All statistical analyses were performed using SPSS software (26.0 edition) (IBM SPSS, Inc. Chicago, IL, USA), which were bilateral tests, and p≤0.05 indicated that the difference was statistically significant. For quantitative data, Shapiro-Wilke test and Levin test were used to test the normality and homogeneity of variance. The Analysis of Variance (ANOVA)(F-test) was used to evaluate the difference among the three groups of data for the quantitative data with normal distribution and uniform variance, and the descriptive statistics were in the form of mean ± standard deviation. Bonferroni test was used for pairwise comparison among the three groups of variables to determine whether there was statistical significance between any two groups. Kruskal Wallis test was used for quantitative data that did not conform to normal distribution or homogeneity of variance, descriptive statistics were expressed in the median (25%, 75%). Qualitative data were compared by chi-square test. Ordered logistic regression analysis was used to construct the regression equation and calculate the odds ratio (OR) and 95% confidence interval (95% CI) of variables.

3.1. Descriptive statistics and difference analysis of demographic characteristics among PACG, non PACG and control groups

In this study, 110 PNA patients were included. According to the glaucoma attack history or visual field changed, they were divided into PACG group (49 cases) and non PACG group (61 cases). And 49 age-related cataract patients treated in the same period were included as the control group. The results of descriptive statistics and difference analysis of demographic characteristics among the three groups were shown in Table 1. There were no statistical differences among the three groups in age, smoking, drinking, hypertension and living conditions. And no statistical differences of educational level and monthly household income (data was not displayed in the table). There were statistical differences in gender (c²=23.679, p<0.001) and sleep quality (c²=11.810, p=0.003) among the three groups. Among the above three variables, there was no statistical difference between PACG group and non PACG group (p>0.05), while there were statistical differences between control group and PACG group and non PACG group (p<0.05).

Table 1 Descriptive statistics and difference analysis of demographic characteristics among PACG, non PACG and control groups

Variable	PACG (n=49)	Non PACG (n=61)	Control (n=49)	F/c²value	P value
Gender [Male n (%)]	12 (24.5)	5 (8.2) ^**	24 (49.0) ^#	23.679	<0.001
Age (Mean ± SD)	63.2 ± 7.9	64.6 ± 7.3	65.5 ± 9.3	1.034	0.358
Smoking [n (%)]	8 (16.3)	5 (8.2)	12 (24.5)	5.463	0.065
Drinking [n (%)]	8 (16.3)	9 (14.8)	9 (18.4)	0.259	0.878
Hypertension [n (%)]	15 (30.6)	18 (29.5)	16 (32.7)	0.127	0.938
Bad sleep quality [n (%)]	26 (53.1)	27 (44.3) ^**	10 (20.4) ^#	11.810	0.003
Living alone [n (%)]	9 (18.4)	11 (18.0)	7 (14.3)	0.367	0.832

Note: *. PACG group versus Non PACG group, p<0.05; #. PACG group versus Control group, p<0.05; **. Non PACG group versus Control group, p<0.05. PACG: primary angle-closure glaucoma.

3.2. Descriptive statistics and difference analysis of clinical indexes among PACG, non PACG and control groups

The results of descriptive statistics and difference analysis of clinical indexes among three groups were shown in Table 2. There were statistical differences in these clinical indexes among the three groups. And there were statistical differences in TDP, NA score, SI score, SAS score and IOP uncontrollable between PACG group and non PACG group.

Table 2 Descriptive statistics and difference analysis of clinical indexes among PACG, non PACG and control groups

Variable	PACG (n=49)	Non PACG (n=61)	Control (n=49)	F/c² value	P value
TDP [n (%)]	37 (75.5) ^*	23 (37.7) ^**	5 (10.2) ^#	43.647	<0.001
NA score (Mean ± SD)	15.4 ± 5.7 ^*	10.9 ± 6.2 ^**	5.1 ± 4.5 ^#	41.042	<0.001
SI score (Mean ± SD)	14.6 ± 5.3 ^*	11.3 ± 5.2 ^**	7.5 ± 5.0 ^#	23.377	<0.001
SAS score (Mean ± SD)	36.4 ± 8.9 ^*	33.5 ± 7.4 ^**	26.1 ± 4.9 ^#	26.046	<0.001
SDS score (Mean ± SD)	39.4 ± 8.5	37.8 ± 10.0 ^**	30.0 ± 5.4 ^#	18.250	<0.001
IOP uncontrollable [n (%)]	38 (77.6) ^*	30 (49.2) ^**	16 (32.7) ^#	20.348	<0.001

Note: *. PACG group versus Non PACG group, p<0.05; #. PACG group versus Control group, p<0.05; **. Non PACG group versus Control group, p<0.05.

IOP: intraocular pressure; NA: negative affectivity; PACG: primary angle-closure glaucoma; SAS: self-rating anxiety scale; SDS: self-rating depression scale; SI: social inhibition; TDP: type D personality.

3.3. Ordered logistic regression analysis among PACG, non PACG and control groups

Among all subjects, PACG, non PACG and cataract were used as three dependent variables; gender, TDP, sleep quality, SAS score, SDS score and IOP uncontrollable were included as independent variables; to construct ordered logistic regression equation (Table 3). The differences among gender, sleep quality, SAS score and SDS score were not statistically significant. The results showed that compared with non-TDP, TDP increased the risk of PACG and PNA, the difference was statistically significant (OR=5.730，95%CI 2.596-12.648，p<0.001); IOP uncontrollable increased the risk of PACG and PNA, and the difference was statistically significant (OR=3.735，95%CI 1.911-7.301，p<0.001).

Table 3 Ordered logistic regression analysis among PACG, non PACG and control groups

Variable		B value	S_b value	Wald c² value	P value	OR value	95%CI of OR
Threshold	Control = 1.00	0.470	1.007	0.218	0.641	-	-
	Non PACG = 2.00	2.920	1.033	7.999	0.005	-	-
Gender	Female	0.675	0.381	3.142	0.076	1.964	0.931-4.145
TDP	Yes	1.746	0.404	18.678	<0.001	5.730	2.596-12.648
Bad sleep quality		0.379	0.374	1.022	0.312	1.460	0.701-3.042
SAS score		0.052	0.035	2.208	0.137	1.053	0.984-1.127
SDS score		0.011	0.028	0.149	0.699	1.011	0.957-1.067
IOP uncontrollable		1.318	0.342	14.845	<0.001	3.735	1.911-7.301

Note: IOP: intraocular pressure; PACG: primary angle-closure glaucoma; SAS: self-rating anxiety scale; SDS: self-rating depression scale; TDP: type D personality.

Previous studies show that TDP was associated with the presence and clinical manifestations of many chronic diseases such as coronary heart disease (CHD), ankylosing spondylitis and diabetes^[19-22]. TDP was confirmed as a risk factor for CHD^[22], that could predict the risk of cardiac events^[23]. Emotions associated with TDP had negative psychological effects (such as anxiety and depression) and could reduce the quality of life^[24]. Jandackova et al. explored the possible mechanism of the relationship between TDP and unhealthy state in healthy people^[25], showed that TDP people have poor glycemic control, systemic inflammation and autonomic nervous system regulation.

With the transformation from biomedical model to biological-psychological-social model, people gradually realize that social psychological factors have a direct impact on the occurrence, developing and outcome of glaucoma^[8]. Large number of previous studies had explored the psychological characteristics of glaucoma patients, and shown that patients with primary glaucoma were prone to anxiety and depression^[26]. Studies have shown that glaucoma patients have a certain degree of negative personality^[8].

However, previous studies paid more attention to POAG patients, and concluded that type A personality (TAP) might be a risk factor of POAG especially for male^[27-29]. The relationship between angle closure glaucoma and personality characteristics has not been reported. In terms of personality evaluation of patients with primary glaucoma, many studies have selected the Eysenck Personality Questionnaire (EPQ), which divided personality characteristics into four dimensions: introversion and extroversion, neuroticism, psychoticism, and concealment, studies have shown that the neuroticism of PACG patients is relatively obvious^[30]. Compared with TAP, TDP has more obvious characteristics of neuroticism. People with higher neuroticism are more likely to be introverted and isolated^[31], that is similar to the SI dimension of TDP. So we believe that TDP may be related with PACG. In our study, we found that there was a certain correlation between TDP and the occurrence and development of PACG, which has not been reported before.

This study found that PNA patients were more prone to anxiety and depression than the control group. This was consistent with the conclusion of a prospective case-control study, which found that the incidence of anxiety and depression in PACG and POAG patients were higher than that in the control group^[26]. In our study, PNA patients were divided into two groups according to whether have diagnosed PACG (glaucoma attack history or visual field changes), and we found that anxiety was more common in patients with PACG patients than in simply PNA patients, but there was no significant difference in the incidence of depression between them. A study found that the incidence of POAG was not related with anxiety and depression^[32]. However, anxiety could increase the risk of the progression of POAG^[33]. This indicates that there are some differences between PACG and POAG in the correlation with anxiety and depression. Anxiety and depression are related to PACG.

Among all subjects, PACG, non PACG and cataract were used as three dependent variables to construct ordered logistic regression equation. The results showed that TDP increased the risk of PACG and PNA with statistically significant (OR=5.730，95%CI 2.596-12.648，p<0.001). Therefore, we believe that patients with TDP in PNA subjects are more likely to develop angle-closure glaucoma.

In this study, the prevalence of TDP in patients with primary chronic angle-closure glaucoma in PNA was statistically analyzed separately. Although these patients may have no history of glaucoma attack, they may have visual field changes. The statistical results were as follows: 6 patients (54.5%) had TDP in 11 patients with primary chronic angle-closure glaucoma, and 60 patients (54.5%) had TDP in 110 PNA patients. The difference was not statistically significant.

In summary, our study shows that TDP and anxiety are significantly associated with PACG, TDP has a certain correlation with PNA, and it may also have a certain relationship with glaucoma attack. The physical and mental health of patients should be considered in the treatment of PNA.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki. This project was approved by the Ethics Committee of the First Affiliated Hospital of China Medical University and was carried out the principles of the Declaration of Helsinki and all subjects signed the informed consent.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

Qinye Wang: No competing interests exist. Yuedong Hu: No competing interests exist. Xinyue Zhang: No competing interests exist. Jue Wang: No competing interests exist.

Funding

Not applicable.

Authors' contributions

Yuedong Hu and Qinye Wang: project development, data analysis, manuscript writing; Xinyue Zhang: manuscript editing; Jue Wang: project development. All authors read and approved the final manuscript.

Acknowledgements

Not applicable.

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No competing interests reported.

The Relationship between Type D Personality and Primary Narrow Angle & Primary Angle Closure Glaucoma

Status:

Version 1

Abstract

1. Introduction

2. Methods

3. Results

4. Discussion

5. Conclusion

Declarations

References

Additional Declarations

Status:

Version 1