Does personality play a role in continuous positive airway pressure compliance?

Emily L. Maschauer; Donna M. Fairley; Renata L. Riha

doi:10.1183/20734735.014916

Tables

Table 1

Summary of studies included in this review

Study	Participants	Intervention	Methods	Outcomes
*Olsen et al.* [1**]	1488 patients with OSA from various studies 1247 male 241 female Age: 46–60 years	An overview of psychologically informed interventions for CPAP adherence The HBM was used in prediction of both CPAP acceptance and adherence	Moderated regression techniques	Applying theoretical models to OSA research has substantially improved the understanding of psychological constructs in CPAP adherence Using psychological and educational interventions for improving CPAP adherence is an understudied area of research; however, CBT-based interventions as well as motivational interventions addressing aspects of CPAP use are suggested as appropriate interventions for this population
*Wild et al.* [2]**	119 patients with OSAHS attending a sleep centre for overnight CPAP titration over an 8-month period 94 male 25 female Age: mean 51 years	Patients completed health value, health locus and self-efficacy prior to CPAP titration	Three psychological measures were used in accordance with Wallston’s learning theory	Objective adherence data measured using CPAP run-time clocks were collected At 3-month follow-up, the mean CPAP use was 3.6±2.7 h per night in this population with 21 (18%) participants receiving some technical intervention for CPAP-related side-effects
*Broström et al.* [3]**	247 patients recruited from a CPAP clinic with three 1-h visits over a period of 2 weeks 203 male 44 female Age: mean 60 years	SECI was posted to perceive the effects on CPAP adherence	ESS, OSAS severity variable and objective adherences to CPAP treatment were obtained from the medical records	Type D patients scored significantly higher (p<0.05–0.001) in 12 of the 15 side-effects compared with non-Type D patients A total of 74 (30%) of the patients with OSAS (28% of the men versus 39% of the women) had Type D personality
Bollig [5]	Review of multiple studies	Clinical status outcomes were collected both before and after 3 months of therapy with questionnaires	ESS, MSLT and FOSQ	Type D personality OSA patients reported a higher complaint of adverse effects from CPAP therapy and reported a higher rate of continued sleepiness than non-D personalities In a discussion, 50% of patients with Type D personality used their CPAP <4 h per night, compared to 16% of the non-Type D participants
*Dieltjens et al.* [6]**	82 patients out of 113 with a known baseline type D scale started using MAD treatment between 2006/2009 58 male 24 female Age: mean 50±1 years	82 patients from 113 patients using MAD completed the DS14 Type D scale at baseline then follow up at 2 years	SDB diagnosis started on a MAD device with demographic and clinical data including results from DS14, and a perceived side-effects and adherence postal questionnaire	Characteristics of the 82 patients: BMI 27.9±4.3 kg·m⁻²; AHI 17±13 events per h; ESS 10±5; VAS 6±2 Of the Type D patients, 45% discontinued MAD treatment with 15% of non-Type D reported treatment discontinuation
*Moran et al.* [4]**	63 participants diagnosed with OSAHS, with CPAP for 30 days, usage defined as >4 h per night on 70% of nights 31 male 32 female Age: mean 57.1 years	Predictors of adherence were identified including demographic variables and personality traits	Mini-IPIP, BIS/BAS and WAYS	On ratings from the BIS/BAS, a raised BIS was a strong predictor of nonadherence (r= −0.452, p<0.01), followed by neuroticism An elevated BIS score and neuroticism may indicate that personality factors are important in the determination of adherence to CPAP
*Ekici et al.* [11]**	The MMPI was used for 94 treatment-naïve snorers and OSA people All patients with OSA and snorers were accepted with SDB (AHI >0 events per h) The threshold of 5 events per h sleep was chosen to define both OSA and snorers	Admitted for overnight PSG with questionnaires	PSG, MMPI, Fatigue scale, Adult ADHD scale, ESS, and SF-36	OSA patients scored significantly higher on Hs scale (65.0±12.0 versus 58.4±7.9, p=0.01) OSA patients compared to snorers have significantly higher rate of clinical elevation on both Pd (13.0 versus 0%, p=0.03) and Hs (26.1 versus 3.3%, p=0.01) The results of the study may indicate that patients with OSAS, compared to snorers, presented with more Hs and Pd personality characteristics
*Hayashida et al.* [12]**	230 patients referred with OSAS with AHI >5 events per h; given CPAP 230 male Age: 20–73 years	ESS, MMPI, SDS, age, BMI, sleep duration during the preceding month and AHI	Single and multiple linear regression analyses were performed to estimate the association between the ESS and the other measures tested	Age had negative association with ESS score (r= −0.245, p<0.001) BMI (r=0.165, p=0.012), AHI (r=0.199, p=0.002), SDS (r=0.169, p=0.010), Hs (r=0.212, p=0.001), Hy (r=0.177, p=0.007), Pd (r=0.133, p=0.044), Pt (r=0.227, p=0.001), Sc (r=0.228, p<0.001) and Ma (r=0.163, p=0.014) all had a positive association with ESS score There were several statistically clear and significant correlations (r≥0.5) among many MMPI variables: Hs versus D Hy, Pd, Pt and Sc D versus Pt, Sc and Si Hy versus Pd and Pt Pd versus Pt and Sc Pt versus Sc
Mols and Denollet [9]	2813 patients total from 12 studies Exclusion from the search included any cardiovascular population and any study with a negative affectivity or social inhibition personality	10-item standardised checklist for pre-defined criteria for systematic review on published papers	A cross-sectional design analysing Type D personality amongst non-cardiovascular patient population in a medical population	Patients with sleep apnoea on treatment reported more side-effects of treatment and were less likely to adhere to treatment than their non-type counterparts (p<0.05–0.001) Type D patients experienced their condition to be more disabling compared to non-Type D patients (40.5 versus 26.4; p=0.015), especially emotionally (p=0.007) and functionally (p=0.033)
*Pierobon et al.* [13]**	157 patients with OSAS from an obese population 106 male 51 female Age: 47±11.9 years	CBA 2.0, neuropsychological assessment, WAIS-R, verbal span test and PSG	Cross-sectional study Patients were assessed using both psychological and neuropsychological variants	Patients reported with higher frequency, compared to the normal distribution, the presence of an extrovert personality trait and depressive behaviours: 15.9% of the patients minimised symptoms and denied distress, whereas 28.0% presented psychological disorders Compared to the normative group, patients’ results were characterised as impaired with a higher percentage in short-term verbal memory (30.6%) and in short-term visual spatial memory (20.5%) Moreover, 30.6% of patients were impaired in one cognitive function, 11.5% in two, 8.9% in three, and 8.2% in four or more cognitive functions No significant relationships between psychological–neuropsychological data and clinical variables emerged
*So et al.* [14]**	88 patients with UARS. 45 male 43 female Age: 36.84±13.85 years 365 patients with OSAS 299 male 66 female Age: 49.52±11.79 years	AIS, PSQI and ESS	Overnight PSG, AIS, PSQI, SCL-90-R and EPQ	The URAS group scored significantly higher than the OSA group on the ESS, AIS and PSQI (p<0.001) Scores of all SCL-90-R subscales in the UARS group were significantly higher than those in the OSA group (all were p<0.001, except somatisation, which was p=0.016) Patients with UARS also scored lower on the EPQ-E (p=0.006) and EPQ-L (p<0.001), and showed higher scores on EPQ-P (p=0.002) and EPQ-N (neuroticism) (p<0.001) than those with OSA/OSAS The ESS scores for UARS and OSAS were 10.2 and 6.8 (p<0.001) Patients with UARS are more likely to have neurotic personalities and tend to be more anxious and sensitive than patients with OSAS (psychoticism 2.97±2.37 versus 2.14±1.76, neuroticism 16.57±4.46 versus 13.10±4.89)
*Ayow et al.* [15]**	8 patients recruited from a multisite sleep clinic, 4 who used CPAP for >5 h for 7 nights and 4 <1 h for 7 nights 4 male 4 female Age: 20–73 years	Demographic data, severity of OSA, extent of CPAP use, use of prescribed adjunct sedatives/hypnotics, and selected comorbidities known to influence CPAP adherence	Semistructured interviews took place in a private office in the clinic and lasted approximately 15–60 min Questions asked about CPAP experience, CPAP use, influences for CPAP use/nonuse and biggest challenge for CPAP use	Perceived physical, psychological and social factors were found to influence both CPAP use and non-use The way patients feel about themselves influences the ways in which they manage their OSA with or without CPAP

HBM: Health Belief Model; CBT: cognitive behavioural therapy; OSHAS: obstructive sleep apnoea–hypopnoea syndrome; SECI: Side-Effects of CPAP Inventory; ESS: Epworth Sleepiness Scale; OSAS: obstructive sleep apnoea syndrome; MSLT: Multiple Sleep Latency Test; FOSQ: Functional Outcomes of Sleep Questionnaire; MAD: mandibular advancement device; SDB: sleep disordered breathing; VAS: visual analogue scale for snoring; IPIP: International Personality Item Pool; BIS/BAS: behavioural inhibition system/behavioural activation system; WAYS: Ways of Coping; PSG: polysomnography; ADHD: attention deficit/hyperactivity disorder; SF-36: 36-item Short Form Survey; Hs: hypochondriasis; Pd: psychopathic deviate; SDS: Self-Rating Depression Scale; Hy: hysteria; Pt: psychasthenia; Sc: schizophrenia; Ma: hypomania; D: depression; Si: social introversion; CBA: Cognitive Behavioural Assessment; WAIS-R: Wechsler Adult Intelligence Scale Revised; UARS: upper airway resistance syndrome; AIS: Athens Insomnia Scale: PSQI: Pittsburgh Sleep Quality Index; SCL-90-R: Symptom Checklist-90 Revision; EPQ: Eysenck Personality Questionnaire; E: extroversion/introversion; L: lie; P: psychoticism; N: neuroticism.

Table 2

Personality tests used in this review

Test	What it measures	Test information
MMPI [11, 12]	Personality characteristics on 10 clinical scales: Hypochondriasis Depression Hysteria Psychopathic deviate Masculinity/femininity Paranoia Psychasthenia Schizophrenia Hypomania Social introversion	567 items True/false
BIS/BAS [7]	Appetite and aversive motives	BAS regulates appetitive motives, moves toward something desired, sensitive to reward and escape from punishment, and associated with positive affect and optimism BIS regulates aversive motives, moves away from something aversive, sensitive to punishment and nonreward, and related to fear and anxiety
DS14 and DS16 [4, 6, 13]	Type D personality	DS14 contains 14 items and a 5-point Likert-type scale ranging from 0 (false) to 4 (true) is used to measure the subjects’ personalities DS16 contains 8 items with negative affectivity and 8 items about social inhibition answered with a 5-point Likert rating scale.
The Big Five [7]	Five main domains of personality (OCEAN)	50 questions to rate on how true they are about the person on a 5-point Likert-scale (1, disagree; 3, neutral; 5, agree)
NEO-FFI [13]	Five main domains of personality (OCEAN)	60 questions assessing the essentials of personality
Mini-IPIP [7]	Five main domains of personality (OCEAN)	20 questions containing 4 items for each of the Big Five traits indicating the degree the statement applies to them on a 5-point scale
DOCCO [7]	Stress, personality and lifestyle	200 questions
CBA [14]	State and trait anxiety, personality characteristics, psychophysiological disorders, fears and phobias, and depressive behaviours	Includes an anamnestic schedule providing information on habits, personal history, sleep, eating behaviour, work, etc.
WAYS [7]	Different domains or aspects of personality, including basic descriptive traits, motivation and coping skills	66 items to measure thoughts and actions used in stressful situations Measures 8 coping factors: confrontive coping distancing self-controlling seeking social support accepting responsibility escape avoidance planful problem solving positive reappraisal
SCL-90-R [16]	Psychiatric symptoms	Multidimensional, self-report symptom inventory consisting of 90 items divided into 9 symptom dimensions: somatisation obsessive–compulsive interpersonal sensitivity depression anxiety hostility phobic anxiety paranoid ideation psychoticism
EPQ [16]	Personality traits measuring psychoticism, neuroticism, extraversion and lying	4-item measures of psychoticism (social psychopath, solitary, troublesome, cruel and inhumane traits), neuroticism (anxious, worrying, moody and frequently depressed), extraversion (sociable, craves excitement, carefree and optimistic) and lying (social desirability)

NEO-FFI: NEO Five Factor Inventory; IPIP: International Personality Item Pool; CBA: Cognitive Behavioural Assessment; WAYS: Ways of Coping; SCL-90-R: Symptom Checklist-90 Revision; OCEAN: openness, conscientiousness, extroversion, agreeableness and neuroticism.