Distressed personality type, or "type D" individuals, tend to suppress powerful negative emotions as a means of coping with stressful events or situations. These individuals suppress feelings of anger or sorrow even when they are in an environment that is supportive of emotional expression, such as suppressing anger when clearly justified, or refusing to cry at a funeral. The type D individual tends to be anxious, irritable, insecure, and uncomfortable with strangers. These types of people are constantly experiencing and anticipating negative emotions, which results in their being more tense and inhibited around others. History The type D personality was defined in the 1990s, describing individuals who experience feelings of negativity, depression, anxiety, stress, chronic anger, and loneliness. The distressed personality type is also prone to pessimism, low self-esteem, and difficulty making personal connections with others. It is thought that about 20% of otherwise-healthy Americans fall under this category. In 1996, Dr. Denollet reported a longitudinal study of 286 men and women who had enrolled in a cardiac rehabilitation program. At the beginning of the program, each participant filled out a questionnaire in order to determine whether they fell under the type D pattern. Eight years later, researchers tracked down the participants in order to find out who had died, and who was still alive. Among those who had been classified as type D, 27% had died; meanwhile only 7% of the non-Ds had died. The majority of these deaths were due to heart disease or stroke. Since this study, the type D personality subtype has been thought to be associated with early death, increased risk for developing cardiovascular problems, poorer response to proven treatments for heart disease, and increased chances of sudden cardiac arrest. Diagnostic criteria A 14-question scale is used to determine whether an individual can be categorized as having a type D personality type. This scale, the D-Scale 14, aims to measure negativity as well as social inhibition. Each of the 14 items on the scale is rated according to a 5 point Likert scale, from 0 to 4 (false to true). Individuals who score high (above a 10) on both negativity and social inhibition can be classified as type D. This questionnaire was developed based on the idea that individuals who score high on negative affectivity are dysphoric and have a negative view of self. They are also prone to more somatic symptoms, and focus more