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 Table of Contents  
Year : 2020  |  Volume : 4  |  Issue : 1  |  Page : 12-20

Adverse childhood experiences and the structure of personality in patients with takotsubo syndrome versus myocardial infarction

1 Department of Psychosomatic Medicine and Psychotherapy, Segeberger Kliniken, Bad Segeberg, Germany
2 Department of Medical Psychology, Faculty of Medicine, LMU Munich, Germany
3 Department of Psychology, Medical School Hamburg, Germany
4 Division of Health Promotion, University of Applied Sciences, Coburg, Germany
5 Department of Psychosomatic Medicine and Psychotherapy, Technical University of Munich, Germany
6 Department of Cardiology, Angiology and Intensive Care Medicine, Medical Clinic II, University Heart Center Lübeck, Germany
7 Department of Cardiology, Segeberger Kliniken, Bad Segeberg, Germany
8 Department of Cardiology, Heart and Vascular Centre, Bad Bevensen, Germany
9 Medical Clinic and Policlinic I, Technical University of Munich, Germany
10 Department of Psychosomatic Medicine, Klinik Barmelweid, Barmelweid, Switzerland

Date of Submission25-Nov-2019
Date of Acceptance22-Feb-2020
Date of Web Publication17-Apr-2020

Correspondence Address:
Dr. Lutz Goetzmann
Department of Psychosomatic Medicine and Psychotherapy, Segeberger Kliniken, Am Kurpark 1, 23795 Bad Segeberg
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/hm.hm_76_19

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Context and Aims: Psychosocial risk factors are known to result in either takotsubo syndrome (TTS) or myocardial infarction (MI). In this article, the results of a cross-sectional study are presented within the framework of “progressive somatization” by comparing the psychosocial traits of TTS and MI patients. Design/Subjects and Methods: 136 patients were administered a battery of questionnaires comprising the Childhood Trauma Questionnaire (CTQ), the Toronto Alexithymia Scale (TAS-20), the Experiences in Close Relationships-Revised Questionnaire, and the Operationalised Psychodynamic Diagnosis Structural Questionnaire (OPD-SQ). Life events prior to the onset of cardiac disease were recorded. Statistical Analysis: Descriptive statistics data were expressed in absolute numbers, percent, and mean and standard deviation. To identify differences between groups, T-tests for independent samples, Chi-square-tests and Mann-Whitney-Tests were used. Pearson correlations were computed to assess the relationship between the patient samples as well as between the patient samples and norms. Results: Few differences were found between TTS and MI patients, with both groups reporting moderate-to-severe “emotional neglect” in their childhood (CTQ). Compared to the norm group, TTS and MI patients showed higher values of “alexithymia” (TAS-20), and MI patients reported higher “attachment avoidance”. There are more “structural limitations of the personality” in TTS and MI patients than in a psychosomatic sample (OPD-SQ). Conclusions: TTS as well as MI patients suffer from “adverse childhood experiences” and “structural limitations of personality.” The results sustain the psychosomatic theory of progressive somatization that leads to severe bodily diseases. Patients might benefit from a specific psychotherapeutical support.

Keywords: Adverse childhood experience, myocardial infarction, progressive somatization, structural limitations of personality, takotsubo syndrome

How to cite this article:
Goetzmann L, Olliges E, Ruettner B, Meissner K, Ladwig KH, Möller C, Deftu-Kloes D, Pohl S, Richardt G, Burgdorf C, Steger A, Ronel J. Adverse childhood experiences and the structure of personality in patients with takotsubo syndrome versus myocardial infarction. Heart Mind 2020;4:12-20

How to cite this URL:
Goetzmann L, Olliges E, Ruettner B, Meissner K, Ladwig KH, Möller C, Deftu-Kloes D, Pohl S, Richardt G, Burgdorf C, Steger A, Ronel J. Adverse childhood experiences and the structure of personality in patients with takotsubo syndrome versus myocardial infarction. Heart Mind [serial online] 2020 [cited 2023 Jun 6];4:12-20. Available from: http://www.heartmindjournal.org/text.asp?2020/4/1/12/282828

  Introduction Top

In addition to physiological aspects among patients suffering from myocardial infarction (MI),[1],[2],[3] psychosocial risk factors are known to result in either takotsubo syndrome (TTS) or MI.[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21] A study of 1750 TTS patients revealed a higher prevalence of psychiatric disorders.[8] TSS patients show a high prevalence of depression before the onset of the syndrome.[11],[12] Emotionally stressful incidents are thought to function as triggers of TTS.[8],[15] The so-called “type-D pattern,” being characterized by hostility, anger, and social inhibition, is proposed as a predictor of MI.[18] Moreover, “adverse childhood experiences” (ACE) go hand-in-hand with an increased risk of stress-related heart diseases.[19],[20],[21] Among the German population, 43.7% of those surveyed reported at least one ACE such as sexual abuse or emotional neglect.[22] In our study, we assessed risk factors such as ACE, alexithymia, dysfunctional attachment behavior, and structural limitations of the personality among TTS and MI patients. As framework, we used the model of “progressive somatization” being developed by Marty et al.[23],[24],[25],[26]

  Subjects and Methods Top


In the multicenter study, TTS and MI patients were examined for psychosocial traits by means of a postal survey consisting of validated questionnaires. The study was approved by the institutional review boards (University of Lübeck, approval number 13-232). The total sample of 136 patients comprised 68 patients diagnosed with TTS and 68 MI patients (f = 128, m = 8) who received diagnosis or treatment in the participating cardiology centers. The acute heart event (i.e., TSS or MI) occurred at least 6 months ago. TTS patients were included according to the Mayo Clinic diagnostic criteria for the TTS. These are (1) transient hypokinesis, akinesis, or dyskinesis of the left ventricular midsegments with or without apical involvement; regional wall motion abnormalities extend beyond a single epicardial vascular distribution; a stressful trigger is often, but not always, present; (2) absence of obstructive coronary disease or angiographic evidence of acute plaque rupture; (3) new electrocardiographic abnormalities (either ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin; and (4) absence of pheochromocytoma or myocarditis.[27] Accordingly, in keeping with the German Cardiology Society criteria, the inclusion criteria for MI (between at least 6 months and 5 years ago) were as follows: (1) relevant increase in troponin concentration; (2) ischemia symptoms; (3) new ST-T changes, new left-bundle branch block or development of pathological Q spikes; and (4) loss of vital myocardium, new wall motion abnormalities or intracoronary thrombus.[28] Patients with low German proficiency, cognitive impairments or reduced ejection fractions, and affected heart valves were excluded from the study. Whereas a high percentage of TTS patients (90% over all centers) were willing to participate in the study, only 60% of the MI patients were prepared to take part. The main reasons given for refusal were old age, personal lack of interest, and participation in earlier studies.

Design and procedure

Patients diagnosed with TTS who metall of the inclusion criteria were identified in local databases. A second list was created consisting of MI patients who matched the TTS patients in terms of age and gender. For blinding purposes, all data were de-identified with codes only available to the study coordinator. Potentially eligible patients were telephoned and informed about the purpose of the study and asked for permission to send the survey packet. If the centers did not receive the questionnaires back, a reminder was sent out.


The survey package sent to patients after oral consent by telephone contained: (a) a cover letter; (b) an information sheet with contact information; (c) a consent form; (d) a prepaid return envelope; and (e) the actual survey consisting of the questionnaires, in addition to a questionnaire collecting sociodemographic data, i.e., gender, age, number of children, current relationship status, housing situation, and current work situation.

The Childhood Trauma Questionnaire (CTQ) retrospectively detects adverse experiences during childhood. Twenty-five items measure “physical abuse,” “emotional abuse,” and “sexual abuse,” as well as “emotional neglect” and “physical neglect.” Three items are included with the aim of detecting trivializing tendencies. All items are rated on a 5-point Likert scale.[29] The German version has demonstrated a good internal consistency of Cronbach's α = 0.67–0.95 for the scales listed above.[30] For comparison, there are data of psychiatric patients available (n = 1524). The reference group comprises patients with the following psychiatric diagnoses: borderline personality disorder (n = 155); dependency disorders (n = 562), depressive disorders (n = 529); anxiety and obsessive disorders (n = 69), dissociative and somatoform disorders (n = 66).[30]

The Toronto Alexithymia Scale (TAS-20) assesses different dimensions of “alexithymia”. Alexithymia describes an individual's inability to perceive, formulate, and process his or her feelings. It is seen as a risk factor for psychological, psychosomatic and somatic disorders, including heart diseases.[31],[32],[33],[34],[35] The 20 items of the TAS-20 are subdivided into three scales: “difficulties in identifying feelings (DIF),” “difficulties in describing feelings (DDF),” and “externally oriented thinking” (EOT). All items are rated on a 6-point Likert scale. Combining the items creates a score range of 20–100 points. The TAS-20 has a good internal consistency of Cronbach's α = 0.81.[35] The German version is validated.[36] Norm data of the general population are available.[36]

The 12-item Experiences in Close Relationships–Revised Scale (ECR-R) serves to assess representations of attachment behavior in adults with the two scales of “attachment anxiety” and “attachment avoidance.”[37] The validated German version ECR-RD[38] shows good psychometric properties, with Cronbach's α = 0.91/0.92. Norm data of the general population are available.[38]

The Operationalised Psychodynamic Diagnosis Structural Questionnaire (OPD-SQ) is used to record “structural limitations of the personality” in terms of personality dysfunctions.[39],[40] The 100-items measure consists of three subscales. The subscale “relationship model” includes relationship experiences and expectations, the subscale “contact forming” includes self-esteem-regulation, contact, and communication of affects, and the subscale “sense of self” comprises aspects of the self (e.g., identity) as well as the ability to regulate one's emotions. The values of the sum score range from 0 (=“highest structure level”) up to 48 (=“lowest structure level”). It is recommended that the overall score should be used. For comparison, data of psychosomatic patients are available (in-patients: n = 670; out-patients: n = 565).[39]

Additionally, the patients were asked whether they could retrospectively identify “life events” immediately before the onset of the heart attack. Response options were (1) occupational stress, (2) conflicts at work, (3) stress within the family, (4) intense, positive experiences, (5) intense, annoying experiences, (6) intense, joyful experiences, (7) cases of death within the immediate surroundings, and (8) further life events, including space for open-ended answers. Multiple responses were possible.


The statistical evaluation was carried out with the IBM SPSS Statistics for Windows, Version 25.0, released 2017 (Armonk, NY: IBM Corp). Descriptive statistics data were expressed in absolute numbers, percent, mean and standard deviation (SD). To identify differences between groups, T-tests for independent samples, Chi-square-tests and Mann-Whitney-Tests were used. Pearson correlations were computed to assess the relationship between the patient samples as well as between the patient samples and norms.

  Results Top

Sociodemographic and medical characteristics

Because the MI patients were matched on the basis of the samples of TTS patients, who, due to the epidemiological characteristics of TTS, consisted for the most part of elderly women, in both groups, the average age is relatively high (68 years). As expected, the female sex predominates (94%). The time span since the diagnosis of the acute heart event and the study examination was 58 months (TSS) and 50 months (MI). [Table 1] gives the sociodemographic and medical characteristics of both the overall sample and of the subsamples of TTS and MI patients.
Table 1: Sociodemographic and medical data

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Adverse childhood experience, alexithymia, attachment style, and limitations of the structure of the personality

As shown in [Table 2], there are no significant differences between TTS and MI patients regarding “adverse childhood experiences” (CTQ). Compared to a sample of patients suffering psychiatric disorders,[30] which are listed in [Table 2], TTS and MI patients exhibit significantly less ACE in almost all dimensions of the CTQ. However, “physical neglect” proves an exception: here, we found no significant differences between TSS and MI patients on the one hand and the psychiatric reference sample on the other hand. The extent of physical neglect in childhood seems to be the same. [Table 2] shows the means and SDs of the “CTQ;” the TTS and MI-samples are compared both with one another and with the sample of psychiatric patients.[30]
Table 2: Values (means and standard deviations) for “adverse childhood experiences” (Childhood Trauma Questionnaire) of TTS and MI patients (n = 68 in both cases), with comparison of the subsamples, as well as the comparison of the subsamples with a reference sample of psychiatric patients[30]

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Moreover, compared to the scaling of the severity of early trauma by Bernstein and Fink,[36] emotional abuse (TTS: 8.15; range 5–8), physical abuse (TTS: 6.27; range: 5–7), sexual abuse (TTS: 4.75; range: 5), and physical neglect(TTS: 8.92; range: 5–9) are of nil-to-minimal significance. The dimension of emotional neglect is termed moderate-to-severe (TTS: 12.58; range: 10–12). The MI patients' data are indicative of low-to-moderate emotional abuse (MI: 9.11; range: 9–12) and physical neglect (10.1; 10–14); of nil or minimal physical abuse (MI: 6.91; range: 5–7) or sexual abuse (MI 5.02; range 5); and of moderate-to-severe emotional neglect (MI: 12.19; range: 10–-12). [Table 3] lists scores for alexithymia, attachment style, and structural limitations of the personality of TTS and MI patients.
Table 3: Values (means and standard deviations) for “alexithymia” (Toronto Alexithymia Scale-20), “attachment problems” (Experiences in Close Relationship-RD) and “limitations of structure of the personality” (Operationalised Psychodynamic Diagnosis-SQS) of TTS and MI patients (n = 68 in both cases), with comparison of the subsamples, as well as comparison of the subsamples with the norm samples of general population[36],[38] or the reference sample of psychosomatic patients[45]

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As shown in [Table 3], the “alexithymia” sum score of the TTS patients is significantly higher than the norm sum score.[34] TTS and MI patients show significantly higher scores in the scale “externally orientated thinking” (indicating more alexithymic problems). Both groups express lower levels of “difficulty in identifying emotions” than the norm sample (basically, we compare our sample with norm groups of the general population. In the case, that norm data are not available, we use clinical reference groups. In the case of the TAS-20 and ECR-R 12, norm data are available. In the case of the CTQ and the OPD-SQ, there are only clinical reference groups, consisting of psychiatric (CTQ) or psychosomatic patients (OPD-SQ)). Both TTS and MI patients report significantly lower “attachment anxiety” than norms. MI patients report a significantly higher “attachment avoidance” than the norm sample.[40] The “structural limitations of the personality” (reflected in the OPD-SQ sum score) are significantly more extended in both heart patient groups than those of a comparative sample of psychosomatic patients.[41] All in all, no considerably significant differences were found between TTS and MI patients in terms of “alexithymia,” “attachment behavior,” and the “structural limitations of the personality.” However, TTS patients report more “difficulties in describing feelings” than MI patients.

Correlations between adverse childhood experience, alexithymia, attachment style, and structural limitations of the personality

[Table 4] shows the significant correlations alexithymia (TAS-20), attachment behavior (ECR-R 12), as well as the structural limitations of the personality (OPD-SQ) and the CTQ-dimensions of ACE.
Table 4: Correlations (Pearson correlation, P value) between “adverse childhood experiences” (Childhood Trauma Questionnaire), “alexithymia” (Toronto Alexithymia Scale-20), “attachment behaviour” (Experiences in Close Relationship-RD) and “structural limitations of the personality” (Operationalised Psychodynamic Diagnosis-SQS) in the subsamples of takotsubo syndrome and myocardial infarction patients (n=68 in both cases)

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As [Table 4] shows, no significant correlations were found between TAS-20 and CTQ among TTS patients. There were no significant correlations between “attachment anxiety” and the CTQ. Positive correlations were found between “attachment avoidance” and “physical neglect,” “emotional neglect,” and the sum score for “neglect.” Most of the correlations between “limitations in structure of personality” and ACE are significant. In the case of the MI patients, there are no correlations between alexithymia and ACE, apart from significant positive correlations between “difficulty in identifying feelings” and “emotional abuse” as well as the sum score of “abuse”. Positive correlations are found between “attachment anxiety” and “emotional abuse” as well as “sexual abuse,” and between “attachment avoidance” on the one hand and “physical neglect,” “emotional neglect” and the sum score of “neglect” on the other hand. Also, among the MI patients, most of the correlations between “limitations in structure of personality” and ACE are positively significant.

Events immediately preceding takotsubo syndrome or myocardial infarction

As depicted in [Table 5], 69% of TTS patients and 60% of MI patients describe “events preceding cardiac decompensation.” In both groups, “family stress” is the reason most frequently given, followed by “conflicts within the family” within the TTS patients, and by “workplace stress” and “strong annoying experiences”, given as reasons by MI patients. TTS patients report “conflicts within the family” significantly more frequently than MI patients. [Table 5] shows the frequency of events preceding TTS or MI.
Table 5: Frequency of “life events” immediately preceding takotsubo syndrome or myocardial infarction in the subsamples of takotsubo syndrome and myocardial infarction patients, with comparison of takotsubo syndrome and myocardial infarction patients (n=68 in both cases)

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Comparison between the total sample and the female sample

Because 94% of the patients are female, we compared the total sample with the female sample, separated according to TSS and MI patients. We found no significant differences between these groups regarding the CTQ, TAS-20, ECR-R, and OPD-SQ and the occurrence of life immediately preceding TTS or MI.

  Discussion Top

In the present study, we investigated ACE and trauma-related psychological patterns among TTS and MI patients. As the matching process would lead us to expect, TTS and MI patients did not differ in terms of their sociodemographic data. The high average age (68 years) and the predominance of women (94%) is due to the characteristics of TTS, which primarily affects postmenopausal women. The results match the findings of a recent study of 1750 TTS patients. 89.8% of whom were female; average age was 66.4 years old.[8]

With regard to the frequency of ACE, we found no differences between TTS and MI patients. If one relates the ACE-results to the scaling of severity.[36] TTS patients reported moderate-to-severe experiences in the shape of “emotional neglect,” and MI patients reported low-to-moderate experiences in the shape of “emotional neglect” and “physical neglect.” Further, we compared the incidence of ACE in heart patients with previously published data from patients suffering from psychiatric disorders.[30] With respect to “physical neglect,” we found no significant difference between TSS and MI patients on the one hand and psychiatric patients on the other hand. Thus, there might be some evidence that “neglect” plays a crucial role in the childhood of TSS and MI patients. According to these results, previous research suggests that childhood neglect has impacts on the physical and emotional well-being lasting into adulthood.[42]

As might be expected, both TTS and MI patients exhibit significantly higher scores for alexithymia in the dimension “externally oriented thinking,” and also the TTS patients' sum score is significantly higher than that of the norm sample. Further, our results show that MI patients exhibit significantly higher “attachment avoidance” than the norm sample.

On the other hand, both TTS and MI patients reported lower “attachment anxiety” than the individuals of the norm sample. One might assume that “attachment avoidance” of MI patients is associated with “type-D” behavior, which is characterized by hostility and a propensity towards anger.[18]

The most striking result may be that TTS as well as MI patients exhibit more “structural limitations of the personality” than a sample of psychiatric patients. Structural limitations are defined by a dysfunctional regulation of affects and self-esteem, problems of personal identity, and problems in coping with interpersonal relationships.[41] These results might indicate a considerable vulnerability of TTS and MI patients. This could be the consequence of early neglect experiences. We hypothesize that interpersonal events prior to TTS or MI may induce a particularly negative effect on the patient's equilibrium that is protected by the avoidance of interpersonal closeness as well as the avoidance of emotions. Then, the emotional overstimulation may contribute to the cardiac decompensation. With other words: Alexithymia as well as attachment avoidance behavior could be understood as protective strategies against interpersonal stressors. In the case that these stressors are too strong, the protective shield would collapse, followed by a psycho-physiological disorganization in the shape of progressive somatization.

As expected, there are various correlations between ACE and psychological parameters in adulthood. However, we did not find significant correlations between ACE and alexithymia, as previous studies showed among psychiatric patients[43] as well as in the general population.[44] One explanation for this result could be that the patient's alexithymia would be associated stronger with the experience of the TTS or MI, and less with childhood traumata (ACE).

Nevertheless, these results can be understood within the theoretical framework of progressive somatization. In the Paris School founded by Marty et al.,[23],[24],[25],[26] heart patients were characterized by an operative, fact-based thinking without emotionality. The authors even speak of an operative or mechanical lifestyle. According to this model of somatization, events such as interpersonal conflicts trigger a severe psychological crisis. This crisis may lead firstly to unspecific depressive symptoms,[11],[12] and in a second step to the catastrophe of somatization. The physiological pathways of TSS and MI were examined by numerous studies.[4],[5],[6],[7],[16],[17],[22] In the case of TSS, stress causes an activation of the adrenergic system with an increased release of catecholamines. These stress hormones induce a contractile dysfunction in the heart's apical and mid-left ventricle.[17] In the case of MI, negative emotions cause alterations in the vascular reactivity and arterial inflammation, leading to myocardial ischemia.[5],[21],[45] Therefore, we hypothesize that ACE and trauma-associated characteristics of the personality are risk factors that lead together with physiological factors to the myocardial injury and dysfunction. The process of somatization is immediately triggered by acute events or mental stress, respectively. [Figure 1] shows the model of somatization according the Paris School of Psychosomatics:[23],[24],[25],[26]
Figure 1: The psychological pathways of somatization among patients with a takotsubo syndrome or with myocardial infarction, respectively

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Limitations of the study

Because of the matching, which was geared to the TTS patients, the sampling is selective, in that predominantly female MI patients of a higher age were recruited. This bias should also be considered with regard to comparative and norm samples. However, we found no significant differences between the total sample and the subsample of female patients. So, the conclusions may apply to the total as well as the female sample. Additionally, it must be borne in mind that alexithymia and dysfunctional attachment behavior could also be aftereffects of the cardiac diseases, and not or not only preceding risk factors.

  Conclusions Top

Our findings indicate that there are hardly any differences in psychological risk factors and outcomes among TTS and MI patients. Both groups are burdened by ACE, alexithymia, and structural limitations of the personality. The findings point to the importance of psychocardiological care. Moreover, the results highlight the need for interdisciplinary investigation of psychophysiological pathways to obtain a consistent model of somatization in patients with heart diseases. Future research should assess the effect of psychotraumatological interventions that integrate the patient's traumatic experiences carefully and step by step, as the Paris School of Psychosomatics recommended.[25],[26] Additionally, the patients might benefit from accompanying stress management programs.[21],[46]


We would like to extend our gratitude to Sanjeev Balakrishnan for revising the English manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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