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4 On Who Gets Sick and Why: The Role of Personality and Stress It has long been thought that personality and physical health are related.From ancient theories of temperament, through ear

4

On Who Gets Sick and Why:

The Role of Personality and Stress

It has long been thought that personality and physical health are related.From ancient theories of temperament, through early clinical descriptions ofphysical disorders, prescientific thinking drew a close association betweenpersonality attributes and various somatic disorders Several threads ofsystematic theory and research on the topic emerged following the birth ofpsychology and psychosomatic medicine Since the middle of the 20thcentury, interest in personality and health has intensified considerably Itnow represents a major focus of psychosocial research concerned withphysical disease (Friedman, 1990)

Potential points of contact between the personality and physical healthdomains are numerous Each, by itself, is a large and complex area ofinquiry The personality field has undergone considerable expansion anddifferentiation over the past 50 years During the latter portion of that timeperiod, there has been tension between two major pursuits: construction of ataxonomy of personality descriptors and development of an understanding ofpersonality process (Cervone, 1991; Mischel & Shoda, 1994; Pervin, 1990).This debate reflects an important component of variation in assumptions andapproaches within the personality field However, there are also widedifferences in the views of investigators within each camp, and many issues

in personality research that have implications for understanding physicalhealth do not map neatly onto the description/process dichotomy

As this handbook will attest, the study of physical health and disease is avast and diverse enterprise Many physical conditions contribute tomorbidity, mortality, and poor quality of life, and any one condition posesseveral subproblems, including diagnosis, epidemiology, etiology,prevention, treatment, and rehabilitation As a result, the study of physicalhealth and disease is a multidisciplinary endeavor, potentially involvinginvestigators from several health-related fields, including psychologistsinterested in personality (Schwartz & Weiss, 1977)

This chapter is concerned with one portion of the personality- healthinterface, namely, that involving personality attributes that are thought tohave health-damaging consequences because they increase psychologicalstress or exacerbate its effects Like personality, stress has long beensuspected of contributing to physical health problems Moreover, thepersonality and stress constructs complement one another in that eachprovides a means of explaining and elaborating the other's role in shapinghuman adaptation The concept of stress points to social and environmentalfactors outside the person that influence psychological well- being andphysical health, and to psychological and physiological processes thatmediate those effects The study of personality points to dispositions withinthe person that can account for individual differences in responses to astressor, and to attributes and processes that explain temporal and cross-situational consistency in stress-related response patterns Thus, researchthat draws from both the personality and stress domains is more likely toprovide a comprehensive understanding of psychosocial influences onphysical health than does work in which one of these constructs is utilized tothe exclusion of the other

This chapter provides a discussion of conceptual issues, empirical findings,and methodological concerns that bear on the relations among personality,stress, and health It examines personality as a psychosocial risk factor fordisease and as a moderator of psychological stress The review is selective inemphasizing research that supports associations between certain personalitydispositions and both measures of physical disorder and markers of disease-related processes The focus is primarily on the relation between personalityand disease promoting processes that involve direct, psychophysiologicaleffects of stress However, some consideration is also given to behavioralfactors that may mediate the health effects of stress-related personalityattributes independently of, or in interaction with, psychophysiologicmechanisms Issues and problems that emerge from this discussion arehighlighted in a final section that takes stock of available theory andempirical findings and points to some potentially fruitful directions forfurther study

Who Gets Sick? Personality As a Risk Factor

“Who gets sick?” is an epidemiological question that can only be answered

by programmatic, prospective, multivariate research in which putative riskfactors are evaluated with respect to their ability to predict objectivelyverified disease endpoints independently of potential confounds (Adler &Matthews, 1994) Personality represents but one of several psychosocialdomains in which risk factors for physical disease have been sought, withother salient examples including psychological stress, social relationships,and health-related behaviors However, the conceptual and methodologicalprinciples that arise from a consideration of the health effects of personalityare relevant to a wide range of possible psychosocial risk factors, and there

is reason to believe that personality and other psychosocial factors related tohealth often interact with one another rather than operating independently This section begins by describing major conceptual features that distinguishpersonality from other psychological constructs, and by discussing theimplications of these features for framing the question, “Who gets sick?” Anoverview is then provided of the numerous personality attributes that havebeen implicated as possibly influencing vulnerability to physical disease.This section concludes with a discussion of those personality attributes forwhich the epidemiological evidence makes the strongest case for risk factorstatus

Conceptual Elements of Personality

The question of how best to define personality and related terms such aspersonology has received extensive consideration (for classic discussions seeAllport, 1937, and Murray, 1938; for more recent treatments, see Mischel,

1968, and Pervin, 1990) These analyses are not reviewed here Instead, thediscussion draws on previous work to provide a heuristic overview of some

of the major conceptual elements of personality psychology This discussion

is necessarily cursory, however, and the reader is urged to consult thesources already cited for more comprehensive coverage of these issues

psychologists do not share a single view of the nature of individualdifferences per se, or of the importance of any one domain of individualdifferences in particular Moreover, not all individual differences involvepersonality Nonetheless, in a general sense, personality and the study ofindividual differences are intimately related

The relevance of individual difference dimensions to the development andcourse of physical health problems depends on their association withmechanisms involved in the etiology and pathogenesis of disease, or withprocesses that affect the detection, control, and outcome of physicaldisorders A rather wide range of individual difference constructs have beenimplicated as possible risk factors for physical illness The field is narrowed,somewhat, when it is limited to those areas of individual differences thatinvolve personality

Patterning in Behavior

Much personality research may be distinguished from other areas ofpsychology by virtue of its focus on two specific forms of patterning inbehavior, namely, temporal and cross-situational consistency It is theobserved or hypothesized stability of individual differences over time and indifferent contexts that provides a rationale for inferring drives, motives,traits, cognitive styles, and other dispositional constructs employed inpersonality psychology Temporal and cross-situational consistency setpersonality attributes apart from other person factors, such as transientcognitive or emotional states, or highly situation-specific behavioraltendencies Of course, psychological states and individual behaviors can bereflective of enduring personality attributes, and may have significant effects

on physical health regardless of such an association However, the nature ofthose effects and the mechanisms whereby they are mediated may at timesdiffer from those involving personality (Cohen, Doyle, Skoner, Gwaltney, &Newsom, 1995; Scheier & Bridges, 1995)

Personality is not the sole source of temporal and cross- situationalconsistency in behavior Enduring factors that exist outside individuals-such

as occupation, economic conditions, and relations between ethnic also may contribute to regularities in a person's behavior Moreover, asargued from the standpoint of transactional theoretical orientations, theexplanation of temporal and cross-situational consistency in behavior maydefy a simple, analysis of variance like partitioning of person, situation, andperson-by-situation interaction (Lazarus & Folkman, 1984) Instead, personand environment factors may reinforce and sustain one another in ways thatmake efforts to disentangle their independent contributions difficult orarbitrary Notwithstanding these complexities, the involvement ofpersonality attributes in behavioral patterning has major implications forspecifying the role of personality as a risk factor for physical disease

groups-The two forms of behavioral patterning associated with personality factorsprovide a theoretical basis for linkages to health damaging processes.Temporal stability in a suspected personality risk factor may indicate arelationship to disease promoting mechanisms that develop gradually overtime For example, as an enduring disposition, hostility may be associatedwith repeated activation of physiologic activity that contributes to slowlyprogressing disorders such as atherosclerosis (T W Smith, 1992) Cross-situational consistency may operate in a similar manner Considerconscientiousness, a trait that may be related to good health (Friedman et al.,

1995) To the degree that conscientiousness involves a pattern of careful,prudent behavior that is displayed in a wide range of situations, theopportunity for the accumulation of risk reducing actions is increased Thus,the two forms of behavioral patterning that define personality attributes asdistinct from other psychological factors are also important for theirimplications regarding associations with disease promoting processes

Recent studies involving naturalistic observations have provided evidence of

a third form of behavioral patterning that may have interesting implicationsfor the interface between personality and health Mischel and colleagues(Mischel & Shoda, 1995; Shoda, Mischel, & Wright, 1994) demonstratedthat individuals show consistent pgtterns of variability in their behavioracross different situations For example, children in a residential summercamp reliably displayed higher levels of particular behaviors (e.g., verbalaggression) in some situations (e.g., being teased by a peer, beingapproached by a peer) than in others (e.g., being warned by an adult, beingpunished by an adult) These situation behavior profiles consist of stable,meaningful variations in behavior, but are treated as random error in themore traditional focus in personality, where behavior often is aggregatedacross situations that may not always be psychologically equivalent Theremay be similar consistencies in patterns of variation in behaviors thatindividuals display in situations that involve exposure to health risk

Organization

The term organization is frequently used by personality psychologists,although with more than one meaning In one usage, organization refers tothe idea that personality is pervasive, involving the whole person as a

unified, although highly complex, system This notion is similar in certainrespects to self- regulation perspectives employed in health psychology andbehavioral medicine (e.g., Carver & Scheier, 1981; Schwartz, 1979) Asystems view of the person is integral to the multilevel, b&psycho-socialmodel of health and disease (Engel, 1977), and also provides a frameworkwithin which to conceptualize processes whereby cognitive, affective, andother psychological systems may influence disease promoting mechanisms,

a topic discussed later in this chapter

In another usage, personality organization refers to the structure ofinterrelationships of personality descriptors Multivariate methods havegenerated evidence of hierarchical organization in which relatively specifictendencies (e.g., being talkative, enjoying parties) cluster together to formmore general dispositions (e.g., sociability, sensation seeking), which in turncluster together to form still more general dispositions (e.g., extraversion;Eysenck, 1967) There is growing consensus that at a certain level ofabstraction personality organization may be described in terms of ataxonomy of five personality factors that have been labeled extraversion,agreeableness, conscientiousness, neuroticism, and openness to experience(McCrae & Costa, 1985) This five-factor model provides a generalframework for characterizing major dimensions of individual differences inpersonality

Some of the traits that form the five-factor model, such as conscientiousness(Friedman et al., 1995) and neuroticism (Bolger & Zuckerman, 1995), havebeen investigated in relation to stress and health However, many personalityvariables of interest to health psychologists-such as Type A behavior(Matthews, 1982), hostility (Barefoot, Dodge, Peterson, Dahlstrom, & R

Williams, 1989), optimism (Scheier & Carver, 1985), hardiness (Kobasa,1979), and repressive coping (Weinberger, Schwartz, & Davidson, 1979)-involve facets of more than one of the five-factor traits, or are defined interms of attributes whose location within the five-factor taxonomy has yet to

be determined Thus, the five-factor model remains to be more fullyexplored as a framework for organizing health-related personality attributes(T W Smith & P G Williams, 1992)

Personality Structure

Structure refers to neurobiological and/or psychological entities that are realand exist beneath the person's skin Personality structures must bedistinguished from the individual difference patterns from which they aretypically inferred A particular pattern of consistency in behavior across timeand context may reflect an underlying personality structure, but thepersonality structure and the behavior pattern are conceptually distinct, withthe former a putative cause of the latter The concept of psychologicalstructure is illustrated by the notion that hostile behavior reflects a set ofunderlying attitudes characterized by cynicism and distrust (T W Smith,1992) An example of neurobiological structure may be found in Krantz andDurel's (1983) proposal that the overt display of Type A behavior is, in part,

a reflection of activity of the sympathetic nervous system

Consideration of the notion of personality structure suggests that, withrespect to the role of personality, the question “Who gets sick?” is reallyasking “What personality structures lead to disease?” The interviews,questionnaires, and other assessment tools used to measure personalitynecessarily provide only an indirect indication of the presence, content, and

form of the underlying psychological structure that presumably gives rise toboth the observable manifestations of the personality attribute and to the riskfor physical disorders Moreover, the disease promoting structure for whichthe assessment device provides a marker may operate through mechanismsthat do not involve all observable manifestations of the personality attribute.For example, it may be that cynical, distrusting attitudes need not beexpressed in hostile behavior in order to increase coronary risk; it maysuffice for those attitudes to operate through more subtle behavioralexpressions to undermine the person's ability to develop and to maintain asupportive social network (T W Smith, 1992) Similarly, an underlyingtendency toward hyperactivity of the sympathetic nervous system may betoxic to the coronary arteries regardless of whether it promotes the overtdisplay of Type A behavior (Contrada, Krantz, & Hill, 1988) Although thisproblem is but a specific instance of the usual, third variable alternative tocausal hypotheses, it is often overlooked in research concerning personalityand health

Context

Corztext refers to factors outside the skin that may influence behavior.Context is a multilevel concept Revenson (1990) referred to four broadcontextual dimensions: situational (immediate stimulus configuration),interpersonal (social relationships, group affiliations), sociocultural(socioeconomic status, reference group), and temporal (life stage) Ofparticular relevance to health problems are situational factors whoseinteraction with personality gives rise to stress and influences the copingprocess (Lazarus, 1966) These interactions must be viewed within theframework of interpersonal relationships from which stressful situations may

emanate and to which the individual may turn for coping assistance (Thoits,1986) The situational and interpersonal context is, in turn, shaped by largersociocultural systems in which the origins of both stressors and copingresources frequently may be found and whose norms and conventions definethe meaning of stress, coping, personality, illness, and health care(Kleinman, 1986) In the life of an individual, the foregoing elements ofcontext are moderated by the temporal dimension within which developmentand maturation occur and shape personality, stress, coping, andphysiological functioning

As noted earlier, the relationship between context and behavior is not a way affair Much has been written about processes whereby person andenvironment shape one another (Bandura, 1978; D M Buss, 1987; Lazarus

one-& Folkman, 1984; Plomin, Lichenstein, Pedersen, McClearn, one-&Nesselroade, 1990; Starr & McCartney, 1983) Theory concerningbidirectional pathways of influence between person and environment has faroutrun its application in the study of personality and health Much of theepidemiologic literature on psychosocial risk factors for physical disordersinvolves studies in which either person or environmental factors, but notboth, have been examined in relation to disease outcomes Thus, forexample, even the relatively simple and familiar notion that Type Aindividuals show pathogenic physiological responses when confronted by

“appropriately challenging and/or stressful situations” has not been givenrigorous test in prospective epidemiological studies, which would requiremeasurement of Type A behavior, environmental stressors, and coronarydisease (Glass, 1977) It is not surprising, therefore, that there has been littleempirical work addressing more difficult questions concerning the health

consequences of personality that may involve bidirectional influencesbetween person and context

Process

The notions of individual differences, patterning, organization, and structureimply numerous psychological processes Broad questions of generalinterest to the larger field of personality concern personality development,expression, and change Of special relevance to the personality-stressinterface are those processes whereby psychological structures becomeactivated, influence construal of the social and physical environment, andregulate the individual's response to those construals (Mischel & Shoda,1995) We will return to this in a later section of this chapter when the stressconstruct is discussed

Possible Personality Rsk factors

Many personality attributes have been implicated as possible contributors tophysical disease Table 4.1 describes a number of personality characteristicsthat have been investigated in research involving measures of health ormarkers for potentially health-related processes The list is meant to beillustrative rather than exhaustive For some of the entries, there is asuggestive empirical basis for a physical health linkage in the form ofassociations with measures of disease endpoints, but much of the work iscross-sectional As a consequence, although this research may be useful ingenerating hypotheses regarding possible risk factors, it does not permitevaluation of those hypotheses (Matthews, 1988) Moreover, in manystudies, whether cross-sectional or prospective, other methodological

problems may be operating, such as selection biases (Suls, Wan, & Costa,1995), or reliance on “soft” disease measures that are susceptible toconfounding (Watson & Pennebaker, 1989), thereby underminingconclusions regarding personality-disease associations

In many cases, the association between personality and disease isconceptual, rather than empirical, in that it is suggested by research or theoryimplying an association between the personality attribute and physiologicalresponses to psychological stress This sort of hypothetical relationship todisease is strongest where the stress response measure itself has been linked

to disease-promoting processes For example, Type A behaviors are reliablyassociated with physiological responses to stress that are relatedtheoretically to atherogenic processes (fiantz & Manuck, 1984;Schneiderman, 1983), and have been associated empirically with coronaryatherosclerosis in animals (Manuck, Kaplan, & Clarkson, 1983) and withrecurrent myocardial infarction and stroke in humans (Manuck, Olsson,Hjemdalh, & Rehnqvist, 1992) A case for health relevance is obviouslyweaker if based on an association between the suspected personality factorand stress measures for which there is neither theory nor evidence to suggest

a relationship to disease promoting processes

A conceptual basis for a personality-disease linkage can also be inferredfrom research demonstrating an association between personality and certainbehaviors The latter may involve behavioral risk factors for disease, such ascigarette smoking or unsafe sex, or behavioral reactions to disease, such astreatment delay or noncompliance with medical regimens As in the case ofphysiologic responses to stress, measures of health-related behaviors vary inthe strength of their association with disease and, whatever the strength of

that relationship, behaviors cannot be taken as proxies for the presence ofphysical disorders At best, the existence of linkages to health damagingbehaviors, like cross-sectional associations with disease, can only suggesthypotheses regarding the possible risk factor status of personality attributes

Promising Personality Risk Factors

As noted earlier, epidemiological principles require that a set of relativelystringent criteria be satisfied before a variable may be elevated to risk factorstatus (Siegel, 1984) Among these are: (a) prospective research designs,which avoid many of the interpretive problems associated with cross-sectional research; (b) objective disease indicators, which reduce the effects

of reporting biases and other confounding factors; (c) evidence of aconsistent association, that is, replication of the personality-disease relationacross diverse study populations and measures; (d) evidence of a strongassociation, such that the magnitude of the relationship is of practicalsignificance; (e) biological plausibility, or the existence of theory andevidence of pathogenic mechanisms that can explain the personality- diseaseassociation Application of these criteria severely shortens the list ofcontending personality attributes

The following sections discuss three sets of personality dispositions:anger/hostility, emotional suppression/repression, and disengagement.Although they are not considered well- established risk factors, each appearspromising as a potential risk factor for physical disease (Contrada, H.Leventhal, & O'Leary, 1990; Scheier & Bridges, 1995) Anger-relatedcharacteristics have for quite some time been subject to attention as possiblecontributors to somatic disorders (for a review, see Siegman, 1994), as has

the suppression or repression of anger and of other negative emotions (e.g.,Alexander, 1930) The term disengagement was recently suggested byScheier and Bridges (1995) to refer collectively to helplessness/hopelessness, pessimism, fatalism, and depression, each of which has beenlinked to negative health outcomes

Anger/Hostility

Anger, hostility, and aggressiveness are salient features of personalityattributes that show promise as possible risk factors for physical disease.These three terms can be used to refer, respectively, to affective, cognitive,and behavioral constructs, and each may be conceived as either a state ortrait (Spielberger et al., 1985) Factor analyses of relevant trait measureshave generated findings consistent with this tripartite approach Severalstudies have identified anger experience and anger expression factors (alsoreferred to as neurotic and antagonistic hostility), which to some extentcorrespond to affective and behavioral dimensions (Musante, MacDougall,Dembroski, & Costa, 1989; Suarez &R B Williams, 1990) A third factor,found in at least one study, was labeled suspicion-guilt (Musante et al.,1989), and appears to be a cognitive-attitudinal dimension

However, data calling into question the psychometric structure of some ofthe more frequently used scales for measuring anger-related attributes (e.g.,Contrada & Jussim, 1992; Spielberger et al., 1985) pose problems for thethreefactor structure of total scale scores Moreover, an item-level factoranalysis conducted by A H Buss and Perry (1992) generated evidence of

four distinguishable anger-related attributes, and a recent, population-basedstudy yielded evidence of eight separate dimensions (T Q Miller, Jenkins,Kaplan, & Salonen, 1995) Given the need for further clarification of theseissues, the terms anger/hostility or anger-related are used here to refercollectively to the full set of characteristics in this domain, recognizing thatthe number and nature of its distinct elements remain to be determined The idea that anger-related attributes may contribute to physical disease has

a long prescientific history (Siegman, 1994) Scientific interest in thishypothesis accelerated rapidly following the emergence of evidencesuggesting that anger and hostility may reflect the “toxic” elements of theType A, coronary-prone behavior pattern (Matthews, Glass, Rosenman, &Bortner, 1977) Currently available evidence provides fairly consistentsupport for this notion, pointing to a possible prospective associationbetween anger/hostility and coronary heart disease (CHD; e.g., Barefoot,Dahlstrom, &R B Williams, 1983; Barefoot, Dodge, Peterson, Dahlstrom,

& R Williams, 1989; see reviews by Helmers, Posluszny, & Krantz, 1994;Scheier &Bridges, 1995; T W Smith, 1992)

In addition to studies of coronary disease, there is research suggesting thatanger-related personality traits may contribute to traditional coronary riskfactors For example, Siegler (1994) reviewed evidence indicating possibleassociations between trait hostility and cigarette smoking, serum lipid levels,and obesity In addition, Suls et al (1995) reported a meta-analysis thatprovides some support for a relationship between trait anger and essentialhypertension However, inconsistencies across studies, and methodologicalproblems in studies reporting positive findings, argue against drawing firmconclusions at the present time regarding the association between

anger/hostility and coronary risk factors It would seem that, for the mostpart, relationships between hostility and coronary disease are mediated bymechanisms not refleeted in measures of traditional risk factors, such as may

be associated with physiologic responses to stress

Support for an association between anger/hostility and health outcomes otherthan coronary disease is limited (Scheier &Bridges, 1995) However, there isevidence to suggest a significant relationship between hostility and non-CHD mortality (Almada et al., 1991; Shekelle, Gale, Ostfeld, & Paul, 1983)

In addition, other prospective studies suggest an association betweenhostility and cancer mortality (Carmelli et al., 1991), general health (Adams,1994; Cartwright, Wink, & Kmetz, 1995), and suicide, attempted suicide,and nontraffic accidents and deaths (Romanov et al., 1994) Cross-sectionalstudies have reported associations between hostility and such non-CHDhealth outcomes such as asthma severity (Silverglade, Tosi, Wise, &D'Costa, 1994) and disorders of endocrine function (Fava, 1994) Althoughthese findings suggest that anger/hostility may contribute to several sources

of morbidity and mortality, the data on coronary disease appear moreconsistent and robust than those for other outcomes (Scheier & Bridges,1995)

Emotional Suppressiod Repression

To an even greater degree than is the case for anger/hostility, “emotionalsuppression/ repression” is a collection of seemingly conceptually relatedattributes whose number and nature have yet to be determined Among thevarious distinctions that have been made within this domain are several thatconcern the emotion portion of the construct, for example, whether it is

negative emotion in general, or anxiety or anger in particular, that isinvolved Other distinctions concern that portion of the construct that has to

do with the individual's coping response to or orientation toward negativeemotion For example, the term repression has sometimes been used in thetechnical, psychoanalytic sense to refer to an ego-defensive process wherebynegative affect and associated thoughts are automatically removed fromconsciousness By contrast, the term suppression has been used to refer tothe deliberate, conscious, and effortful inhibition of negative affect and/or itsexpression Other relevant constructs include denial (Lazarus, 1983),alexithymia (G 3 Taylor, 1984), conflict over emotional expression (King

& Emmons, 1990), and inhibited power motivation (Jemmott, 1987).Although these attributes are in many cases conceptually distinct, and do notalways show expected interrelationships (e.g., Newton & Contrada, 1994),the designation “emotional suppressionlrepression” is used as a generalrubric in the discussion that follows except where greater specificity isrequired

The notion that emotional suppression/repression may promote physicaldisease is contained in very early writings (see Siegman, 1994, for anoverview) This idea overlaps with interest in anger/hostility in the form ofthe psychosomatic hypothesis linking anger suppression to essentialhypertension (Alexander, 1930) A recent evaluation provided a degree ofsupport for this hypothesis In the Suls et al (1995) meta-analysis citedearlier, the strongest evidence for an association between anger and restingblood pressure came from studies examining anger-related traits that involvenot only a tendency to experience anger, but also a reluctance to expresssuch feelings There is also evidence from the Framingham Heart study

indicating that the tendency to suppress anger may operate as a CHD riskfactor for women, though not for men (Haynes, Feinleib, Kannel, 1980)

In addition to work in the cardiovascular area, emotionalsuppression/repression has been examined in relation to cancer Indeed, lowemotional expressiveness is a key feature of a “Type C” behavior patternthat has been suggested as a possible cancer risk factor (Temoshok, 1987).Support for this notion has been obtained in quasi-prospective studiesindicating less frequent expression of anger in breast biopsy patients laterfound to have malignancies (Greer & Morris, 1975; Jansen & Muenz, 1984).However, negative results also have been obtained in this area (e.g., Greer,Morris, & Pettingale, 1979), and there is some evidence linking increasedexpression of emotion to breast cancer (Greer & Morris, 1975) Otherfindings indicate a possible prospective association between emotiqnalinexpressiveness and cancer incidence (e.g., Grossarth-Maticek, Kanazir,Schmidt, & Vetter, 1982), but methodological considerations argue that thisconclusion should be viewed guardedly, at best (Fox, 1978; Scheier &Bridges, 1995)

Disengagement

As noted earlier, Scheier and Bridges (1995) suggested that the termdisengagement be used to refer collectively to a set of conceptually relatedattributes that include helplessness/hopelessness, pessimism, fatalism, anddepression Not all of these constructs are personality dispositions in thestrict sense Depending on how they are operationalized, they may showonly modest levels of temporal stability, and often are measured in relation

to specific situations However, such context-specific person factors may

reflect personality and, in any case, need to be taken into consideration toprovide a more comprehensive theoretical account of psychosocialinfluences on physical disease

One attribute that falls into this category is the pessimistic explanatory style,

a tendency to attribute negative life events to internal, stable, and globalcauses This construct was developed as a means of accounting forindividual differences in the severity, generality, and duration of humanresponses to uncontrollable stressors (Peterson & Seligman, 1984).Pessimistic explanatory style has been linked to illness as reflected in self-report measures of health (Peterson, 1988), physician health ratings(Peterson, Seligman, & Vaillant, 1988), and shorter survival time in patientswith coronary disease (Buchanan, 1995) and breast cancer (Levy, Morrow,Bagley, & Lippman, 1988)

Fatalism, like pessimism, involves negative expectations about futureoutcomes (Scheier & Bridges, 1995) These constructs bear a resemblance tohelplessness/hopelessness, a passive orientation toward psychological stressthat has been linked to poor cancer prognosis (Greer et al., 1979; Greer &Haybittle, 1990; Pettingale, Morris, & Greer, 1985) Scheier and Bridges(1995) suggested that “fatalism” may be a better label for a “realisticacceptance” construct that was implicated as a factor producing shortersurvival time among individuals with AIDS in a study reported by Reed,Kemeny, Taylor, Wang, and Visscher (1994) There is also evidence of anassociation between pessimism/fatalism and enhanced risk of complicationsfrom coronary artery bypass graft surgery (CABG; Scheier et al., 1989)

The term depression has been used to refer to depressive symptomatology,that is, self-reports of low self-satisfaction, psychological distress, vegetativesymptoms, and somatic complaints, which should be distinguished from aformally diagnosed clinical disorder (Coyne, 1994) There is evidencelinking depression to cardiovascular events such as myocardial infarction(MI), CABG, and stroke (Carney, Freedland, & Lustman, 1994;Wassertheil-Smoller et al., 1994), and depression may operate as anindependent risk factor for death following an MI (Frasure-Smith,Lesperance, & Talajic, 1993; Ladwig, Kieser, & Konig, 1991) Researchexamining depression in relation to the progression of AIDS has yieldedmixed findings, however, and studies attempting to demonstrate arelationship between depression and cancer have yielded predominantlynegative results (Scheier & Bridges, 1995)

Why Do Certain Individuals Get Sick?: Personality and Stress

Research reviewed in the previous section provides promising cluesconcerning the personality attributes of individuals who may be expected tobecome sick Those attributes- tendencies toward anger/hostility, emotionalsuppressionlrepression, and disengagement-provide a tentative and partialanswer to what is essentially an empirical question: “Who gets sick?” Thequestion, “Why do individuals with certain personality attributes get sick?”addresses the issue of causal process This chapter is concerned with healthdamaging processes associated with psychological stress

Health-related processes most closely associated with stress involvepathogenic changes that are produced as a result of direct,psychophysiological responses to environmental events or conditions

Research conducted in the past few decades has shed considerable light onthe psychophysiology of stress Building on Cannon's (1925) seminalresearch on the sympathetic-adrenomedullary system, and that of Selye(1956) on the pituitary-adrenocortical system, there now exist fairly detailedmodels describing the effects of stress on neuroendocrine, cardiovascular,immunological, and other biological systems There has also beensubstantial progress in the identification of pathways whereby thesephysiological effects may influence mechanisms involved in the etiologyand pathogenesis of physical disorders (e.g., Herbert & Cohen, 1993; Krantz

& Manuck, 1984) To the degree that personality influences the frequency,intensity, and/or duration of stress, the psychophysiological correlates ofstress constitute a plausible mediator of the effects of personality on health

It was noted earlier that, in addition to direct, psychophysiologicalinfluences on disease mechanisms, personality may promote disease throughits effects on health behaviors,

and on reactions to illness Health behaviors are those actions and inactionsthat affect the likelihood of injury or disease and include factors such asphysical risk taking, diet, exercise, substance use, and the practice ofunprotected sex Reactions to illness are actions and inactions that occur inresponse to injury and sickness, and include factors such as the detection andinterpretation of physical symptoms, the decision to seek medical treatment,adherence to medical regimens, responses to invasive medical procedures,recovery from acute illness, and adjustment to chronic disease Whetherpsychological stress provides an explanation for observed associationsbetween personality and either health behaviors or reactions to illness isoften an open question in a given piece of research However, health

behaviors such as cigarette smoking and alcohol use have beenconceptualized in terms of coping processes (e.g., Abrams & Niaura, 1987),

as have the processes involved in monitoring the signs and symptoms ofdisease and managing illness (Contrada, E Leventhal, & Anderson, 1994;Miller, Shoda, & Hurley, 1996) In addition, both health behaviors andreactions to illness often must be considered as alternative explanations forpersonality disease linkages that appear to involve the direct physiologicaleffects of psychological stress (Watson & Pennebaker, 1989) Thus, for boththeoretical and methodological reasons, findings that bear on the behavioralpathways to illness are highly germane to the present discussion

This section begins by describing the major constructs involved inpsychological stress theory This sets the stage for an analysis of thepathways whereby personality may promote stress and its health damagingeffects The section concludes with a discussion of some of the evidencelinking anger/hostility, emotional suppression/repression, anddisengagement to measures that may reflect health damaging processesassociated with psychological stress

Conceptual Elements of Psychological Stress and Coping

As in the case of personality, conceptual issues surrounding the stressconstruct have been subject to considerable discussion and debate (Lazarus,1966; Lazarus & Folkman, 1984; Mason, 1975; Selye, 1975) Concernsabout the scientific status of the stress concept have led to suggestions thatthe term stress be abandoned or limited to a nontechnical usage to refer to ageneral topic or area of study Nonetheless, scientific interest in stress hasendured, and the concept obviously serves a useful purpose, albeit often at a

rather general level of analysis The following discussion focuses on majorconceptual categories rather than attempting to present a detailed review ofissues and controversies

Stressors

Stressors are events or conditions that are demanding, challenging, orconstraining in some way Among types of stressors that have receivedintensive study are calamitous events such as natural and technologicaldisasters (e.g., Baum, Cohen, & Hall, 1993); major life changes such asmarriage, divorce, and bereavement (Holmes & Rahe, 1967); minor eventssuch as the daily “hassles” of living (Kanner, Coyne, Schaefer, & Lazarus,1981); and chronic conditions such as occupational stress (Karasek, Baker,Marxer, Ahlbom, & Theorell, 1981), crowding (Baum Bt Valins, 1977), andmarital conflict (Kiecolt-Glaser et al., 1987) The designation of events andconditions as stressors is probabilistic in the sense that their occurrence may

or may not precipitate a stress response Whether or not this occurs isthought to reflect the operation of psychological processes discussed next

Appraisal

The concept of cognitive uppraisat has been discussed at length by Lazarus(1966; Lazarus & Folkman, 1984) It refers to an automatic, cognitive-evaluative process whereby events and conditions are judged with respect totheir relevance to physical and psychological well-being Primary appraisalinvolves an evaluation of harm or loss that has already been sustained or isthreatened Secondary appraisal involves an evaluation of availablestrategies and resources for managing the problem and its effects on the

person Stressful appraisals include harm/loss (damage has already beensustained), threat (damage appears likely), and challenge (threataccompanied by the possibility of growth or gain) They arise whenindividuals perceive that circumstances tax or exceed their adaptiveresources (Lazarus & Folkman, 1984)

Problem Representation

Leventhal and associates (e.g., H Leventhal, Meyer, & Nerenz, 1980) usedthe term problem representution to describe the initiating psychologicalevent in the stress process Closely related to the notion of cognitiveappraisal, problem representation refers to the creation of a mental structurethat characterizes the stressor in terms of specific attributes For example, aphysical symptom constitutes a health threat depending on how it isconstrued by the person Relevant attributes include its label (e.g., cancer),causes (e.g., smoking), consequences (e.g., death), and time line (e.g., slowlyworsening), and form part of a conceptual problem space that defines thehealth threat Other features of the problem space include propositionsrepresenting specific actions that may cure the disorder or minimizepotential damage, such as health care seeking or self-medication This sort offeature analysis presumably accompanies and follows the appraisal process(Lazarus, 1966) Thus, the concept of problem representation may be used torefer broadly to the set of psychological processes whereby the individualencodes a stressor by developing a cognitive-affective structure Thatstructure includes features corresponding to attributes of the stressor and ofpossible coping strategies, and is associated with an appraisal of thesignificance of the stressor for physical and/or psychological well-being

Details of appraisal and problem representation have at least two majorconsequences for subsequent phases of the stress process: They influence thequality and intensity of the ensuing emotional response, and guide theselection of procedures for coping with the stressor (Lazarus, 1991) Forexample, depending on specific features of perceived threat, harm, or loss,the individual may experience anger, fright, or sadness In addition, it is thestressor as perceived by the individual, and the emotional reaction that arisesfrom that perception, that influence the subsequent selection of copingprocedures aimed at managing the situation Because emotional andbehavioral responses to stressors are accompanied by potentially pathogenicphysiological changes, can involve disease promoting behaviors, and mayaffect the interpretation and response to physical symptoms and illness, itfollows that the processes of cognitive appraisal and problem representationthat mediate those responses are critically involved in the putative healthdamaging effects of stress

Response Generation: Coping and Automatic Self-Regulation

Coping refers to effortful cognitive and behavioral activity that is aimed atmanaging either the stressor or its effects on the person (Lazarus &Folkman, 1984) Numerous coping strategies have been identified in stressresearch, and a broad distinction has been drawn between two forms ofcoping that have come to be referred to as problem focused and emotionfocused (Lazarus, 1966; Mechanic, 1962) Problem-focused coping involvesstrategies aimed at altering the situation that gave rise to the stress appraisal,such as planning, information- seeking, and efforts at mastery Emotion-focused coping involves strategies aimed at managing subjective responses

to stressors, such as suppression of negative affect, distraction, and

minimization Alternative coping classifications also have been suggested inwhich additional, major classes of coping activity are distinguished fromproblem- and emotion- focused coping, such as avoidance strategies(Dunkel-Schetter, Feinstein, Taylor, & Falke, 1992) and relationship-focused coping (Coyne & Downey, 1991)

Not all cognitive and behavioral responses to stressors reflect coping.Lazarus and Folkman (1984) used the term coping to refer to activity that isconscious, deliberate, and effortful Exposure to stress may elicit other, moreautomatic responses that, like coping, may play a role in determining howthe stressful encounter is resolved Examples of such automatic responsesinclude motor patterns involved in the expression of emotion though facialmovements (Tomkins, 1962) or vocal tone (Scherer, 1986), processesinvolved in the inhibition of communication between brain centers involved

in emotion and language (Davidson, 1984), and ego-defense mechanismssuch as repression (Haan, 1977) Rather than a categorical distinction, thedifference between coping, and what might be referred to as more automaticself-regulation, may be conceptualized in terms of a continuum involvingdifferences in the degree to which the activity is mediated by verbal-propositional cognition as opposed to schematic cognitive processing, or, at

a more rudimentary level, reflex circuits

The Stress Response

Stress may be manifested in many ways Coping and the more automaticself-regulatory responses already discussed represent one set of stressmanifestations However, the term stress response is usually used to refer toindicators that reflect the negative impact or adaptive cost of stressful

transactions These responses may be characterized as falling within severalbroad domains, namely, subjective experience, cognitive functioning,emotional expression, physiological activity, and instrumental behavior(Baum, Grunberg, & Singer, 1982)

The stress response also may be viewed at a social level of analysis.Psychological stress can cause strain and conflict in interpersonalrelationships, undermine group cohesion, and disrupt the functioning oforganizations and institutions Transactional approaches to stress point to thepotential importance of the interplay between individual and social levelstress processes An individual may employ coping strategies whose effects

on the social and physical environment have implications for future stress.Coping activity may eliminate, moderate, create, maintain, or exacerbatesocial level stressors (T W Smith, 1989), or it may enhance or diminish thesocial resources available to support subsequent coping efforts (Hobfoll,1989)

The Personality-Stress Interface

The diagram in Fig 4.1 depicts a framework that integrates the keyconceptual elements implied by the personality and stress constructs Thischapter is concerned with the four major pathways whereby personalitystructure may influence the stress process The reader is referred elsewherefor discussion of other aspects of the model (Contrada, 1994; Contrada et al.,1990) and of self-regulation principles on which the model is based (e.g.,Carver & Scheier, 1981)

Stressor Exposure

There are several processes whereby personality may influence exposure tostressors Three general mechanisms through which individuals determinethe amount of contact they have with particular types of environmentalsettings were referred to by D M Buss (1987) as selection, evocation, andmanipulation Selection involves choosing whether or not to enter particularenvironments By contrast, evocation and manipulation refer to the person'simpact on the environment once it has been entered In the case of evocation,attributes of the person elicit or provoke responses from the physical orsocial environment unintentionally, whereas manipulation entails intentionalefforts to alter, create, or otherwise modify the environment A fourth way aperson can influence exposure to stressors is to prolong or shorten the length

of stay in demanding situations

Several personality attributes may promote disease, at least in part, byincreasing exposure to stressful situations There is evidence, for example,that Type A individuals hold demanding achievement-related goals forthemselves, which may encourage them to take on difficult tasks (Matthews,1982; Snow, 1978) Type As also prolong exposure to uncontrollablestressors they cannot master rather than relinquishing control to morecompetent others (S M Miller, Lack, & Asroff, 1985) Depressives elicitnegative reactions from others (Coyne, 1976), and a similar process maywork to increase the amount of interpersonal stress experienced by hostileindividuals (T W Smith, 1989) There is also evidence that neuroticismincreases exposure to life stressors (Bolger & Schilling, 1991; Bolger &Zuckerman, 1995) Beyond exerting an influence on the amount of stress aperson experiences, the regulation of environmental exposures may reinforceand sustain the underlying personality structure, and reduce the availability