Tài liệu tâm lý học sức khỏe: Nhân cách và bệnh

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 of
physical disorders, prescientific thinking drew a close association between
personality attributes and various somatic disorders. Several threads of
systematic theory and research on the topic emerged following the birth of
psychology and psychosomatic medicine. Since the middle of the 20th
century, interest in personality and health has intensified considerably. It
now represents a major focus of psychosocial research concerned with
physical disease (Friedman, 1990).
Potential points of contact between the personality and physical health
domains are numerous. Each, by itself, is a large and complex area of
inquiry. The personality field has undergone considerable expansion and
differentiation over the past 50 years. During the latter portion of that time
period, there has been tension between two major pursuits: construction of a
taxonomy of personality descriptors and development of an understanding of
personality process (Cervone, 1991; Mischel & Shoda, 1994; Pervin, 1990).
This debate reflects an important component of variation in assumptions and
approaches within the personality field. However, there are also wide
differences in the views of investigators within each camp, and many issues
in personality research that have implications for understanding physical
health do not map neatly onto the description/process dichotomy.


As this handbook will attest, the study of physical health and disease is a
vast and diverse enterprise. Many physical conditions contribute to
morbidity, mortality, and poor quality of life, and any one condition poses
several

subproblems,

including

diagnosis,

epidemiology,

etiology,

prevention, treatment, and rehabilitation. As a result, the study of physical
health and disease is a multidisciplinary endeavor, potentially involving
investigators from several health-related fields, including psychologists
interested in personality (Schwartz & Weiss, 1977).
This chapter is concerned with one portion of the personality- health
interface, namely, that involving personality attributes that are thought to
have health-damaging consequences because they increase psychological
stress or exacerbate its effects. Like personality, stress has long been
suspected of contributing to physical health problems. Moreover, the
personality and stress constructs complement one another in that each
provides a means of explaining and elaborating the other's role in shaping
human adaptation. The concept of stress points to social and environmental
factors outside the person that influence psychological well- being and
physical health, and to psychological and physiological processes that
mediate those effects. The study of personality points to dispositions within
the person that can account for individual differences in responses to a
stressor, and to attributes and processes that explain temporal and crosssituational consistency in stress-related response patterns. Thus, research
that draws from both the personality and stress domains is more likely to
provide a comprehensive understanding of psychosocial influences on

physical health than does work in which one of these constructs is utilized to
the 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 for
disease and as a moderator of psychological stress. The review is selective in
emphasizing research that supports associations between certain personality
dispositions and both measures of physical disorder and markers of diseaserelated processes. The focus is primarily on the relation between personality
and disease promoting processes that involve direct, psychophysiological
effects of stress. However, some consideration is also given to behavioral
factors that may mediate the health effects of stress-related personality
attributes independently of, or in interaction with, psychophysiologic
mechanisms. Issues and problems that emerge from this discussion are
highlighted in a final section that takes stock of available theory and
empirical findings and points to some potentially fruitful directions for
further 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 risk
factors are evaluated with respect to their ability to predict objectively
verified disease endpoints independently of potential confounds (Adler &
Matthews, 1994). Personality represents but one of several psychosocial
domains in which risk factors for physical disease have been sought, with
other salient examples including psychological stress, social relationships,
and health-related behaviors. However, the conceptual and methodological
principles that arise from a consideration of the health effects of personality
are relevant to a wide range of possible psychosocial risk factors, and there

is reason to believe that personality and other psychosocial factors related to
health often interact with one another rather than operating independently.
This section begins by describing major conceptual features that distinguish
personality from other psychological constructs, and by discussing the
implications of these features for framing the question, “Who gets sick?” An
overview is then provided of the numerous personality attributes that have
been implicated as possibly influencing vulnerability to physical disease.
This section concludes with a discussion of those personality attributes for
which the epidemiological evidence makes the strongest case for risk factor
status.
Conceptual Elements of Personality
The question of how best to define personality and related terms such as
personology has received extensive consideration (for classic discussions see
Allport, 1937, and Murray, 1938; for more recent treatments, see Mischel,
1968, and Pervin, 1990). These analyses are not reviewed here. Instead, the
discussion 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 the
sources already cited for more comprehensive coverage of these issues.
Individual Differences
Individual differences refer to between-person variations in behavior. In this
context, “behavior” may be construed narrowly in terms of a single domain
of psychological activity, or it may be defined broadly to include cognition,
affect, motivation, overt action, and neurobiological activity. Personality


psychologists do not share a single view of the nature of individual
differences per se, or of the importance of any one domain of individual
differences in particular. Moreover, not all individual differences involve

personality. Nonetheless, in a general sense, personality and the study of
individual differences are intimately related.
The relevance of individual difference dimensions to the development and
course of physical health problems depends on their association with
mechanisms involved in the etiology and pathogenesis of disease, or with
processes that affect the detection, control, and outcome of physical
disorders. A rather wide range of individual difference constructs have been
implicated as possible risk factors for physical illness. The field is narrowed,
somewhat, when it is limited to those areas of individual differences that
involve personality.
Patterning in Behavior
Much personality research may be distinguished from other areas of
psychology by virtue of its focus on two specific forms of patterning in
behavior, namely, temporal and cross-situational consistency. It is the
observed or hypothesized stability of individual differences over time and in
different contexts that provides a rationale for inferring drives, motives,
traits, cognitive styles, and other dispositional constructs employed in
personality psychology. Temporal and cross-situational consistency set
personality attributes apart from other person factors, such as transient
cognitive or emotional states, or highly situation-specific behavioral
tendencies. Of course, psychological states and individual behaviors can be
reflective of enduring personality attributes, and may have significant effects


on physical health regardless of such an association. However, the nature of
those effects and the mechanisms whereby they are mediated may at times
differ from those involving personality (Cohen, Doyle, Skoner, Gwaltney, &
Newsom, 1995; Scheier & Bridges, 1995).
Personality is not the sole source of temporal and cross- situational
consistency in behavior. Enduring factors that exist outside individuals-such

as occupation, economic conditions, and relations between ethnic groupsalso may contribute to regularities in a person's behavior. Moreover, as
argued from the standpoint of transactional theoretical orientations, the
explanation of temporal and cross-situational consistency in behavior may
defy a simple, analysis of variance like partitioning of person, situation, and
person-by-situation interaction (Lazarus & Folkman, 1984). Instead, person
and environment factors may reinforce and sustain one another in ways that
make efforts to disentangle their independent contributions difficult or
arbitrary.

Notwithstanding

these

complexities,

the

involvement

of

personality attributes in behavioral patterning has major implications for
specifying the role of personality as a risk factor for physical disease.
The two forms of behavioral patterning associated with personality factors
provide a theoretical basis for linkages to health damaging processes.
Temporal stability in a suspected personality risk factor may indicate a
relationship to disease promoting mechanisms that develop gradually over
time. For example, as an enduring disposition, hostility may be associated
with repeated activation of physiologic activity that contributes to slowly
progressing disorders such as atherosclerosis (T. W. Smith, 1992). Crosssituational consistency may operate in a similar manner. Consider

conscientiousness, 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, the
opportunity for the accumulation of risk reducing actions is increased. Thus,
the two forms of behavioral patterning that define personality attributes as
distinct from other psychological factors are also important for their
implications 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 implications
for the interface between personality and health. Mischel and colleagues
(Mischel & Shoda, 1995; Shoda, Mischel, & Wright, 1994) demonstrated
that individuals show consistent pgtterns of variability in their behavior
across different situations. For example, children in a residential summer
camp reliably displayed higher levels of particular behaviors (e.g., verbal
aggression) in some situations (e.g., being teased by a peer, being
approached by a peer) than in others (e.g., being warned by an adult, being
punished by an adult). These situation behavior profiles consist of stable,
meaningful variations in behavior, but are treated as random error in the
more traditional focus in personality, where behavior often is aggregated
across situations that may not always be psychologically equivalent. There
may be similar consistencies in patterns of variation in behaviors that
individuals 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 to
the idea that personality is pervasive, involving the whole person as a

unified, although highly complex, system. This notion is similar in certain
respects to self- regulation perspectives employed in health psychology and
behavioral medicine (e.g., Carver & Scheier, 1981; Schwartz, 1979). A
systems view of the person is integral to the multilevel, b&psycho-social
model of health and disease (Engel, 1977), and also provides a framework
within which to conceptualize processes whereby cognitive, affective, and
other psychological systems may influence disease promoting mechanisms,
a topic discussed later in this chapter.
In another usage, personality organization refers to the structure of
interrelationships of personality descriptors. Multivariate methods have
generated evidence of hierarchical organization in which relatively specific
tendencies (e.g., being talkative, enjoying parties) cluster together to form
more general dispositions (e.g., sociability, sensation seeking), which in turn
cluster together to form still more general dispositions (e.g., extraversion;
Eysenck, 1967). There is growing consensus that at a certain level of
abstraction personality organization may be described in terms of a
taxonomy 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 general
framework for characterizing major dimensions of individual differences in
personality.
Some of the traits that form the five-factor model, such as conscientiousness
(Friedman et al., 1995) and neuroticism (Bolger & Zuckerman, 1995), have
been investigated in relation to stress and health. However, many personality
variables 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 in

terms of attributes whose location within the five-factor taxonomy has yet to
be determined. Thus, the five-factor model remains to be more fully
explored 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 real
and exist beneath the person's skin. Personality structures must be
distinguished from the individual difference patterns from which they are
typically inferred. A particular pattern of consistency in behavior across time
and context may reflect an underlying personality structure, but the
personality structure and the behavior pattern are conceptually distinct, with
the former a putative cause of the latter. The concept of psychological
structure is illustrated by the notion that hostile behavior reflects a set of
underlying attitudes characterized by cynicism and distrust (T. W. Smith,
1992). An example of neurobiological structure may be found in Krantz and
Durel'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, with
respect to the role of personality, the question “Who gets sick?” is really
asking “What personality structures lead to disease?” The interviews,
questionnaires, and other assessment tools used to measure personality
necessarily provide only an indirect indication of the presence, content, and


form of the underlying psychological structure that presumably gives rise to
both the observable manifestations of the personality attribute and to the risk
for physical disorders. Moreover, the disease promoting structure for which
the assessment device provides a marker may operate through mechanisms
that do not involve all observable manifestations of the personality attribute.
For example, it may be that cynical, distrusting attitudes need not be

expressed in hostile behavior in order to increase coronary risk; it may
suffice for those attitudes to operate through more subtle behavioral
expressions to undermine the person's ability to develop and to maintain a
supportive social network (T. W. Smith, 1992). Similarly, an underlying
tendency toward hyperactivity of the sympathetic nervous system may be
toxic to the coronary arteries regardless of whether it promotes the overt
display of Type A behavior (Contrada, Krantz, & Hill, 1988). Although this
problem is but a specific instance of the usual, third variable alternative to
causal hypotheses, it is often overlooked in research concerning personality
and health.
Context
Corztext refers to factors outside the skin that may influence behavior.
Context is a multilevel concept. Revenson (1990) referred to four broad
contextual dimensions: situational (immediate stimulus configuration),
interpersonal

(social

relationships,

group

affiliations),

sociocultural

(socioeconomic status, reference group), and temporal (life stage). Of
particular relevance to health problems are situational factors whose
interaction with personality gives rise to stress and influences the coping
process (Lazarus, 1966). These interactions must be viewed within the

framework 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 larger
sociocultural systems in which the origins of both stressors and coping
resources frequently may be found and whose norms and conventions define
the meaning of stress, coping, personality, illness, and health care
(Kleinman, 1986). In the life of an individual, the foregoing elements of
context are moderated by the temporal dimension within which development
and maturation occur and shape personality, stress, coping, and
physiological functioning.
As noted earlier, the relationship between context and behavior is not a oneway affair. Much has been written about processes whereby person and
environment shape one another (Bandura, 1978; D. M. Buss, 1987; Lazarus
&

Folkman,

1984;

Plomin,

Lichenstein,

Pedersen,

McClearn,

&

Nesselroade, 1990; Starr & McCartney, 1983). Theory concerning
bidirectional pathways of influence between person and environment has far
outrun its application in the study of personality and health. Much of the
epidemiologic literature on psychosocial risk factors for physical disorders
involves studies in which either person or environmental factors, but not
both, have been examined in relation to disease outcomes. Thus, for
example, even the relatively simple and familiar notion that Type A
individuals show pathogenic physiological responses when confronted by
“appropriately challenging and/or stressful situations” has not been given
rigorous test in prospective epidemiological studies, which would require
measurement of Type A behavior, environmental stressors, and coronary
disease (Glass, 1977). It is not surprising, therefore, that there has been little
empirical work addressing more difficult questions concerning the health


consequences of personality that may involve bidirectional influences
between person and context.
Process
The notions of individual differences, patterning, organization, and structure
imply numerous psychological processes. Broad questions of general interest
to the larger field of personality concern personality development,
expression, and change. Of special relevance to the personality-stress
interface are those processes whereby psychological structures become
activated, influence construal of the social and physical environment, and
regulate the individual's response to those construals (Mischel & Shoda,
1995). We will return to this in a later section of this chapter when the stress
construct is discussed.
Possible Personality Rsk factors
Many personality attributes have been implicated as possible contributors to
physical disease. Table 4.1 describes a number of personality characteristics

that have been investigated in research involving measures of health or
markers for potentially health-related processes. The list is meant to be
illustrative rather than exhaustive. For some of the entries, there is a
suggestive empirical basis for a physical health linkage in the form of
associations with measures of disease endpoints, but much of the work is
cross-sectional. As a consequence, although this research may be useful in
generating hypotheses regarding possible risk factors, it does not permit
evaluation of those hypotheses (Matthews, 1988). Moreover, in many
studies, 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 to
confounding

(Watson

&

Pennebaker,

1989),

thereby

undermining

conclusions regarding personality-disease associations.
In many cases, the association between personality and disease is
conceptual, rather than empirical, in that it is suggested by research or theory

implying an association between the personality attribute and physiological
responses to psychological stress. This sort of hypothetical relationship to
disease is strongest where the stress response measure itself has been linked
to disease-promoting processes. For example, Type A behaviors are reliably
associated with physiological responses to stress that are related theoretically
to atherogenic processes (fiantz & Manuck, 1984; Schneiderman, 1983), and
have been associated empirically with coronary atherosclerosis in animals
(Manuck, Kaplan, & Clarkson, 1983) and with recurrent myocardial
infarction and stroke in humans (Manuck, Olsson, Hjemdalh, & Rehnqvist,
1992). A case for health relevance is obviously weaker if based on an
association between the suspected personality factor and 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 inferred
from research demonstrating an association between personality and certain
behaviors. The latter may involve behavioral risk factors for disease, such as
cigarette smoking or unsafe sex, or behavioral reactions to disease, such as
treatment delay or noncompliance with medical regimens. As in the case of
physiologic responses to stress, measures of health-related behaviors vary in
the strength of their association with disease and, whatever the strength of


that relationship, behaviors cannot be taken as proxies for the presence of
physical disorders. At best, the existence of linkages to health damaging
behaviors, like cross-sectional associations with disease, can only suggest
hypotheses regarding the possible risk factor status of personality attributes.
Promising Personality Risk Factors
As noted earlier, epidemiological principles require that a set of relatively
stringent criteria be satisfied before a variable may be elevated to risk factor
status (Siegel, 1984). Among these are: (a) prospective research designs,

which avoid many of the interpretive problems associated with crosssectional research; (b) objective disease indicators, which reduce the effects
of reporting biases and other confounding factors; (c) evidence of a
consistent association, that is, replication of the personality-disease relation
across diverse study populations and measures; (d) evidence of a strong
association, such that the magnitude of the relationship is of practical
significance; (e) biological plausibility, or the existence of theory and
evidence of pathogenic mechanisms that can explain the personality- disease
association. Application of these criteria severely shortens the list of
contending 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 appears
promising as a potential risk factor for physical disease (Contrada, H.
Leventhal, & O'Leary, 1990; Scheier & Bridges, 1995). Anger-related
characteristics have for quite some time been subject to attention as possible
contributors 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 by
Scheier and Bridges (1995) to refer collectively to helplessness/
hopelessness, pessimism, fatalism, and depression, each of which has been
linked to negative health outcomes.

Anger/Hostility
Anger, hostility, and aggressiveness are salient features of personality
attributes 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 or
trait (Spielberger et al., 1985). Factor analyses of relevant trait measures

have generated findings consistent with this tripartite approach. Several
studies have identified anger experience and anger expression factors (also
referred to as neurotic and antagonistic hostility), which to some extent
correspond 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 of
the more frequently used scales for measuring anger-related attributes (e.g.,
Contrada & Jussim, 1992; Spielberger et al., 1985) pose problems for the
threefactor structure of total scale scores. Moreover, an item-level factor
analysis conducted by A. H. Buss and Perry (1992) generated evidence of


four distinguishable anger-related attributes, and a recent, population-based
study yielded evidence of eight separate dimensions (T. Q. Miller, Jenkins,
Kaplan, & Salonen, 1995). Given the need for further clarification of these
issues, the terms anger/hostility or anger-related are used here to refer
collectively to the full set of characteristics in this domain, recognizing that
the 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 this
hypothesis accelerated rapidly following the emergence of evidence
suggesting that anger and hostility may reflect the “toxic” elements of the
Type A, coronary-prone behavior pattern (Matthews, Glass, Rosenman, &
Bortner, 1977). Currently available evidence provides fairly consistent
support for this notion, pointing to a possible prospective association
between 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 that
anger-related personality traits may contribute to traditional coronary risk
factors. For example, Siegler (1994) reviewed evidence indicating possible
associations between trait hostility and cigarette smoking, serum lipid levels,
and obesity. In addition, Suls et al. (1995) reported a meta-analysis that
provides some support for a relationship between trait anger and essential
hypertension. However, inconsistencies across studies, and methodological
problems in studies reporting positive findings, argue against drawing firm
conclusions at the present time regarding the association between


anger/hostility and coronary risk factors. It would seem that, for the most
part, relationships between hostility and coronary disease are mediated by
mechanisms 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 other
than coronary disease is limited (Scheier &Bridges, 1995). However, there is
evidence to suggest a significant relationship between hostility and nonCHD mortality (Almada et al., 1991; Shekelle, Gale, Ostfeld, & Paul, 1983).
In addition, other prospective studies suggest an association between
hostility 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-sectional
studies have reported associations between hostility and such non-CHD
health outcomes such as asthma severity (Silverglade, Tosi, Wise, &
D'Costa, 1994) and disorders of endocrine function (Fava, 1994). Although
these findings suggest that anger/hostility may contribute to several sources
of morbidity and mortality, the data on coronary disease appear more
consistent 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, “emotional
suppression/ repression” is a collection of seemingly conceptually related
attributes whose number and nature have yet to be determined. Among the
various distinctions that have been made within this domain are several that
concern the emotion portion of the construct, for example, whether it is


negative emotion in general, or anxiety or anger in particular, that is
involved. Other distinctions concern that portion of the construct that has to
do with the individual's coping response to or orientation toward negative
emotion. For example, the term repression has sometimes been used in the
technical, psychoanalytic sense to refer to an ego-defensive process whereby
negative affect and associated thoughts are automatically removed from
consciousness. By contrast, the term suppression has been used to refer to
the deliberate, conscious, and effortful inhibition of negative affect and/or its
expression. 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 not
always show expected interrelationships (e.g., Newton & Contrada, 1994),
the designation “emotional suppressionlrepression” is used as a general
rubric in the discussion that follows except where greater specificity is
required.
The notion that emotional suppression/repression may promote physical
disease is contained in very early writings (see Siegman, 1994, for an
overview). This idea overlaps with interest in anger/hostility in the form of
the psychosomatic hypothesis linking anger suppression to essential
hypertension (Alexander, 1930). A recent evaluation provided a degree of
support for this hypothesis. In the Suls et al. (1995) meta-analysis cited

earlier, the strongest evidence for an association between anger and resting
blood pressure came from studies examining anger-related traits that involve
not only a tendency to experience anger, but also a reluctance to express
such feelings. There is also evidence from the Framingham Heart study


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

addition

to

work

in

the

cardiovascular

area,

emotional

suppression/repression has been examined in relation to cancer. Indeed, low
emotional expressiveness is a key feature of a “Type C” behavior pattern
that has been suggested as a possible cancer risk factor (Temoshok, 1987).
Support for this notion has been obtained in quasi-prospective studies

indicating less frequent expression of anger in breast biopsy patients later
found 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 increased
expression of emotion to breast cancer (Greer & Morris, 1975). Other
findings indicate a possible prospective association between emotiqnal
inexpressiveness and cancer incidence (e.g., Grossarth-Maticek, Kanazir,
Schmidt, & Vetter, 1982), but methodological considerations argue that this
conclusion should be viewed guardedly, at best (Fox, 1978; Scheier &
Bridges, 1995).
Disengagement
As noted earlier, Scheier and Bridges (1995) suggested that the term
disengagement be used to refer collectively to a set of conceptually related
attributes that include helplessness/hopelessness, pessimism, fatalism, and
depression. Not all of these constructs are personality dispositions in the
strict sense. Depending on how they are operationalized, they may show
only 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 to
provide a more comprehensive theoretical account of psychosocial
influences 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 global
causes. This construct was developed as a means of accounting for
individual differences in the severity, generality, and duration of human
responses to uncontrollable stressors (Peterson & Seligman, 1984).
Pessimistic explanatory style has been linked to illness as reflected in selfreport measures of health (Peterson, 1988), physician health ratings
(Peterson, Seligman, & Vaillant, 1988), and shorter survival time in patients

with coronary disease (Buchanan, 1995) and breast cancer (Levy, Morrow,
Bagley, & Lippman, 1988).
Fatalism, like pessimism, involves negative expectations about future
outcomes (Scheier & Bridges, 1995). These constructs bear a resemblance to
helplessness/hopelessness, a passive orientation toward psychological stress
that 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 “realistic
acceptance” construct that was implicated as a factor producing shorter
survival time among individuals with AIDS in a study reported by Reed,
Kemeny, Taylor, Wang, and Visscher (1994). There is also evidence of an
association between pessimism/fatalism and enhanced risk of complications
from 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, vegetative
symptoms, and somatic complaints, which should be distinguished from a
formally diagnosed clinical disorder (Coyne, 1994). There is evidence
linking depression to cardiovascular events such as myocardial infarction
(MI), CABG, and stroke (Carney, Freedland, & Lustman, 1994; WassertheilSmoller et al., 1994), and depression may operate as an independent risk
factor for death following an MI (Frasure-Smith, Lesperance, & Talajic,
1993; Ladwig, Kieser, & Konig, 1991). Research examining depression in
relation to the progression of AIDS has yielded mixed findings, however,
and studies attempting to demonstrate a relationship between depression and
cancer have yielded predominantly negative results (Scheier & Bridges,
1995).
Why Do Certain Individuals Get Sick?: Personality and Stress
Research reviewed in the previous section provides promising clues
concerning the personality attributes of individuals who may be expected to

become sick. Those attributes- tendencies toward anger/hostility, emotional
suppressionlrepression, and disengagement-provide a tentative and partial
answer to what is essentially an empirical question: “Who gets sick?” The
question, “Why do individuals with certain personality attributes get sick?”
addresses the issue of causal process. This chapter is concerned with health
damaging processes associated with psychological stress.
Health-related processes most closely associated with stress involve
pathogenic

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 on
the psychophysiology of stress. Building on Cannon's (1925) seminal
research on the sympathetic-adrenomedullary system, and that of Selye
(1956) on the pituitary-adrenocortical system, there now exist fairly detailed
models describing the effects of stress on neuroendocrine, cardiovascular,
immunological, and other biological systems. There has also been
substantial progress in the identification of pathways whereby these
physiological effects may influence mechanisms involved in the etiology
and 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 of
stress constitute a plausible mediator of the effects of personality on health.
It was noted earlier that, in addition to direct, psychophysiological
influences on disease mechanisms, personality may promote disease through
its effects on health behaviors,
and on reactions to illness. Health behaviors are those actions and inactions
that affect the likelihood of injury or disease and include factors such as
physical risk taking, diet, exercise, substance use, and the practice of
unprotected sex. Reactions to illness are actions and inactions that occur in
response to injury and sickness, and include factors such as the detection and
interpretation 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. Whether
psychological stress provides an explanation for observed associations
between personality and either health behaviors or reactions to illness is
often an open question in a given piece of research. However, health


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

as have the processes involved in monitoring the signs and symptoms of
disease and managing illness (Contrada, E. Leventhal, & Anderson, 1994;
Miller, Shoda, & Hurley, 1996). In addition, both health behaviors and
reactions to illness often must be considered as alternative explanations for
personality disease linkages that appear to involve the direct physiological
effects of psychological stress (Watson & Pennebaker, 1989). Thus, for both
theoretical and methodological reasons, findings that bear on the behavioral
pathways to illness are highly germane to the present discussion.
This section begins by describing the major constructs involved in
psychological stress theory. This sets the stage for an analysis of the
pathways whereby personality may promote stress and its health damaging
effects. The section concludes with a discussion of some of the evidence
linking anger/hostility, emotional suppression/repression, and disengagement
to measures that may reflect health damaging processes associated with
psychological stress.
Conceptual Elements of Psychological Stress and Coping
As in the case of personality, conceptual issues surrounding the stress
construct have been subject to considerable discussion and debate (Lazarus,
1966; Lazarus & Folkman, 1984; Mason, 1975; Selye, 1975). Concerns
about the scientific status of the stress concept have led to suggestions that
the term stress be abandoned or limited to a nontechnical usage to refer to a
general topic or area of study. Nonetheless, scientific interest in stress has
endured, and the concept obviously serves a useful purpose, albeit often at a


rather general level of analysis. The following discussion focuses on major
conceptual categories rather than attempting to present a detailed review of
issues and controversies.
Stressors
Stressors are events or conditions that are demanding, challenging, or

constraining in some way. Among types of stressors that have received
intensive study are calamitous events such as natural and technological
disasters (e.g., Baum, Cohen, & Hall, 1993); major life changes such as
marriage, divorce, and bereavement (Holmes & Rahe, 1967); minor events
such 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), and
marital conflict (Kiecolt-Glaser et al., 1987). The designation of events and
conditions as stressors is probabilistic in the sense that their occurrence may
or may not precipitate a stress response. Whether or not this occurs is
thought 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, cognitiveevaluative process whereby events and conditions are judged with respect to
their relevance to physical and psychological well-being. Primary appraisal
involves an evaluation of harm or loss that has already been sustained or is
threatened. Secondary appraisal involves an evaluation of available
strategies and resources for managing the problem and its effects on the


person. Stressful appraisals include harm/loss (damage has already been
sustained),

threat

(damage

appears

likely),

and challenge

(threat

accompanied by the possibility of growth or gain). They arise when
individuals perceive that circumstances tax or exceed their adaptive
resources (Lazarus & Folkman, 1984).
Problem Representation
Leventhal and associates (e.g., H. Leventhal, Meyer, & Nerenz, 1980) used
the term problem representution to describe the initiating psychological
event in the stress process. Closely related to the notion of cognitive
appraisal, problem representation refers to the creation of a mental structure
that characterizes the stressor in terms of specific attributes. For example, a
physical symptom constitutes a health threat depending on how it is
construed by the person. Relevant attributes include its label (e.g., cancer),
causes (e.g., smoking), consequences (e.g., death), and time line (e.g., slowly
worsening), and form part of a conceptual problem space that defines the
health threat. Other features of the problem space include propositions
representing specific actions that may cure the disorder or minimize
potential damage, such as health care seeking or self-medication. This sort of
feature analysis presumably accompanies and follows the appraisal process
(Lazarus, 1966). Thus, the concept of problem representation may be used to
refer broadly to the set of psychological processes whereby the individual
encodes a stressor by developing a cognitive-affective structure. That
structure includes features corresponding to attributes of the stressor and of
possible coping strategies, and is associated with an appraisal of the
significance of the stressor for physical and/or psychological well-being.