Psychological Factors

The numerous theories about personality in human history reflect a variety of cultural, religious, philosophic, and scientific perspectives. Two of these, “hardiness” and the five-factor model, are discussed here. We also review key features of the literature on the relationship between emotions and health.

Hardiness is one personality construct that has received considerable research support in explaining who does and who does not become sick under stress (Kobasa, 1979). Hardiness includes three characteristics (Table 3-2): (1) a strong sense of personal control; (2) commitment, a sense of purpose or involvement in events or activities; and (3) challenge, the ability to see change as an opportunity for growth. Kobasa and her colleagues (1982) demonstrated that people with high levels of the “three Cs” of control, commitment, and challenge tended to remain healthier than their less hardy counterparts. Studies show that illness increased with stress and decreased with greater hardiness and exercise. A physician’s knowledge of a patient’s degree of hardiness may help in assessing the patient’s response to stressors.

Table 3-2 The Three “C”s of Hardiness

The most prominent approach to personality at present is the five-factor model (Goldberg, 1993). The five broad personality domains in this model, for which OCEAN can be an acronym, are openness to experience, conscientiousness, extraversion, agreeableness, and neuroticism (Table 3-3). Research on the relationship of these factors to health variables has generated several findings. Conscientiousness has been associated with longevity among healthy individuals and better functional status in those with physical illnesses or impairments, whereas neuroticism is consistently found to be negatively correlated with health (Goodwin and Friedman, 2006; Smith and Mackenzie, 2006). Agreeableness, extraversion, and openness to experience generally tend to have weaker associations with health and therefore are considered less relevant to understanding links between personality and health.

Table 3-3 Five-Factor Model of Personality

Because personality style is regarded as stable across the life span, physician focus on changing personality for health reasons is not a sensible pursuit. However, viewing personality from a broader perspective, with specific regard to how individuals experience and manage emotion, does offer the physician more latitude in intervention.

The experience of chronic negative emotions (depression, anxiety, and anger) tends to be associated with poorer health. There is an extensive research literature linking negative affectivity and pessimism to adverse health outcomes (Peterson et al., 1988; Salovey et al., 2000). Although the experience of negative emotions is a natural part of the human experience, effective management of such emotions through cognitive strategies, active coping, and social support can be learned, and medications can be a helpful adjunct when negative emotional states are prolonged or severe.

Likewise, a large body of research indicates that positive emotional states are associated with better health and longevity. Happiness, optimism, and positive attitudes toward aging have been associated with 7 more years of life (Danner et al., 2001; Levy et al., 2002). Almost three decades of research have shown that an optimistic outlook has a positive effect on coping and on mental and physical health outcomes (Peterson and Steen, 2002). Family physicians have long recognized the importance of mobilizing and maintaining patient hopefulness through encouraging words that foster positive expectations of medical treatment. Additionally, the demonstrated efficacy of placebos affirms the importance of this approach (Sobel, 1991).

Social Factors

A gradient between socioeconomic status (SES) and health is consistently found in epidemiologic studies (Marmot, 2004). Persons with less education and income tend to have poorer health than their better-educated and richer counterparts. Interestingly, subjective SES (i.e., individuals’ perceptions of where they view themselves on the social ladder) has an even stronger relationship to health than objective SES (Singh-Manoux et al., 2005). Negative affect, stress, pessimism, and a decreased sense of control are among the factors thought to contribute to the relationship between lower subjective SES and poorer health (Operario et al., 2004).

In general, social support reduces stress and contributes to more positive health outcomes. Social support refers to the process by which a social network provides psychological and material resources to enhance an individual’s ability to cope with stress (Cohen, 2004). Both quantity and quality of support are important, and sources of support include spouse, lover, friends, family, co-workers, and health care professionals. A person who has many friends but no confidant may have inadequate social support in a time of need. Some people report high levels of satisfaction with just a few close friends, whereas others require larger social networks.

There are several varieties of social support (Cohen, 2004). Emotional support involves the expression of caring, concern, and empathy toward the person and typically involves opportunities for the recipient to express emotions and vent. Instrumental support involves providing some type of direct assistance, which might include financial resources, transportation, or help with daily tasks. Informational support involves giving advice or providing relevant information to an individual.

Social support appears to undergird health by buffering the person against negative effects of stress, perhaps by affecting the cognitive appraisal of stress. When people encounter a strong stressor, such as a major financial crisis, individuals with high levels of social support may appraise the situation as less stressful than will those with low levels of support. Social support may further buffer the stress by modifying people’s response to a stressor as they turn to friends for advice, reassurance, or material aid. Social integration, or participating in a broad range of social relationships, benefits health and well-being by enhancing self-esteem and fostering positive health behaviors in people who believe that others count on them. Social integration is beneficial, whether or not an individual is experiencing stress (Cohen, 2004).

Relationships also can involve significant negative social exchange and be harmful to health. For example, negative interactions in troubled marriages have adverse effects on cardiovascular, endocrine, and immune system function (Robles and Kiecolt-Glaser, 2003).

Misconceptions

Polan (1993) identified and addressed two common misconceptions about the biopsychosocial model. First, contrary to popular belief, the physician who is “humanistic” is not necessarily practicing biopsychosocial medicine. A physician can be ethical and caring but still neglect scientific knowledge from psychology, sociology, anthropology, and relevant data from the patient’s life. For example, compassion by itself is of limited usefulness to a physician who needs an effective treatment plan for an asthmatic patient who smokes. Knowledge of the social environment and of the individual psychology of the patient is crucial.

The second common misconception is that people can be reduced to distinct biologic, psychological, and social categories, or that problems can then be expressed as a set of scientific principles from which diagnosis and treatment can be neatly derived. In fact, use of the biopsychosocial model increases rather than decreases the level of complexity required to understand patient status, introducing multiple avenues for intervention. Interpreting the biopsychosocial model as a new opportunity for reductionist thinking diminishes the power to inform more holistic treatment. Borrell-Carrio and colleagues (2004) proposed a biopsychosocially oriented clinical practice, based on self-awareness, active cultivation of trust, an emotional style characterized by empathic curiosity, self-calibration to reduce bias, cultivation of emotional sensitivity to assist with diagnosis and therapeutic relationships, use of informed intuition, and communication of clinical evidence to foster dialogue.