Personality and Cardiovascular Illness
The following entry describes the role of personality in the context of its relation to cardiovascular illness, or cardiovascular disease.
The World Health Organization and the Global Burden of Disease Study identify cardiovascular diseases, including ischemic heart disease and stroke, as being among the top leading causes of death worldwide (Lozano et al. 2012). Given the high prevalence for cardiovascular illness and great need to understand its causes, for decades, researchers have been exploring the possible influence of personality dynamics on cardiovascular health. Many assert that the undercurrents of certain specific personality types, traits, and disorders are important predictors of cardiovascular health, while other research scientists have proposed that a reciprocal relationship exists between cardiovascular health and personality. Early research remained largely stalwart in terms of what personality features impact this relationship, while contemporary research has expanded on this knowledge extensively. However, over time, there has been a considerable amount of disagreement about the strength of these effects or whether one exists at all, as many feel that our current understanding is still in its infancy.
Type A Personality
During the latter half of the twentieth century, most research about personality and its relation to cardiovascular illness focused on personality types. It has long been suggested that neurotic individuals who had ambitious and compulsive work habits were more liable to develop cardiovascular complications, with the famous coronary-prone “Type A” personality largely dominating early research in this area (Rosenman and Chesney 1980). Type A personality, of course, is one that is marked by sustained aggression, hostility, ambition, competitiveness, and a chronic sense of time urgency, as well as impatience, an intense commitment to occupational goals, and behavioral alertness, and is characteristic of patients with cardiovascular disease (Eysenck 1985; Booth-Kewley and Friedman 1987).
Early Type A literature suggested a link between hostile and aggressive personalities to heart attack and stroke (Williams et al. 1980) and that these traits are reliable predictors of coronary disease (Booth-Kewley and Friedman 1987), with some research suggesting that hostility acts as the hallmark feature of the connection between Type A behavior and cardiovascular disease (MacDougall et al. 1985). Additionally, many scientists have concluded that evidence exists to suggest that those who experience heightened levels of hostility also, in turn, experience intense arousal of negative emotions (Esler et al. 1977), have increased prevalence of atherosclerosis (Bareford et al. 1983), and have increased susceptibility to total mortality (Williams et al. 1984). Even unexpressed and repressed hostility has been identified as markers for cardiovascular disease, regardless of age, in a study that utilized an all-male sample (Ibrahim et al. 1966).
Additional work in this area has even suggested a genetic component to specific personality features (Digman 1990; Rushton et al. 1986), though this concept is not without controversy. In a twin study examining Type A personality, similar scores on a questionnaire assessing trait dimensions were achieved by sibling pairs suggesting that Type A behavior may be in part a heritable construct (Eysenck and Fulker 1983). In contrast, Bass and Wade (1982) suggested that there is no significant association between Type A scores and the extent of coronary disease, genetically or otherwise, and Type A behavior is probably more indicative of hypochondriasis than of cardiovascular illnesses, such as coronary heart disease. These findings furthered those by Ahnve et al. (1979), who found that more men admitted to a coronary care unit because of chest pain who were shown to have no evidence of ischemic heart disease had significantly higher Type A scores than did those who had genuine infarction. As such, they were able to suggest a parallel between psychosomatic presentations with no underlying physical cause and Type A personality.
For those who do defend the relationship, Type A behavior appears to relate reliably to cardiovascular illness, specifically with coronary heart disease, angina, myocardial infarction, and atherosclerosis (Booth-Kewley and Friedman 1987). Additionally, the assertion has been made that Type A behavior is not only linked with current risk factors but future risks as well, and thus it is important to identify the different dimensions that can contribute beyond the Type A classification (Eysenck 1985). Stress, for example, is an environmental factor that has been associated with cardiovascular disease (Bammer and Newberry 1981). As such, various stress factors have been investigated in terms of immune system functioning (Borysenko and Borysenko 1982) and their impact on different personality categories, such as introversion and extraversion. Duckitt and Broil (1982) found that extraverts appear to be significantly more tolerant of recent life changes than introverts, which could certainly speak to a potential course of cardiovascular health.
With regard to specific personality traits, many research scientists have suggested that certain elements of Type A personality, rather than the whole syndrome, are what may predict coronary illness. In line with this thinking, the person at risk for cardiovascular disease is hypothesized to be high on personality factors of neuroticism and psychoticism, but negatively correlated with extraversion, as it appears to serve a protective factor (Eysenck 1985). Speaking generally, higher neuroticism and lower conscientiousness have been found to predict overall morbidity (Chapman et al. 2013), with high neuroticism being strongly linked to physical illness (Barquero et al. 1981). More specifically, however, neuroticism and extraversion were found to be correlated with Type A personality across samples (Eysenck and Fulker 1983). It has also been stated that as far as hostility and aggression are concerned, when taken together with traits such as neuroticism, the at-risk coronary-prone patient might also exhibit a high degree of psychoticism (Eysenck 1985).
Some have suggested that eliminating Type A personality could presumably lessen the likelihood of developing cardiovascular disease (Friedman and Booth-Kewley 1987). Fortunately, when personality is essentially defined by habitual patterns of behavior, it can be modified. A study by Friedman et al. (1984) showed that modification of Type A behavior can significantly lessen recurrence of cardiac infarcts, though the effect was not considered large and was difficult to allocate to a specific type of behavior change. Much more impressive are three large-scale studies carried out by Grossarth-Maticek et al. (1983) that discovered that reversing the type of behavior that was found to contribute to cardiovascular disease would reduce risk and produce longevity. In another study by Friedman et al. (1984), 800 patients were randomly assigned to either receive or not receive psychological counseling. Those who had received counseling saw a significantly reduced rate of recurrence of nonfatal myocardial infarctions.
A criticism of Type A pattern that seems to apply concerns its generalizability, or its ability to pertain to the majority of people. Predictively speaking, there seems to be a divergence in its applicability beyond middle-class white American men as the results do not appear to be as predictive for African Americans, the working class, or females (Eysenck 1985). However, some evidence suggests Type A-disease relation is as strong or stronger for women as it is for men (Booth-Kewley and Friedman 1987). Beyond this, some researchers also argue for the predictive quality of personality, suggesting that chronic illnesses such as coronary heart disease may be present long before being diagnosed and may thus be influenced over a long time period by personality and its associated behaviors. Additionally, lifestyle and other factors and not personality directly and alone may contribute meaningfully, though some argue that unhealthy behaviors such as overeating and smoking could be products of personality-driven behavior (Friedman and Booth-Kewley 1987). In concordance with this line of thinking, some scientists have suggested that it is important to note that personality is not the only cause of disease. Most disease processes are complex and multidimensional containing potentials for genetic predisposition to disease, invading stressors such as viruses or traumas, age, hormonal differences, and other factors (Weiner 1977). Other contaminants may include other psychological attributes such as anxiety, depression, perceived social support, and perceived locus of control (Booth-Kewley and Friedman 1987). However, it appears that the construct of Type A is worth retaining and investigating further, though it should be regarded as only one part of the coronary-prone personality.
A difference in opinion has led the scientific community to broaden their search for answers, and although Type A personality has not necessarily fallen out of favor, more recently, other personality features have been identified as risk factors for cardiovascular illness, including a Type D or “dismissing” personality style (Sher 2005). Type D behavior is characterized by tendencies to experience negative emotions and to inhibit them while avoiding socializing meaningfully with others. These dimensions of negative affectivity and social inhibition are associated with greater reactivity to stress, increased cardiovascular morbidity, and increased risk of mortality (Sher 2005). Whereas expressed hostility, anger (Williams et al. 2000), and aggression have largely been associated with problematic cardiovascular precursors in the past such as sympathetic nervous system activation (Suarez et al. 1998) and hypertension among young adults (Yan et al. 2003), studies suggest that inhibiting these types of negative emotions can be just as, if not more, detrimental in terms of predicting prognostic risk factors such as high blood pressure (Steffen et al. 2003) and increased cardiovascular mortality (Harburg et al. 2003).
Type D personality has also been found to be related to an increased prevalence of metabolic syndrome and unhealthy lifestyle, suggesting both behavioral and biological vulnerabilities for development of cardiovascular disorders, similar to what was previously discovered in early Type A research (Mommerstag et al. 2010). Additionally, Type D personality has also been associated with increased risk of recurrent cardiac events and impaired quality of life (Pedersen and Denollet 2003).
Given the potency of this relationship, the concern has shifted to what can be done with this information. Denollet (2005) created a standard via the Type D Scale-14 (DS14), which is a psychometrically sound measure of negative affectivity and social inhibition which has largely become the method of choice in assessing Type D personality in order to better understand a patient’s risks and potential outcomes with cardiovascular illness. Notwithstanding, although the understanding of Type D personality and its influence on cardiac events is becoming more and more established, the mechanisms underlying this relationship still remain largely uncertain (Kupper and Denollet 2007), and more research is necessary to identify other markers. In addition to the work on Type A and Type D personality constellations, global trait research has also begun to play a role in research on coronary health.
Global Personality Traits
Personality traits are important psychological predictors of health (Hampson 2012) and associations between personality and health hold across decades (Hampson et al. 2007). Whereas previous research highlighted the importance of anger and hostility in its role in predicting cardiovascular health, other traits have come to the forefront, specifically those that comprise the big five personality traits: extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience (Digman 1990). Within the past few decades, studies have emerged demonstrating that higher levels of neuroticism, lower levels of conscientiousness (Hagger-Johnson et al. 2012), and lower levels of extraversion were associated with poorer cardiovascular health. More recently, research has been widening its scope beyond single trait associations within the five-factor model and looking toward multiple health processes working in conjunction to influence the development of cardiovascular disease (Weston et al. 2015). For example, when considering stroke diagnosis, which is predicted by both conscientiousness and openness, it is worth examining the associated risk factors for having a stroke, which include smoking, excessive alcohol abuse, poor exercise and eating habits, and poor cognitive functioning (Boden-Albala and Sacco 2000).
Interestingly, conscientiousness has been associated with each of these behaviors (Bogg and Roberts 2004), suggesting that this trait’s effects may be largely seen through its related behavioral mechanisms (Jackson et al. 2010). Lower conscientious, as such, has been associated with risk of premature mortality, which should come as no surprise as the lowered inhibitions and higher-risk impulsive behaviors associated with this trait have also been associated with obesity (Sutin et al. 2011), inflammation (Sutin et al. 2010), physical inactivity (Tolea et al. 2012), diet (Mõttus et al. 2012), and other health-risk behaviors, such as cigarette smoking and substance use (Turiano et al. 2012). Higher conscientiousness, on the other hand, has been associated with avoidance of health risk behaviors and higher level of education (Goodwin and Friedman 2006). Conscientiousness has also been found to be the only personality modifier of cardiovascular response to occupational stress reflected by systolic blood pressure (Merecz et al. 1999).
Openness, however, has a strong association with cognitive functioning and cognition-related activities that challenge the mind, unlike conscientiousness (Sharp et al. 2010). Thus, openness is likely serving as a protective factor through cognitive pathways rather than behavioral ones. Extraversion has shown similar patterns in its protective capacities, but the benefits do not continue once an illness has developed (Weston et al. 2015). Additionally, more openness to experience has been found to reduce the likelihood of being diagnosed with multiple diseases, suggesting it may have a larger effect on health than previously thought. In addition to conscientiousness and neuroticism, the trait of openness predicted the onset of stroke, heart disease, and high blood pressure (Weston et al. 2015). Thus, the association between openness and disease diagnosis has been identified as protective in health processes (Ferguson and Bibby 2012). Openness may also promote activity engagement or more creative coping strategies to relieve stress (Connor-Smith and Flachsbart 2007); and individuals high in openness may improve their health through better communication with their physicians (Eaton and Tinsley 1999).
Neuroticism, although previously identified in early research as an indicator of cardiovascular health, has recently been seen quite differently. In recent thinking, conscientiousness served a protective factor, while neuroticism served as a risk factor (Weston et al. 2015). One cross-sectional study even found that coronary heart disease, pulmonary disease, and high cholesterol were related to higher-level traits associated with neuroticism (Yousfi et al. 2004); however, beyond conceptualizing this trait dimension in terms of risk alone, neuroticism has been linked with autoimmune functioning in the context of cardiovascular issues as its associated negative affectivity weakens the body’s ability to fend off pathogens (Smith 2006). Together though, multiple trait associations with disease such as these have suggested multiple conduits to developing cardiovascular illness.
One of these pathways, in which traits work in tandem with other factors, suggests that traits have also been associated with social environmental factors, such as occupational success (Roberts et al. 2003), marital stability (Roberts et al. 2007), relationship quality (Hill et al. 2014), and broader affiliations such as degree of community membership and religiosity (Lodi-Smith and Roberts 2007), all of which has demonstrated a relationship with the development of cardiovascular health. Gender differences have been accounted for in that women have been found to be more extraverted, agreeable, conscientious (Goodwin and Friedman 2006), and neurotic than men, while older adults were less extraverted, conscientious, neurotic, and open than younger ones. Married individuals have also been found to be more conscientious, open, and emotionally stable than nonmarried individuals (Weston et al. 2015). One area that deserves more attention and that could prove beneficial is to underscore how traits and their associated behaviors operate at the physiological level (Hill and Roberts 2016).
Beyond trait dimensions serving as predictors of general health or as risk factors for the development of disease (Weston et al. 2015), personality traits have also been associated with disease progression (Sutin et al. 2013), with it being slower for more open, extraverted, and conscientious individuals (Ironson et al. 2008). There is reason to suspect, however, that disease could have an effect on personality development, rather than the other way around. An abrupt change in personality or other psychological factors such as anxiety or depression may be one of the first indicators of acute disease development. For example, a severe spike in high blood pressure is often detected because of sudden changes in personality and increased irritability (Mayo Clinic 2012). As such, disease burden, such as what is seen in cardiovascular illness, can impact personality features in ways such as what can be seen in openness to experience. Specifically, as patients become progressively more ill, they prefer more familiar environments, and their emotional responses become more muted. Disease progressions have also been found to reduce positivity, optimism, and cheerfulness that would typically be associated with extraversion and can have long-standing changes on personality (Weston et al. 2015).
Given that there exist many gaps in the literature regarding the impact of personality on the development and progression of cardiovascular illness, much more research must be conducted and replicated cross-sectionally to understand this relationship.
Though research on Type A personality, Type D personality, and global personality traits has all shown significant promise, more research is needed to understand fully the relationship between personality and cardiovascular illness.
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