Module 2

Introduction to Social Support

Types of Social Support
Social Support for People suffering with various health problems

Introduction
The role of social support in adaptation to illness and in health outcomes is one of the
most studied topics in health psychology.

Social relationships have been posited to influence the maintenance of health and well-
being by scientists and practitioners in both behavioral science and medical disciplines.

In this topic, we review key definitions of social support and health and
empirical studies linking social relationships with a variety of health outcomes.
What Is Social Support?
Social support is defined as the perception or experience that one is loved and cared for by
others, esteemed and valued, and part of a social network of mutual assistance and
obligations (Wills, 1991).

Social support may come from a partner, relatives, friends, coworkers, social and
community ties, and even a devoted pet (Siegel, 1993).

Taxonomies of social support have usually classified support into several specific forms.

Informational support occurs when one individual helps another to understand

a stressful event better and to ascertain what resources and coping strategies may be
needed to deal with it.
Through such information or advice, a person under stress may determine exactly
what potential costs or strains the stressful event may impose and decide how best to
manage it.

Instrumental support involves the provision of tangible assistance such as services,

financial assistance, and other specific aid or goods.
Examples include driving an injured friend to the emergency room or providing
food to a bereaved family.
Emotional support involves providing warmth and nurturance to another individual
and reassuring a person that he or she is a valuable person for whom others care.

But as the definition makes clear, social support can also involve simply the perception
that such resources are available, should they be needed.
For example, knowing that one is cared for and/or that one could request
support from others and receive it may be comforting in its own right.

Thus, social support may involve specific transactions whereby one person explicitly
receives benefits from another, or it may be experienced through the perception that
such help and support are potentially available.
Social support is typically measured in terms of either
the structure of socially supportive networks or
the functions that network members may provide (e.g., Wills, 1998).

Structural social support, often referred to as social integration, involves the

number of social relationships in which an individualis involved and

the structure of interconnections among those relationships.

Social integration measures assess

the number of relationships or social roles a person has,
the frequency of contact with various network members, and
the density and interconnectedness of relationships among the network members.

Functional support is typically assessed in terms of the specific functions (informational,

instrumental, and emotional) that a specific member may serve for a target individual and
is often assessed in the context of coping with a particular stressor.

Thus, an individual might be asked how much of different kinds of support each member of
a supportive network provided during a stressful event.
Social Support Definitions

Paper-and-pencil, interview, and observational methods have been used to

measure social support.

Measurement methods are guided by the perspectives taken on understanding

support mechanisms, as different types of support are hypothesized to exert their effects
in different ways.

The most common distinctions made in social support measurement are the distinctions
between
perceived support,
received support, and
social integration (Cassel, 1976; Cobb, 1976; Weiss, 1974).
Perceived support, which is actually more of an appraisal than an actual support-related
interaction,
-is the perception that specific types of social support would be available if needed.
-The proposed mechanism for perceived support is protection of the individual by altering
his or her interpretation of the threat or harm posed by situations (Cohen & McKay, 1984).

Received support is defined as actual supportive behaviors.

The majority of investigators studying received support hypothesize that it exerts a
beneficial effect because it promotes adaptive coping (Cutrona & Russell, 1990).

A third method of measuring support, social integration, asks the individual to report how
many different roles he or she has or the degree to which the individual is active
in different activities (e.g., church).

The proposed mechanism for this type of support is that a person who has a greater
number of roles or is more active in social activities has a more differentiated identity and
that stressful events in one area of life, or one role function, would be less likely to impact
the individual because fewer roles and areas of life are disrupted.
Both perceived and received support have been measured
by assessing the degree to which others would provide perceived support or
actually provide (received support) the basic functions of social support.

The key support dimensions have varied from theorist to theorist (see House,
1981;Weiss, 1974), but the majority of theories have incorporated
emotional, instrumental, informational, companionship, and validation support
(Argyle, 1992; House, 1981).

The multidimensional nature of support measures provides a powerful tool

because researchers can investigate the degree to which different
functions of support are helpful for dealing with different types of stressors.
Social Support and Health Outcomes
Cardiovascular Function

The majority of studies examining the role of social support in physiological processes have
focused on aspects of cardiovascular function.

One reason investigators are interested in this area of research is that increased
cardiovascular reactivity has been linked to the development of cardiovascular disease.

Increased sympathetic nervous system (SNS) responses have been associated with a
number of pathophysiological processes that may lead to coronary heart disease (see
Rozanski, Blumenthal, & Kaplan, 1999).

Differences between individuals in terms of their cardiovascular reactivity to stressors are

assumed to be markers of increased SNS responsivity, as studies have shown that
individuals who have increased reactivity to mental stress are at higher risk for
hypertension (e.g., Menkes et al., 1989),
arteriosclerosis (Barnett, Spence, Manuck, & Jennings, 1997), and
recurrent heart attacks (Manuck, Olsson, Hjemdahl,&Rehnqvist, 1992).
Majority of the studies examining the association between support and cardiovascular
function indicate that social support is associated with lower blood pressure, lower
systolic blood pressure (SBP), and lower diastolic blood pressure (DBP)
(e.g., Hanson, Isacsson, Janzon, Lindell, & Rastam, 1988; Janes, 1990).
A small subset of studies reported no relationship between social support and
cardiovascular function (e.g., Lercher, Hortnagl, & Ko”er, 1993), and
one study reported that social support was associated with poorer cardiovascular
function (Hansell, 1985).

One early study by Kamarck, Manuck, and Jennings (1990) compared cardiovascular
reactivity during two tasks.

Half of the subjects completed the tasks without social support, and
half of the subjects brought a friend who provided support by touching the
subject on the wrist during the task.

Results indicated a significant reduction in cardiovascular response when the friend was
present.
Edens, Larkin, and Abel (1992) found that, during a mental arithmetic task,
the presence of a friend resulted in lower heart rate (HR), SBP, and DBP than
when a friend was not present during the task.

A second study evaluated the potential buffering effects of social support in stress
reactivity among women under conditions of high or low social threat (i.e., punitive
consequences).

Kamarck, Annunziato, and Amaateau (1995) found that, under conditions of low stress,
the availability of social support made no difference in heart rate or blood pressure.
Under conditions of high stress, the same social support reduced
cardiovascular response.
Studies found that social support interventions result in reduced blood pressure when the
participants underwent a stressor challenge assessment post intervention.
For example, Sallis, Grossman, Pinski, Patterson, and Nader (1987) randomly
enrolled participants in a support education group (support group), relaxation training, or
a multicomponent stress management intervention, and intervention or a control group.

Results indicated that support education and relaxation training intervention resulted in
smaller increases in DBP from preintervention to follow-up, and lower DBP levels during
recovery from a cold pressure stress test, compared with the multicomponent stress
management intervention.

Among individuals at higher cardiovascular risk (hypertensives),

studies have consistently shown that interventions focusing on increasing
positive support, particularly support provided by family, result not only in short-term
decreases in DBP, but also in long-term effects on blood pressure regulation (Levine et al.,
1979).

Indeed, a recent metaanalysis of these intervention studies suggests that social support
manipulations can assist in the reduction of blood pressure (Uchino et al., 1996).
Endocrine Function
The most commonly studied endocrine measures are the
catecholamines (e.g., norepinephrine [NE] and epinephrine [EPI]) and
cortisol.

Studies evaluating endocrine function are important because of its association with the
cardiovascular and immune systems.

Catecholamines play an important role in cardiovascular regulation functions such as

constriction of arterial blood vessels.

The association between endocrine function and social support has not been well
documented.
The majority of these studies have found an association between social support and
catecholamine levels (e.g., Seeman, Berkman, Blazer, & Rowe, 1994; Fleming, Baum,
Gisriel, & Gatchel, 1982).

For example,
Ely and Mostardi (1986) studied 331 men and found that high social support, de“ned as
social resources and marital status, was associated with lower NE than low social support.
However, studies of cortisol and support suggest that increasing social contact does not
influence cortisol levels.
One study examined the association between support from a stranger or partner
and cortisol reactivity during acute psychological stress (Kirschbaum, Klauer, Filipp,&
Hellhammer, 1995).

The results indicated that men who received support from their partners evidenced
lower cortisol levels than men who received stranger support or no support.

However, women evidenced a trend toward greater cortisol response during the
partner-supported conditions compared with the other two conditions.

Overall, the link between social support and endocrine function has not been very
consistently confirmed.
Immune Function

Studies linking social support to immune function indices suggest that higher social support
is associated with better immune system function.

Levy and colleagues (1990) examined the association between perceived emotional
support from spouse, family member, friends, doctors, and nurses and the immune system
function in women with breast cancer.
The results indicated that emotional support from spouse and physician was
associated with greater natural killer cell activity (NKCA).

Some studies have controlled for the influence of other psychological factors, such as mood
and stressful life events, that could contribute to the association between support and
immune function.

Baron and colleagues (Baron, Cutrona, Hicklin, Russell, & Lubaroff, 1990) evaluated
the association between perceived support and immune indexes among spouses of cancer
patients and
found that all aspects of support were related to NKCA, even after controlling for
life events and depression.
Social Support for People suffering with various health problems

AIDS

A relatively large literature evaluates the association between social support and human
immunode“ciency virus (HIV) progression in gay and bisexual men.

Theorell and colleagues (1995) evaluated the association between perceived support
and CD4 T-lymphocyte levels in HIV-infected hemophiliacs, and found that
lower perceived support was associated with greater declines in CD4
levels over a “ve-year period.

As HIV infection progresses, the number of these cells declines. When the CD4
count drops below 200, a person is diagnosed with AIDS. A normal range for CD4 cells is
about 500-1,500.
Social support was assessed as received informational and emotional support, as well as
network size (number of social contacts).
Individuals with 15 persons in their network had an 84% chance of remaining alive
after 48 months, while those who listed only two people had a 44% chance.

Among participants that were symptomatic at baseline,

higher ratings of informational support predicted a longer survival time
after controlling for depressive symptoms and network size.

Overall, support played a mixed role in predicting HIV disease progression.

Among participants with more advanced symptoms at baseline,

longevity was positively associated with network size and informational
support.

Among participants with asymptomatic disease status at baseline,

a large network size predicted more immediate onset of symptoms.

The authors suggest that the negative influence of network size may be related to the
stress of disclosure of HIV status to others or to poor health habits.
Miller, Kemeny, Taylor, Cole, and Visscher (1997) conducted a three year longitudinal
study measuring the association between social integration (de“ned as the number of
close friends), the number of family members, and the number of groups or organizations
to which the participant belonged, and HIV progression (immune parameters, AIDS
diagnosis, death from AIDS).
Contrary to other studies, they did not find an association between social
support and HIV progression.

In summary, studies linking social support to HIV progression to AIDS have shown mixed
results.

Social support may have a protective effect among individuals with more advanced
symptoms, although “ndings have been inconsistent.
Other Diseases

Relatively few studies have evaluated the link between social support and disease
outcomes other than HIV, AIDS, and cardiac events.

Social support has been studied in the context of end-stage renal disease (ESRD).

Burton, Kline, Lindsay, and Heidenheim (1988) followed a group of 351 ESRD patients
for 17 months.

Perceived social support was not associated with mortality or with inability to
perform home dialysis (versus returning to the clinic for dialysis).
Social Support and Psychological Outcomes

Social support has been one of the most studied predictors of psychological adaptation
to health problems, particularly
disabling medical problems such as arthritis or
life-threatening health problems such as cancer.

Studies evaluating supports role in several key diseases will be reviewed next.
Cancer
Measurement of Support

Much of the early literature on social support and psychological adaptation among
individuals with cancer focused on understanding
what types of responses were perceived as helpful, and
what responses were perceived as unhelpful.

Dakof and Taylor (1990) categorized types of social support into three main categories:

esteem/emotional support,
informational support, and
tangible support.

Unhelpful responses were not categorized.

The authors described nine unhelpful actions by others:

criticisms of the patients• response to cancer, minimization of the
impact of cancer on the patient,
Expressions of too much worry or pessimism, expressions of too little
concern or empathy, avoiding social contact with the patient,
rudeness, provision of incompetent medical care,
acting as a poor role model, and provision of insuf“cient information.
Komproe, Rijken,Winnubst, Ros, and Hart (1997)
found that perceived available support, as rated by women who recently
underwent surgery for breast cancer (84% early stage cancer), was associated with lower
levels of depressive symptoms.

Arthritis
Rheumatoid arthritis (RA) is a chronic, unpredictable, and progressive in”ammatory
disease affecting primarily the joints. Osteoarthritis is a similar chronic disease that is
painful, but typically less disabling and progressive in nature.

Both diseases have numerous physical consequences, including pain and severe physical
disability that can result in signi“cant social and psychological impact.

It is perhaps because of the chronic and disabling nature of RA that the “ndings
regarding the role of both perceived and received social support have been consistent.
Studies using measures of both perceived available support and support received (e.g.,
Doeglas et al., 1994),
structural (e.g., Pennix et al., 1997),
qualitative (e.g., Af”eck, Pfeiffer, Tennen, & Fi“eld, 1988; Revenson,
Schiaf“no, Majerovitz, & Gibovsky, 1991), and
quantitative (e.g., Evers, Kraaimaat, Geenen, & Bijlsma, 1997;
Nicassio, Brown, Wallston, & Szydlo, 1985; Pennix et al., 1997)
measures have all shown associations.

Although the majority of studies have employed cross-sectional designs,

several studies using longitudinal designs have also reported
associations between social support and psychological distress (e.g, Evers et al., 1997).
Mechanisms for Social Support’s Effects on Well-Being

Social support is likely to have both direct and indirect effects on psychological outcomes.
There have been a number of discussions of how support may impact psychological
outcomes.

One potential mechanism is that

advice and guidance from others may alter the threatening appraisal of a difficult
situation to a more benign appraisal of a situation.

For example, a breast cancer patient who is facing mastectomy may see the surgery as a
threat to her body image; however, if her husband suggests that reconstructive surgery
will restore her body to close to what it was prior to the surgery, her appraisal of the
situation as threatening may lessen.

Second, social support can function as a coping assistant; that is, supportive others
may provide help in identifying adaptive coping strategies and assistance in using these
strategies (Thoits, 1985).
Studies of individuals with arthritis (Manne & Zautra, 1989) and cancer
(Manne, Pape, Taylor, & Dougherty, 1999) have found that positive reappraisal coping
mediates the relation between spousal support and psychological well-being.
Third, listening, caring, and reassuring a friend or loved one that he or she is worthy and
loved can directly bolster self-esteem.
Druley and Townsend (1998) found that self-esteem mediated the relation
between marital interactions and depressive symptoms among individuals with lupus.
When Is Social Support Beneficial?
Whether social contacts are experienced as supportive may depend on several factors.

These include
how large or dense one’s social support networks are;
whether the support provided is appropriate for meeting the stressor; and
whether the right kind of support comes from the right person.

people who belong to both formal and informal organizations in their communities,
such as church groups, the PTA, clubs, and the like,
enjoy the health and mental health benefits of social support.

This may be because such people are

more socially skilled to begin with and thus seek out contacts from others, or
it may be a direct consequence of participation in supportive networks.

Social networks may also be important for accessing specific types of assistance during
times of stress (such as social services; Lin & Westcott, 1991).
one of the risks of social support networks is that overly intrusive social support may
actually exacerbate stress (Shumaker & Hill, 1991).

People who belong to dense social networks of friends or family who are highly
interactive may find themselves
overwhelmed by the advice they receive and
interference that occurs in times of stress.

As comedian George Burns noted,

“Happiness is having a large, loving, caring, close-knit family in another city.”
Effective social support may depend on an appropriate balance
between the needs of the recipient and
what that recipient gets from those in the social network (Cohen & McKay,
1984; Cohen & Wills, 1985).

This “matching hypothesis” suggests that,

to be supportive, the actions of the provider must meet the specific needs of
the recipient (Thoits, 1995).

Thus, for example, if a person needs emotional support but receives advice instead, the
misfired effort at support may actually increase psychological distress (Horowitz et al.,
2001; Thoits, 1986).

Research generally supports this hypothesis.

Different kinds of support, for example, may be valued from different members of a social
support network.
Emotional support may be most helpful from intimate others and actually resented when
casual friends attempt to provide it,
whereas information and advice may be especially valuable from experts but
regarded as inappropriate from wellintentioned friends or family with questionable
expertise (e.g., Benson, Gross, Messer, Kellum, & Passmore, 1991; Dakof & Taylor, 1990).

Consistent with this perspective, Helgeson and Cohen (1996) reviewed research on the
impact of social support on adjustment to cancer.
They found that emotional support was most desired by patients and
appeared to have the greatest beneficial influence on adjustment.
However, peer support group interventions whose goal was providing
emotional support did not, for the most part, have benefits; rather, educational groups
that provided information were perceived more positively.

Although there are several possible interpretations of these findings,

it may be that emotional needs were best met by those close to cancer
patients, rather than by the relative strangers in the peer group, and
that educational interventions in peer groups better met the cancer patients’
specific informational needs.
Research has suggested that there may be heritable aspects of social support.

Some of these heritable factors may involve social competence.

Some people are more effective than others in extracting the social support they
need, suggesting that social support involves a considerable degree of skill.
For example, Cohen, Sherrod, and Clark (1986) assessed incoming college
freshman as to their social competence, social anxiety, and self-disclosure skills to see if
these skills influenced whether the students were able to develop and use social support
effectively and whether these same skills could account for the positive
effects of social support in combating stress.

Those students who began college with greater social competence, lower social anxiety,
and better self
Personality and Illness

Why do some people become sick, whereas other seemingly similar people remain
healthy or quickly recover from disease?

Is it true that people with “hurry sickness” suffer heart attacks, and worriers develop
ulcers, and shy people face cancer?

Is relaxation an elixir, and will having a smile on your face make you live longer?

Do you believe, as many do, that people who suffer from ulcers tend to be worriers or
‘‘workaholics’’?

Or that people who have migraine headaches are highly anxious?

If you do, then you believe there is a link between personality and illness.

The term personality refers to a person’s cognitive, affective, or behavioral tendencies

that are fairly stable across time and situations. Researchers have found evidence linking
personality traits and health.
For example, people whose personalities include:

• Low levels of conscientiousness measured in childhood or adulthood are more

likely to die at earlier ages, such as from cardiovascular diseases, than individuals
high in conscientiousness (Kern & Friedman, 2008; Terracciano et al., 2008).

• High levels of positive emotions, such as happiness or enthusiasm, tend to live

longer than individuals with low levels of these emotions (Chida & Steptoe, 2008; Xu
& Roberts, 2010).

• High levels of anxiety, depression, hostility, or pessimism are at risk for dying early
and developing a variety of illnesses, particularly heart disease (Grossardt et al.,
2009; Smith & Gallo, 2001).

Anxiety, depression, hostility, and pessimism are reactions that often occur when
people experience stress, such as when they have more work to do than they think
they can finish or when a tragedy happens. Many people approach these situations
with relatively positive emotions.
Their outlook is more optimistic than pessimistic, more hopeful than desperate.
These people are not only less likely to become ill than are people with less positive
personalities, but when they do, they tend to recover more quickly (Scheier &
Carver, 2001; Smith & Gallo, 2001).
The link between personality and illness is not a one-way street:
illness can affect one’s personality, too (Cohen & Rodriguez, 1995). People who suffer
from serious illness and disability often experience feelings of anxiety, depression,
anger, and hopelessness.

But even minor health problems, such as the flu or a toothache, produce temporary
negative thoughts and feelings (Sarason & Sarason, 1984). People who are ill and
overcome their negative thoughts and feelings can speed their recovery.

Our glimpse at the relationships of the person’s lifestyle and personality in illness
demonstrates why it is important to consider psychological and social factors in health
and illness.

- Psychosomatic medicine
- Behavioral medicine
The relationships among individual differences, disease, and health have been
investigated scientifically for more than 100 years, and many thousands of findings have
been reported.

The general verdict (subject to numerous exceptions and qualifications) is that

a person who is chronically irritated, depressed, hostile, impulsive,
bored, frustrated, lonely, or powerless is indeed more likely to develop illnesses and to
die prematurely than is someone
who generally feels emotionally balanced and effective, is in a satisfying
job, has stable and supportive social relationships, and is well integrated into the
community
(Booth-Kewley & Friedman, 1987; Cohen & Williamson, 1991;
Friedman & Booth- Kewley, 1987; House, Landis, & Umberson, 1988; Kiecolt-Glaser,
Glaser, Cacioppo, & Malarkey, 1998; Miller, Smith, Turner, Guijarro, & Hallett, 1996;
Repetti, Taylor, & Seeman, 2002; Smith & Gallo, 2001).
Friedman developed the constructs termed
disease-prone personalities and
self-healing personalities (Friedman 1991/2000; 1998; Friedman & Booth-Kewley,
1987; Friedman & VandenBos, 1992).

These constructs direct theory and research away from associations between single
predictors and single outcomes,
focusing instead on multiple-predictor, multiple-outcome developments over
long periods of time.

For example,
instead of a medical focus on type A behavior and myocardial infarction,
attention moves to biopsychosocial homeostasis and overall well-being and mortality risk,
in a sociocultural context.
So-called risk factors mostly do a poor job of predicting who will succumb,
and when and why they will do so.

Most cookie lovers do not develop breast cancer,

most couch potatoes do not suffer strokes, and it is even the case
that most smokers do not develop lung cancer.

Typically, a solitary risk factor, even if well documented (as many are not),
produces only a marginal increase in an individual’s risk for a
particular disease, again revealing the marked variability.

Multiple risk factors, if coupled with detailed knowledge of sociobehavioral

environments, can, however, do a fairly good job of predicting subpopulation risk.
Prognosis is a medical term for predicting the likely or expected development of a
disease, including whether the signs and symptoms will improve or worsen or remain
stable over time;
Historical Context
The idea of links between personality and health dates back thousands of years and clearly
appears in the writings of Hippocrates, Galen, and their followers.

The ancient Greeks, keen observers of the human condition, saw four essentials—the so
called bodily humors—as key to both individuality health.

People with a healthy, balanced supply of blood would likely turn out to be
sanguine—having the healthy temperament and ruddy complexion characteristic of a
person dominated by this humor.
(Sanguine nowadays refers to someone who is cheerful, confident, passionate, and
optimistic.)

Excessive black bile (or melancholy—sadness, gloom, splenic moroseness) might lead to
depression and degenerative diseases or cancer.

Yellow bile (or choler—peevish, angry, bilious people) would produce (if present in excess) a
bitter, angry personality and associated feverish diseases.

Finally, phlegm was said to be characteristic of a phlegmatic (sluggish, unemotional), cold

apathy, associated, for example, with rheumatism. Although notions of bodily humors have
been discarded, the underlying conception that individuals can be categorized as sanguine,
depressed, hostile, and repressed remains with us.
In the late 1940s, a number of medical students at Johns Hopkins University were studied
in terms of their biological and psychological characteristics, categorized as either
slow and solid (wary, self-reliant),
rapid and facile (cool, clever), or
irregular and uneven (moody, demanding).

They were then followed for 30 years, during which time about half of them developed
some serious health problem.

Most (77%) of the previously labeled “irregular and uneven” types

developed a serious disorder during these 30 years,
but only about a quarter of the rest suffered a major health setback.

In a follow-up, the “irregular and uneven” temperament types were again much more
likely to have developed disease or to have died (Betz & Thomas, 1979).
A later study found those physicians who seemed to have social and emotional problems
(were repressed loners)
were more likely to develop cancer (Shaffer, Graves, Swank, & Pearson, 1987).

Analogously, a study of lung cancer in 224 men and women followed patients who had
been diagnosed within the prior few months and found that
those who were more likely to die within the year were patients who had a
personality that was either much more sober or much more enthusiastic than average
(Stavraky, Donner, Kincade, & Stewart, 1988).

Such early work on personality balance helped set the stage for the current-day focus on
allostasis—the ability to achieve stability through change (McEwen, 1998).
In classic work beginning in the 1930s, Flanders Dunbar (1955) described conflicted
patients such as one named Agnes, an unhappy and unattractive woman of 50 plagued with
a serious heart condition that her doctors labeled “cause unknown.”

Agnes went in and out of hospitals until, finally, she died in the hospital on her birthday
because, Dunbar said, Agnes had always wanted to show her resentment at being born.

The influential psychoanalyst Alexander (1950) suggested that various diseases are
caused by specific unconscious emotional conflicts.
For example,
ulcers were linked to oral conflicts (an unconscious desire to have basic infantile
needs satisfied),
And
asthma to separation anxiety (i.e., an unconscious desire to be protected by one’s mother).

Thus, although internal medicine exploded in influence on the medical scene in the 1950s
and 1960s with pharmaceuticals based on biochemistry,
there was a substantial but underappreciated history in medicine that
considered the importance of the psychology of the individual (see Friedman & Adler, this
volume).
However, like much psychoanalytic work, most of the early psychosomatic work could
not be studied directly in a scientific manner.

In this context, modern research on personality and health was launched (or at least
greatly boosted) in the 1950s, when two cardiologists,
Meyer Friedman and Ray Rosenman (1974),
proposed the idea of the type A behavior pattern.
The Example of Coronary-Proneness,
Type A Behavior, and Heart Disease

Despite extensive clinical observations, systematic study of the association between

emotional behavior and heart disease did not begin until the 1950s, when type A people
were defined as those involved in a constant struggle to do more and more things in less
and less time, and who are often quite hostile or aggressive in their efforts to achieve them.

Type A people always seem to be under the pressure of time and to live a life characterized
by competitiveness.

They are hasty, impatient, impulsive, hyperalert, and tense.

When under pressure, most people may exhibit some behaviors that are similar to this
pattern, but type A individuals exhibit this behavior very often, for example, turning even
the most potentially relaxing situation (recreational sports such as tennis) into a high-
pressure event
(Chesney & Rosenman, 1985).
Furthermore,
in a formulation where type A behavior is defined as synonymous with coronary-
proneness,
the approach begs the question of whether this type of personality does
indeed predict coronary disease.

Interestingly, people who do not show type A characteristics are called type B.

Excessive competitiveness and constant hostility do seem, for some people in some
circumstances, to increase the likelihood of CHD .

But being hurried and working hard at one’s job are generally not risk factors.

Thus the original formulation was only partly confirmed. By inspiring so much empirical
research, the flawed type A idea helped the establishment of a broader and deeper
approach.
For example,
the construct of a disease-prone personality (Friedman & Booth-Kewley, 1987) as
applied to this issue simultaneously considers multiple aspects of personality (such as
chronic anger, chronic anxiety, or chronic depression) and multiple diseases.
Extended Typologies

Other researchers subsequently also have pursued the typology approach, looking for a
pattern or a collection of psychobiological symptoms associated with a particular disease.

For example, some have added the effects of repressed emotions on health, offering the
type C personality, which is hypothesized to be cancer-prone (Temoshok et al., 1985).
This personality is repressed, apathetic, and hopeless.

A type D personality describes distressed people who are supposedly at increased risk of
cardiac events (Denollet, 2000).

Type D people are high on both

negative affectivity (tendency to experience negative emotions) and
social inhibition (tendency to inhibit the expression of emotions).
Pioneering work by Salvador Maddi and Suzanne C. Ouellette Kobasa (1984) on hardiness
helped provide a basic framework for thinking about staying healthy in the face of
challenge.

First, they suggest that a healthy personality maintains a sense of control. This is not
necessarily a wild sense of optimism but rather a sense that one can control one’s own
behaviors.

Second, there is a commitment to something that is important and meaningful in one’s life,
such as important values and goals.

Third, hardy people welcome challenge.

For example, they may view change as an exciting opportunity for growth and development.

Hardiness generally involves a productive orientation, in which one shows a zest for life.
Why is personality especially significant to health promotion and disease prevention?

The question is an important one because it leads directly to the issue of causal linkages.

In other words, personality is of interest here to the extent

that it allows better intervention to improve health or, at the very least,
good prediction of future health and disease.

By studying personality and health, we are forced to gather research on

psychoimmunology, stress, and unhealthy habits and see how the pieces fit together in
the whole person.

Similarly, after examining social relations or socioeconomic status or social integration, we

are forced to return to study how these forces affect the individual.

In the applied sphere,

the study of personality encourages a focus on individual differences in reactions to
interventions, and
it cultivates attention to the individual’s selection of health-relevant environments
(Friedman, 2000).
In short,

 personality is important because it is the individual person who lives a unique life
path, becomes ill or stays well, and lives long or dies prematurely.

 It matters to some extent whether one’s cells or organs are uninfected and
functioning well, but only because these affect the whole person.

 It matters whether a city has polluted air or uncooperative patients, but only
because these may affect or characterize the individual.

There is no isomorphism between risk factors and an individual’s outcomes.

There are a number of key models of causal linkages between personality and health,
each of which may have its own subsets and variations.

In many instances, more than one linkage is simultaneously causing an observed

association.
Most study designs, however, are not set up to detect multiple causal linkages.

Personality-Caused Disease:

1. The Behavioral Route

A commonly investigated causal model proposes that personality can lead directly to
disease through
patterns of unhealthy behaviors such as poor diet and lack of physical activity.

A frequent and sensible step in examining links between personality and disease is thus
to isolate and control for known behavioral causes of disease,
such as cigarette smoking’s strong effects on lung disease.
Behavioral Mediating Mechanisms

Special research attention should be directed at smoking because

smoking is by far the most powerful common behavioral influence on health.

Alcohol and drug abuse are other common and potent behavioral mediators, although they
also vary by time and place and are of minor import in countries that strictly ban or limit
these substances.

Injury—violence and accidents—is a health outcome that is often strongly affected by

person ality-influenced health behaviors; this is especially true before middle age
(Zuckerman & Kuhlman, 2000).

Risky sports, unsafe driving, and exposure to violent situations (including those that
increase the risk of homicide and suicide)
are a major threat to health and longevity, but usually the causes are multifactorial.
Personality-Caused Disease:

2. The Psychophysiological Route

Personality can affect disease directly through physiological mechanisms.

That is, individual reaction patterns can trigger unhealthy neurohormonal states.

This pathway is the one that laypersons most often assume when they speak about
individual differences and disease.

Models of personality causing disease through psychophysiological mediating mechanisms

often begin with a focus on poor coping with stress.

Depending on the challenge,

individuals who are depressed, introverted, repressed, unconscientious, or
otherwise unbalanced are often less successful in bringing to bear necessary psychological,
social, and behavioral resources to face challenge
(Aspinwall & Taylor, 1997).
3. Biological Underlying (Third) Variables

Genetic endowments and early experiences can affect both

later personality and later health. In the simplest or most extreme case, there is
a severe genetic defect shaping both personality and disease.

For example, people with Down syndrome (trisomy 21) are at high risk for congenital heart
disease as well as for premature mortality, usually dying before age 50. Although personality
varies, there are clearly differences from people without this condition,
such as in average mental acuity.

Another chromosomal disorder, Angelman syndrome (deleted area in chromosome 15),

leads to children who are unusually happy and laugh excessively. They develop movement
disorders, seizure disorders, and mental retardation.

In such cases there is an association between personality and health, but changing the
health would not change the personality, and influencing the personality would not change
the health.

Only an intervention that affected the biological sequelae of the genetic abnormality would
have consequences.
Yet such examples are a useful entry to thinking about more subtle and complex
underlying biological variables.

In many people, biological third variables are affecting both personality and health.

Finally, it is also the case that people with chronic anxiety are more likely to feel pain
and other symptoms. They also may be especially vigilant about bodily sensations
(Pennebaker, 1982).
Disease-Caused Personality Changes
Many observed associations between personality and health are the result of patterns that
follow from the onset of disease. That is, the disease “causes” (affects) the personality.
However, this area is understudied, and the extent of this phenomenon is unknown.

4. Brain Mediated
Not surprisingly, diseases that affect the brain also have a dramatic impact on personality.
Consider Parkinson’s disease and Parkinson-like syndromes, characterized by tremor, muscle
rigidity, and movement problems.

It has long been noticed that people with Parkinson’s disease tend to appear stoic. Because
Parkinson’s disease involves a deficiency of dopamine (as neurons in the substantia nigra
degenerate), it may be that this defect produces this aspect of personality.

This process is likely both genetically and environmentally influenced. Even here, there can
be multiple causal links, although the cause is usually unknown.

For example, Parkinson’s may sometimes result from brain infection, which then affects
personality; but there also can be an underlying third variable,
as when people who mine manganese or live in regions with volcanic soil (high in
manganese) sometimes become compulsive fighters and later develop Parkinson’s (due to
this heavy metal poisoning).
Ironically, professional boxers who receive multiple blows to the head can also develop
Parkinson’s as a result (so called pugilistic Parkinson’s syndrome).
There is well-documented personality change associated with excessive alcohol
consumption.
Alcoholism can lead to anxiety and depression, although it is sometimes anxiety and
depression that contributed to the drinking.

At the extreme, in Wernicke- Korsakoff syndrome, there are memory problems, confusion,
and delusions, due to brain damage from severe deficiency of thiamine (vitamin B1) in
malnourished chronic alcoholics.

Analogously, drugs such as cocaine and LSD can occasionally produce long-lasting, dramatic
alterations in personality.

Other diseases that commonly affect personality through effects on the brain include
strokes (which affect personality differentially as a function of the location of the stroke),
metabolic disorders involving the thyroid, or conditions such as diabetes that involve
glycemic control.

Sometimes the personality changes result from medical treatment effects, as in long-term
mental status changes after coronary bypass surgery (Newman et al., 2001),
occasionally nicknamed “pump head.”

Further, many widely prescribed drugs, especially psychotropic drugs like tranquilizers,
sleeping pills, and antidepressants, may have significant effects on personality.
Psychologically Mediated

Encounters with serious illness, such as suffering a myocardial infarction or receiving a

diagnosis of cancer, can sometimes precipitate a dramatic change in
personality.

This is similar in some respects to a religious conversion (and indeed sometimes a

religious conversion is the response).

Behaviorally Mediated
Disease may cause changes in motivation (or cravings) and in social status,
as occurs if a stroke or cancer victim loses a job, gets divorced, and becomes
hostile and depressed.

New pressures and social groups may then alter the likelihood of smoking, drinking, risky
behavior, and so on, thereby further changing both the individual’s personality and
health.
Self-Healing

Although most research focuses on disease, it is equally important to examine those

people in whom there is a self-healing personality,
which maintains a physiological and psychosocial homeostasis (Friedman, 1991/2000).

Such individuals tend to wind up in certain healthy environments,

evoke positive reaction from others, and
have a healing emotional style that matches the individual with the environment.

In these people,
good mental health tends to promote good physical health, and
good physical health tends to promote good mental health.

Various healthy patterns go together, which can be termed co-salubrious effects.

As one good pattern or reaction leads to another, positive results cumulate. There is
evidence that a process of “broaden-and-build” develops, as coping skills improve, social
networks expand, and recuperation processes improve (Fredrickson, 2001).

Because medical care is typically focused on pathology,

such links have been mostly ignored in health care.
Neuroticism: Worrying, Hostility, and Depression

Perhaps the most complex associations between personality and health involve neuroticism.

Neuroticism, or emotional instability, refers to people who tend to be anxious, high-strung,

tense, and worrying; they are also often impulsive, hostile, and prone to depression because
they cope poorly with stress.

There is long-standing, incontrovertible evidence that many diseases are associated with
higher levels of hostility, anxiety, and depression (Barefoot & Schroll, 1996; Friedman &
Booth-Kewley, 1987; Goodwin & Friedman, in press; Kubzansky, Kawachi, Weiss, & Sparrow,
1998; Miller et al. 1996; Schulz, Martire, Beach, & Scheier, 2000),
but the causal pathways have rarely been elucidated.

Neurotic people are more likely to feel and report symptoms, and disease can cause distress
(Costa & McCrae, 1987; Watson & Pennebaker, 1989).

Hence, some links of neuroticism to disease are correlational, artifactual, or reverse causal.
the general association between depression and risk of heart disease has since been
confirmed in many studies.

Depression and related states of chronic anxiety, pessimism, and vital exhaustion
predict risk of heart disease in both initially healthy persons and those who already
have heart disease.
Extroversion and Sociability
When it comes to matters of health, extroversion is a double-edged sword. Extroverted
people are warm, assertive, sociable, active, talkative, and seeking of stimulation and
excitement.

This tendency has been shown to lead to both health-promoting and health-damaging
behavioral patterns.
The seeking of stimulation and excitement can of course be health damaging, especially for
young men in today’s societies.

Even children with accident- related injuries tend to be more extroverted (Vollrath, Landolt,
& Ribi, 2003).
Extroverts are generally at greater risk for smoking and alcohol abuse, although most of the
evidence comes from adolescents or young adults (Grau & Ortet, 1999; Martsh & Miller,
1997; Tucker et al., 1995).

Studies confirm that such associations with extroversion are best understood in context
(Ham & Hope, 2003; Watson, 2000).

Although extroverts may perform risky behaviors, it is generally to increase positive

rewards and experiences; in certain circumstances the health effects may be different.
For example, to the extent that extroverts sometimes tend to be more physically
active, they gain the health benefits of activity (exercise), despite some risk of injury.
If sociability leads to good social relations and social integration, then the sociability aspect
of extroversion is likely to be health promoting.
However, the most sociable people do not necessarily have the best social relations.

An example of the context-dependent effects of sociability comes from the Terman study.
Using ratings by parents and teachers in childhood, sociability was defined in terms
of fondness for large groups, popularity, leadership, preference for playing with several other
people, and preference for social activities such as parties.

Sociable individuals did not live longer than their unsociable peers (Friedman et al., 1993).

There was simply no evidence that sociable children were healthier or lived
longer across many decades.

In fact, sociable children were somewhat more likely to grow up to smoke and drink (Tucker
et al., 1995). To further analyze this finding, Terman’s own grouping of the men in the sample
into “scientists and engineers” versus “businessmen and lawyers” was examined.
(Terman had found the former group much more unsociable and less interested
in social relations at school and in young adulthood.)

It turned out that those in the scientist and engineer group were at slightly less risk of
premature mortality, despite their unsociable nature (Friedman et al., 1994). For example,
these studious men often ended up in the well-adjusted, socially stable, and well-integrated
Perception of Health in different cultures

Limitations of Health in various cultures

Motivating Healthy Behavior in patients

Asian Americans/Pacific Islanders

Morbidity and Mortality

Heart disease and cancer are leading causes of death for Asians and Paci“c Islanders
(APIs).

Hoyert and Kung (1997) found a great variation in the leading causes of deaths by age
among the API subgroups, which included Samoan, Hawaiian, Asian Indian, Korean, and
Japanese.

They also found that ageadjusted death rates were the greatest and life expectancy was
the lowest for Samoan and Hawaiian populations (Hoyert & Kung, 1997).

Prevalence of diabetes has been found to be high among Hawaiians, which suggests that
other Asian and Paci“c Island populations may share similar susceptibility to diabetes
(Grandinetti et al., 1998).

Morbidity refers to the unhealthy state of an individual, while mortality refers to the state
of being mortal. ... For example, a morbidity rate looks at the incidence of a disease
across a population and/or geographic location during a single year. Mortalityrate is the
rate of death in a population.
Major Behavioral Risk and Protective Factors
Tobacco Use.
Relatively little is known about Asian American tobacco and alcohol use patterns. The little
that is known suggests that Chinese use less tobacco than other cultures. For example, a
study by Thridandam, Fong, Jang, Louie, and Forst (1998) indicates that the prevalence of
both tobacco and alcohol use is lower for San Francisco•s Chinese population than for the
general population.

Diet.
There are complicated scenarios related to diet and acculturation among Asian Americans.
For example, acculturation has been found to affect dietary patterns of Korean Americans.
Korean Americans who were more acculturated ate more •American foodsŽ such as
oranges, low-fat milk, bagels, tomatoes, and bread mostly during breakfast meals (S. Lee,
Sobal, & Frongillo, 1999). In contrast, there may be lost health benfits for Asian Americans
who opt to change to American-style diets rather than more traditional Asian diets.
For example, there is evidence that Japanese diets may reduce the prevalence of diabetes
(Huang et al., 1996) and that soy intake among Asians may be related to a reduction in the
risk of breast cancer (Wu, 1998).
Physical Activity.
As in other minority groups, there is evidence that physical activity serves as a protective
factor against chronic illness among Asian Americans. Research on Japanese American men
who participated in the Honolulu Heart Program study suggests that physical activity is
associated inversely with incident diabetes, coronary heart disease morbidity, and mortality
(Burch“el et al., 1995a, 1995b; Rodriguez et al., 1994).
ETHNIC MINORITIES AND HEALTH

In the UK, rates of premature mortality amongst people in ethnic minorities are typically
higher than those of the white population.
Less information is available on morbidity (Harding & Maxwell, 1997).

Similarly, in the USA, blacks have higher age adjusted mortality rates for a variety of
diseases including various
cancers, heart disease,
liver disease, diabetes and pneumonia (Krieger et al., 1999).
They are also more likely to die as a result of violence (Markides, 1983).

There is also marked variation within ethnic categories.

Epidemiological data from the UK (Balarajan & Raleigh, 1993; Landman & Cruickshank,
2001) shows a 36 per cent higher rate of CHD amongst males from the Indian
subcontinent, with rates for those between 20 and 39 years of age being two to three
times higher than for whites.

In addition, there are higher levels of diabetes among Asians and a greater incidence
of obesity amongst South Asians.
For Afro- Caribbeans,
a particularly high prevalence rate of hypertension and strokes has been observed.
For the former, mortality rates four times above the national average for males and
seven times greater for females have been recorded.

For strokes, males demonstrated a rate of 76 per cent and

females a rate of 110 percent above the national average.

In contrast, African Caribbeans and Asians have lower rates of cancer than the national
average (Barker & Baker, 1990).
Consequently, disentangling the various genetic, social and psychological factors that
may contribute to differences in morbidity and mortality between ethnic groups has
proved extremely difficult.

The high incidence of mental illness among African Caribbeans living in the
UK, for example, has variously been explained by theories focusing on
genetics, economic
deprivation, discrimination and
service provision problems (Littlewood & Lipsedge, 1988),

whilst in the USA, explanations have focused on interactions between

restricted socioeconomic mobility,
lack of social resources,
poor living conditions, racism and
the internalization of negative cultural stereotypes (Williams & Williams,
2000).

Here we focus on three levels of explanation:

normative health behaviours,
social disadvantage, and
prejudice and discrimination.
Motivating Healthy Behavior in patients

Who practices healthful behavior and why?

We are far from a complete answer to this question, but there are
gender, sociocultural, and age differences in practicing health behaviors (Schoenborn,
1993; NCHS, 2009a).

For instance, an international survey of adults in European countries found that women
perform more healthful behaviors thanmen (Steptoe et al., 1994).

One reason for such differences is that people seem to perform behaviors that are salient to
them.

For example, a study compared the health behaviors ofmedical and nonmedical students
and found that the medical students exercised more and were much less likely to smoke
cigarettes, drink alcohol excessively, and use drugs (Golding & Cornish, 1987).
You probably know some individuals who are highly health-conscious and others who
display little concern about their health.

To some extent individuals who practice certain behaviors that benefit their health
also practice other healthful behaviors and continue to perform these behaviors over time
(Schoenborn, 1993).

But other people show little consistency in their health habits (Kaczynski et al., 2008;
Mechanic, 1979). Research results suggest three conclusions.

First, although people’s health habits are fairly stable, they often change over time.

Second, particular health behaviors are not strongly tied to each other—that is, if we know
a person practices one specific health habit, such as using seat belts, we cannot accurately
predict that he or she practices another specific habit, such as exercising.

Third, health behaviors do not seem to be governed in each person by a single set of
attitudes or response tendencies. Thus, a girl who uses seat belts to protect herself from
injury may watch her weight to be attractive and not smoke because she is allergic to it.
Why are health behaviors not more stable and strongly linked to each other?

Here are a few reasons (Leventhal, Prohaska, & Hirschman, 1985).

First, various factors at any given time in people’s lives may differentially affect different
behaviors.
For instance, a person may have lots of social encouragement to eat too much
(‘‘You don’t like my cooking?’’), and, at the same time, to limit drinking and smoking.

Second, people change as a result of experience.

For example, many people did not avoid smoking until they learned that it is harmful.

Third, people’s life circumstances change.

Thus, factors, such as peer pressure, that may have been important in initiating and
maintaining exercising or smoking at one time may no longer be present, thereby
increasing the likelihood that the habit will change.
