Personality and Health: Advantages and Limitations of the Five-Factor Model

Timothy W. Smith and Paula G. Williams University of Utah

ABSTRACT Interest in the association between personality characteristics and physical health has been renewed in recent years. Theory and research in this area has also been complicated by conceptual and methodological limitations. The present article briefly reviews this literature and discusses the advantages and limitations of the five-factor model of personality as an integrating framework for studies of personality and health. The model has already been fruitfully applied in several contexts, and more possibilities exist. Although it has some potential limitations, the application of the five-factor model— as well as other aspects of current personality theory and research—is likely to facilitate progress in the study of how personality influences health. The notion that enduring dimensions of personality can influence subsequent physical health has appeared in medical and philosophical writings for many centuries (McMahon, 1976). This basic hypothesis—that specific character traits are causally related to illness—was developed in detail in the psychoanalytic approach to psychosomatics of Alexander (1950) and Dunbar (1943). The waning influence of the psychoanalytic perspective within psychology combined with a weak empirical foundation to hasten the demise of the classical psychosomatic approach. In the past two decades, however, interest in this issue has resurfaced. Theory and research concerning the influence of personality on health and disease have been a central focus and driving force within the Address all correspondence concerning this article to Timothy W. Smith, Department of Psychology, University of Utah, Salt Lake City, UT 84112. Journal of PersonaUty 60:2, June 1992. Copyright © 1992 by Duke University Press. CCC 0022-3506/92/51.50

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developing fields of behavioral medicine and health psychology (Suls & Rittenhouse, 1987). In its current form, interest in personality and health focuses on three general issues. Similar to the analytic approach to psychosomatics, the first and most prominent issue concerns the possible effect of personality traits on the development and course of disease. The presumed mechanisms by which personality traits exert their effects involve the physiological effects of stress. Through a variety of pathways, personality characteristics are hypothesized to influence the frequency, duration, and/or intensity of physiological stress responses, which in turn are hypothesized to initiate and hasten the development of disease. The second issue concerns the extent to which personality traits are causally related to specific behaviors, which in turn may increase the risk of illness. Personality characteristics associated with unhealthy habits, such as a sedentary life-style, imprudent diet, and other behavioral risks, are the focus of this research. Finally, the third issue addresses the ways in which personality characteristics moderate the impact of acute medical stressors such as hospitalization or surgery and the adjustive demands of chronic medical illness. This issue is the subject of much activity in behavioral medicine and health psychology and centers around the hypothesis that certain personality characteristics make people more vulnerable to the dysphoric emotions and behavioral dysfunction that sometimes accompany medical crises and chronic illness. These second and third issues have not been emphasized in older research models. The study of these topics within the context of personality and health has been accumulating at a rapid pace, particularly the question of whether personality traits are risk factors for illness. Yet, this enterprise is not without its critics, ranging from outright condemnation (Angell, 1985) to thoughtful caution (Holroyd & Coyne, 1987). The constructive criticism has addressed several aspects of personality and health research. Several authors have voiced concerns about the inadequacy of personality measurement techniques employed in much of this work (Holroyd & Coyne, 1987; Smith, Pope, Rhodewalt, & Poulton, 1989). In addition to traditional questions of reliability and validity, many of the personality measures developed in the field arise from specific theoretical models. As a result, the question of their overlap with existing constructs and measures is often neglected, raising the possibility that researchers "reinvent constructs under new labels" (Holroyd & Coyne, 1987, p. 367). Although interesting and often productive, research in the field is producing a somewhat scattered accumulation

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of conceptually isolated measures and traits (Costa & McCrae, 1987a). Other criticisms have focused on the lack of precision about the specific psychobiological mechanisms linking personality and health, as well as a lack of sophistication in the measurement of health outcomes (Costa & McCrae, 1987b; Krantz & Hedges, 1987). During the same period that the study of personality and health was reappearing and maturing under criticism, the study of personality itself was experiencing a revitalization. In the 1960s, critics had argued that personality traits had little utility in the prediction of behavior (Mischel, 1968) and perhaps existed solely in the mind and language of observers rather than as actual characteristics of people (D'Andrade, 1965). These and other critiques tempered interest in personality assessment and research for several years. Subsequent research has demonstrated the temporal stability, convergent validity across sources of information (e.g., self versus significant other), and predictive utility of trait ratings (e.g., McCrae, 1982; McCrae & Costa, 1984, 1987), and the field is quite active once again (Carson, 1989; Digman, 1990). Despite its obvious relevance and parallel cycle of activity, theory and research in personality and health has not taken full advantage of the conceptual and methodological developments in the more general study of personality occurring in recent years. Although there have been advocates for the application of newer approaches to personality (Costa & McCrae, 1987a; Holroyd & Coyne, 1987; Smith & Anderson, 1986; Suls & Sanders, 1989), much—perhaps most—of the research on personality and health has not been informed by the more general field. The misfortune of this oversight is that current personality theory, research, and methods contain potential solutions to many of the problems currently plaguing the study of personality and health. The purpose of this article is to explore one such possible contribution—the potential utility of the five-factor model in personality and health research. As Costa and McCrae (1987a, 1987b; Costa, McCrae, & Dembroski, 1989) have argued, this trait taxonomy has much to offer personality and health researchers. A great deal of research over several decades indicates that the dimensions of Neuroticism or Emotional Stability, Extraversion, Openness to Experience, Agreeableness, and Conscientiousness provide an adequate taxonomy of personality traits (Digman, 1990; McCrae & John, this issue). Further, although certainly not unique to the five-factor model, this personality research tradition includes invaluable tools in the form of measurement devices and validation procedures. Although thefive-factormodel certainly will

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not cure all the ills of personality and health research, it provides at least a partial solution to many troubling problems. In what follows, we will briefiy review the central topics in current personality and health research. As an organizational scheme, we will review the specific traits comprising this area of research. Our primary focus is on the question of psychosomatics: Is personality causally related to physical illness? After this review, we will discuss the advantages and disadvantages of using the five-factor model in personality and health research, as well as potential new directions for research resulting from its application to the field of psychosomatics. Current Areas of Personality a n d Health Research Studies of personality and health have appeared in the medical and behavioral science literature in vast numbers in recent years. A comprehensive review of this literature is obviously beyond our present purpose and scope. We will, however, provide brief reviews of the major foci of research in this area, as well as discuss potential similarities between the traits investigated in personality and health research and the elements of the five-factor model. In some cases, traits from the Big Five have been specifically involved, but the majority of studies in this area have not explored this approach. Type A behavior, hostility, and antagonism. Without question, a main, driving force in the reemergence of personality and health research following the demise of the psychoanalytic approach to psychosomatics was Friedman and Rosenman's (1959) articulation of the Type A behavior pattern as a risk factor for coronary heart disease. Friedman and Rosenman (1959, 1974) purposefully avoided describing the Type A pattern as a personality type or trait in an attempt to avoid identification with the older psychosomatic approach. Indeed, their emphasis on overt behavioral characteristics—competitiveness, hostility, impatience, achievement striving, job involvement, and a loud, explosive vocal style—foreshadowed the more empirical approach of current personality and health research. Two decades of generally confirmatory research led a panel of experts convened by the American Heart Association to conclude that the Type A pattern was indeed a significant risk factor for coronary heart disease (Cooper, Detre, & Weiss, 1981). The panel concluded that Type A's

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were approximately twice as likely to develop coronary heart disease as were more easygoing, patient, and soft-spoken Type B's. Subsequently, several notable failures to replicate this relationship have appeared (e.g., R. B. Case, Heller, N. B. Case, & Moss, 1985; Shekelle, Gale, & Norusis, 1985). Despite these negative findings, a recent meta-analysis of all the relevant prospective studies concluded that Type A behavior is a significant risk factor (Matthews, 1988). The primary proposed link between Type A behavior and coronary heart disease is heightened cardiovascular and neuroendocrine reactivity to environmental challenges and demands (Friedman & Rosenman, 1974; Glass, 1977). The available evidence is consistent with the hypothesis that Type A's display more pronounced increases in heart rate, blood pressure, and neuroendocrine levels (e.g., catecholamines, cortisol, etc.) in response to stressors than do Type B's (Harbin, 1989; Houston, 1988). Recent evidence that modification of the Type A pattern in heart patients reduces the likelihood of recurrent cardiac events (Friedman et al., 1984; Powell & Thoresen, 1988) has strengthened interest in the Type A pattern. Research in this area has witnessed two important, related developments in recent years. The first issue concerns the assessment of Type A behavior. Although many devices exist, three are considered primary by virtue of their use in large, prospective studies—the Type A Structured Interview (SI; Rosenman, 1978), the Jenkins Activity Survey (JAS; Jenkins, Zyanski, & Rosenman, 1974), and the Framingham Type A Scale (FTAS; Haynes, Feinleib, & Kannel, 1980). Although originally purported to assess the same construct, these measures are quite moaestiy correlated'CCfiesney, Slack, CfiadwicR, & Rosenman, 1981; Matthews, Krantz, Dembroski, & MacDougall, 1982). Thus, the convergent validity of Type A assessment devices is poor. Further, these three measures show distinct patterns of correlations with other individual difference dimensions (e.g., Chesney et al., 1981; O'Keeffe & Smith, 1988; Smith, O'Keeffe, & Allred, 1989), suggesting that they measure different personality constructs. Finally, consistent evidence linking Type A behavior to subsequent heart disease in more than one study is found only for the SI (Matthews, 1988). Thus, poor convergent validity of the available assessment devices—and insufficient attention to construct validation in the early development of this area—is the source of much of the inconsistency and confusion surrounding the Type A construct. The second development in this area has been the examination of individual Type A components. Several recent studies have quantified

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the Type A characteristics assessed by the SI separately and found that hostility is more consistently related to coronary disease than are other Type A dimensions, such as competitiveness and achievement striving (Dembroski, MacDougall, Costa, & Grandits, 1989; Dembroski, MacDougall, Williams, Haney, & Blumenthal, 1985; Hecker, Chesney, Black, & Frautchi, 1988; Matthews, Glass, Rosenman, & Bortner, 1977). These findings have produced a great deal of interest in the health consequences of hostility. Other measures of hostility, such as the Cook and Medley (1954) Hostility (Ho) Scale have been pressed into service as a result. The relationship between Ho scores and subsequent health outcomes has been inconsistent across the available studies (e.g., Barefoot, Dodge, Peterson, Dahlstrom, & Williams, 1989; Hearn, Murray, & Leupker, 1989; Leon, Finn, Murray, & Bailey, 1988; Shekelle, Gale, Ostfeld, & Paul, 1983). Until recently, a lack of information about the construct validity of the Ho Scale has limited the conclusions that can be drawn from the epidemiological studies (Megargee, 1985). To address this problem, the construct validity of measures of hostility used in this context has been the focus of several recent studies (Musante, MacDougall, Dembroski, & Costa, 1989; Pope, Smith, & Rhodewalt, 1990; Smith & Frohm, 1985; Smith, Sanders, & Alexander, 1990). The results have supported the interpretation of these measures as refiecting individual differences in hostility, but have also drawn attention to the differences among aspects of hostility. These measures differ in the extent to which they assess subjective or experiential aspects of hostility such as feelings of anger, irritation, and resentment, as opposed to objective or expressive aspects of hostility, such as verbal aggression. Some evidence indicates that the latter aspects of hostility may be more closely related to coronary heart disease than the former (Dembroski et al., 1989; Siegman, Dembroski, & Ringel, 1987). This distinction may explain the inconsistent results obtained with the Ho Scale; although it is significantly correlated with measures of objective or expressive aspects of hostility, it is at least as closely correlated with subjective or experiential features (Smith et al., 1990; Smith & Frohm, 1985). The five-factor model may provide much-needed clarification in the study of Type A behavior, hostility, and their health consequences. It is clear that the development and evaluation of assessment devices in this area of research could benefit from the strong psychometric tradition in current personality research. Beyond this general contribution, how-

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ever, attention to the specific traits in the five-factor model is likely to prove useful. It is clear that the Type A pattern as originally defined refiected, in part. Conscientiousness, Neuroticism, Extraversion, and low levels of Agreeableness, or at least facets of these broader dimensions. From this perspective, it is not surprising that the original construct proved difficult to assess and too broad in its depiction of health-relevant traits. The five-factor model is also useful in explicating the subsequent work on hostility as the toxic component within the Type A pattern. Hostility is represented in two places in thefive-factortaxonomy. Angry or hostile thoughts and feelings are a facet of Neuroticism or Emotional Stability, and an overtly hostile interpersonal style describes in large part the trait of Agreeableness versus Antagonism. As discussed below, Costa and McCrae (1987b) and others (Watson & Pennebaker, 1989) have demonstrated that Neuroticism is not a robust predictor of actual physical health outcomes, though it does reliably predict somatic complaints. In contrast. Antagonism corresponds to those aspects of hostility found to be more closely related to coronary disease (Dembroski et al., 1989; Siegman et al., 1987). Thus, as Costa and his colleagues have argued (Costa et al., 1989; Costa & McCrae, 1987a; Dembroski & Costa, 1987), Antagonism may be the coronary-prone component in the Type A pattern, and the distinction between Antagonism and neurotic hostility may be important in refining the measurement of hostility and understanding its contribution to disease. Neuroticism. A second area of research on personality and health that has relied explicitly on the five-factor model concerns the health effects of Neuroticism. The chronic negative emotions reflective of the trait of Neuroticism would appear to be plausibly related to physical illness. Negative emotions certainly have autonomic correlates, and, since the appearance of Selye's (1956) seminal work, sustained or chronic physiological arousal has often been hypothesized to contribute to the development of physical illness. However, a large body of research suggests that the apparent relationship between Neuroticism and health is artifactual, and this misleading association has important methodological, conceptual, and perhaps even clinical implications. Many studies have indicated that individuals who score high on measures of Neuroticism also report more frequent physical illnesses, as well as more frequent and severe physical symptoms (for reviews, see Costa & McCrae, 1987b; Watson & Pennebaker, 1989). Certainly, re-

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ports of illness and/or symptoms are often associated with actual physical illness. They are not synonymous with physical illness, however. Actual illness is associated with illness behavior, such as visiting a physician, taking medicine, staying home from work, and complaining of pain or other symptoms. However, illness and illness behavior are obviously not perfectly correlated. One's illness behavior may be excessive, as in the case of a hypochondriacal individual, or unusually restrained, as in the case of the stoic. Health complaints have been empirically linked to objective, concurrent health status (e.g., B. S. Linn & M. W. Linn, 1980) and subsequent objective health outcomes such as mortality (e.g., Idler, Kasl, & Lemke, 1990), but these statistically significant associations reflect modest amounts of common variance. As a result, much of the variance in self-report measures of illness reflects somatic complaints in the absence of disease. One unambiguous index of health is mortality. Although there are some exceptions in the literature (e.g., Eysenck, 1990; Somervell et al., 1989), the bulk of the evidence indicates that measures of Neuroticism or emotional distress do not predict subsequent mortality (Costa & McCrae, 1987b; Watson & Pennebaker, 1989). Thus, Neuroticism apparently does not pass this most stringent test as a health risk factor. Costa and McCrae (1987b) do acknowledge that Neuroticism could contribute to nonlethal illness, which in turn would be reflected in illness reports. It is also likely, however, that Neuroticism is associated with reporting biases or increased attention to and concern about normal physical sensations. Such processes would contribute to increased symptom reports among dysphoric persons (Costa & McCrae, 1987b; Watson & Pennebaker, 1989). One interesting context where the Neuroticism-symptom-reporting association operates is reports of angina-like chest pain in the absence of coronary disease. As many as 20% of patients undergoing cardiac catheterization and coronary angiography (i.e., radiographic studies of the coronary arteries) to evaluate suspected coronary artery disease are found to have insignificant degrees of coronary occlusion (Mayou, 1989). Patients who complain of chest pain but are found on angiography to be free of disease have a life expectancy equal to the general public and longer than patients who have similar chest pain complaints accompanied by documented coronary artery occlusions (Ockene, Shay, Alpert, Weiner, & Dalen, 1980; Pasternak, Thilbault, Savoia, Desanetis, & Hutler, 1980). These disease-free patients, however, also score higher on measures of Neuroticism than do the patients

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with actual disease and normal controls (Bass & Wade, 1984; Beitman et al., 1989; Costa, Fleg, McCrae, & Lakatta, 1982; Lantinga, Spafkin, & McCroskery, 1988). Although it is possible that these pseudo-angina patients actually suffer from noncardiac pain with a clear physical basis (e.g., upper gastrointestinal disorders), their elevated levels of Neuroticism may also account for the complaints. Highly dysphoric individuals may be more sensitive to normally occurring symptoms such as chest wall pain of muscular origin, and may be more likely to worry about and overinterpret these sensations. Consistent with this hypothesis, among patients with normal coronary arteries on coronary angiography, continued chest pain reports are associated with the patients' perceived vulnerability to coronary disease (Wielgosz & Earp, 1986). Convincing and persistent complaints may be sufficient to lead these individuals to undergo an expensive, invasive diagnostic test in the absence of actual disease. To avoid continued testing and health-care seeking, these patients may require psychological intervention (e.g., Hegel, Abel, Etscheidt, Cohen-Cole, & Wilmer, 1989). The association between Neuroticism and excessive physical complaints has important implications for research on personality and health. Many measures of personality used in health research are either known to be or are plausibly correlated with Neuroticism. Further, many studies assess physical health through self-reported symptoms. As a result, studies purporting to find an association between a specific personality trait and actual health may instead demonstrate the much different association between Neuroticism and physical complaints in the absence of illness. This methodological confound may explain the fact that some measures of Type A behavior are more closely related to angina (i.e., chest pain of presumed cardiac origin) than to more objective indicators of cardiac disease such as myocardial infarction or cardiac death (Smith et al., 1989). Similarly, Friedman and BoothKewley (1987) recently argued that psychological distress contributes to the development of disease (see also Booth-Kewley & Friedman, 1987). However, their purported support for this "disease-prone personality" includes many studies relying on self-report measures of health. As a result, the Neuroticism-illness-report association may artifactually contribute to the apparent health consequences of emotional distress (Stone & Costa, in press). Finally, much of the research suggesting that stressful life events contribute to the development of physical illness relies on self-report health outcomes. As a result, the stress-illness association in such studies may actually reflect the fact that Neuroticism is correlated

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with reports of both more stressful life circumstances and more frequent or severe physical symptoms (Depue & Monroe, 1986). Thus, it is clear that Neuroticism is an important, but often unrecognized factor in studies of personality and health. Future research should examine the association of measures used in studies of personality and health research with Neuroticism. The possible confounding elfects of Neuroticism should also prompt researchers to forego the convenience of self-report health measures and employ more objective assessments. In addition, the mechanisms underlying the Neuroticism-symptom-reporting association should be explored (Costa & McCrae, 1987b; Watson & Pennebaker, 1989). Hardiness. Another central focus of the renewed interest in personality and health research has been the construct of hardiness, first proposed by Kobasa and Maddi (Kobasa, 1979; Kobasa, Maddi, & Kahn, 1982). It has long been recognized that the association between stressful life events and subsequent illness is small, albeit significant (Rabkin & Struening, 1976). Kobasa and Maddi hypothesized that some individuals are resistant to the adverse health effects of stress because of their personality traits. Based in existential theories of personality, hardy or stress-resistant persons were hypothesized to display a strong sense of commitment, control, and challenge. In this model, commitment refers to the belief in the importance and meaningfulness of one's activities and experiences. Control refers to the belief that life events and other experiences are predictable consequences of one's actions, and challenge is the belief that change is normal and represents a positive opportunity rather than a threat. Together, these traits are hypothesized to moderate the stress-illness association. According to the model, hardy individuals are able to reappraise potential stressors as less aversive and are likely to engage in adaptive coping practices. As a result, hardy persons would display reduced physiological responses to potential stressors, and consequently reduced vulnerability to illness. The assessment devices used to measure hardiness were initially selected from a group of personality tests based on existential theory. In retrospective studies, the tests were found to discriminate between groups of male executives who reported high versus low levels of illness following periods of high stress (Kobasa, 1979, 1982). A variety of shortened versions of these scales have appeared in the literature, as well as new versions. The results of direct tests of the proposed stress-moderating effects of

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hardiness have been mixed. Some studies have reported the predicted Stress X Hardiness interaction (Kobasa et al., 1982; Kobasa &Puccetti, 1983; Rhodewalt & Zone, 1989), but others have not (Kobasa, Maddi, Puccetti, & Zola, 1985; Roth, Wiebe, Fillingim, & Shay, 1989; Wiebe & McCallum, 1986). Most of the latter studies have found a simple, linear relation between high scores on measures of hardiness and low concurrent or subsequent reports of illness. Several studies have examined the hypothesized mechanisms linking hardiness and health. Both controlled laboratory studies (Allred & Smith, 1989) and correlational studies of life stressors (Rhodewalt & Augusdottir, 1984; Rhodewalt & Zone, 1989; Williams, Wiebe, & Smith, in press) have found that individuals high in hardiness appraise potential stressors as less threatening and employ more adaptive coping strategies than do persons low in hardiness. Tests of the psychophysiological correlates of hardiness, however, have not produced consistent results. Some studies suggest that individuals high in hardiness display less physiological arousal in response to laboratory stressors than those who are low (Contrada, 1989; Wiebe, 1991), while other studies suggest the opposite (Allred & Smith, 1989). In addition to the inconsistent findings concerning the association of hardiness with illness and physiological indices of stress, hardiness research has been plagued by a number of criticisms. Many of the supportive findings concerning health outcomes come from retrospective studies, and all the relevant research relies on self-reports of health. Further, the majority of studies have been conducted with exclusively male samples. The measurement of hardiness has been the subject of much recent concern. The original Hardiness Scale (Kobasa, 1979, 1982) and its shortened versions contain items primarily reflecting lack of commitment, control, and challenge and are derived from measures of maladaptive traits, such as alienation. As a result. Funk and Houston (1987) have suggested that this scale may assess general maladjustment or Neuroticism rather than anything resembling the conceptual definition of hardiness. As noted above, the potential confounding of hardiness with Neuroticism or negative afl'ectivity presents a plausible alternative interpretation of studies of hardiness and health. Rather than reflecting an association of commitment, challenge, and control with reduced likelihood of physical illness, the results of such studies may simply replicate the correlation between Neuroticism and somatic complaints. A recent convergent-discriminant validation study using multiple

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measures of hardiness and Neuroticism has indicated that although these constructs are highly correlated, they are distinct (Wiebe, Williams, & Smith, 1990). The correlations between measures of hardiness are significantly higher than their correlations with Neuroticism. The large correlations with Neuroticism, however, reinforce the concern that shared variance with this dimension may explain the apparent association of hardiness and health. Empirical tests of this alternative hypothesis have produced mixed results. Two studies indicated that the statistical control of Neuroticism or negative affectivity eliminated the correlation between hardiness and health reports (Funk & Houston, 1987; Rhodewalt & Zone, 1989), while one study found that this correlation remained significant (Wiebe et al., 1990). Statistical control of Neuroticism apparently does not eliminate the correlation between measures of hardiness and adaptive cognitive and coping processes (Allred & Smith, 1989; Williams et al., in press). A second criticism of the typical measurement of hardiness concerns the assumption of its unidimensional nature. Although composed of three conceptual elements, Kobasa (1979, 1982) described the construct as unitary and reported that the scale consists of a single factor (Kobasa, 1982). However, consistent with recent discussions of the need to explore the complex structure of traits and associated scales (Carver, 1989), Hull, Van Treuren, and Virnelli (1987) found that the Hardiness Scale contains three distinct components. Further, only commitment and control were significantly related to health outcomes. As in the case of Type A behavior, the five-factor model has much to offer researchers interested in hardiness. It is clear that although it may not be synonymous with Neuroticism, hardiness as currently measured is sufficiently correlated with this dimension to warrant its simultaneous assessment and statistical control in future hardiness research. The measurement of hardiness has been sufficiently problematic as to raise concerns about whether or not hardiness theory has been adequately tested. If new measures are to be developed, the validation procedures associated with approaches to many personality traits and their assessment, including the five-factor model, would provide a clear advance over the present level of psychometric sophistication in hardiness research. The five-factor model may also provide alternative conceptions and assessments of hardiness more directly. Although researchers have been concerned with the empirical overlap of hardiness scales and measures of Neuroticism, the conceptual definition of hardiness shares common features with some descriptions of the trait of Openness to Experience

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(McCrae & Costa, in press). The conceptual similarity of these dimensions, as well as the availability of valid measures and Openness to Experience's established place in five-factor taxonomy, suggests that future research should examine the potential stress-moderating effects of Openness to Experience. Optimism. A more recent entry in the array of personality traits used in studies of health is optimism. Scheier and Carver (1985, 1987) define dispositional optimism as a stable, generalized expectation that good things will happen. Without consideration of the causal attributions for events, individual differences in optimism versus pessimism simply reflect relatively enduring, broad expectations concerning the likelihood of positive versus negative outcomes. In the context of their control theory approach to self-regulation (Carver & Scheier, 1982), Scheier and Carver (1985, 1987) suggest that individual differences in optimism are important influences on the process of adjustment. When individuals become aware of a discrepancy between a behavioral goal or standard and their present situation, this individual difference influences the subsequent course of action. Optimists, expecting that positive outcomes are likely, will attempt to solve or cope actively with the situation. In contrast, pessimists, expecting bad outcomes, are prone to passive or fatalistic responses. Scheier and Carver (1985, 1987) argue that the more adaptive coping of optimists should lessen the effects of stressors on emotional adjustment and physical health. Optimism is assessed with the Life Orientation Test (LOT; Scheier & Carver, 1985), an eight-item questionnaire. Recent research has indicated that high optimism scores are associated with reduced reports of physical illness (Scheier & Carver, 1985), higher levels of problemfocused coping, and less use of passive coping strategies such as avoidance (Scheier, Weintraub, & Carver, 1986). Other findings suggest that expectant mothers with high LOT scores are less likely to experience postpartum depression (Carver & Gaines, 1987), and that in alcoholic populations high LOT scores are associated with greater chances of completing treatment (Strack, Carver, & Blaney, 1987). Recently, Scheier et al. (1989) found that optimistic cardiac surgery patients demonstrated better postoperative recoveries and less likelihood of an intra-operative myocardial infarction compared to their more pessimistic counterparts. These results are quite consistent with the conceptual model of optimism and adjustment. Some of the correlates of optimism, such as symptom reporting and

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specific coping behaviors, are also known to be associated with Neuroticism or negative affectivity (Costa & McCrae, 1987b; McCrae & Costa, 1986; Vitaliano, Maiuro, Russo, & Becker, 1987; Watson & Pennebaker, 1989). Thus, once again this basic personality trait provides a potential alternative explanation. A recent convergent-discriminant validity study suggested the LOT is closely correlated with Neuroticism. In three independent samples, this measure of optimism was as closely correlated with measures of Neuroticism as it was with a second measure of optimism (Smith, Pope, Rhodewalt, & Poulton, 1989). That is, the LOT did not demonstrate discriminant validity with regard to the trait of Neuroticism. The LOT could be construed as a measure of Neuroticism (i.e., scored in the opposite direction), and at the very least is heavily contaminated with this trait. This raises the question of whether or not shared variance with Neuroticism accounts for the apparent correlations of optimism with the adjustment processes described above. In two studies, statistical control of Neuroticism eliminated the otherwise significant correlation between LOT scores and physical symptoms and coping behaviors (Smith, O'Keefe, & Allred, 1989, Studies 1 and 2). As a result, some of the supportive findings regarding optimism as assessed by the LOT may be more appropriately interpreted as effects of Neuroticism. Other correlates of optimism-pessimism are not so readily attributable to shared variance with Neuroticism, such as the likelihood of intraoperative complications. Nonetheless, the high degree of overlap with Neuroticism suggests that correlations of the LOT with other variables cannot be unambiguously interpreted as reflecting optimism. In this aspect of personality and health research, the five-factor model again provides an important methodological caution. Scheier et al. (1989) have argued that the problematic overlap with Neuroticism may be due to the fact that optimism-pessimism is a subfactor or facet within the broader dimension of Neuroticism, and that optimism may be related to coping and health independent of other facets of the broader trait. This hypothesis is consistent with previous discussions of the limitations of broad, complex traits (Briggs, 1989; Carver, 1989). Peterson and Seligman (1987) have proposed a health-relevant construct similar to optimism. Explanatory style refers to the characteristic causal attributions individuals make for positive and negative outcomes. According to this model, an optimistic explanatory style consists of internal, stable, and global attributions for positive events, and external, unstable, and specific attributions for negative events. The pessimis-

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tic explanatory style is characterized by the opposite pattern of causal attributions. Explanatory style can be assessed with either structured questionnaires or a rating technique using written or verbal descriptions of events. Preliminary results suggest that explanatory style may indeed predict subsequent health (for a review, see Peterson & Seligman, 1987). For example, a pessimistic explanatory style is associated with subsequent increased reports of illness and visits to a physician. Further, these associations appear to be mediated by pessimists' decreased reports of healthy behaviors (e.g., regular exercise), increased reports of stressful life events, and low self-efficacy regarding their ability to stay healthy (Peterson, 1988). Although the limitations of research using illness behavior as an outcome apply to these findings, subsequent research on explanatory style is more compelling. Peterson, Seligman, and Vaillant (1988) found that a pessimistic explanatory style was associated with physicians' ratings of subjects as less healthy over a 35-year follow-up. Despite these positive results, it is important to note that the assessment procedures used in the most compelling prospective studies of health have not been subjected to rigorous evaluations of construct validity. As a result, these techniques may be useful in predicting health outcomes, but the interpretation of results is limited by the lack of independent evidence of construct validity. Correlations with the dimensions of the five-factor model would be a useful first step in rectifying this problem. Inhibited power motivation. One of the personality characteristics studied in current health psychology is based on McClelland's (1975, 1985) work on power motivation. Power motivation is defined as the desire to have an impact on others, either by controlling, influencing, aggressing against, or even helping them (McClelland, 1975). When inhibited or frustrated, either by psychological processes such as selfrestraint or situational factors, power motivation is hypothesized to contribute to the development of disease. Inhibited power motivation is assessed through the use of projective techniques similar to and including the Thematic Apperception Test. These ratings are quite reliable and are stable over time (for a review, see Jemmott, 1987), although independent evaluations of construct validity have been scarce. Inhibited power motivation has been linked to a variety of health outcomes. In two cross-sectional studies, McClelland (1979) found that individuals high in inhibited power motivation were more likely to have

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high blood pressure, and in a 20-year prospective study found that inhibited power motivation was associated with increased risk of developing hypertension. This dimension has also been linked to greater reports of physical illness (McClelland & Jemmott, 1980). Further, inhibited power motivation is associated with a variety of measures of reduced immunocompetence, suggesting that such individuals would be at greater risk of a variety of infections and neoplastic diseases (Jemmott et al., 1983; Jemmott et al., 1990; McClelland, Alexander, & Marks, 1982; McClelland, Floor, Davidson, & Saron, 1980). These studies suggest that inhibited power motivation confers an increased risk of disease. The associations with high blood pressure and suppressed immune functioning suggest plausible physiological mechanisms linking enduring motives and health. Lacking from this nomological net, however, are larger, prospective studies evaluating the utility of trait in predicting mortality or serious illness. Although plausible, such a relationship is yet to be established empirically. It is interesting to note that a second motive complex studied by these investigators—unstressed affiliation—has been found to be associated with fewer reported illnesses and better immune system functioning (e.g., Jemmott et al., 1990; for a review, see Jemmott, 1987). Individuals high in inhibited power motivation are described as assertive, argumentative, and competitive, while those characterized by the unstressed affiliation motive are seen as friendly, avoiding causing disagreement, and enjoying time with others (Jemmott, 1987). Although these characteristics may be related to several traits within the five-factor model (e.g., Extraversion), it is clear that these two motive constellations are quite similar to the poles of the Antagonism versus Agreeableness dimension. This parallel has yet to be explored, but motivationally based systems of personality have been successfully tied to the five-factor model in previous research (Costa & McCrae, 1988). Other dimensions of personality. The list of traits considered in personality and health research extends well beyond our present scope. However, several others are worth noting because of their current prominence in the field. Health locus of control (B. S. Wallston, K. A. Wallston, Kaplan, & Maides, 1976; K. A. Wallston, B. S. Wallston, & DeVellis, 1978) has been widely studied in many contexts (K. A. Wallston, 1989). Individuals who believe that their health is controllable are more likely to seek relevant information, comply with prescribed treatment regimens, and avoid the depression that often accompanies chronic illness.

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The psychoanalytically based concept of alexythymia has received increasing attention. Alexythymic individuals are characterized by a lack of psychological insight and difficulty identifying and expressing emotions. Although questions remain about the validity of available assessment devices, a number of studies are consistent with the notion that these individuals may be at increased risk of physical illness (Lesser, 1981). Antonovsky (1979) has proposed that one's sense of coherence is an important determinant of vulnerability to illness. This construct is defined as a "feeling of confidence that one's internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected" (Antonovsky, 1979). Although there is little empirical evidence to support this hypothesis at present, this model has attracted considerable interest. Advantages a n d Limitations ot the Five-Factor Model The preceding review of personality and health research is likely to produce several impressions. First, a great deal of research has been and continues to be undertaken. Second, a rather disparate set of personality constructs has been articulated and studied. Third, although the theoretical models are often interesting and compelling, their translation into measurement procedures is often lacking, incomplete, or haphazard. Finally, while some strong points exist, the evidence of clear links to health outcomes is often tentative. Thus, despite its current vitality, several large challenges must be addressed if the current wave of personality and health research is to avoid the fate of its predecessor. The five-factor model is certainly an asset in this effort, but it is not a complete solution and if used uncritically may actually pose new problems of its own. It is clear that the personality measures used in current research on health are often lacking. Scale development rarely takes full advantage of the current state of the art in personality measurement technology. Similarly, after their initial development, very few of these measures are subjected to thorough construct validation. As a result, we have little confidence that the scales actually assess the intended constructs and not conceptually irrelevant but well-established traits. The five-factor model has two potential contributions in this regard. Although this model certainly does not have a monopoly on sophisticated psychometrics in personality research, the tradition of personality

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research in which the model is embedded provides rich and thorough lessons in scale development and validation. The psychometric considerations of convergent and discriminant validity require that the construct of interest be located in a theoretically relevant conceptual space. Correlations with the five factors provide a comparison to the broad domain of personality traits that might be useful initial steps in this construct validation process. Further, the specific devices that have been developed to assess this taxonomy have known validity and may be directly useful. Measures of Neuroticism are clearly important for methodological purposes. Measures of Agreeableness and Openness to Experience may capture the dimensions suggested by past theory and research as influences on health. The unintegrated nature of the current set of health-relevant traits creates the risk of redundant research efforts. As others have noted (Costa & McCrae, 1987a; Holroyd & Coyne, 1987; Smith, Pope, Rhodewalt, & Poulton, 1989), when theoretical models and associated measures are developed without careful attention to the broader personality literature, it is likely that traits will be reinvented or mislabeled. After a period of rapid, divergent growth, the field is in need of exploration of commonalities, integration, and a common language. The five-factor model provides the language, reference points, and measurement tools for just such an effort. The five-factor model is not without its potential limitations as an aid to personahty and health research, however. For example, the model's major contribution is in the description of personality, not in explanations of how personality might be related to health. While such descriptions are a much-needed tool, they do not contribute all that is needed for theoretical accounts of personality structure and for understanding psychosomatic mechanisms or processes. It could be argued that at present the most pressing issues are at the level of description and measurement—what are the relevant traits and what is their predictive utility in studies of disease? However, once clear descriptions and robust associations with health are established, explanation becomes important. While clearly valuable, a strictly descriptive, empirical application of the five-factor model would ignore the likelihood that theoretical models provide important guides in the selection of traits and health outcomes and the design of tests of association. Much of behavioral medicine is relatively atheoretical. The unsophisticated adoption of a powerful descriptive taxonomy presents the risk of making it even more atheoretical. Further, some of the existing conceptual models may not

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mesh well with the five-factor taxonomy. This is particularly true for constructs derived from cognitive or social learning approaches, such as optimism and health locus of control. The cognitive perspective and specific individual difference dimensions of these approaches are not well represented in the Big Five taxonomy. A related potential limitation of the five-factor model is the breadth of the dimensions within the taxonomy. Because the entire domain of personality is reduced to five traits, the conceptual and operational definitions of each of these dimensions are by necessity broad. One potential drawback of this approach is a loss of specificity in the description and measurement of individual traits. For example, Scheier et al. (1989) argued that the difficulty in detecting effects of optimism independent of Neuroticism reflects the fact that optimism is a component of the broader, complex trait. As noted above, they argue further that when individual components of Neuroticism are assessed, unique effects of optimism are detectable. Several authors have voiced this concern about personality measurement (Briggs, 1989; Carver, 1989). Fortunately, some measures of the five-factor model provide information about facets or components within the broader dimensions (Costa & McCrae, 1985), and development of additional measures at this level of analysis is progressing (McCrae & Costa, in press). The five-factor model could be interpreted as an example of traditional trait approaches to personality. In such approaches, traits are construed as stable individual differences, exerting effects across long periods of time and a wide range of situations. Much of the research on personality and health follows the traditional statistical strategy of testing main effects of personality on health or related outcomes. In contrast, many of the underlying theories of this research view health as influenced by the interaction of personality traits and relevant characteristics of situations (Matthews, 1983; Smith, 1989). For example, stress moderation models predict that associations between personality and health will be most apparent under stressful environmental conditions. Thus, by testing only the main effects of traits and failing to consider situational variables, much of the research on personality and health does not address the general Person x Situation interactional assumptions (Endler & Magnusson, 1976) of the underlying theories. Of course, there is nothing within the five-factor model to preclude the consideration of situations and their statistical interaction with traits. In fact, more precise conceptualization and measurement of personality dimensions could lead to improved specification and assessment

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of relevant situational parameters. However, by providing an emphasis on the conceptualization and measurement of traits, an uncritical adoption of the model may inadvertently maintain this limitation of previous research. Thus, a similar conceptual and measurement scheme for situational factors is needed, as well as direct tests of interactional predictions. Traits and situations do not simply interact statically or statistically; these classes of variables interact actively as well (Endler & Magnusson, 1976). Personality traits influence choices about which situations to enter and avoid, as well as the interpretation of situational factors. That is, through their thoughts and actions, people create many of the situations they encounter and, in turn, are influenced by these created situations (Bandura, 1977; Mischel, 1973). This type of active interactional process may underlie the statistical association between personality traits and health outcomes (Smith & Anderson, 1986; Smith & Pope, 1990). Again, there is nothing inherent in the five-factor model that precludes consideration of the dynamic, reciprocal relationship between persons and situations, and its thoughtful use may actually refine our understanding of such processes. However, by making stable, crosssituational person variables salient, adoption of the five-factor model may divert attention from these important considerations. Many of these potential limitations of the five-factor model could be avoided if personality and health researchers avoid a narrow, traditional view of the trait taxonomy, and borrow more from the current personality field than the emerging taxonomy and its associated measurement tools. Static and dynamic interactional models have a long and developed history in the field. Established and newer, evolving concepts and methods are available for exploring these issues (Cantor, 1990; Carson, 1989). Thus, other aspects of recent personality theory and research, when combined with the five-factor model, may provide a truly comprehensive improvement in health research. New Directions for Research Even before exploration of complex interrelationships among persons and situations, adoption of the five-factor model has valuable implications for future personality and health research. Most obviously, correlations of existing measures in personality and health research with measures of the Big Five would be useful (cf. Barefoot et al., 1989; Costa et al., 1989; Dembroski & Costa, 1987). Such efforts not only

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would provide much-needed evaluations of construct validity, but would begin to develop a common language and organizational scheme for this often-scattered and confusing area of research. As interest in the five-factor model has increased in recent years, a number of empirical comparisons of this system with other approaches to personality have been conducted (e.g., Costa & McCrae, 1988; McCrae & Costa, 1989a, 1989b; McCrae, Costa, & Busch, 1986). These efforts have increased integration among seemingly disparate views of personality. Such studies also provide clear examples of the type of empirical integration presently lacking in health research. The second obvious direction for new health research is a direct examination of the predictive utility of five-factor model measurement systems. The association of individualfive-factormodel traits and interactive combinations of traits (e.g., Eysenck, 1990) with disease outcomes would be of considerable interest. From the review presented in this article, it is clear that measures of Agreeableness and Neuroticism will prove to be useful predictors of health and health behavior. As noted previously. Openness to Experience may be associated with the stress-reducing—and therefore illness-buffering—cognitive appraisals identified in other models of personality and health. Other possibilities exist. For example, individual differences in Conscientiousness may account for the wide range of levels of compliance with prescribed regimens commonly observed among medical patients, and Extraversion or its facets may identify people who would be most and least likely to profit from social support during times of stress. Clearly, a large and potentially important research agenda can be articulated from the application of the five-factor model to issues of physical health. A more coherent conceptual and empirical foundation for the study of personality and health would likely emerge from such efforts, and consolidation of the current list of health-relevant traits into a more organized taxonomy would do much to facilitate progress in the field. The assessment of individuals in clinical health settings would be improved, and lasting answers to recurring questions about the influence of personality on health might finally appear. REFERENCES Alexander, F. (1950). Psychosomatic medicine. New York: Horton. Allred, K. D., & Smith, T. W. (1989). The hardy personality: Cognitive and physiological responses to evaluative threat. Journal of Personality and Social Psvcholoev 56. 257-266. " ^ «. '

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