LIVE FYRAND, LARS WICHSTRØM, TORBJØRN MOUM,

ANNE GLENNÅS and TORE K. KVIEN

THE IMPACT OF PERSONALITY AND SOCIAL SUPPORT ON

MENTAL HEALTH FOR FEMALE PATIENTS WITH
RHEUMATOID ARTHRITIS

(Accepted 6 February 1997)

ABSTRACT. The relationship between personality traits, social support and

mental health problems was studied in 138 female patients with rheumatoid
arthritis (RA).
Structural equation modelling showed that instrumental support was uncorre-
lated with mental health problems. The effect of emotional support on mental
health was spurious and due to personality traits. Companionship had a direct
effect on mental health in addition to partially mediating the effects of both extra-
version and neuroticism. However, the total effect of social support was moderate
compared to a strong influence of neuroticism. The therapeutical implications are
discussed.

Numerous studies have found rather strong inverse relationships

between perceived social support, well-being, psychological distress
and symptoms of poor mental health. Some studies show that social
support has particularly strong effects on well-being (Heady and
Wearing, 1992); other on depression (Cohen and Hoberman, 1983;
Schaefer et al., 1981); other studies show more generalized effects
of socials support on psychological distress in terms of both anxiety
and depression (Norbeck and Tilden, 1983; Turner and Noh, 1983).
In addition to the apparently beneficial main effects of social
support on well-being, psychological distress, social support appears
to buffer the adverse effects of life events and life stresses on mental
health (Aneshensel and Stone, 1982; Brown et al., 1986; Cohen and
Wills, 1985; Cohen and Hoberman, 1983; Turner, 1983).
It is not entirely clear, however, if these patterns reflect on-going,
dynamic processes of interpersonal exchange and nurturing or if
stable personality traits, such as neuroticism and extraversion
to some extent act as confounders that create spurious correla-
tions between social support and mental health. Four papers have

Social Indicators Research 40: 285–298, 1997.

c 1997 Kluwer Academic Publishers. Printed in the Netherlands.

VICTORY: PIPS No.: 136959 HUMSKAP

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286 LIVE FYRAND ET AL.

addressed this possibility. Taylor and Chave (1964) found that the
effect of social support on nervous problems – but not psychosis
– was lost when personality was taken into account. This was also
the principal finding in a community study in Canberra, Australia
(Henderson et al., 1981). McLennan and Omodei (1988) studied
psychological adjustment among married couples, and found that
the effect of social support on women’s but not men’s psychological
adjustment was lost when controlling for neuroticism and extraver-
sion. Finally, Bolger and Eckenrode (1991) studied the anxiety level
among 56 college students before and after taking an exam. They
found that both neuroticism and extraversion acted as confounders
for the relationship between perceived social support and anxiety.
However, when personality was controlled for, a significant influ-
ence of discretionary social contacts on anxiety remained.
In sum, these studies indicate that the often-cited buffering effect
of social support with respect to mental health problems may in
fact be spurious and due to stable personality traits. However, so far
this has only been tested in the general population and in relation
to acute stress. Several writers have emphasized the importance of
social support in coping with chronic stress, such as incapacitating
somatic diseases.
It has been suggested that social support alleviates the mental
health problems associated with Rheumatoid Arthritis (RA)
(Fitzpatrick et al., 1988; Newman et al., 1989). But, as Bolger
and Eckenrode (1991) pointed out, one does not know whether or
not personality acts as a confounder among persons in such preva-
lent clinical populations. Social support measures mostly have been
unidimensional, with a growing acknowledgement of the limitations
this creates for the social support research field. Social relationships
have been assessed from two perspectives: the structural (e.g., social
network and social integration) and the functional (e.g., emotional
and instrumental support) (Bolger and Eckenrode, 1991; Cohen et
al., 1985; Cohen and Wills, 1985; Ganster and Victor, 1988; House
and Kahn, 1985). Social companionship can be seen as one aspect of
social integration. Rook (1987) defines companionship as “shared
leisure and other activities that are undertaken primarily for the
intrinsic goal of enjoyment” (pp. 1133). Emotional and instrumental
support, however, concerns problem-based aid in a relationship

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 SOCIAL SUPPORT, PERSONALITY AND MENTAL HEALTH 287

(Bolger and Eckenrode, 1991; DiMatteo and Hays, 1983; House

and Kahn, 1985; Rook, 1987).
Results from numerous studies comparing different types of social
support tentatively can be summed up as follows: Instrumental
support is inconsistently (Cohen et al., 1985; Hart and Hittner, 1991)
and emotional support consistently (Thoits, 1985) correlated to
mental health, but when personality is controlled for, the effect of
emotional support seems to disappear (Bolger and Eckenrode, 1991;
Henderson et al., 1981). There is a consistent effect of companion-
ship on mental health (Hart and Hittner, 1991; Rook, 1987) which
seems to remain even when taking personality into account (Bolger
and Eckenrode, 1991). However, because these studies have mainly
studied the healthy populations, we do not know if this will be the
picture among patients coping with chronic somatic disease.
Furthermore, there is one other possibility that has not been consi-
dered so far, namely, that social support is a mediating factor (an
intervening variable) between personality and mental health. In this
case, persons with different personalities are hypothesized to attract
different amounts of support from their social environment, but the
link between social support and mental health itself is seen as truly
causal (as is the link between personality and social support).
In sum, no study so far has addressed the full complexity of the
interrelationships between different types of personality, different
types of social support, and various aspects of mental health. We
should take into consideration direct effects, spurious effects, as
well as indirect effects.
The present article will therefore address the following research
questions: 1) Is there a positive association between social support
and mental health among RA-patients? 2) If so, does the correla-
tion between social support and mental health reflect a direct causal
relationship or is it confounded by personality traits such as neuroti-
cism and extraversion? 3) If a relationship between social support
and mental health can be documented, does social support operate
as a mediating link (a “mechanism”) between personality traits and
mental health? 4) Do different types of social support show differ-
ential relationship to personality and mental health?

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288 LIVE FYRAND ET AL.

METHODS

Subjects
The subjects were females with RA of more than 6 years duration
(N = 138), aged 18–67 years, (mean age = 55 years, SD = 12), living
in the city of Oslo. The patients were selected from The Norwegian
Lutheran Hospital, Oslo City Department of Rheumatology, based
on consecutive admissions to the hospital. They were screened by the
disability subscale of the Health Assessment Questionnaire (HAQ)
(Fries et al., 1980). The physical functioning subscale ranges from
0–3, 0 being functioning independently and without any difficulties,
to 3 being totally dependent on help from others. Patients with scores
between 0.1 and 2.99 were included. Mean HAQ-scores was 1.56
(SD = 0.8). The mean duration of RA was 20 years (SD = 10).
A broad range of socio economic strata was represented, as
measured by the subjects’ educational level: 14.9% had only junior
high school; 25.7% had one additional course beyond junior high
school; 26.4% had completed senior high school; while an addi-
tional 23.0% had some additional education beyond the high school
level. The mean net income for the family was NOK 175,000,–
(approx. USD 26,000,–), SD = NOK 106,000,–. Almost two thirds
were currently living with a spouse or partner (62.5%).

Instruments
Personality traits, namely extraversion and neuroticism, were
measured by Eysenck’s Personality Questionnaire for Adults (EPQ)
(Eysenck and Eysenck, 1975). Both showed adequate reliability,
(alpha = 0.84, 21 items and 0.86, 23 items, respectively). Examples
of sample items for measuring extraversion are: “Are you a talkative
person?”; “Are you rather lively?”; and for neuroticism: “Does your
mood often go up and down?”; “Do you often worry about things
you should not have done or said?”.
Social support was measured by the Social Support Question-
naire of Transaction (SSQT) (Suurmeijer et al., 1995; van Sonderen,
1990). SSQT allegedly measures five types of social support;
1: “Everyday emotional support”, 2: “Emotional support with
problems”, 3: “Social companionship”, 4: “Everyday instrumental
support” and 5: “Instrumental support with problems”. An explora-

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tory factor analysis (principal components, varimax solution) with

eigenvalues >1 as criterion of the items in SSQT, yielded 7 factors,
but they could not be interpreted in a meaningful way. A 3-factor
solution yielded a factor structure that corresponded with the hypoth-
esized dimensions, but with no distinction between the two types
of emotional support and between the two types of instrumental
support. All but two factor loadings were higher than 0.54 and only
one lower than 0.40 (viz. 0.35), and no cross-loadings >0.30. We
therefore created one emotional support index by combining the
two emotional types. We ended up making three additive indexes
measuring types of social support, namely emotional support (sam-
ple items: “Do you experience friendliness and sympathy in your
contracts with other people?”; “Do you talk problems over with
other people?”) (alpha = 0.83, 10 items); social companionship
(sample items: “Does it ever happen that people drop in for a
(pleasant) visit?”; “Have you ever had a pleasant day out with other
people?”) (alpha = 0.75, 5 times); and instrumental support (sample
item: “Does it ever happen to you that people help you do odd jobs?”;
“Have you ever been given help with things like, for example, a car
or anything else of great value?”) (alpha = 0.52, 6 items). High
scores on the social support variables indicate much support. All
indexes are based on 0/1-weights for individuals items (“little jiffy”)
and are thus allowed to be correlated between themselves.
Mental health problems were operationalized as symptoms of
anxious and depressed mood, and measured by the General Health
Questionnaire (GHQ-28) (Goldberg and Hillier, 1979). Favourable
reliabilities were found for both anxiety and depression (alpha =
0.84, 7 items and 0.88, 7 items, respectively). High scores on the
mental health indexes indicate many symptoms. Examples of sample
item for measuring anxiety: “Have you recently had difficulty in
staying asleep once you are off?”; and for depression: “Have you
recently found at times you couldn’t do anything because your nerves
were too bad?”.

Procedure
The above-mentioned measures were part of a larger study of RA-
patients comprising both an interview and questionnaires the total
procedure took approximately 2 hours to complete. Most (75%) of

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290 LIVE FYRAND ET AL.

TABLE I
Zero-order correlations between personality traits, mental health problems and
social support
1 2 3 4 5 6 7
1 Emotional support 1.00
2 Companionship 0.49b 1.00
3 Instrumental support 0.44b 0.39b 1.00
4 Anxiety ,0.19a ,0.12 ,0.08 1.00
5 Depression ,0.35b ,0.38b ,0.12 0.50b 1.00
6 Extraversion 0.33b 0.29b 0.17 ,0.07
a
,0.19a 1.00
7 Neuroticism ,0.41b ,0.34b ,0.06 0.49b 0.59b ,0.19a 1.00
a
p < 0.05; b p < 0.01.

the interviews took place in the respondent’s home, whereas 25%

were conducted in the hospital.

RESULTS

Zero-Order Correlations
Table I shows the intercorrelations between personality traits, social
support and mental health problems.
As can be seen from this table, several of our initial expectations
were confirmed with respect to emotional support which was related
both to anxiety and depression. Companionship was only related
to depression, whereas instrumental support was unrelated both to
anxiety and depression. It should be noted that social support was
more strongly correlated with depression than with anxiety. Both
emotional support and companionship were positively correlated
with extraversion and also strongly correlated with neuroticism.
Again, instrumental support was weakly related to extraversion and
unrelated to neuroticism. It was also found that neuroticism, showed
rather strong positive correlations with both anxiety and depression,
whereas extraversion only showed a slight negative correlation with
depression.
Thus, previous findings concerning the relationship between
social support and mental health problems were replicated to some
extent, but the data suggest that important differences exist between

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 SOCIAL SUPPORT, PERSONALITY AND MENTAL HEALTH 291
TABLE II
Model fitting
Model Chi-sq. df p GFI AGFI
M1 original 76.19 4 0.000 0.853 ,0.028
M2 free psi (2,1) (3,1) (3,2) 13.42 1 0.000 0.974 0.268
M2 trimmed fixed
beta (4,1) (5,3)
gamma (4,1) (5,1) 13.66 5 0.018 0.974 0.852
M2 trimmed psi (5,4) free 0.34 4 0.987 0.999 0.995

Note: GFI = Goodness of Fit Index, AGFI = Adjusted Goodness of Fit Index.

different types of social support. Moreover, the pattern of correla-

tions suggest that personality traits, in particular neuroticism, might
influence the relationship between social support, viz. emotional
support and companionship, and mental health problems, partic-
ularly those relating to depressed mood.

Path Analysis

In order to evaluate the relative importance of the direct and indirect

effects of personality and social support on mental health problems,
structural equation modelling was carried out using the LISREL-VII
program (Jöreskog and Sörbom, 1988).
Table II shows the results from the model fitting procedure.
The original model (M1 ) treating neuroticism and extraversion as
exogenous variables, with social support categories as a mediat-
ing endogenous variable and anxiety and depression as endogenous
variables, did not include correlation between measures of social
support, nor between the two measures of mental health (i.e. anxiety
and depression). As can be seen, the fit was rather poor. Allow-
ing the residuals of the social support measures to be correlated,
improved the fit considerably. Trimming the model by excluding
the direct effects of extraversion on anxiety and depression, as well
as between companionship and anxiety, and between instrumental
support and both anxiety and depression, all gammas <0.04 n.s.
(standardized path coefficient) did not alter the fit. Allowing for
a correlation between anxiety and depression, i.e. in effect treating

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292 LIVE FYRAND ET AL.

Figure 1 Path model of the impact of personality and social support on mental
health.

them as oblique factors, resulted in the best fit. This model is depicted
in Figure 1.
By comparing Figure 1 with Table 1 it can be seen that the initial
relationship between emotional support and depression disappeared
and the relationship between companionship and depression was
weakened somewhat, but remained significant. Although the path
from companionship to depression was significant and the path from
emotional support and depression was non-significant, the difference
in strength between these two effects only bordered on significance,
z = 1.89 (n.s.). The direct effect of extraversion on depression was
lost. However, companionship served as a mediator between both
extraversion (indirect effect = ,0.056) and neuroticism (indirect
effect = 0.063, both p < 0.05) on depression. Thus, almost all the
effect of extraversion on depression (Table I) was indirect. It can
also be seen that the initially strong relationship between emotional
support and depression in fact was totally spurious, owing to neuroti-
cism.

DISCUSSION

Causal Assumptions
A cautionary note is called for with respect to the causal status of the
observed statistical relationships between personality, social support

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 SOCIAL SUPPORT, PERSONALITY AND MENTAL HEALTH 293

and mental health. We would like to stress the cross-sectional nature

of our results; conclusions regarding causality should therefore be
suspended until follow-up studies of the present sample are avail-
able. However, it might be argued that basic personality traits such
as neuroticism and extraversion most probably are causes rather
than effects of both mental health status and social support. The
directionality of the relationship between social support and mental
health, however, is more uncertain. On the one hand, various types
of psychological problems may make people more dependent on
the company of others. On the other hand, psychological problems
may also lead to fear of seeing other people, and other people may
find interacting with distressed persons awkward and uncomfortable.
Nevertheless, studies generally show markedly higher test-retest
stability for EPQ than for GHQ (Farley and Power, 1988; Sanderman
and Ranchor, 1994). This indicates that mental health status is not
simply a subdimension of personality traits. However, the possibility
of measurement redundancy between personality and mental health
should not be completely ignored (Monroe and Steiner, 1986).

The Relationship of Different Social Support Types to Mental

Health

The present study of patients with RA confirms previous findings

from healthy populations concerning the correlation between mental
health and social support. Social support was more strongly corre-
lated with depression than with anxiety. The degree of correlation
varied with the type of social support in question; instrumental social
support proved to be uncorrelated with mental health. Emotional
support and companionship clearly played different roles in the
relationship between personality and mental health – the effect of
emotional support was totally spurious, whereas companionship had
a direct effect on depression in addition to mediating the effects of
both extraversion and neuroticism on depression.
The present findings underscore the importance of not treating
social support as one uniform dimension. Clearly, studies applying a
differentiated concept of social support might suggest more focused
interventions, as opposed to studies applying unidimensional
measures. With respect to intervention efforts it is pertinent to under-

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294 LIVE FYRAND ET AL.

stand why companionship seems to work better than other aspects

of social support.
This finding is in accordance with previous studies compar-
ing companionship with other types of social support (Bolger and
Eckenrode, 1991; Eckenrode and Wethington, 1990; Henderson et
al., 1981; Hirsch, 1980; Rook, 1987; Wills, 1985).
One possible explanation would focus on the content in the
different social support types. Companionship covers pleasurable
activities shared in an equal and symmetric relationship, whereas
emotional and instrumental support is problem-based aid exchanged
in an asymmetric “helper-helpee” relationship (Bolger and Ecken-
rode, 1991; Rook, 1987), underscoring the chronic patient’s status as
an “impaired” person in relation to the supportive others (DiMatteo
and Hays, 1987). Lack of reciprocity as a result of giving problem-
based aid and long-term provision of care to persons with physical or
mental disabilities, may have psychological effects both on the helper
and helpee (Eckenrode and Wethington, 1990). Thus the helpee-role
may imply several negative feelings connected with the burden they
feel that they put upon the supportive others as a result of their needs
(DiMatteo and Hays, 1983), feelings of embarrassment, vulner-
ability, weakness or indebtedness (Eckenrode and Wethington,
1990); which, taken together, imply that the costs may be greater
than the benefits.
The costs may be particularly burdensome for people with chronic
disease; feelings of inadequacy, lack of control over and dysfunc-
tional coping with the chronic stressors (following a chronic disease
may inhibit the helper-helpee relationship in a negative and dysfunc-
tional way (Eckenrode and Wethington, 1990). Self-disclosure is a
necessary pathway by which problems become known to poten-
tial supporters in their social network (Eckenrode and Wethington,
1990). Patients may wish to conceal their stigmatized identity from
others. Social detachment and the failure to disclose information
may be a consequence of this (DiMatteo and Hays, 1983). On the
other hand, avoiding a helpee-role may be costly in other domains,
particularly so for patients with chronic disease.

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 SOCIAL SUPPORT, PERSONALITY AND MENTAL HEALTH 295

Companionship as Mediator Between Personality Traits and

Depression

Companionship partly mediated the effect of both extraversion and

neuroticism on depression. One possible explanation for this is that
both extraverted and neurotic behaviour elicit different types of reac-
tions within the social network. Extraverted people are more out-
reaching, sociable and warm (Costa and McCray, 1980) these traits
possibly create positive interaction, positive feedback-processes,
functional social competence and much companionship as a natural
consequence, with a decrease in depression as a possible result.
In contrast, guilt proneness, anxiety, psychosomatic concerns and
worry characterize highly neurotic people (Costa and McCray, 1989;
Headey and Wearing, 1992). They have a tendency to withdraw,
suppressing their own needs for contact. Such deficiencies in social
competence have a negative influence on companionship with other
people, resulting in a possible increase in depression (Heady and
Wearing, 1992; Monroe and Steiner, 1986).
Chronic patients with strongly neurotic personality traits in this
way may be more exposed to challenges connected with the disease.
A dysfunctional coping which communities too many problems and
worries to their supportive others, may be a burden on the rela-
tionship itself, contributing to a negative and mistrustful process
between the partners possibly inducing both to withdraw from con-
tinued interaction (Eckenrode and Wethington, 1990).

Personality Traits; the Main Influential Factor on Mental Health?

With respect to the impact of personality traits on social support,

neuroticism was the important dimension, not extraversion. More-
over, neuroticism accounted for far more of the variance in mental
health than did social support.
Other studies confirm this finding (Bolger and Eckenrode, 1991;
Henderson et al., 1981; McLennan and Omodei, 1988). Neuroticism
has been found to be related to an increase in anxiety under stress, e.g.
through dysfunctional coping strategies as “wishful thinking” and
“self-blame” (Bolger, 1990). Cross-sectional studies have shown that
this coping strategy predicts distress, which appears to be particularly
characteristic of highly neurotic people (Bolger, 1990).

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296 LIVE FYRAND ET AL.

This type of coping can also be seen as parts of an attributional

style that creates vulnerability for depression. There seems to be firm
evidence that a negative cognitive triad increases the vulnerability
for depression (Abramson et al., 1978). However, such a negative
attributional style may be inherent in the neurotic personality (Hill
and Kemp-Wheeler, 1986).
Our results indicate that health and social workers should at least
be somewhat cautious in expecting quick and easy results from net-
work intervention on mental health. Tentatively it might be suggested
that increasing the possibilities of informal and causal social interac-
tions can prove beneficial. It might be appropriate to have a combina-
tion of social skills training – to enhance patients social competence
– and network intervention aiming to increase the possibilities for
companionship.

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Department of Research
Diakonhjemet College, Oslo
and
Department of Behaviorial Science in Medicine,
University of Oslo

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