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 limita-
tions. The present article briefly reviews this literature and discusses the advan-
tages 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 sub-

sequent physical health has appeared in medical and philosophical writ-
ings 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 foun-
dation 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
396 Smith and Williams

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 person-
ality 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, person-
ality characteristics are hypothesized to influence the frequency, dura-
tion, 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 ill-
ness. 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 enter-
prise 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 inade-
quacy 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 spe-
cific theoretical models. As a result, the question of their overlap with
existing constructs and measures is often neglected, raising the possi-
bility 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
Personality and Health 397

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 re-
search 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 gen-
eral 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 contribu-
tion—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 Emo-
tional 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
398 Smith and Williams

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 cur-
rent personality and health research. As an organizational scheme, we
will review the specific traits comprising this area of research. Our pri-
mary focus is on the question of psychosomatics: Is personality causally
related to physical illness? After this review, we will discuss the advan-
tages 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 compre-
hensive 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 ele-
ments 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 fol-
lowing the demise of the psychoanalytic approach to psychosomatics
was Friedman and Rosenman's (1959) articulation of the Type A be-
havior 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 identifi-
cation with the older psychosomatic approach. Indeed, their emphasis
on overt behavioral characteristics—competitiveness, hostility, impa-
tience, achievement striving, job involvement, and a loud, explosive
vocal style—foreshadowed the more empirical approach of current per-
sonality 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
Personality and Health 399

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, & Noru-
sis, 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 be-
tween Type A behavior and coronary heart disease is heightened cardio-
vascular 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 modi-
fication 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 develop-
ments in recent years. The first issue concerns the assessment of Type
A behavior. Although many devices exist, three are considered pri-
mary by virtue of their use in large, prospective studies—the Type A
Structured Interview (SI; Rosenman, 1978), the Jenkins Activity Sur-
vey (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 indi-
vidual 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
400 Smith and Williams

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 striv-
ing (Dembroski, MacDougall, Costa, & Grandits, 1989; Dembroski,
MacDougall, Williams, Haney, & Blumenthal, 1985; Hecker, Ches-
ney, Black, & Frautchi, 1988; Matthews, Glass, Rosenman, & Bort-
ner, 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., Bare-
foot, 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 hos-
tility 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 at-
tention to the differences among aspects of hostility. These measures
differ in the extent to which they assess subjective or experiential as-
pects 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 objec-
tive 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-
Personality and Health 401

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 re-
fiected, 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 com-
plaints. In contrast. Antagonism corresponds to those aspects of hos-
tility 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 ill-
ness. 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 sug-
gests that the apparent relationship between Neuroticism and health is
artifactual, and this misleading association has important methodologi-
cal, conceptual, and perhaps even clinical implications.
Many studies have indicated that individuals who score high on mea-
sures 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-
402 Smith and Williams

ports of illness and/or symptoms are often associated with actual physi-
cal 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 complain-
ing 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 em-
pirically 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 sig-
nificant 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 Neuroti-
cism 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 nor-
mal 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 ab-
sence 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, how-
ever, also score higher on measures of Neuroticism than do the patients
Personality and Health 403

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 Neuroti-
cism 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, con-
tinued 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 com-
plaints 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 Booth-
Kewley (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 con-
tribute to the apparent health consequences of emotional distress (Stone
& Costa, in press). Finally, much of the research suggesting that stress-
ful 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
404 Smith and Williams

with reports of both more stressful life circumstances and more fre-
quent 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 pos-
sible 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 individu-
als 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 ex-
periences 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 individu-
als 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 ill-
ness 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
Personality and Health 405

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 link-
ing 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 psychophysio-
logical correlates of hardiness, however, have not produced consistent
results. Some studies suggest that individuals high in hardiness dis-
play 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 sup-
portive 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 commit-
ment, control, and challenge and are derived from measures of mal-
adaptive 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 reflect-
ing 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
406 Smith and Williams

measures of hardiness and Neuroticism has indicated that although

these constructs are highly correlated, they are distinct (Wiebe, Wil-
liams, & Smith, 1990). The correlations between measures of hardi-
ness are significantly higher than their correlations with Neuroticism.
The large correlations with Neuroticism, however, reinforce the con-
cern 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 cor-
relation remained significant (Wiebe et al., 1990). Statistical control of
Neuroticism apparently does not eliminate the correlation between mea-
sures 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 ex-
plore 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 mea-
surement of hardiness has been sufficiently problematic as to raise con-
cerns about whether or not hardiness theory has been adequately tested.
If new measures are to be developed, the validation procedures asso-
ciated 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
Personality and Health 407

(McCrae & Costa, in press). The conceptual similarity of these dimen-

sions, 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 re-
flect 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 sub-
sequent 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 in-
dicated that high optimism scores are associated with reduced reports
of physical illness (Scheier & Carver, 1985), higher levels of problem-
focused coping, and less use of passive coping strategies such as avoid-
ance (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 alco-
holic 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 pessimis-
tic 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
408 Smith and Williams

specific coping behaviors, are also known to be associated with Neuroti-

cism or negative affectivity (Costa & McCrae, 1987b; McCrae & Costa,
1986; Vitaliano, Maiuro, Russo, & Becker, 1987; Watson & Penne-
baker, 1989). Thus, once again this basic personality trait provides a
potential alternative explanation. A recent convergent-discriminant va-
lidity 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 mea-
sure 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 Neu-
roticism (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 cor-
relations 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 as-
sessed by the LOT may be more appropriately interpreted as effects of
Neuroticism.
Other correlates of optimism-pessimism are not so readily attribut-
able to shared variance with Neuroticism, such as the likelihood of intra-
operative 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 con-
struct 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 in-
ternal, stable, and global attributions for positive events, and external,
unstable, and specific attributions for negative events. The pessimis-
 Personality and Health 409

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 be-
havior 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 assess-
ment procedures used in the most compelling prospective studies of
health have not been subjected to rigorous evaluations of construct va-
lidity. As a result, these techniques may be useful in predicting health
outcomes, but the interpretation of results is limited by the lack of inde-
pendent 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 self-
restraint 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 includ-
ing 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
410 Smith and Williams

high blood pressure, and in a 20-year prospective study found that

inhibited power motivation was associated with increased risk of de-
veloping hypertension. This dimension has also been linked to greater
reports of physical illness (McClelland & Jemmott, 1980). Further, in-
hibited 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 (Jem-
mott 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 inves-
tigators—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 as-
sertive, argumentative, and competitive, while those characterized by
the unstressed affiliation motive are seen as friendly, avoiding caus-
ing 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 moti-
vationally 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 per-

sonality 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. Wall-
ston, 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.
Personality and Health 4H

The psychoanalytically based concept of alexythymia has received

increasing attention. Alexythymic individuals are characterized by a
lack of psychological insight and difficulty identifying and express-
ing emotions. Although questions remain about the validity of avail-
able 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" (Antonov-
sky, 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 pro-
duce 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 theo-
retical models are often interesting and compelling, their translation
into measurement procedures is often lacking, incomplete, or haphaz-
ard. 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 per-
sonality 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 com-
plete 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 sophisti-
cated psychometrics in personality research, the tradition of personality
412 Smith and Williams

research in which the model is embedded provides rich and thorough

lessons in scale development and validation. The psychometric con-
siderations 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 person-
ality literature, it is likely that traits will be reinvented or mislabeled.
After a period of rapid, divergent growth, the field is in need of ex-
ploration of commonalities, integration, and a common language. The
five-factor model provides the language, reference points, and mea-
surement 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 expla-
nations of how personality might be related to health. While such de-
scriptions are a much-needed tool, they do not contribute all that is
needed for theoretical accounts of personality structure and for under-
standing 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 impor-
tant. 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
Personality and Health 413

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 de-
scription 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 compo-
nent 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 informa-
tion 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 tradi-
tional 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 char-
acteristics 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 con-
ditions. 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 person-
ality dimensions could lead to improved specification and assessment
414 Smith and WiUiams

of relevant situational parameters. However, by providing an empha-

sis on the conceptualization and measurement of traits, an uncritical
adoption of the model may inadvertently maintain this limitation of pre-
vious 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 & Magnus-
son, 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 inter-
actional process may underlie the statistical association between per-
sonality 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 be-
tween persons and situations, and its thoughtful use may actually refine
our understanding of such processes. However, by making stable, cross-
situational 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, tradi-
tional view of the trait taxonomy, and borrow more from the current
personality field than the emerging taxonomy and its associated mea-
surement 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 implica-
tions for future personality and health research. Most obviously, cor-
relations 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
Personality and Health 415

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 empiri-
cal 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 inte-
gration presently lacking in health research.
The second obvious direction for new health research is a direct ex-
amination of the predictive utility of five-factor model measurement
systems. The association of individualfive-factormodel traits and inter-
active combinations of traits (e.g., Eysenck, 1990) with disease out-
comes 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 possibili-
ties exist. For example, individual differences in Conscientiousness may
account for the wide range of levels of compliance with prescribed regi-
mens 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 physio-
logical responses to evaluative threat. Journal of Personality and Social Psvcholoev
56. 257-266. " ^ «. '
416 Smith and Williams

Angell, M. (1985). Disease as a reflection of the psyche. New England Journal of

Medicine, 312, 1570-1572.
Antonovsky, A. (1979). Health, stress, and coping. San Francisco: Jossey-Bass.
Bandura, A. (1977). Social learning theory. Englewood Cliffs, NJ: Prentice-Hall.
Barefoot, J. C , Dodge, K. A., Peterson, B. L., Dahlstrom. W. G., & Williams,
R. B., Jr. (1989). The Cook-Medley Hostility Scale: Item content and ability to
predict survival. Psychosomatic Medicine, 51. 46-57.
Bass, C., & Wade, C. (1984). Chest pain with normal coronary arteries: A comparative
study of psychiatric and social morbidity. Psychological Medicine, 14, 51-61.
Beitman, B. D., Mukerji, V., Lamberti, J. W., Schmid, L., DeRosear, L., Kushner, M.,
Flaker, G., & Basha, I. (1989). Panic disorder in patients with chest pain and
angiographically normal coronary arteries. American Journal of Cardiology, 63,
1399-1403.
Booth-Kewley, S., & Friedman, H. S. (1987). Psychological predictors of heart dis-
ease: A quantitative review. Psychological Bulletin, 101, 343-362.
Briggs, S. R. (1989). The optimal level of measurement for personality constructs. In
D. M. Buss & N. Cantor (Eds.), Personality research for the 1990s (pp. 246-260).
New York: Springer-Verlag.
Cantor, N. (1990). From thought to behavior: "Having" and "doing" in the study of
personality and cognition. American Psychologist, 45, 735-750.
Carson, R. C. (1989). Personality. Annual Review of Psychology, 40, 227-248.
Carver, C. S. (1989). How should multifaceted personality constructs be tested? Issues
illustrated by self-monitoring, attributional style, and hardiness. Journal of Person-
ality and Social Psychology, 56, 577-585.
Carver, C. S.. & Gaines, J. G. (1987). Optimism, pessimism, and postpartum depres-
sion. Cognitive Therapy and Research, 11, 449-462.
Carver, C. S., & Scheier, M. F. (1982). Control theory: A useful conceptual framework
for personality—social, clinical, and health psychology. Psychological Bulletin, 92.
111-135.
Case, R. B., Heller, S. S., Case, N. B., & Moss, A. J. (1985). Type A behavior and
survival after acute myocardial infarction. New England Journal of Medicine, 312,
737-741.
Chesney, M. A., Black, G.W., Chadwick, J. H.. & Rosenman, R. H. (1981). Psycho-
logical correlates of the Type A behavior pattern. Journal of Behavioral Medicine,
4, 217-229.
Contrada, R. J. (1989). Type A behavior, personality hardiness, and cardiovascular
response to stress. Journal of Personality and Social Psychology, 57, 895-903.
Cook, W., & Medley, D. (1954). Proposed hostility and pharisaic virtue scales for the
MMPI. Journal of Applied Psychology, 38, 414-418.
Cooper, T., Detre, T., & Weiss, S. M. (1981). Coronary-prone behavior and coronary
heart disease: A critical review. Circulation, 63. 1199-1215.
Costa, P. T., Jr., Fleg. J. L., McCrae, R. R., & Lakatta, E. G. (1982). Neuroticism,
coronary artery disease, and chest pain complaints: Cross-sectional and longitudinal
studies. Experimental Aging Research, 8, 37-44.
Costa, P. T., Jr., & McCrae, R. R. (1985). The NEO Personality Inventory manual.
Odessa, FL: Psychological Assessment Resources.
Costa, P. T., Jr., & McCrae. R. R. (1987a). Personality assessment in psychosomatic
Personality and Health 417

medicine. In T. M. Wise (Ed.). Advances in psychosomatic medicine (pp. 71-82).

Basel, Switzerland: Karger.
Costa, P. T., Jr.. & McCrae, R. R. (1987b). Neuroticism, somatic complaints, and
disease: Is the bark worse than the bite? Journal of Personality, 55, 299-316.
Costa. P. T., Jr., & McCrae. R. R. (1988). From catalog to classification: Murray's
needs and the five-factor model. Journal of Persotmlity and Social Psychology, 55,
258-265.
Costa, P. T.. Jr.. McCrae, R. R.. & Dembroski, T, M. (1989). Agreeableness vs. an-
tagonism: Explication of a potential risk factor for CHD. In A. W. Siegman & T. M.
Dembroski (Eds.), In search of coronary-prone behavior (pp. 41-63). Hillsdale, NJ:
Lawrence Erlbaum.
D'Andrade. R. B. (1965). Trait psychology and componential analysis. American
Anthropologist, 67, 215-228.
Dembroski, T. M., & Costa, P. T , Jr. (1987). Coronary-prone behavior: Components
of the Type A pattern and hostility. Journal of Personality, 55, 211-235.
Dembroski, T. M., MacDougall, J. M., Costa, P. T., Jr.. & Grandits, G. A. (1989).
Components of hostility as predictors of sudden death and myocardial infarction in
the Multiple Risk Factor Intervention Trial. Psychosomatic Medicine, 51, 514-522.
Dembroski. T. M., MacDougall, J. M., Williams. R. B.. Jr.. Haney, T. L., & Blumen-
thal, J. A. (1985). Components of Type A, hostility and anger-in: Relationship to
angiographic findings. Psychosomatic Medicine, 47, 219-233.
Depue, R. A., & Monroe, S. M. (1986). Conceptualization and measurement of human
disorder in life stress research: The problem of chronic disturbance. Psychological
Bulletin, 99, 36-5\.
Digman, J. M. (1990). Personality structure: Emergence of the five-factor model.
Annual Review of Psychology, 41, 417-440.
Dunbar, H. F. (1943). Psychosomatic diagnosis. New York: Hoeber.
Endler, N. S., & Magnusson, D. (Eds.). (1976). Interactional psychology and person-
ality. New York: Wiley.
Eysenck, H. J. (1990). Type A behavior and coronary heart disease: The third stage.
Journal (rfSocial Behavior and Personality, 5, 25-44.
Friedman, H. S., & Booth-Kewley, S. (1987). The '"disease-prone personality": A
meta-analytic view of the construct. American Psychologist, 42, 539-555.
Friedman. M., & Rosenman, R. H. (1959). Association of a specific overt behav-
ior pattern with increases in blood cholesterol, blood clotting time, incidence of
arcus senilis and clinical coronary artery disease. Journal of the American Medical
Association, 169, 1286-1296.
Friedman, M.. & Rosenman, R. H. (1974). Type A behavior and your heart. New
York: Knopf.
Friedman, M., Thoresen, C. E., Gill, J. J., Powell, L. H., Ulmer, D., Thompson, L.,
Price, V. A., Rabin, D. D., Breall, W. S., Dixon. T., Levy, R., &Bourg, E. (1984).
Alteration of the Type A behavior pattern and reduction in cardiac recurrences in
postmyocardial infarction patients. American Heart Journal, 108, 237-248.
Funk, S. C , & Houston, B. K. (1987). A critical analysis of the Hardiness Scale's
validity and utility. Journal of Personality and Social Psychology, 53, 572-578.
Glass. D. C. (1977). Behavior patterns, stress, and coronary disease. Hillsdale, NJ:
Lawrence Erlbaum.
418 Smith a n d Williams

Harbin, T. J. (1989). The relationship between Type A behavior pattern and physio-
logical responsivity: A quantitative review. Psychophysiology, 26, 110-119.
Haynes, S. G., Feinleib, M., & Kannel, W. B. (1980). The relationship of psycho-
social factors to coronary heart disease in the Framingham Study: 111. Eight-year
incidence of coronary heart disease. American Journal of Epidemiology, 111, 37-58.
Hearn, M. D., Murray, D. M., & Leupker, R. V. (1989). Hostility, coronary heart dis-
ease, and total mortality: A 33-year follow-up study of university students. Journal
of Behavioral Medicine, 12, 105-121.
Hecker, M. H. L., Chesney, M. A., Black, G. W., & Frautchi, N. (1988). Coronary-
prone behaviors in the Western Collaborative Group Study. Psychosomatic Medicine,
50, 153-164.
Hegel, M. T., Abel, G. C , Etscheidt, M., Cohen-Cole, S., & Wilmer, C. 1. (1989).
Behavioral treatment of angina-like chest pain in patients with hyperventilation
syndrome. Journal of Behavior Therapy and Experimental Psychiatry, 20, 31-39.
Holroyd, K. A., & Coyne, J. C. (1987). Personality and health in the 1980s: Psycho-
somatic medicine revisited? Journal of Personality, 55, 359-375.
Houston, B. K. (1988). Cardiovascular and neuroendocrine reactivity, global Type A,
and components of Type A behavior. In B. K. Houston & C. R. Snyder (Eds.),
Type A behavior pattern: Research, theory, & intervention (pp. 212-253). New
York: Wiley.
Hull, J. G., Van Treuren, R. R., & Virnelli, S. (1987). Hardiness and health: A cri-
tique and alternative approach. Journal of Personality and Social Psychology, 53,
518-530.
Idler, E. L., Kasl, S. V., & Lemke, J. H. (1990). Self-evaluated health and mortality
among the elderly in New Haven, Connecticut, and Iowa and Washington Counties,
Iowa, 1982-1986. American Journal of Epidemiology, 131, 91-103.
Jemmott, J. B., II]. (1987). Social motives and susceptibility to disease: Stalking
individual differences in health risks. Journal of Personality, 55, 267-298.
Jemmott, J. B., Ill, Borysenko, J. Z., Boresenko, M., McClelland, D. C , Chap-
man, R., Meyer, D., & Benson, H. (1983). Academic stress, power motivation,
and decrease in salivary secretory immunoglobulin A secretion rate. Lancet, 1,
1400-1402.
Jemmott, J. B., Ill, Hellman, C , McClelland, D. C , Locke, S. E., Kraus, L., Wil-
liams, R. M., & Valeri, C. R. (1990). Motivational syndromes associated with
natural killer cell activity. Journal of Behavioral Medicine, 13, 53-73.
Jenkins, C. D., Rosenman, R. H., & Zyzanski, S. J. (1974). Prediction of clini-
cal coronary heart disease by a test for the coronary-prone behavior pattern. New
England Journal of Medicine, 23, 1271-1275.
Kobasa, S. C. (1979). Stressful life events, personality and health: An inquiry into
hardiness. Journal (^Personality and Social Psychology, yi, I-l 1.
Kobasa, S. C. (1982). Commitment and coping in stress-resistance among lawyers.
Journal of Personality and Social Psychology, 42, 707-717.
Kobasa, S. C , Maddi, S. R., & Kahn, S. (1982). Hardiness and health. Journal of
Personality and Social Psychology, 42, 168-177.
Kobasa, S. C , Maddi, S. R., Puccetti, M. C , & Zola, M. A. (1985). Effectiveness
of hardiness, exercise, and social support as resources against illness. Journal of
Psychosomatic Research, 29, 525-533.
Personality and Health 419

Kobasa, S. C , & Puccetti, M. C. (1983). Personality and social resources in stress

resistance. Journal of Personality and Social Psychology, 45, 839-850.
Krantz, D. S., & Hedges, S. M. (1987). Some cautions for research on personality
and health. Journal of Personality, 55, 351-357.
Lantinga, L. J., Spafkin, R. P., & McCroskery, J. H. (1988). One-year psychosocial
follow-up of patients with chest pain and angiographically normal coronary arteries.
American Journal of Cardiology, 62, 209-213.
Leon, G. R., Finn, S. E., Murray, D., & Bailey, J. M. (1988). The inability to pre-
dict cardiovascular disease from hostility scores or MMPI items related to Type A
behavior. Journal af Consulting and Clinical Psychology, 56, 597-600.
Lesser, I. M. (1981). A review of the alexithymia concept. Psychosomatic Medicine,
43, 531-543.
Linn, B. S., & Linn, M. W. (1980). Objective and self-assessed health in the old and
very old. Social Science and Medicine, 14, 311-315.
Matthews, K. A. (1983). Assessment issues in coronary-prone behavior. In T. M. Dem-
broski, T. H. Schmidt, & G. Blumchen (Eds.), Biobehavioral bases of coronary
heart disease (pp. 62-78). Basel, Switzerland: Karger.
Matthews, K. A. (1988). CHD and Type A behavior: Update on and alternative to
the Booth-Kewley and Friedman quantitative review. Psychological Bulletin, 104,
373-380.
Matthews, K. A., Glass, D. C , Rosenman, R. H., & Bortner, R. W. (1977). Competi-
tive drive. Pattern A, and coronary disease: A further analysis of some data from
the Western Collaborative Group Study. Journal of Chronic Diseases, 30, 489-498.
Matthews, K. A., Krantz, D. S., Dembroski, T. M., & MacDougall, J. M. (1982).
Unique and common variance in structured interview and Jenkins Activity Sur-
vey measures of the Type A behavior pattern. Journal of Personality and Social
Psychology, 42, 303-313.
Mayou, R. (1989). Atypical chest pain. Journal of Psychosomatic Research, 33, 393-
406.
McClelland, D. C. (1975). Power: The inner experience. New York: Irvington-Halsted.
McClelland, D. C. (1979). Inhibited power motivation and high blood pressure in men.
Journal of Abnormal Psychology, 88, 182-190.
McClelland, D. C. (1985). Human motivation. Glenview, IL: Scott-Foresman.
McClelland, D. C., Alexander, C., & Marks, E. (1982). The need for power, stress, im-
mune function, and illness among male prisoners. Journal of Abnormal Psychology,
91, 61-70.
McClelland, D. C , Floor, E., Davidson, R. J., & Saron, C. (1980). Stressed power
motivation, sympathetic activation, immune function, and illness. Journal of Human
Stress, 6(2), 11-19.
McClelland, D. C , & Jemmott, J. B., III. (1980). Power motivation, stress, and
physical illness. Journal of Human Stress, 6(4), 6-15.
McCrae, R. R. (1982). Consensual validation of personality traits: Evidence from
self-reports and ratings. Journal of Personality and Social Psychology, 43, 293-303.
McCrae, R. R., & Costa, P. T., Jr. (1984). Emerging lives, enduring dispositions:
Personality in adulthood. Boston: Little-Brown.
McCrae, R. R., & Costa, P. T., Jr. (1986). Personality, coping, and coping effectiveness
in an adult sample. Journal of Personality. 54. 385-405.
420 Smith and Williams

McCrae, R. R., & Costa. P. T., Jr. (1987). Validation of the five-factor model of
personality across instruments and observers. Journal of Personalitv and Social
Psychology, 52, 81-90.
McCrae. R. R.. & Costa. P. T.. Jr. (1989a). The structure of interpersonal traits;
Wiggins' circumplex and the five-factor model. Journal of Personality and Social
Psychology. 56. 586-595.
McCrae. R. R . & Costa. P. T.. Jr. (1989b). Reinterpreting the Myers-Briggs Type
Indicator from the perspective of the five-factor model of personality. Journal of
Personality. 57. 17-40.
McCrae. R. R.. & Costa, P. T.. Jr. (in press). Conceptions and correlates of open-
ness to experience. In S. R. Briggs, W. H. Jones. & R. Hogan (Eds.), Handbook of
personality. New York: Academic Press.
McCrae, R. R.. Costa, P. T., Jr.. & Busch. C. M. (1986). Evaluating comprehensive-
ness in personality systems: The California Q-Set and the five-factor model. Journal
of Personality. 54, 430-446.
McMahon, C. E. (1976). The role of imagination in the disease process: Pre-Cartesian
medical history. Psychological Medicine, 6, 179-184.
Megargee, E. I. (1985). The dynamics of aggression and their application to cardiovas-
cular disorders. In M. A. Chesney & R. H. Rosenman (Eds.), Anger and hostility in
cardiovascular and behavioral disorders {^p. 31-57). Washington. DC: Hemisphere.
Mischel, W. (1968). Personality and assessment. New York: Wiley.
Mischel, W. (1973). Toward a cognitive social learning reconceptualization of person-
ality. Psychological Review. 80, 252-283.
Musante, L.. MacDougall, J. M., Dembroski, T. M.. & Costa, P. T., Jr. (1989).
Potential for hostility and dimensions of anger. Health Psychology, 8, 343-354.
Ockene, I. S., Shay, M. J., Alpert. J. S., Weiner, B. H., & Dalen, J. E. (1980).
Unexplained chest pain in patients with normal coronary arteriograms: A follow-up
study of functional status. New England Journal of Medicine. 303. 1249-1252.
O'Keeffe, J. L., & Smith, T. W. (1988). Self-regulation and Type A behavior. Journal
of Research in Personality, 11. 232-251.
Pasternak. R. C . Thilbault, G. E.. Savoia. M., Desanetis, R. W.. & Hutler. A. M.
(1980). Chest pain with angiographically insignificant coronary arterial obstruc-
tion: Clinical presentation and long-term follow-up. American Journal of Medicine,
68, 813-817.
Peterson, C. (1988). Explanatory style as a risk factor for illness. Cognitive Therapy
and Research. 12. 119-132.
Peterson, C , & Seligman, M. E. P. (1987). Explanatory style and illness. Journal of
Personality, 55, 237-265.
Peterson. C , Seligman, M. E. P., & Vaillant, G. E. (1988). Pessimistic explanatory
style as a risk factor for physical illness: A thirty-five-year longitudinal study. Journal
of Personality and Social Psychology. 55, 23-27.
Pope. M. K., Smith, T. W.. & Rhodewalt, F. (1990). Cognitive, behavioral, and affec-
tive correlates of the Cook and Medley Ho Scale. Journal of Personality Assessment.
54, 501-514.
Powell, L. H.. & Thoresen. C. E. (1988). Effects of Type A behavioral counseling
and severity of prior acute myocardial infarction on survival. American Journal of
Cardiology, 61, 1159-1163.
Personality and Health 421

Rabkin, J. G., & Struening, E. H. (1976). Life events, stress, and illness. Science,
194, 1013-1020.
Rhodewalt, R, & Agustsdottir, S. (1984). On the relationship of hardiness to the Type
A behavior pattern: Perception of life events versus coping with life events. Journal
of Research in Personality, 18, 212-223.
Rhodewalt, R, & Zone, J. B. (1989). Appraisal of life change, depression, and illness
in hardy and nonhardy women. Journal of Personality and Social Psychology. 56,
81-88.
Rosenman, R. H. (1978). The interview method of assessment of the coronary-prone
behavior pattern. In T. M. Dembroski, S. M. Weiss, J. L. Shields, S. G. Haynes,
& M. Feinleib (Eds.), Coronary-prone behavior (pp. 55-70). New York: Springer-
Verlag.
Roth, D. L., Wiebe, D. J., Fillingim, R. B., & Shay, K. A. (1989). Life events, fit-
ness, hardiness, and health: A simultaneous analysis of proposed stress-resistance
effects. Journal of Personality and Social Psychology. 57. 136-142.
Scheier, M. R, <& Carver, C. S. (1985). Optimism, coping, and health: Assessment and
implications of generalized outcome expectancies. Health Psychology. 4, 219-247.
Scheier, M. R, & Carver, C. S. (1987). Dispositional optimism and physical well-
being: The influence of generalized outcome expectancies on health. Journal of
Personality. 55, 169-210.
Scheier, M. R, Matthews, K. A., Owens, J. R, Magovern, G. J., Lefebvre, R. C ,
Abbott, R. A., & Carver, C. S. (1989). Dispositional optimism and recovery from
coronary artery bypass surgery: The beneficial eifects on physical and psychological
well-being. Journal of Personality and Social Psychology. 57, 1024-1040.
Scheier, M. R, Weintraub, J. K., & Carver, C. S. (1986). Coping with stress: Divergent
strategies of optimists and pessimists. Journal of Personality and Social Psychology,
51. 1257-1264.
Selye, H. (1956). The stress of life. New York: McGraw-Hill.
Shekelle, R. B., Gale, M., & Norusis, M. (1985). Type A score (Jenkins Activity
Survey) and risk of recurrent coronary heart disease in the Aspirin Myocardial
Infarction Study. American Journal of Cardiology, 56, 221-225.
Shekelle, R. B., Gale, M., Ostfeld, A. M., & Paul, O. (1983). Hostility, risk of
coronary heart disease, and mortality. Psychosomatic Medicine, 45, 109-114.
Siegman, A. W., Dembroski. T., & Ringel. N. (1987). Components of hostility and
the severity of coronary artery disease. Psychosomatic Medicine, 48, 127-135.
Smith. T. W. (1989). Interactions, transactions, and the Type A pattern: Additional
avenues in the search for coronary-prone behavior. In A. W. Siegman & T. M. Dem-
broski (Eds.), In search of coronary-prone behavior (pp. 91-116). Hillsdale, NJ:
Lawrence Erlbaum.
Smith, T. W., & Anderson, N. B. (1986). Models of personality and disease: An inter-
actional approach to Type A behavior and cardiovascular risk. Journal of Personality
and Social Psychology. 50, 1166-1173.
Smith, T. W., & Frohm, K. D. (1985). What's so unhealthy about hostility? Con-
struct validity and psychosocial correlates of the Cook and Medley Ho Scale. Health
Psychology. 4, 503-520.
Smith. T.W., O'Keeffe, J. L., & AUred, K. D. (1989). Neuroticism, symptom reports.
422 Smith and Williams

and Type A behavior: Interpretive cautions for the Framingham scale. Journal of
Behavioral Medicine, 12 1-11.
Smith, T. W., & Pope, M. K. (1990). Cynical hostility as a health risk: Current status
and future directions. Journal of Social Behavior and Personality, 5, 77-88.
Smith, T. W., Pope, M. K., Rhodewalt, R, & Poulton, J. R (1989). Optimism, neu-
roticism, coping, and symptom reports: An alternative interpretation of the Life
Orientation Test. Journal of Personality and Social Psychology, 56, 640-648.
Smith, T. W., Sanders, J. D., & Alexander, J. R (1990). What does the Cook and
Medley Hostility Scale measure? Affect, behavior, and attributions in the marital
context. Journal of Personality and Social Psychology, 58, 699-708.
Somervell, P. D., Kaplan, B. H., Heiss, G., Tyroler, H. A., Kleinbaum, D. G., &
Obrist, P. A. (1989). Psychologic distre.ss as a predictor of mortality. American
Journal of Epidemiology, 130, 1013-1023.
Stone, S. V., & Costa, P. T., Jr. (in press). Disease-prone personality or distress-prone
personality? The role of neuroticism in coronary heart disease. In R. Friedman
(Ed.), Personality and illness. New York: Wiley.
Strack, S., Carver, C. S., & Blaney, P. H. (1987). Predicting successful completion of
an aftercare program following treatment for alcoholism: The role of dispositional
optimism. Journal of Personality and Social Psychology, 53, 579-584.
Suls, J.. & Rittenhouse, J. D. (1987). Personality and health: An introduction. Journal
of Personality. 55, 155-167.
Suls, J., & Sanders, G. S. (1989). Why do some behavioral styles place people at coro-
nary risk? In A. W. Siegman & T. M. Dembroski (Eds.), Jn search of coronary-prone
behavior (pp. 1-20). Hillsdale, NJ: Lawrence Erlbaum.
Vitaliano, P. P., Mairuo, R. D., Russo, J., & Becker. J. (1987). Raw versus relative
scores in the assessment of coping strategies. Journal of Behavioral Medicine. 10,
1-18.
Wallston, B. S., Wallston, K. A., Kaplan, G. D., & Maides, S. A. (1976). Devel-
opment and validation of the Health Locus of Control (HLC) Scale. Journal of
Consulting and Clinical Psychology, 44, 580-585.
Wallston, K. A. (1989). Assessment of control in health-care settings. In A. Steptoe
& A. Appels (Eds.), Stress, personal control and health (pp. 85-105). Brussels-
Luxembourg: Wiley.
Wallston, K. A., Wallston, B. S., & DeVellis, R. (1978). Development of the Multi-
dimensional Health Locus of Control (MHLC) scales. Health Education Mono-
graphs, 6, 161-170.
Watson, D., & Pennebaker, J. W. (1989). Health complaints, stress, and distress: Ex-
ploring the central role of negative affectivity. Psychological Review, 96, 234-254.
Wiebe, D. J. (1991). Hardiness and stress moderation: A test of proposed mechanisms.
Journal of Personality and Social Psychology. 60, 89-99.
Wiebe, D. J., & McCallum, D. M. (1986). Health practices and hardiness as mediators
in the stress-illness relationship. Health Psychology, 5, 425-438.
Wiebe, D. J., Williams, P. W., & Smith, T. W. (1990). Hardiness, neuroticism. and
life events: Independent or overlapping effects? Unpublished manuscript.
Wielgosz, A. T., & Earp, J. (1986). Perceived vulnerability to serious heart disease
and persistent pain in patients with minimal or no coronary disease. Psychosomatic
Medicine, 48, 118-124.
Personality and Health 423

Williams, P. W., Wiebe, D. J., & Smith, T. W. (in press). Coping processes as me-
diators of the relationship between hardiness and health. Journal of Behavioral
Medicine.

Manuscript received June 20, 1990; revised November 2, 1990.