Friday, September 01, 2006

Determinants of health-enhancing behaviours

Personality

Might it not be the case that our personalities play a very significant role in determining our adoption, or otherwise, of health-enhancing behaviours? Certainly there seem to be many psychologists who believe this is the case, as evidenced by the amount of research conducted in this area. Probably the most popular explanation offered has concerned the so-called Type A and B personalities.

The concept of the Type A personality was introduced by Friedman and Rosenman (1974) to describe psychological characteristics which they believed to be associated with proneness to coronary heart disease (CHD). The Type A personality is: highly competitive and achievement oriented, does not suffer fools gladly, always in a hurry and unable to bear delays and queues, hostile and aggressive, it also reads, eats and drives very fast, and is constantly thinking what to do next, even when supposedly listening to someone else. In contrast to this the Type B personality is relaxed, laid back, lethargic, even-tempered, amiable and philosophical about life, relatively slow in speech and action, and generally has enough time for everyone and everything.

The classification of individuals as Type A or B has traditionally been made on the basis of a structured interview (Rosenman, 1978) in which people are not only asked questions about their Type A/B modes of behaviour but also provoked into directly manifesting such behaviour by being subjected to pauses and delays in the interview, deliberately interrupted and challenged about their answers to questions. Their responses to these provocations enable the interviewers to refine their ratings of Type A/B characteristics. The structured interview (SI) is generally considered to be the best method for assessing the Type A/B personality but many researchers have adopted the less time consuming approach of using standardized self-report questionnaires of which the Jenkins Activity Survey has been most commonly used. This simply asks questions about B modes of behaviour.

Early research tended to lend strong support to these ideas. For example, the Western Collaborative Group Study (WCGS) in which over 3/000 Califomian men, aged from 39 to 59 at entry, were assessed as Type A or B using the SI and followed up initially over a period of eight and a half years, and later extending over 22 years. In an influential report on the results at the eight nd a half year follow-up, Rosenman et al. (1975) found that Type As were twice as likely as Type Bs to suffer from subsequent CHD. Of the sample 7% developed some signs of CHD and two-thirds of these were Type As. This increased risk was apparent even when other risk factors assessed at entry, such as blood pressure and cigarette smoking, were statistically controlled for.

However more recent research has not found this level of relationship, so instead researchers have now tended to focus on more specific aspects of the Type A personality that may determine illness (Adler & Matthews, 1994). One component that has generated a decent amount of research has been hostility. As in the case of the Type A/B personality, research on hostility and health is divided between studies using SI methods to assess hostility and those using questionnaires, usually the Cook-Medley Ho Scale. For example, Barefoot, Dahlstrom, and Williams (1983) found that high hostility increased the risk for CHD. They used the Ho scale to analyze the hostility scores of a group of physicians during medical school and followed up 25 years later. The results indicated that hostility was associated with more than a fourfold increase in the chances for CHD.

Unconscious Processes

From a Freudian perspective there may be many unconscious processes involved in determining health behaviours. Freud consistently argued that what was in the unconscious would often become manifested in behavioural ways, thus given that health behaviours are in no way different to other behaviours why could we not become well or ill due to unconscious factors? One psychoanalyst who to this idea to its more extreme conclusions was Georg Groddeck.

Georg Groddeck propounded a somewhat bizarre and largely intuitive theory based upon his experiences in analysing cases of heart disease, cancer, and other serious organic illnesses. The individual according to this theory does not live his own life and has little to do with his fate. He is, in fact, lived by the 'It' which seems to be conceived as a compound of the Freudian 'Id' with the wisdom of the Jungian collective unconscious. It was the 'It' which decided when the individual would be born, and it also decides when he will die, whether or not he will succeed, and when and how he becomes ill. Every disease, from a wart to a cancer, is an expression of the omnipresent and omnipotent 'It'. For example, a woman with a small wart on the inner aspect of her thigh was told by Groddeck that she wished to become a man and had therefore produced (or, rather, her 'It' had produced) a miniature penis. A woman with a tumour of the uterus had obviously developed the tumour because, lacking a child, the 'It' had caused this deadly substitute 'child' to grow within her. A fracture case would be asked: 'Why did you break your arm?' and a case of laryngitis: 'Why did you wish to be unable to speak?' (Brown, 1964, pp.89-90).

The evidence offered by Groddeck is purely anecdotal and most people would regard his views on the causes of physical illness as absurd, but is it necessarily ridiculous to propose that a real physical illness can sometimes come about as the result of an unconscious impulse? To take a fairly extreme example, if we accept that, in the case of an hysterical pregnancy, many of the physical symptoms of a real pregnancy can be brought about by an unconscious wish, is it not conceivable that, on some occasions, a real heart attack can occur in someone who has an unconscious wish to commit suicide?

Rather than propose that the symptoms of organic disease always have a symbolic meaning for the sufferer, an alternative and more influential approach from the psychosomatic schools has been based on the concept of unrelieved tension. When certain problematic emotions, such as anxiety, depression, aggression and sexual impulses, cannot be effectively discharged or rechannelled, they can have physiological consequences which predispose the individual to develop specific organic diseases. One area that gained a great deal of attention during the 1940-50's was trying to why some people developed cancer. Leshan and Worthington (1956), reviewing research in this area for the British Journal of Medical Psychology, drew the following inclusions:

There appear to be four separate threads which run through the literature in this area. These are (1) the patient's loss of an important relationship prior to the development of the tumour; (2) the cancer patient's inability successfully to express hostile feelings and emotions; (3) the cancer patient's unresolved tension concerning a parental figure; (4) sexual disturbance. (Lesham and Worthington, 1956, p. 54)

Whilst some of these ideas may seem somewhat bizzare, the notion that we are responsible for our own health and that we may or may not engage in health-enhancing behaviours for reasons that we are not aware of, is still an assumption that seems plausible today. For example it is still used in attempting to explain why some people experience eating disorders and others do not.

Mental State

Whilst we may assume that mental health states (e.g. being very happy or sad) will contribute to determining health behaviours, we may be wrong. For example, Adler & Matthews (1994) reviewed findings linking positive and negative dispositions to illness and they report a fairly perplexing set of contrasting findings. For example, Peterson et al (1988), in a 35-year follow-up of 99 graduates of the Harvard University classes of 1942-44, found that pessimistic explanatory style, as assessed in tests taken by the participants while undergraduates, were predictive of poor physical health in later life as assessed by physicians. Yet in stark contrast to this, Friedman et al. (1993) found that children who had been rated by their parents and teachers as having a good sense of humour and being optimistic and cheerful were more likely than other children to die early in adulthood.

Another somewhat counter-intuitive finding is that of Reed et al (1994) who investigated the relationship between realistic acceptance and survival time of men suffering from AIDS. They found that those who were assessed as showing a realistic acceptance of their deteriorating condition and eventual death had a mean survival time which was nine months less than those who were assessed as being unduly optimistic. In an earlier review of research concerning mental health Taylor and Brown (1988) concluded that overly positive self-evaluations, exaggerated perceptions of control and mastery and unrealistic optimism, far from being associated with psychological difficulties, were actually associated with good mental health. Reed et al. appear to have shown that this surprising result extends even into the field of physical health. Thus it does not appear to be too clear what mental states are relates to health behaviours and well-being.

Finally, another mental state which has been of interest to health psychologists over the last 20 years is the notion of locus of control. Originally formulated by Rotter (1954), this concept was applied to health beliefs by Wallston et al (1978) who developed the Multidimensional Health Locus of Control (MHLC) Scale. This questionnaire has three subscales measuring the extent to which people attribute their state of health to their own behaviour (internal locus), and/or external factors including both powerful others, especially medical professionals, and chance or fate. In a detailed review of research on the topic, Norman and Bennett (1996) found that the results were mixed and they concluded that the relationship between locus of control and health behaviour is a weak one, a conclusion which was recently confirmed by a large-scale study of a representative sample of 11,632 people who completed the MHLC in Wales (Norman et , 1998).

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