Patient reported outcomes have become more and more important in clinical practice and research. Evaluating subjective perceptions of patients has become mandatory for a full assessment of treatment responses. In this context, clinimetrics, the science of clinical measurements, provides unprecedented opportunities for psychosomatic assessment. This volume illustrates how this approach can be translated into everyday practice complementing and improving the medical interview. The most sensitive and reliable clinical methods are presented for evaluating specific psychosocial aspects of disease, i.e. childhood adversities, life events and chronic stress, lifestyle, sexual function, subclinical and affective disturbances, personality, illness behavior, well-being and family dynamics. Each chapter provides practical illustrations as to how crucial information can be obtained with specific methods individualized according to the patients’ needs. A hyperlink is provided to a website that contains many of the instruments assessed in the volume. This book enables the reader to understand the value of patient reported outcomes in clinical practice. It is intended to expand and refine the skills of clinicians who work in general and specialized medicine and psychiatry, whether physicians, psychologists or other health professionals.
Fiammetta Cosci, 2011. "Assessment of Personality in Psychosomatic Medicine: Current Concepts", The Psychosomatic Assessment: Strategies to Improve Clinical Practice, G.A. Fava, N. Sonino, T.N. Wise
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The notion that personality variables can affect vulnerability to specific diseases has been widely promoted in psychosomatic medicine. Over the time, some personality patterns have been extensively studied. Among them, alexithymia, type A, and type D personality are the most relevant. However, also temperament and character has increasingly been object of studies. Alexithymia is currently recognized as a risk factor for medical, psychiatric, or behavioral problems; type A personality is recognized to increase the risk for coronary artery disease, and type D personality has been related to adverse cardiac events and cardiovascular outcomes. The growing interest and clinical role of the personality constructs in psychosomatic medicine has been favored by the revolutionary understanding that personality factors are not causes of medical disease but their moderators/mediators, and by the decline of the psychometric distinction between state and trait. Indeed, it is nowadays recognized that psychological constructs traditionally conceived as trait dimensions may surprisingly display sensitivity to change in specific clinical situations. Assessing personality, thus, has become worth pursuing since it may give unique information about individuals with medical conditions and contribute to completely understand medical patients and their global health as well as formulating optimal decision-making and treatment planning. In this framework, the present chapter has the aim to provide insight into personality dimensions in psychosomatic medicine and describe the main instruments to assess it.
The notion that personality variables can affect vulnerability to specific diseases was prevalent in the first phase of the development of psychosomatic medicine (1930-1960). Thereafter, this notion declined together with the prospects for psychosomatic medicine itself. In the last decades, changes in medicine provided a basis for an alternate approach to psychosomatic medicine [1]. Contributing to this process was the recognition of limitations of the narrow biomedical model and the emerging role of the biopsychosocial model of illness [2]. In this new psychosomatic perspective, personality received a relevant role.
Over the time, some personality patterns have been thought to be strictly linked to somatic illness and have been extensively studied. Moreover, new personality constellations have been developed attracting the attention of many researchers worldwide. One of the seminal personality constructs in psychosomatic medicine is undoubtedly alexithymia; one of the most influential constructs has certainly been type A personality, and one of the most promising constructs for the next years is type D personality.
The popularity of alexithymia in psychosomatic medicine has been highlighted by many authors. It has been conceived as a deficiency in the cognitive processing of emotions, which is not specific to psychosomatic disorders but it is currently recognized as a risk factor for medical, psychiatric, or behavioral problems that are influenced by difficulties modulating arousal, appropriately expressing or suppressing emotions, employing fantasy, and obtaining and using social support [3].
Type A personality has become a classic construct in psychosomatic medicine and indicates a ‘specific emotion-action complex’ of individuals aggressively committed to struggle to achieve more and more in less and less time [4]. Many data have accumulated, particularly in cardiology, according to which subjects with a type A personality might have an increased risk for coronary artery disease if compared to subjects without such personality characteristics.
Type D personality, a general propensity to distress that is defined by high scores on the ‘negative affectivity’ (NA) and ‘social inhibition’ traits, is increasingly studied, and a growing literature shows that it is related to adverse cardiac events and, being characterized also by a general propensity to psychological distress, to cardiovascular outcomes.
In general, the above-mentioned personality constructs, together with additional emerging ones, have earned a growing interest and an increasing clinical role in psychosomatic medicine. Their assessment has become worth pursuing because it can give unique information about individuals with medical conditions that traditional medical methods cannot reveal [5].
In this framework, the present chapter has the aim to provide insight into the assessment of personality dimensions in psychosomatic medicine as a contribution to the understanding of medical patients and their global health. The main instruments to assess personality in psychosomatic settings will be described to encourage their use in daily clinical practice.
Alexithymia
The term alexithymia literally means ‘lacking words for feelings’ and was coined to describe certain clinical characteristics observed among patients with psychosomatic disorders who had difficulty engaging in insight-oriented psychotherapy [6]. Alexithymic patients demonstrate deficiencies in emotional awareness and communication and show little insight into their feelings, symptoms, and motivation. When asked about their feelings in emotional situations, they may experience confusion (e.g. ‘I don't know’), give vague or simple answers (e.g. ‘I feel bad’), report bodily states (e.g. ‘my stomach hurts’), or talk about behavior (e.g. ‘I want to punch the wall’).
The alexithymia construct was originally conceptualized by Nemiah et al. [7] as encompassing a cluster of cognitive traits including difficulty identifying feelings and describing feelings to others, externally oriented thinking, and a limited imaginal capacity. This original view of alexithymia has been the most influential in contemporary theory and research [3]. An alternative conceptualization, that alexithymia is a global impairment in emotional processing resulting in limited emotional expression and recognition, has been less influential thus far [8]. Yet, both definitions agree that alexithymia is a deficit, inability, or deficiency in emotional processing rather than a defensive process, and this deficit view is gaining increasing support from basic laboratory and neuroimaging research [9, 10]. For more details on alexithymia conceptualizations, see Taylor [11].
Alexithymia was first described in people with psychosomatic disorders, and subsequent research has confirmed elevated levels of alexithymia in people with rheumatoid arthritis, essential hypertension, peptic ulcer, and inflammatory bowel disease [3]. Yet, studies have found elevated alexithymia in patients with a range of other conditions (e.g. cardiac disease, noncardiac chest pain, breast cancer, diabetes, chronic pain, eating disorders, substance dependence, kidney failure, stroke, HIV infection, fibromyalgia). The growing recognition that alexithymia is not specific to psychosomatic disorders has led to the view of alexithymia as a risk factor for those medical, psychiatric, or behavioral problems that are influenced by disordered affect regulation [3, 12]. Indeed, alexithymia has been associated with a failure to use adaptive affect regulation processes such as modulating arousal, appropriately expressing or suppressing emotions, employing fantasy, obtaining and using social support, tolerating painful emotions, cognitive assimilation, and accommodation. Evidence shows that the alexithymic deficit in processing feelings is likely to affect mental and somatic health through behavioral actions as ways to regulate affective states (e.g. alcohol abuse, eating behaviors), psychopathology directly related to emotional dysregulation (e.g. somatoform disorder, panic disorder), posttraumatic shutdown of emotions (e.g. posttraumatic stress disorder, acute reactions to severe organic diseases), altered autonomic, endocrine, and immune activity (e.g. vulnerability to inflammatory processes), somatosensory amplification, health care-seeking behavior, and negative treatment outcomes [13, 14]. More recently, treatment studies on alexithymia showed, for instance, that it is not appropriate to assume that alexithymic patients have reservations about entering into a psychotherapeutic treatment [15] and that cancer patients may benefit from a multicomponent psychological intervention in terms of cancer pain and alexithymia [16]. Similarly, prognostic studies showed that lower levels of childhood sexual abuse decreased the risk of being highly alexithymic, thus reducing the likelihood and severity of depression [17], that the presence of alexithymia at the time of the percutaneous transluminal coronary angioplasty in coronary heart disease (CHD) patients is a unique significant psychological predictor of poorer physical functioning at 6 months [18], and that alexithymia is a strong risk factor for all-cause 5-year mortality in hemodialysis patients [19].
Several methods have been developed to measure alexithymia, including structured interviews, self-report scales, by proxy information, and the Rorschach. Currently, the most commonly used method is the 20-item version of the Toronto Alexithymia Scale (TAS-20), a self-report questionnaire. Extensive validation, replication of the factor structure in several languages and countries, short administration time, and ease of use have been among the reasons why the TAS-20 has become the reference standard for measuring alexithymia in several psychiatric and medical settings [14].
The TCI seems to allow a reliable assessment of the seven dimensions and sub-dimensions of Cloninger s model of personality, with a stable internal structure and numerous indices of external validity. However, some authors have suggested that the TCI reliability [132] could be increased and the factorial structure strengthened [133, 134]. The most frequent psychometric limitations emerging in validation studies of the TCI are the weak reliability parameters (test-retest reliability, internal structure and consistency) obtained for Persistence and RD, the unequal numbers of sub-scales for all dimensions, and the true/false response mode which is known to be less reliable than Likert modalities. These observations and the psychometric analyses emerging from more than 10 years of TCI utilization led Cloninger to propose a new version of this questionnaire, named TCI-Revised (TCI-R) [129]. The major differences between the two versions are the following:
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The response mode has been modified: true/false statements in the TCI, and five-point rating scale in the TCI-R (1 = definitively false; 2 = mostly or probably false; 3 = neither true nor false, or about equally true or false; 4 = mostly or probably true; 5 = definitively true). This modality is meant to improve the reliability of the responses, because moderate answers are possible. In particular, the more informative response set was designed to improve the precision of measuring the subscales without increasing the number of items.
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The total number of items is the same in both versions (i.e. 240) but only 189 items are common to TCI and TCI-R; 37 items have been eliminated (mostly related to character dimensions), and 51 new items have been introduced in the TCI-R, including five validity items.
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The constitution of the four temperament dimensions and the three character dimensions has been modified and homogenized, with an increase in subscales measuring RD and P for a total of 29 TCI-R subscales.
The last point is perhaps the most important because RD included P in the TPQ. These two dimensions were later distinguished for psychometric reasons, so there was only one short scale measuring P and three scales measuring RD. This may explain why RD and P are the least robust dimensions in most populations [135, 136]. Nevertheless, Persistence appeared to be a very relevant construct with, for example, a prognostic value for relapse in alcohol dependence following treatment [137].
The TCI and its revised version seem to be increasingly used to evaluate the personality characteristics of patients suffering from specific medical conditions. There is evidence on the possible relationship between migraine, tension-type headache (TTH), and the TCI. Nylander et al. [138] studied the personality profile of 26 adult migraine patients and 87 controls. On the subscale level of Novelty seeking, a slightly higher average in the Exploratory excitability subscale and a significantly higher average in the Impulsivity subscale were observed in migraine patients when compared to controls. Moreover, Boz et al. [139] evaluated 81 patients with TTH, 56 patients with migraine, and matched healthy controls, and found that TTH patients had higher HA scores than controls.
There is also evidence that certain temperament and character dimensions are more likely to be represented in patients with specific dermatologic diseases. Kim et al. [140] evaluated 50 male patients with atopic dermatitis (AD) and 83 healthy controls, and found that AD patients scored higher on HA and lower on RD, self-directedness, and cooperativeness than controls. It was suggested that AD patients might have distinctive temperament and character dimensions. In particular, those with high HA and a low RD might be cunning, devious, ineffectual, reserved, underachieving, alienated, and cynical [141]; while the AD patients with low self-directedness and cooperativeness scores might show a higher tendency toward personality problems than the healthy controls [142]. Finally, Kiliç et al. [143] evaluated 105 psoriasis patients and 109 healthy individuals, and found that the psoriasis group had significantly higher scores of HA and lower scores on self-directedness than the control group. This study might provide a contribution in understanding the role of personality characteristics in psoriasis, one of the psychosomatic disorders, which is still being investigated whether it is a hereditary or an acquired disease.
The Five-Factor Model
The five-factor model (FFM) of personality is a version of trait theory which holds that the many ways in which individuals differ in their enduring emotional, interpersonal, experiential, attitudinal, and motivational styles can be summarized in terms of five basic factors called Neuroticism, Extraversion, Openness to experience, Agreeableness, and Conscientiousness [144, 145].
N (for Neuroticism, NA, or nervousness) is the dimension underlying the chronic experience of distressing emotions, such as fear, guilt, and frustration. E (for Extraversion, energy, or enthusiasm) means interpersonally sociability and dominance and temperamentally high activity level and cheerfulness. O (for Openness to experience or originality) refers to individuals who are imaginative, aesthetically sensitive, intellectually curious, and attitudinally liberal. A (for Agreeableness or altruism) is a dimension that implies trust and sympathy but contrasts cooperation with cynicism, callousness, and antagonism. Finally, C (or Conscientiousness, control, or constraint) encompasses sense of competence and duty, need of achievement, organization, planning, and self-discipline.
After its initial development, little more was done with the FFM until 1980 when Goldberg [146] renewed interest in the field and led to the development of the five-factor NEO Personality Inventory (NEO-PI) [147].
Assessment of the Five-Factor Model
The NEO-PI was developed to measure the FFM using rational and factor analytic methods on large samples of normal adult volunteers. The questionnaire consisted of 181 items, answered on a 5-point scale ranging from strongly disagree (1) to strongly agree (5). Each of the three original domains (N, E, O) was assessed as the sum of six more specific facet scales. Total N, for example, was the sum of scores for the Anxiety, Hostility, Depression, Self-Consciousness, Impulsiveness, and Vulnerability (to stress) scales. Global 18-item scales were used to assess A and C [147]. The NEO-PI requires only a sixth-grade reading level and has been used by subjects ranging in age from 16 to the 90s. Respondents typically take 20-30 min to complete the questionnaire that can be also administered, scored, and interpreted by a personal computer. The NEO-PI has a good cross-observer validity and longitudinal stability, its scales are balanced to control for the effects of acquiescent responding and are not overly sensitive to social desirability effects. Internal consistency reliabilities for the five domain scales range from 0.76 to 0.93 in volunteer samples [148].
Form S is used for self-reports; a third-person version, Form R, can be used by raters and appears to have comparable reliability and validity when completed by knowledgeable raters, such as spouse or long-time friends. Separate profile sheets are available for male and female adult self-reports, college student self-reports, and adult ratings [148].
The most comprehensive, and perhaps the best validated, version of this instrument is the Revised NEO-PI [147]. It is a 240-item questionnaire developed using a top-down strategy, beginning with the five well-established factors or domains (N, E, O, A, C) and subdividing each into six more specific facet scales. Domains are defined as multifaceted collections of specific cognitive, affective, and behavioral tendencies that might be grouped in many different ways. Facets are designated as the lower level traits corresponding to these grouping. A short version of the instrument, the NEO-Five Factor Inventory, is a 60-item questionnaire which provides estimates of the five factors. Each domain is measured by 12 items. The five domains are: neuroticism which includes anxiety, angry hostility, depression, self-consciousness, impulsivity, and vulnerability; extraversion which includes warmth, gregariousness, assertiveness, activity, excitement-seeking, and positive emotion; openness which includes fantasy, aesthetics, feelings, actions, ideas and values; agreeableness which includes altruism, trust, compliance, tender-mindedness, straightforwardness, and modesty, and conscientiousness which includes self-discipline, competence, order, dutifulness, achievement striving, and deliberation.
The same five dimensions measured via the NEO-PI are represented in whole or in part in other instruments such as the Eysenck Personality Questionnaire [149], the Guilford-Zimmerman Temperament Survey [150], the California Psychological Inventory [151], the Personality Research Form [152], and the Myers-Briggs Type Indicator [153]. However, such instruments, together with the commonly accepted psychopathology inventories such as the MMPI-2 [125] or the Personality Assessment Inventory [154], have been largely replaced by the NEO-PI since it has several potential advantages including the provision of a more detailed and comprehensive picture of personality structure [155, 107].
Given these findings, the NEO-PI and its subsequent versions would appear to be ideal, yet they have been criticized for their failure to include validity scales that would provide measures of response bias and distortion.
In psychosomatic medicine, an increasing number of studies have used the NEO-PI and its derived versions. For instance, Tanum and Malt [156] showed that patients with functional gastrointestinal disorders have significantly higher levels of NEO-PI Neuroticism than healthy controls. More recently, Nater et al. [157] observed that chronic fatigue syndrome patients have significantly higher scores on Neuroticism and lower scores on Extraversion than those with Insufficient fatigue or healthy controls. Finally, several researchers have become increasingly interested in the relationships between personality traits and mortality. For instance, Christensen et al. [158] found that patients suffering from chronic renal insufficiency who had low Conscientiousness or high Neuroticism scores were more likely to have died during a 4-year follow-up period. Weiss and Costa [159] highlighted that NEO-Five Factor Inventory Neuroticism, Agreeableness, and Conscientiousness were significantly associated with a reduced mortality. Jonassaint et al. [160] showed that the facets Openness to feelings, actions, ideas, and aesthetics were protective against cardiac deaths. Taylor et al. [161] observed that people who died during a 10 year follow-up period had significantly lower Openness and Conscientiousness scores than people who survived. Finally, Sutin et al. [162] found that low Conscientiousness and traits related to Impulsivity were associated with lower HDL cholesterol and higher triglycerides.
Conclusions
The present chapter reviewed the personality constructs having a fundamental role in psychosomatic medicine and their instruments of assessment. The aim was to encourage a proper assessment to contribute in completely understanding medical patients and their global health, and in formulating optimal decision-making and treatment planning.
Such a role of personality has developed particularly in the last decade thanks to the philosophical and scientific revolution. Indeed, first, personality factors have been no longer treated as causes of medical disease but as moderators/mediators that variously influence preclinical and clinical levels of illness from risk factors and vulnerability to maintenance of symptoms and recovery. Second, the psychometric distinction between state and trait has declined supporting the evidence that psychological constructs traditionally conceived as trait dimensions may surprisingly display sensitivity to change in a specific clinical situation, whereas constructs viewed as state dimensions may display unexpected stability throughout the longitudinal development of the disorder [163]. Thus, the psychometric distinction between state and trait may be feasible in a healthy population, but seems to run against a large body of evidence in clinical populations [164, 165] including the occurrence of episodic personality dysfunction [166]. As a confirmation, the state/trait dichotomy does not appear to apply anymore to clinical studies concerned with psychological well-being and resilience and their modifications [167, 168]. Moreover, there is already evidence suggesting that cognitive behavioral interventions might teach alexithymic patients to learn emotion terms, label emotional situations, observe their own symptoms, and link emotional labels with their symptoms [169], and that variations of psychodynamic therapy, such as labeling feelings for patients rather than asking them how they feel, might help alexithymic patients [3].
In brief, since personality is a moderator/mediator that can variously influence preclinical and clinical levels of illness and can be changed in specific clinical situations, it seems relevant to assess it in clinical settings in order to formulate a proper treatment planning, thus influencing the outcome of the medical illness. Of course, such an assessment should be realized according to the emerging guidelines which highlight the need for repeated measures, clinimetric methods, using macro- and microanalysis, individualized treatment, and multidisciplinary team treatment [170].
In this framework, we hope the present chapter will shed some light on the value of personality in medical settings and increase its assessment in clinical practice.
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