Rheumatoid arthritis

Rheumatoid arthritis (RA) has been declared a women's health issue (Callahan, 1996). This chronic disease is an inflammatory autoimmune disorder characterized by pain, stiffness, fatigue, and progressive joint destruction. RA affects approximately 1-2% of the population; like other autoimmune disorders, it predominantly occurs among women (2-3 times more among women than among men; Newman, Fitzpatrick, Revenson, Skevington, & Williams, 1996). Therefore, gender-sensitive treatment is necessary (Chrisler & Parrett, 1995).

Moreover, because RA is a chronic disease that has detrimental effects on both physical activity and role functioning (DeVellis, Revenson, & Blalock, 1997), the implications of RA for the mental health as well as physical health of women and men are tremendous. Although depression is as prevalent among those with RA as among those with other chronic diseases (DeVellis, 1993, 1995), depression is higher among those with RA than among matched healthy controls (Katz & Yellin, 1994) and is highly correlated with disability (Parker & Wright, 1995), which makes RA an important area for investigation.

A further complication is the possibility that personality factors, specifically gender-linked personality factors that have been associated with mental and physical health outcomes in other health populations, may exacerbate some peoples' experience with RA. These personality factors may affect self-care as well as interactions with others, including health care providers and significant social network members. The patient-physician relationship is already laden with stereotypical expectations (e.g., women's symptoms may be more likely to be attributed to psychological than physiological origins); therefore, personality factors that are consistent with the feminine gender role may put people at a distinct disadvantage in their treatment seeking and treatment receipt for RA symptoms.

Personality factors have a long history of being implicated in the development and progression of rheumatic disease. In the 1940s and 1950s, evidence for a direct causal link between the "rheumatoid arthritis personality" and disease onset was described in the psychosomatic medicine literature (King, 1955). Over the past 40 years that finding has been proven false by a number of empirical studies that demonstrated the plausibility of bidirectional causality. That is, personality characteristics are as likely to be reactions to the onset of the illness and the stresses of living with RA as they are to be causes of it (Baum, 1982; Oberai & Kirwan, 1988; Scotch & Geiger, 1962).

Although psychosomatic models have lost favor over the years, there is renewed interest in how personality affects health (Ouellette & DiPlacido, 2001; Smith & Gallo, 2001). Within this arena, the gender-linked personality orientations of agency and communion have received a good deal of recent attention. Individuals with an agentic orientation focus more on themselves and forming separations (Helgeson, 1994). They use more instrumental, problem-solving strategies to cope with stress. Individuals with a more communal orientation focus on others' needs and forming connections (Helgeson, 1994) and are more emotionally expressive (Helgeson & Fritz, 1996). The extreme and unsocially desirable forms of agency and communion are referred to as unmitigated agency and unmitigated communion. Unmitigated agency involves an extreme orientation toward oneself (without regard for others) and difficulty expressing emotions (Helgeson & Lepore, 1997). Unmitigated communion refers to an extreme orientation toward others, in which individuals become overinvolved with others to the detriment of their own well-being. These personality orientations are theoretically and empirically intercorrelated (Helgeson, 1994; Helgeson & Fritz, 1999): The regular form of one orientation (e.g., agency) negatively correlates with the unmitigated form of the other (i.e., unmitigated communion), and the regular form of one orientation (e.g., communion) positively correlates with the unmitigated form of the same orientation (i.e., unmitigated communion). The regular forms of both orientations are uncorrelated (i.e., agency and communion).

The personality orientations of agency and communion were conceptualized originally as gender-linked traits. Agency (instrumentality) was seen as representing one aspect of masculinity and communion (expressiveness) as one aspect of femininity (Spence, 1984). Consistent with this conceptualization, men typically score higher than women do on the measures of unmitigated agency (Helgeson, 1990) and agency, and women typically score higher than men on the measures of communion and unmitigated communion (Helgeson & Fritz, 1996).

Agency and communion generally are related to adaptive levels of functioning, whereas the unmitigated forms of these personality orientations, particularly unmitigated communion, are associated with behaviors in relationships and general health behaviors that may lead to "hazardous health consequences" (Helgeson, 1994, p. 417). For example, unmitigated communion has been associated with delays in seeking early treatment for cardiac symptoms (Helgeson, 1990); poorer metabolic control and greater psychological distress among adolescent girls with diabetes (Helgeson & Fritz, 1996); and poor health behavior, negative social interactions, and greater psychological distress and cardiac symptoms following a coronary event (Fritz, 2000). Unmitigated agency has been associated with poor health behaviors, such as slowness to seek treatment (Helgeson, 1990) and drug and alcohol use (Snell, Belk, & Hawkins, 1987); it has also been associated with cancer-related emotional difficulties among men with prostate cancer (Helgeson & Lepore, 1997).

In contrast, agency has been linked to better physical and mental health across a number of chronic illnesses, including coronary heart disease (Helgeson, 1990, 1993), prostate cancer (Helgeson & Lepore, 1997), and diabetes (Helgeson & Fritz, 1996). Communion does not appear to predict health outcomes, though it has been linked with positive social outcomes (e.g., marital satisfaction, Helgeson & Fritz, 1996).

Agency and unmitigated communion have been shown to predict important psychological and health-related outcomes among people with coronary heart disease, diabetes, and cancer, but these personality variables have not yet been studied among people with musculoskeletal or rheumatic disease. We chose to examine these gender-linked personality orientations among women and men with RA because RA is a progressive, disabling, chronic disease that may decrease ability to take care of oneself and to take care of others, prominent features of agency and communion, respectively.

In this prospective study of a sample of women and men with RA, we tested for interrelationships among agency, communion, unmitigated agency, and unmitigated communion that have been found in previous research (Helgeson, 1994). Then we tested the hypotheses that (a) agency is associated with better mental and physical health outcomes and (b) unmitigated communion is associated with poorer mental and physical health outcomes. Although communion and unmitigated agency have been correlated with health-related behaviors (e.g., communion with help seeking, reviewed in Helgeson, 1994; unmitigated agency with drug and alcohol use, Snell et al., 1987), they have not typically been correlated with mental and physical health outcomes (Fritz, 2000; Helgeson, 1993; Helgeson & Fritz, 1996); therefore, we did not predict those associations in this sample. Finally, because these personality orientations are conceptualized as gender-linked, we tested the independent contribution of the relevant personality orientations to the prediction of mental and physical health outcomes after controlling for gender, in order to determine the contribution of personality above and beyond its theoretical and empirical relationship with gender (Helgeson, 1994).

METHOD

Participants

The 127 women and 31 men in the sample ranged in age from 26 to 90 years (M = 58.6, SD = 13.9). Half (53.2%) were currently in marital-type relationships (i.e., married or in a committed relationship), and nearly 27% were members of an ethnic minority group. More men than women were White (90.3% men, 68.5% women), [chi square](1, N = 155) = 5.95, p < .05, and married (80.6% men, 46.5% women), [chi square](1, N = 158) = 11.70, p < .05. In terms of socioeconomic status, half of the respondents had a college or graduate education, although the median household income was low for this level of education, between $20,000 and $50,O00.

Only 29% of the sample were currently employed (full- or part-time), 32% were retired, 11% described themselves as homemakers, 3% indicated that their occupation was "other," and 25 % reported that they were unemployed due to disability. This last group had levels of education similar to the rest of the sample, [chi square](1, N = 112) = 2.29, p > .05, but significantly lower household incomes, [chi square](6, N = 127) = 16.41, p < .05.

Measures

Personality Orientation

Separate 8-item bipolar adjective scales from the Extended Personal Attributes Questionnaire (E-PAQ; Spence, Helmreich, & Holahan, 1979) measured Agency ([alpha] = .75), Communion ([alpha] = .83), and Unmitigated Agency ([alpha] = .81). These widely-used scales have documented reliability and validity (Helgeson, 1994). Examples of items that assess agency are "not at all independent--very independent" and "not at all self-confident--very self-confident." Examples of items that assess communion are "difficult to devote self completely to others--easy to devote self to others" and "not at all aware of others' feelings--very aware of others' feelings." Examples of items that assess unmitigated agency are "not at all greedy--very greedy" and "looks out for self--looks out for others." Responses were scored from 1 (low) to 5 (high). (5) The unmitigated communion scale in the E-PAQ lacked sufficient reliability and validity, and therefore Helgeson and Fritz (1998) designed a new scale, described below.

Unmitigated Communion was measured with the 9-item Revised Unmitigated Communion scale, which has been validated by its authors (Helgeson & Fritz, 1998). Participants indicated the extent to which they agree or disagree with each item, using a 5-point scale ([alpha] = .75). Sample items include "I often worry about others' problems" and "For me to be happy, I need others to be happy." The nine items were averaged to form a scale that ranges from 1 (low unmitigated communion) to 5 (high unmitigated communion).

Adjustment Outcomes

Functional disability was measured with the Modified Stanford Health Assessment Questionnaire (MHAQ; Pincus, Summey, Soraci, Wallston, & Hummon, 1983). The MHAQ ([alpha] = .93) assesses ability to perform eight activities of daily living, such as dressing and grooming, walking, and reaching. Items were rated on a scale from 1 (without any difficulty) to 4 (unable to do). Pincus et al. (1983) have demonstrated that the MHAQ provides data comparable to that obtained by the longer HAQ.

Pain was measured with a 100-mm visual analog scale that had endpoints anchored with no pain and pain as bad as it can be. Participants were instructed to rate their current level of pain. Self-report visual analog scales have been established as valid and reliable and are widely used in pain research (Price, 1988).

Psychological distress was measured with the Hopkins Symptom Checklist-25 (HSCL-25; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1974). This measure has been used internationally to detect psychological distress (Sandanger et al., 1998). On a scale from 1 (not at all) to 4 (extremely), participants rated how much they were bothered by symptoms (e.g., "feeling hopeless about the future") during the past month. To determine whether somatic symptoms associated with RA might artificially inflate HSCL-25 scores, we removed 11 items that measure potentially overlapping symptoms of RA and depression (e.g., "feeling everything is an effort"). Because the correlation of this shortened scale with the full measure was .96, we opted to use the full 25-item scale ([alpha] = .93), which is known to be psychometrically sound and allowed us to compare our sample to published norms.

Life satisfaction was measured by the Satisfaction with Life Scale (SWLS; Diener, Emmons, Larsen, & Griffen, 1985). This measure of global life satisfaction contains five items rated on a scale that ranges from 1 (strongly disagree) to 7 (strongly agree), [alpha] = .87. Examples of items are "I am satisfied with my life" and "In most ways my life is close to my ideal." Using data from samples of college students and elderly volunteers, Diener et al. (1985) reported that the SWLS had high internal consistency and temporal reliability, as well as moderate correlation with other measures of subjective well-being and no correlation with a measure of social desirability.

Procedure

Participants were recruited from the patient registry of a metropolitan hospital that specializes in orthopedic and rheumatic disorders. Because RA is less prevalent among men, additional referrals for men with RA were requested from rheumatologists in the metropolitan area who were not affiliated with the hospital.

A multistage recruitment strategy was used to minimize coercion. Potential participants (339 women and 70 men) received a personalized letter from their rheumatologist that invited them to participate in a longitudinal study of coping with RA. Individuals were asked to return a response card to the study's investigators if they were interested in receiving a telephone call, during which the study would be discussed in more depth and participation solicited. Two of the 211 individuals who returned the card could not be reached by phone after multiple attempts, and five decided not to participate.

Questionnaires, consent forms, and postage-paid return envelopes were sent to 204 individuals; 158 (77%) completed the questionnaire. There were no gender differences in response rates.

RESULTS

Descriptive Statistics

The average levels of agency (M = 3.66, SD = 0.68), communion (M = 4.12, SD = 0.69), unmitigated agency (M = 2.14, SD = 0.67), and unmitigated communion (M = 3.44, SD = 0.73) were similar to levels in other health populations (Fritz, 2000; Helgeson, 1990; Helgeson & Fritz, 1996). The average level of functional disability (M = 2.10, SD = 0.59) of participants was somewhat higher than the average for the hospital patient registry from which the sample was drawn (M = 1.90). Average level of pain on the 0100 visual analog scale was 30.98. The mean score on the HSCL-25 (43.08) was at the cutoff suggested for detecting psychological distress in psychiatric screening of primary care patients (M = 43; Sandanger et al., 1999). Average life satisfaction (M = 21.52) was slightly lower than that reported by Diener et al. (1985) for a sample of community-residing elderly adults (M = 25.8).

Gender Differences

Table I displays descriptive statistics for the total sample and by gender. The only significant gender difference was that men (M = 3.99, SD = 0.60) had significantly higher agency scores than did women (M = 3.57, SD = 0.68), t(147) = 3.06, p < .05. Women and men had statistically equivalent unmitigated communion scores (Ms = 3.43, SD = 0.68, and 3.45, SD = 0.92, respectively). No gender differences for the mental and physical health outcomes were found.

Interrelationships Among Personality Orientations

According to Helgeson (1994), the gender-linked personality orientations of agency, communion, unmitigated agency, and unmitigated communion are theoretically and empirically interrelated. For example, the unmitigated form of one orientation (e.g., unmitigated agency) is negatively correlated with the regular form of the other orientation (i.e., communion). As shown in Table II, we found that communion was significantly negatively correlated with unmitigated agency, r = -.52, p < .05, and that agency was negatively correlated with unmitigated communion, but not significantly, r = -.13, p = .12. In addition, the unmitigated form and regular form of the same orientation are expected to be correlated (e.g., communion and unmitigated communion). Communion was significantly positively correlated with unmitigated communion, r = .26, p < .05, although agency was not significantly correlated with unmitigated agency, r = .08, p = .32.

Testing for Potential Demographic Covariates in Predicting Mental and Physical Health Outcomes

The relationships of demographic variables to the mental and physical health outcomes were examined first for potential covariates. Although gender was not significantly correlated with any of the mental and physical health outcomes, race/ethnicity, marital status, and age were significantly correlated with mental and physical health outcomes. Race and marital status were significantly associated with disability. Specifically, Whites (M = 36.10, SD = 9.65) had lower disability scores than did racial minorities (M = 42.74, SD = 11.84), t(153) = 3.57, p < .05, and those in marital-type relationships (M = 34.58, SD = 8.52) had lower disability scores than those who were not in marital-type relationships (M = 41.30, SD = 11.69), t(132) = 4.08, p < .05. Therefore, these variables were covaried (as a set) for analyses to predict disability.

Marital status was significantly associated with pain. Those in marital-type relationships (M = 25.03, SD = 22.72) reported less pain than those who were not in marital-type relationships (M = 37.76, SD = 29.69), t(132) = 2.96, p < .05. Therefore, marital status was covaried for analyses to predict pain.

Race, age, and marital status were significantly associated with psychological distress. Specifically, Whites (M = 41.49, SD = 11.44) had lower psychological distress scores than did racial minorities (M = 48.45, SD = 15.18), t(44)= 2.42, p < .05; age was significantly negatively correlated with psychological distress scores, r = -.23, p < .05; and those in marital-type relationships (M = 41.24, SD = 11.62) had lower psychological distress scores than those who were not in marital-type relationships (M = 45.59, SD = 13.75), t(135)= 2.00, p < .05. Therefore, these variables were covaried (as a set) for analyses to predict psychological distress.

Lastly, race, age, and marital status were significantly associated with life satisfaction. Whites (M = 22.60, SD = 7.75) had higher life satisfaction scores than did racial minorities (M = 17.82, SD = 6.78), t(140) = -3.23, p < .05; age was significantly positively correlated with life satisfaction scores, r = .19, p < .05; and those in marital-type relationships (M = 22.78, SD = 7.66) had higher life satisfaction scores than those who were not in marital-type relationships (M = 19.87, SD = 7.58), t(143) = -2.28, p < .05. Therefore, these variables were covaried (as a set) for analyses to predict life satisfaction.

Predicting Mental and Physical Health Outcomes From Personality Orientations

Linear regression analyses were used to examine the relationships between personality and mental and physical health outcomes. The covariates described above were entered on the first step of the equation. The four personality orientation variables were entered on the second step of the equation. Consistent with predictions, agency predicted better physical health outcomes (i.e., significantly lower disability, see Table III; a trend toward lower pain, see Table IV, and better mental health (i.e., significantly lower psychological distress), see Table V; significantly greater life satisfaction, see Table VI). Unmitigated communion predicted poorer mental and physical health (i.e., significantly greater disability, see Table III; significantly greater psychological distress, see Table V; a trend toward lower life satisfaction, see Table VI). As expected, communion was not significantly related to either physical or mental health outcomes. Unmitigated agency predicted significantly greater psychological distress (see Table V) and a trend toward lower life satisfaction (see Table VI).

Controlling for Gender When Predicting Mental and Physical Health Outcomes From Agency

We were interested in testing whether agency and unmitigated communion would continue to predict mental and physical health outcomes after we controlled for gender (Helgeson, 1994). We conducted these analyses for agency but not for unmitigated communion, because the latter did not differ significantly between women and men. Regression analyses that controlled for gender (and the previously controlled demographic variables of race/ethnicity, marital status, and age) revealed that agency predicted significantly lower disability, [beta] = -.20, p < .05; [R.sup.2] = .14, p < .05; [DELTA][R.sup.2] = .04, p < .05,lower pain, [DELTA] = -.27, p < .05; [R.sup.2] = .14, p < .05; [DELTA][R.sup.2] = .07, p < .05; lower psychological distress, [beta]3 = -.31, p < .05; [R.sup.2] = .22, p < .05; [DELTA][R.sup.2] = .09, p < .05; and higher life satisfaction, [beta] = .31, p < .05; [R.sup.2] = .25, p < .05; [DELAT][R.sup.2] = .09, p < .05.

DISCUSSION

RA may decrease an individual's ability to take care of self and others; because a focus on self versus others distinguishes agency from communion, it is important to examine these orientations among people with RA. Moreover, RA occurs predominantly among women, and the feminine-linked unmitigated communion orientation has been associated with adverse mental and physical health outcomes in other medical populations.

The present findings support the robustness of these personality constructs. Similar interrelationships among the personality orientations were found in this sample of people with RA as have been reported in other samples of medical patients and in healthy people. We found that adults diagnosed with RA appear to have agency and communion-related personality profiles similar to adolescents with Type I diabetes (Helgeson & Fritz, 1996) and adult cardiac patients (Fritz, 2000; Helgeson, 1990, 1993) in that the regular forms of one personality orientation were negatively correlated with the unmitigated forms of the others. And, in general, the regular form of one orientation was correlated with the unmitigated form of the same orientation in the expected direction.

Consistent with previous research (Helgeson, 1994; Helgeson & Fritz, 1996), both agency and unmitigated communion were related differentially to mental and physical health outcomes after we controlled for demographic factors. Agency was associated with better mental and physical health outcomes for both women and men with RA. Also, as predicted, unmitigated communion was associated with poorer mental and physical health outcomes.

Given that agency, communion, and their unmitigated forms are conceptualized as gender-linked, we sought to test the independent contribution of these personality orientations to the prediction of mental and physical health outcomes above and beyond the contribution of gender. We performed this analysis on agency, which was the only one of the four personality orientations that correlated significantly both with gender and with mental and physical health outcomes. Controlling for gender did not substantially increase the amount of variance in the outcomes predicted by each model, nor did it substantially increase the contribution of agency itself to the prediction models. Agency is gender-linked. It continues to be endorsed more often by men than by women, and, therefore, may be one of the psychological mechanisms by which gender affects functional and mental health. However, gender alone may not be protective for men, as women and men in this sample, as in other adult medical populations (Fritz, 2000), had similar unmitigated communion scores. Although these constructs are conceptualized as personality orientations, perhaps the dependence on others that often results from living with physical disability increases an individual's level of unmitigated communion; this is an interesting area for further long-term study. For example, the men in our sample had higher unmitigated communion scores (M = 3.45) than male college students had (M = 3.18; Fritz & Helgeson, 1998, Study 1) on the continuum of 1 through 5. Alternatively, the measurement tool that is used to assess unmitigated communion (Likert-evaluated sentences) versus that which is used to assess the other three orientations (bipolar adjective scales) may be less gender-sensitive.

Gender-linked or not, recognition of these personality orientations is important in that it may assist health care professionals in the identification of people who may be at high risk for maladjustment problems. For example, identification of people who are high on the personality orientation of unmitigated communion might lead to further assessment of psychological distress and functional disability.

In addition to assisting with identification of patients in health care settings who may be at risk for adverse outcomes, assessment of these personality traits may inform interventions. For example, people with RA who are high in the trait of unmitigated communion should be encouraged to appreciate the importance of caring for themselves as well as caring for others; this could include a discussion of ways that self-care enhances ability to care for others. People with RA also benefit from assistance in finding ways to nurture others within the range of their own physical abilities (Abraido-Lanza, 1997; Goodenow, Resine, & Grady, 1990). Individuals with an agentic orientation are likely to be successful in caring for themselves without sacrificing their relationships; however, a move toward unmitigated agency might be harmful, as has been shown for men with prostate cancer (Helgeson & Lepore, 1997), cardiac patients (Helgeson, 1990), and college students (Snell et al., 1987). As we did not study health behaviors, their relationship with unmitigated agency among this sample of individuals with RA is unknown. We did discover, however, that unmitigated agency was significantly associated with greater depression and a trend toward lower life satisfaction. This finding suggests detrimental correlates of this particular personality orientation, in addition to poor health behaviors (Helgeson, 1990; Snell et al., 1987), that require additional attention from researchers interested in personality and health.

Although this study succeeded in replicating the findings of previous investigations of these personality orientations among people with other chronic illnesses, its limitations should be noted. Because RA affects women and men disproportionately, our sample of men was small. This gender imbalance may have contributed to the lack of gender differences found in levels of unmitigated communion. The men in this study may not have been representative of the larger population of men with RA. Furthermore, because of the small number of male participants there was not adequate statistical power to test for interactive effects. In addition, the data collected were self-report. Longitudinal research, however, has indicated that self-reported disease impact is not simply reflecting negative affectivity in individuals with RA (Smith, Wallston, & Dwyer, 1995).

Future researchers should continue this exploration of the roles of agency, communion, their unmitigated forms, and gender in predicting mental and physical health outcomes in people with RA, as well as in people with other rheumatic diseases. Researchers should investigate the biobehavioral mechanisms through which personality has an influence on health; psychological variables such as coping and interpersonal relationships are possible candidates. For example, we have reported elsewhere (Danoff-Burg, Revenson, Trudeau, & Paget, in press) that for women with high levels of unmitigated communion, the perception of fewer social constraints may have a buffering effect on distress. In addition, it is important to specify the unique contributions of personality and gender to mental and physical health outcomes. Although arthritis has been referred to as a women's health issue (Callahan, 1996), both women and men can benefit from coping with their health problems in an agentic (i.e., self-focused, instrumental) fashion.

ACKNOWLEDGMENTS

This research was supported by a Postdoctoral Award from the Arthritis Foundation to Sharon Danoff-Burg and a Summer Student Research Fellowship from the New York Chapter of the Arthritis Foundation to Kimberlee J. Trudeau. We thank Katy Tai for her help with the patient registry and Allan Gibofsky for assistance with physician referrals.

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(5) Because of a clerical error, the E-PAQ had only a 4-point versus a 5-point scale; however, there was still adequate variance for all items. Therefore, to be comparable with other published studies, the 4-point scores were statistically transformed to equal a 5-point scale for reporting herein.

Kimberlee J. Trudeau, (1,4) Sharon Danoff-Burg, (2) Tracey A. Revenson, (1) and Stephen A. Paget (3)

(1) Social-Personality Psychology Program, The Graduate Center, City University of New York, New York.

(2) Department of Psychology, University at Albany, State University of New York, New York.

(3) Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York.

(4) To whom correspondence should be addressed at Social-Personality Psychology Program, CUNY Graduate Center, 365 Fifth Avenue, New York, New York 10016-4309; e-mail: kjtrudeau@prodigy.net.

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