Introduction

A positive mental attitude is one of the important foundational elements of good health. This axiom has been contemplated by philosophers and physicians since the time of Plato and Hippocrates. In addition to simple conventional wisdom, modern research has also verified the important role that attitude—the collection of habitual thoughts and emotions—plays in determining the length and quality of life. Specifically, studies using various scales to assess attitude, including the Optimism–Pessimism (PSM) scale of the Minnesota Multiphasic Personality Inventory (MMPI), have shown that individuals with a pessimistic explanatory style have poorer health, are prone to depression, are more frequent users of medical and mental health care delivery systems, exhibit more cognitive decline and impaired immune function with aging, and have a shorter survival rate compared to optimists.^1–8 One of the most recent studies involved a large cohort of 5566 people who completed a survey at two time points, aged 51–56 years at Time 1 and 63–67 years at Time 2. This survey included a questionnaire to determine positive psychological well-being by measuring self-acceptance, autonomy, purpose in life, positive relationships with others, environmental mastery, and personal growth. The results showed that people with low positive well-being were 7.16 times more likely to be depressed 10 years later.⁹ This research highlighted the fact that although life is full of events that are beyond one’s control, people can control their responses to such events. Attitude goes a long way toward determining how people view and respond to the stresses and challenges of life.

Attitude is reflected by explanatory style, a term developed by noted psychologist Martin Seligman to describe a cognitive personality variable that reflects how people habitually explain the causes of life events.⁸ Explanatory style was used to explain individual differences in response to negative events during the attributional reformulation of the learned helplessness model of depression developed by Seligman (described in Chapter 142).

To determine a patient’s level of optimism, have him or her take the Attributional Style Questionnaire developed by Seligman or use the PSM scale of the MMPI. Techniques to help patients learn to be optimistic are given in the following discussion.

Attitude, Personality, Emotions, and Immune Function

The importance of attitude to human health has been examined in the link among the brain, emotions, and the immune system. Research in the field of psychoneuroimmunology indicates that every part of the immune system is connected to the brain in some way, either via a direct nervous tissue connection or through the complex language of chemical messengers and hormones. What scientists are discovering is that every thought, emotion, and experience sends a message to the immune system that either enhances or impairs its ability to function. A simplistic view is that positive emotions, such as joy, happiness, and optimism, tend to boost immune system function, whereas negative emotions, such as depression, sadness, and pessimism, tend to suppress it.

Studies examining immune function in optimists versus pessimists have demonstrated significantly better immune function in the optimists. Specifically, studies have shown that optimists have increased secretory immunoglobulin-A function, natural killer cell activity, and cell-mediated immunity, which is demonstrated by better ratios of helper to suppressor T-cells than those of pessimists.^5,10–13

The immune system is so critical to preventing cancer that, if emotions and attitude were risk factors for cancer, one would expect to see an increased risk of cancer in people who have long-standing depression or a pessimistic attitude. Research supports this association; for example, smokers who are depressed have a much greater risk of lung cancer than smokers who are not depressed.¹⁴

Depression and the harboring of other negative emotions contribute to an increased risk of cancer in several ways. Most research has focused on the impact of depression and other negative emotions on natural killer cells. Considerable scientific evidence has now documented the link between a higher risk of cancer and negative emotions, stress, and a low level or activity of natural killer cells.¹⁵ Negative emotions and stress paralyze many aspects of immune function and literally can cause natural killer cells to burst.^15,16 Furthermore, the prototypical cancer personality—an individual who suppresses anger, avoids conflicts, and has a tendency to have feelings of helplessness—has lower natural killer cell activity than other personality types.^12,13 These studies also indicate that individuals with a personality type that is prone to cancer have an exaggerated response to stress, which compounds the detrimental effects stress has on natural killer cells and the entire immune system.

Depression and stress not only affect the immune system but also appear to hinder the cell’s ability to repair damage to DNA. Most carcinogens cause cancer by directly damaging DNA in cells, thereby producing abnormal cells. One of the most important protective mechanisms against cancer in the cell’s nucleus is the enzymes responsible for the repair or destruction of damaged DNA. Several studies have shown that depression and stress alter these DNA repair mechanisms; for example, in one study, lymphocytes (a type of white blood cell) from depressed patients demonstrated impairment in the ability to repair cellular DNA damaged by exposure to x-rays.^17,18

Just as research has identified personality, emotional, and attitude traits that are associated with impaired immune function, likewise the field of psychoneuroimmunology has identified a collection of “immune power” traits that include a positive mental attitude, an effective strategy for dealing with stress, and a capacity to confide traumas, challenges, and feelings to oneself and others.^15,19

Attitude and Cardiovascular Health

In addition to the brain and immune system, the cardiovascular system is another body structure intricately tied to emotions and attitude. The relationship of an optimistic or pessimistic explanatory style with incidence of coronary heart disease was examined as part of the Veterans Affairs Normative Aging Study, an ongoing cohort study of older men.⁷ These men were assessed by the MMPI PSM scale. During an average 10-year follow up, 162 cases of incident coronary heart disease occurred: 71 cases of incident nonfatal myocardial infarction, 31 cases of fatal coronary heart disease, and 60 cases of angina pectoris. Men reporting high levels of optimism had a 45% lower risk for angina pectoris, nonfatal myocardial infarction, and coronary heart disease death than men reporting high levels of pessimism. Interestingly, a clear dose–response relationship was found between levels of optimism and each outcome.

To illustrate how closely the cardiovascular system is linked to attitude, one study showed that measures of optimism and pessimism affected something as simple as ambulatory blood pressure.²⁰ Pessimistic adults had higher blood pressure levels and felt more negative and less positive than optimistic adults. These results suggest that pessimism has broad physiologic consequences.

Excessive anger, worrying, and other negative emotions have also been shown to be associated with an increased risk for cardiovascular disease; however, these emotions may simply reflect a pessimistic explanatory style.

Attitude and Self-Actualization

A physician’s role should include not only facilitating the health of the patient but also helping the patient achieve self-actualization, which is a concept developed by Abraham Maslow, the founding father of humanistic psychology. His work and theories were the result of intense research on psychologically healthy people over more than 30 years. Essentially, Maslow was the first psychologist to study healthy people. He strongly believed that the study of healthy people would create a firm foundation for the theories and values of a new psychotherapy.

Maslow discovered that healthy individuals are motivated toward self-actualization, a process of “ongoing actualization of potentials, capacities, talents, as fulfillment of a mission (or call, fate, destiny, or vocation), as a fuller knowledge of, and acceptance of, the person’s own intrinsic nature, as an increasing trend toward unity, integration, or synergy within the person.”²¹

Maslow developed a five-step pyramid of human needs in which personality development progresses from one step to the next. The needs of the lower levels must be satisfied before the next level can be achieved. When needs are met, the individual moves toward well-being and health. Figure 7-1 displays Maslow’s hierarchy of needs.

FIGURE 7-1 Maslow’s hierarchy of needs.