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Emotions have long been believed to play a signiﬁcant role in health. However, deﬁnitive evidence on the nature of this role and the mechanisms involved is still being developed. On the one hand, patients often have emotional reactions to the diagnosis of serious or life-threatening illness, responses that can inﬂuence emotional as well as physical well-being. On the other hand, emotions and their expression or inhibition have been linked with the development of various disease conditions. This research paper explores what is currently known about these links between emotions and health and the implications for both theory and intervention.
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Following a period dominated by behaviorism and stimulus-response approaches to behavior, there has of late been an explosion of interest in the emotions, their nature, antecedents, and consequences. Beginning in the 1980s, this interest has been brought about by a growing acceptance of a cognitive mediational approach to human behavior which goes beyond a simple stimulus-response model of human behavior to seeing behavior as being strongly mediated by internal psychological processes of which, of course, emotions are a part (Lazarus 1993).
At the most basic level, emotions are the aﬀective or feeling states that people experience in response to external events, internal cognitions, or a combination of both. Beyond this, however, there are numerous controversies about the nature of human emotions. For example, there is debate over whether emotions are best described in terms of categories or dimensions, how many emotions can be delineated, and the ways in which emotions diﬀer across cultures. These controversies, however, are beyond the scope of this research paper that speciﬁcally is concerned with the interrelationship of emotions and physical health. For the purposes of this research paper we will be concerned with emotions as feeling states which can be diﬀerentiated into identiﬁable emotions, are embedded in a social context, may be only experienced internally or also expressed outwardly, and are associated with identiﬁable patterns of physiological activity.
Work on emotions and health bears a close aﬃnity to work on the relationship of stress to health as well as work on personality and health. The relationship of emotion to stress has been delineated very persuasively by Lazarus (1993) who notes that the term stress has often been used to refer globally to negative emotional responses that people have to situations involving threat or harm and argues that stress should be understood as a subset of the emotions. This view has the advantage of bringing together two closely related but generally separate research literatures and allows for a more diﬀerentiated understanding of stress and its eﬀects on health. The relationship of the work on emotions and health to that on personality and health derives from the fact that at least some of the personality traits found to be related to health are associated with emotion (Friedman 1990).
We begin our discussion with a consideration of the emotional impact of illness and then move on to a discussion of emerging evidence for the role of emotion in the development of disease.
2. Emotional Responses To Illness
Diagnosis with a chronic or life-threatening disease has been described as a crisis for patients which produces strong emotional responses. Patients diagnosed with serious conditions frequently experience intense feelings of fear, anxiety, grief, anger, and other emotions. These emotional responses often lessen with time as the person comes to grips with the condition but can lead to serious emotional maladjustment. Key determinants of quality of emotional adjustment appear to be age, the severity of the condition, coping strategies, and social support. Older patients appear to have less diﬃculty adjusting to disability than younger persons, perhaps because of an expectation of greater disability as one gets older whereas more severe disease is often associated with greater emotional upset. Further, coping strategies appear to be critical determinant of emotional adjustment. For example, positive adaptation to breast cancer appears to be facilitated by ﬁnding a sense of meaning in the experience of cancer as well as developing a sense of mastery and control over the disease and using downward comparison to help one feel good about how one is doing in the face of the disease (Taylor 1983). Finally, having supportive social relationships is critical to positive adaptation.
Emotional responses to serious illness can also have important implications for the person’s physical well being. For example, 10-year survival rates for breast cancer patients who responded to their diagnosis with feelings of helplessness, denial, or stoic acceptance have been found to be substantially lower than those for patients who responded to their diagnosis with what has been termed a ‘ﬁghting spirit,’ which included optimism in the face of their disease and a determination to do everything in their power to overcome the disease (Pettingale 1984).
3. Emotions And The Development Of Disease
Emotions have also been linked to the development of a variety of disease conditions. In what follows, evidence is examined concerning emotions that are associated with a higher risk of disease as well as others which appear to be protective against ill health.
3.1 Emotions As Health Risk
Not surprisingly, emotions associated with increased risk of disease are negative ones. Evidence has accumulated linking various negative emotions to the experience of ill health as well as the development of various disease conditions (Friedman 1990). Further, there is a tendency for the experience of diﬀerent negative emotions to be correlated with each other and as such it makes sense to refer to a general tendency towards the experience of negative emotions. This tendency is known as negative aﬀectivity and is closely related to the personality trait of neuroticism. A number of studies have found negative aﬀectivity to be a common ingredient running through various health-related measures of stress, emotion, coping, and illness experience. As such it has been argued that ﬁndings relating such measures as life stress, pessimism, loneliness, low life satisfaction, and other measures of psychological distress to poor health can be explained, at least in part, as being a reﬂection of this general tendency to experience negative emotions and interpret experience in negative terms (Clark and Watson 1991).
Other evidence indicates that it is not just the experience of negative emotions that is associated with poorer health but more speciﬁcally the lack of expression of these emotions. Since the 1980s research evidence has been accumulating on the negative health eﬀects of emotional inhibition. In particular, people with repressive coping styles as well as those actively inhibiting the expression of emotion have been found to have generally poorer health and to show negative psychophysiological as well as immunological changes as a result of suppressing the expression of negative feelings (Pennebaker 1995).
Although these general variables of negative aﬀectivity and emotional inhibition are associated with poor health generally, there is also good reason to believe that a full understanding of the relationship of emotion to health requires examination of the ways in which speciﬁc emotions relate to health status and to speciﬁc disease conditions. In particular, the relationships of diﬀerent emotions to speciﬁc health conditions are somewhat variable, suggesting at least a certain amount of speciﬁcity in the role of emotions in health.
Most likely the strongest relationship with health outcomes has been obtained for anger and its cognitive and dispositional counterpart, hostility. Even though anger and hostility can be conceptually diﬀerentiated they are discussed together because they are clearly closely related, measures of these two constructs generally share a common core of variance, and they are frequently discussed together in the research literature. Numerous studies have found signiﬁcant associations between anger/hostility and deaths from coronary heart disease as well as mortality from all causes, an association that remains signiﬁcant when other risk factors are statistically controlled. In the case of coronary heart disease this association has been described as being at least as large as those reported for more traditional risk factors for CHD such as cigarette smoking, high blood pressure, and high serum cholesterol (Miller et al. 1996). Anger and hostility also appear to be related to other disease conditions such as cancer and arthritis but the strength of these relationships appears to be somewhat weaker than that found with CHD. Interestingly, while it appears to be the expression of anger that is associated with CHD, the suppression of anger is associated with cancer (Friedman 1990).
Depression is a second emotional state with signiﬁcant health implications. The most obvious association between depression and health is with suicide. However, depression has been found to have an association with a number of other medical conditions as well. On the one hand, there is evidence that depression is associated with an increased likelihood of conditions such as heart disease and cancer as well as with overall mortality (Wulsin et al. 1999). On the other hand, depression has been found to be associated with poorer prognosis for patients diagnosed with conditions such as AIDS, cancer, and heart disease. For example, work by Frasure-Smith et al. (1995) has found depression to be a signiﬁcant predictor of mortality among cardiac patients whereas similar ﬁndings have been obtained for cancer patients (Pettingale 1984) and patients with AIDS (Patterson et al. 1996).
Relatedly, grief has been found to have signiﬁcant health implications. Several studies have found in-creased illness as well as mortality among individuals who have been recently bereaved. This increased mortality has been found to be greatest in the ﬁrst six months following bereavement and to derive from a number of causes including accidents, violence, heart disease, and cancer (Wulsin et al. 1999).
Finally, anxiety and fear have been found to have signiﬁcant health implications. For one thing, anxiety can be converted into physical complaints through somatization. For example, studies of patients’ visits to physicians have found that a large portion of such visits are often the result of physical complaints with an emotional basis, often anxiety (Barsky and Klerman 1983). In addition, anxiety has been found to be associated with conditions as diverse as CHD, asthma, ulcers, arthritis, and headaches (Friedman 1990; Friedman and Booth-Kewley 1987) and severe fright has been linked to sudden death from heart attacks (Hafen et al. 1996).
3.2 Emotions As Protector Of Health
The ﬂip side of the coin is that positive emotions may be protective of health. Evidence for this is not as strong as for the eﬀects of negative emotions but links are being established. As with negative emotions, there is a tendency for dispositional measures of positive emotion to correlate with each other, a construct termed positive aﬀectivity. Positive aﬀectivity is largely independent of negative aﬀectivity and, whereas negative aﬀectivity is closely associated with neuroticism, positive aﬀectivity is closely related to extroversion. Current evidence indicates that on its own, positive aﬀectivity is generally unrelated to health complaints. However, conceptually, positive aﬀectivity is closely related to optimism and low levels of positive aﬀectivity appear to be an important ingredient in depression. As such there has been speculation that it is the positive aﬀectivity components of these emotional states that are responsible for their relationships to physical health (Clark and Watson 1991).
Perhaps the strongest evidence for positive emotions as a protector of health comes from work on optimism. Optimism refers to a person’s tendency to look on the positive side of events and to believe that events will work out for the best. As such optimists can be expected to experience positive emotions more often than more pessimistic individuals. And, in fact, as noted, optimism is associated closely with positive aﬀectivity. Research on optimism indicates that optimists tend to live longer, healthier lives than more pessimistic individuals and also to be less susceptible to viral infections, such as the common cold. In addition, optimistic cancer patients tend to live longer than more pessimistic ones and optimism is associated with greater immune system competence as indicated by the ratio of T4 to T8 cells (Peterson and Bossio 1991).
4. Mechanisms Linking Emotions And Health
As noted above there is accumulating evidence that emotions are signiﬁcantly related to health and indications that emotional states may play a signiﬁcant role in the development of disease as well as in the healing process. How can these relationships be explained? What are the mechanisms linking emotions and health? The answers to these questions are still emerging but a number of plausible hypotheses have been proposed. These hypotheses relate to both indirect and direct eﬀects that emotions may have on disease processes.
4.1 Indirect Links Between Emotions And Health: The Health Behavior Connection
One possibility is that emotions inﬂuence health indirectly through their eﬀects on behavior, particularly health behaviors. Numerous studies have noted that stress, which often includes emotional upset, is associated with poorer health behaviors. For example, higher levels of stress have been associated with higher levels of smoking as well as increased alcohol and drug usage and poorer eating habits. Speciﬁc emotions also appear to be associated with health behaviors. For example, there is evidence that higher levels of hostility are associated with greater consumption of cigarettes and alcohol as well as less physical exercise and poorer self-care (Smith 1992). It is well establised that these health behaviors are associated with poorer health outcomes and thus it seems highly plausible that emotions may well aﬀect health outcomes in this manner.
4.2 Direct Links Between Emotions And Health: The Physiological Connection
There also appear to be direct physiological links between emotions and health. In addition to their experiential aspects emotions are very much physiological events. There has been much controversy over the years about the precise relationship of emotions to physiology, whether there are speciﬁc patterns of physiological changes that correspond to speciﬁc emotions, and whether the phenomenological experience of emotion precedes or is the result of such physiological changes, but there is no doubt that emotions are associated with a variety of physiological changes. These changes occur in a number of diﬀerent bodily systems including the nervous, cardiovascular, respiratory, endocrine, and muscular systems and vary considerably in intensity. A substantial number of studies have attempted to chart these changes and relate them to speciﬁc emotions. Results from such studies have been mixed in that physiological changes found for speciﬁc emotions tend to vary considerably between studies and with the methods used for evoking emotion as well as measuring physiological changes. In many respects, this variation is not surprising given the complexity of physiological events and the methodological hurdles in establishing their relationship to particular emotions (Cacioppo et al. 1993). However, there is no doubt that emotions are associated with substantial physiological changes and it seems highly plausible that these changes may mediate the relationship between emotions and health.
Although there is considerable controversy about the precise relationship between emotions and physiology, progress has been made in charting likely physiological pathways between emotions and speciﬁc diseases. Some of the most detailed evidence to date comes from work on the relationship of anger and hostility to cardiovascular disease. A number of studies have found that individuals high in anger and hostility tend to show heightened physiological, and particularly cardiovascular, responses to various stressors. Although results have not been entirely consistent there is evidence that individuals who are high in hostility, and who are thus more prone to the experience of anger, show larger stress-related increases in blood pressure, heart rate, and stress-related hormones than do individuals lower in hostility. This heightened physiological reactivity appears particularly likely when the person is faced with social stressors such as harassment or other social challenge and is considered by some to be at least a marker if not a causal agent for the future development of cardiovascular disease (Smith 1992). One possible mechanism is that increased blood pressure and catecholamine reactivity as a result of repeated episodes of anger may be related to increased likelihood of injury to the interior walls of blood vessels which in turns accelerates the process of atherosclerosis (Manuck 1994).
In addition to heightened reactivity in the face of stressors, it is also quite possible that high hostile individuals experience more situations evoking anger, either because they gravitate toward such situations and/or because their actions tend to evoke hostile responses from others. For example, there is evidence that high levels of hostility are associated with generally high levels of interpersonal conﬂict and low levels of social support. In addition, high hostility has been associated with the experience of more frequent and severe daily hassles as well as major negative life events. This tends to suggest a synergism between poor interpersonal relationships and high physiological reactivity which would further increase the high hostile individual’s vulnerability to disease (Smith 1992).
Heightened physiological reactivity is one link between emotions and health but it is certainly not the only one. Another important link concerns the relationship of emotion to immune functioning. In this respect there is a growing literature showing that the tendency to experience certain emotions can aﬀect immuno-competence, as can transient moods. First, indices of immuno-competence have been found to be lower among individuals with depressive symptomotology as well as among recently bereaved individuals strongly suggesting that dysphoric moods may lead to the suppression of immune functioning (O’Leary 1990). One possible explanation for this is that withdrawal responses and the generally more passive coping responses associated with helplessness and depression are associated with the activation of the hypothalamic-pituitary-cortical axis which leads to increases in cortisol output which in turn have the eﬀect of suppressing immune functioning (Antoni 1987). Such processes have important implications for a variety of immune related diseases including cancer, AIDS, and autoimmune diseases. This may well be one of the reasons why individuals with a so-called ‘Type C’ personality, which includes the traits of being unassertive, patient, and unexpressive of negative emotions, all of which are related to passive coping, are more likely to develop cancer (Friedman 1990). Second, humor and positive emotions have been found to be related to increases in immuno-competence among other physiological changes. For example, several studies have found that laughter is associated with increases in concentrations of lymphocytes as well as increased natural killer cell activity and overall immune responsiveness, and a reduction in the secretion of cortisol. Similarly, studies on optimism have found that optimists have stronger immune functioning than do people with a more pessimistic attitude towards life (Hafen et al. 1996). Finally, there is growing evidence that the suppression and expression of emotion have both physiological and immunological eﬀects. Inhibition of emotion has been shown to lead to changes in electrodermal as well as cardiovascular activity. Also, in addition to evidence cited above that suppression of negative emotions is related to reduced immune functioning, there is evidence from a growing number of studies that the expression of negative feelings as a form of catharsis can result in improved immune functioning. For example, several studies have now demonstrated that having people write or talk about traumatic experiences they have not disclosed to other people previously results in an increase in immune responsiveness. This occurs when they focus on the emotions involved but not when they focus only on the facts of what happened (Pennebaker 1995).
4.3 Common Underlying Factors Between Emotions And Health: Constitutional Vulnerability
A third possible link between emotions and health is that there may be common underlying factors for both emotionality and the occurrence of disease. For example, there may be genetic factors that inﬂuence, on the one hand, the emotions a person experiences and how those emotions are expressed and, on the other hand, the occurrence of ill health in general as well as speciﬁc disease conditions. As yet no such genetic links have been established but this does not mean that they do not exist. With the rapid progress currently being made in the genetics of disease as well as work on the genetics of personality such links may well be established in the future.
5. Reducing Health Risk
The emerging pattern of linkages between emotions and health raises the question of what can be done to reduce the health risk from negative emotions and boost the beneﬁts from positive ones. Three possibilities are considered here but these are best seen as only representative of interventions that may be eﬀective.
First, psychotherapeutic techniques can be used to help people deal more eﬀectively with negative emotions as well as boost positive emotions. Numerous techniques have been developed, and there is reason to believe that at least some of these may have positive beneﬁts for physical health as well as mental health. For example, psychotherapy interventions have been shown to be eﬀective in boosting immune responsiveness and improving physical health in both cancer patients and noncancer populations. Psychotherapy with cancer patients has been shown to reduce recurrence and increase ﬁve-year survival rates which is consistent with data showing that psychotherapy with a variety of medically ill patients can lead to improved health outcomes (Fawzy and Fawzy 1994). Of course, psychotherapy does more than simply reduce negative emotions and boost positive ones but such data, in conjunction with the evidence on the role of emotions in health, suggest the potential of psychotherapy for reducing the negative eﬀects of emotions on health.
Closely related to these eﬀects of psychotherapy in general is work showing the psychological and physical beneﬁts of writing or talking about traumatic events. Research by Pennebaker and others has produced substantial evidence for the positive psychological and physical beneﬁts of writing as well as talking about traumatic events. Overall, when people, ranging from university students to holocaust survivors, are induced to write or talk about traumatic experiences positive psychological beneﬁts are found and there are reductions in harmful arousal as well as improvements in immune functioning and subsequent reductions in the number of times the person seeks medical attention. Such changes are particularly evident when the person writes or talks about traumas that had not been previously disclosed to others and when he or she writes about the emotions involved and not just the facts of the situation (Pennebaker 1995). This strongly argues for the health beneﬁts of disclosure of negative experiences to others and suggests an apparently powerful way of reducing the harmful eﬀects of emotion on health.
Finally, evidence on the role of anger and hostility in heart disease strongly argues for interventions directed towards reducing these potentially harmful emotions. A number of strategies have been suggested and there is evidence that teaching people to be aware of their feelings and then utilizing a series of strategies for dealing with diﬃcult life situations can have positive eﬀects both on the person’s relationships and psychological adjustment and possibly on their physical health as well (Williams and Williams 1997). Deﬁnitive evidence on the eﬀects of these interventions is not yet available but the results to date are promising.
6. Implications And Future Directions
Findings concerning the relationships of emotion to health are a prime example of the way in which psychological and social factors are closely intertwined with biological processes in determining one’s health status. Disease is clearly a biological phenomenon but it is one that is strongly inﬂuenced by psychosocial factors. Also, phenomena such as emotions that are generally viewed in the realm of the psychological have a deﬁnite basis in biological processes. As such one cannot speak of psychological processes without consideration of the biological and vice versa.
Although the evidence relating emotions to health has been growing rapidly there are still many questions that remain to be answered. One major question concerns the degree to which speciﬁc emotions are related to speciﬁc disease conditions. There has long been speculation about such relationships but as yet there has been no clear resolution of this question. Whereas work on such topics as negative aﬀectivity tends to suggest a general relationship between negative emotions and ill health, other work tends to suggest at least a degree of speciﬁcity. This is a question that needs further work and one which will beneﬁt from a clearer speciﬁcation of how one can best diﬀerentiate between diﬀerent emotions both psychologically and physiologically.
Relatedly, there are still many questions about the mechanisms linking emotions and health. Evidence for the roles of physiological reactivity and immunocompetence in this linkage is growing but much remains to be learned. Exactly how is it that diﬀerent emotions produce these physiological changes? What other biological processes operate in linking emotion to health? How are genetic factors involved in this relationship? These are fascinating questions that still remain to be addressed.
Finally, much remains to be done with respect to capitalizing on what has been learned in this area for improving health. Current interventions have been described but these would appear to only scratch the surface of what might be possible with respect to harnessing psychological methods for improving physical health.
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