Personality and Individual Differences 96 (2016) 7–11

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Personality and Individual Differences

journal homepage: www.elsevier.com/locate/paid

Personality and health in chronic pain: Have we failed to appreciate

a relationship?
C. Suso-Ribera a,⁎, D. Gallardo-Pujol b,c
a
Pain Unit, Vall d'Hebron Hospital, Barcelona, Spain
b
Department of Personality, Faculty of Psychology, University of Barcelona, Spain
c
Brain, Cognition and Behavior Research Institute (IR3C), University of Barcelona, Spain

a r t i c l e i n f o a b s t r a c t

Article history: Pain research has failed to replicate personality-health associations found in the general population. Two hypoth-
Received 14 December 2015 eses were tested in the present study. First, that methodological shortcomings found in previous research are
Received in revised form 21 February 2016 responsible for the inconsistencies. Second, that pain is a contextual factor (i.e., moderator) influencing the rela-
Accepted 24 February 2016
tionship between personality and health. We enrolled 495 patients with chronic pain (mean age = 58.54 years,
Available online 1 March 2016
63% women). Most had low back pain (59%). The study design was cross-sectional. We assessed the Five Factor
Keywords:
Model of personality, several components of health, and pain intensity at the time of assessment. The relation
Personality between personality and health was not moderated by pain levels. In contrast, results revealed a main effect of
Five Factor Model neuroticism, extraversion, and conscientiousness beyond the contribution of pain intensity, age, and gender. In
Chronic pain light of the study results, the first hypothesis was supported. That is, when using a robust methodological
Health work (i.e., using a large sample and controlling for covariates and type I errors), personality-health associations
found in the general population are replicated in pain settings. In contrast, our results did not support the second
hypothesis, that is, that pain moderated the relationship between personality and health. Clinical implications are
discussed.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction frequent. For instance, most reviewed samples are weakly powered
for the analyses conducted and the risk of type I errors is often ignored.
The relationship between the Five Factor Model (FFM) of personality These limitations were raised many years ago, but they remain unre-
and health in the general population is well established. Individuals solved (Asghari & Nicholas, 1999). Additionally, most results come
scoring high in neuroticism (N) present poorer subjective well-being from bivariate correlational analyses, which do not account for the effect
and more internalizing problems (i.e., depression and anxiety). In of important covariates of health in chronic pain, such as age, gender,
contrast, extraverts (E) tend to report higher levels of mental health, and pain levels (Keogh & Herdenfeldt, 2002; Mun, Okun, & Karoly,
as well as improved physical and social performance. Conscientiousness 2014; Rustøen et al., 2005).
(C) mostly contributes to physical functioning and, ultimately, to Another possibility is that, in the presence of pain, the relation
longevity. Finally, openness (O) and agreeableness (A) present the between personality and health becomes more complex. It has been
weakest associations with health outcomes (Ozer & Benet-Martínez, suggested that the influence of personality is less likely to be revealed
2006; Roberts, Kuncel, Shiner, Caspi, & Goldberg, 2007). when the demands of a situation are high (Higgins & Scholer, 2008).
Attempts have been made to replicate these findings in chronic pain Pain is, in fact, an example of a demanding situation (Cunha, Burke,
settings. So far, the relation between personality and the physical health França, & Marques, 2008). Therefore, pain might act as a contextual
of chronic pain patients has not been replicated and the strength of factor in the relation between personality and health in chronic pain.
associations between personality and emotional health varies widely In the present investigation, we tested both possibilities. First, that
across investigations (Affleck, Tennen, Urrows, & Higgins, 1992; methodological shortcomings found in previous research were respon-
Martínez, Sánchez, Miró, Medina, & Lami, 2011; Newth & DeLongis, sible for the inconsistencies found in the relationship between personal-
2004; Schmidt, Hooten, & Carlson, 2011). The role of personality in ity and health in chronic pain. Second, that pain was a contextual factor
social performance has been overlooked in the context of pain. (i.e., moderator) influencing the relationship between personality and
There might be several reasons for the inconsistencies found in health. To test the first hypothesis we explored the main effects of per-
personality research in chronic pain. Methodological shortcomings are sonality while controlling for potential confounders. We used a large
sample size and corrected alpha levels to address the methodological
⁎ Corresponding author at: Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain. shortcomings of existing data. Then, we investigated whether pain
E-mail address: [email protected] (C. Suso-Ribera). was a contextual factor in the relationship between personality and

http://dx.doi.org/10.1016/j.paid.2016.02.063
0191-8869/© 2016 Elsevier Ltd. All rights reserved.
8 C. Suso-Ribera, D. Gallardo-Pujol / Personality and Individual Differences 96 (2016) 7–11

health (second hypothesis). That is, pain was used as a moderator of the 2.4. Data analysis strategy
personality-health associations to see whether the influence of person-
ality decreased with pain. We conducted Pearson correlations between personality traits and
health components. We used Bonferroni's correction to minimize type
I errors. Next, we performed two sets of hierarchical regressions. First,
2. Method
we explored the contribution of each personality trait in the prediction
of health. To do so, we included age, gender, and pain intensity as covar-
2.1. Participants
iates in the first block, and then entered personality dimensions as a
second block. We also investigated whether the relation between per-
We included 495 heterogeneous patients with chronic pain. Almost
sonality and health was contextually determined. Therefore, in a second
all were born in Spain (94.3%), most were women (63.63%), and the
set of regressions we predicted each health component using one per-
mean age was 58.54 ± 15.05 years. The main pain diagnoses were
sonality trait, current pain intensity, and the interaction term between
low back pain (59.0%), neck pain (9.3%), post-surgery pain (5.8%),
both factors. The first block included the simple effects of current pain
and osteoarthritis (5.7%). The remaining diagnoses occurred at very
intensity and personality. We added the interaction term in the second
low rates. Patients had experienced pain for between 3 months and
block. Moderation occurred when the interaction term between pain in-
53 years (84.01 ± 116.13 months). Most patients were married
tensity and personality significantly predicted health while controlling
(60.3%), but several were widowed (14.1%), single (13.1%), or divorced
for the main effect of pain intensity and personality, as recommended
(12.5%). Almost 46% had more than 12 years' education, and 68.6% were
in the classic article by Baron & Kenny (1986). We centered all variables
not working at the time of assessment.
before the analyses.

2.2. Measures 3. Results

2.2.1. Personality 3.1. Personality correlates of health

We used the Spanish adaptation of the short form of the NEO-
Personality Inventory, the NEO-Five-Factor-Inventory (Solé i Fontova, The bivariate associations between personality and health outcomes
2006). The questionnaire assessed five domains of personality: N, E, O, are shown on Table 1. Using a restrictive alpha level (.004), we found
A, and C. Individuals were asked to rate the degree to which they agreed that N (−), E, and C were significantly associated with bodily pain,
with 60 statements, using 5-point scales. The NEO-Five-Factor- general health, vitality, social functioning, role emotional, and mental
Inventory has adequate psychometric properties (0.66 b α b 0.81) health. C was also positively related to physical functioning. O was
(Solé i Fontova, 2006). The internal consistency in our sample was also linked to physical functioning, general health, and mental health,
good (0.70 b α b 0.84). while A was associated with mental health only.

2.2.2. Health 3.2. Multivariate analysis of health

We used the Spanish adaptation of the Short Form-36 Health Survey
(Alonso et al., 1998) to measure health status. The scale addresses phys- We then performed a series of hierarchical regressions using age,
ical and mental components of health. Physical aspects include the ability gender, and pain intensity as covariates in block 1 and personality traits
to perform daily activities (physical functioning) and work-related activ- in the second block (Table 2). Higher current pain resulted in poorer
ities (role physical), plus the average intensity of pain in the last four health across all health dimensions. Older participants performed less
weeks (bodily pain). Some elements referred to both physical and men- well in their daily activities, while females reported being less vital.
tal health, such as the perception of present and future health (general Of the FFM, N contributed to bodily pain, general health, vitality, so-
health), the evaluation of personal energy (vitality), and the interference cial functioning, role emotional, and mental health. E was associated
of health problems in their interpersonal life (social functioning). The with vitality and social functioning. C was related to physical function-
remaining components, namely the role of emotions on functioning ing and general health. A contributed to the prediction of role emotion-
(role emotional) and psychological well-being (mental health), mainly al, but because the correlation between A and role emotional was non-
address the psychological aspects of health (Bergman, Jacobsson, significant (r = .025, p = .585), we further explored if significance in
Herrström, & Petersson, 2004). The psychometric properties of the ques- the prediction model was due to a suppression effect (Chaplin, 2007).
tionnaire are good (0.78 b α b 0.94) (Alonso et al., 1998), and the internal Indeed, the inclusion of N was responsible for the significant effect
consistency was also good in our sample (0.75 b α b 0.92). of A on role emotional (β before the inclusion of N = −.064,
t = − 1.360, p = .174; β after the inclusion of N = −.124,
t = −2.821, p = .005), so we did not interpret the effect of A on role
2.2.3. Pain intensity
emotional.
We assessed current pain intensity by means of a numerical rating
The largest contributions of personality traits as a block emerged for
scale from 0 (no pain) to 10 (worst possible pain). This instrument is
the components that correlate to mental health only, that is, role emo-
widely used in the assessment of chronic pain and has become a stan-
tional and mental health (18.6 and 31.8% respectively). The increase in
dard tool (Farrar, Young, LaMoreaux, Werth, & Poole, 2001). A measure
explained variance ranged from 10 to 14.1% for the components that
of current pain intensity is frequently used as a covariate of health
correlate to both physical and mental health, namely general health,
(Asghari & Nicholas, 2009).
vitality, and social functioning. We found the smallest contributions
for physical functioning (2.8%) and role physical (1.6%), while the effect
2.3. Procedure of personality traits as a block was not significant for bodily pain.

Participants were 495 consecutive patients attending a large Tertiary 3.3. Moderation analyses
Pain Clinic in Barcelona (Spain). All patients were contacted by letter
and returned the completed questionnaires the day of their next For each regression, we entered one personality trait, a measure of
appointment. current pain, and the interaction term of both. We set a more restrictive
The Research Ethical Committee at the Vall d'Hebron Hospital ap- alpha level of 0.01 to control for type I errors. None of the interaction
proved the study and procedures. terms tested reached significance, so results are not shown in a Table.
 C. Suso-Ribera, D. Gallardo-Pujol / Personality and Individual Differences 96 (2016) 7–11 9

Table 1
Means, standard deviations, and correlations between study variables.

Age Pain N E O A C PF RP BP GH VT SF RE MH

Age – .20⁎⁎⁎ −.12⁎⁎ −.04 −.24⁎⁎⁎ .11⁎ .04 −.38⁎⁎⁎ −.05 −.11⁎ −.15⁎⁎⁎ −.10⁎ −.06 .01 −.05
Pain – .15⁎⁎⁎ .01 −.07 .05 .01 −.45⁎⁎⁎ −.23⁎⁎⁎ −.51⁎⁎⁎ −.34⁎⁎⁎ −.33⁎⁎⁎ −.32⁎⁎⁎ −.17⁎⁎⁎ −.27⁎⁎⁎
N – −.40⁎⁎⁎ −.07 −.27⁎⁎⁎ −.42⁎⁎⁎ −.13⁎⁎ −.14⁎⁎⁎ −.14⁎⁎⁎ −.35⁎⁎⁎ −.38⁎⁎⁎ −.33⁎⁎⁎ −.45⁎⁎⁎ −.59⁎⁎⁎
E – .27⁎⁎⁎ .24⁎⁎⁎ .42⁎⁎⁎ .13⁎⁎ .11⁎ −.01 .22⁎⁎⁎ .29⁎⁎⁎ .25⁎⁎⁎ .16⁎⁎⁎ .34⁎⁎⁎
O – .02 .08 .15⁎⁎⁎ .01 .05 .14⁎⁎⁎ .12⁎⁎ .07 .04 .15⁎⁎⁎
A – .26⁎⁎⁎ −.02 −.02 −.01 −.02 .07 .10⁎ .03 .17⁎⁎⁎
C – .14⁎⁎⁎ .07 .02 .23⁎⁎⁎ .26⁎⁎⁎ .18⁎⁎⁎ .24⁎⁎⁎ .30⁎⁎⁎
PF – .45⁎⁎⁎ .54⁎⁎⁎ .46⁎⁎⁎ .49⁎⁎⁎ .56⁎⁎⁎ .26⁎⁎⁎ .38⁎⁎⁎
RP – .47⁎⁎⁎ .32⁎⁎⁎ .37⁎⁎⁎ .46⁎⁎⁎ .22⁎⁎⁎ .26⁎⁎⁎
BP – .38⁎⁎⁎ .49⁎⁎⁎ .50⁎⁎⁎ .29⁎⁎⁎ .31⁎⁎⁎
GH – .56⁎⁎⁎ .40⁎⁎⁎ .38⁎⁎⁎ .47⁎⁎⁎
VT – .58⁎⁎⁎ .39⁎⁎⁎ .64⁎⁎⁎
SF – .48⁎⁎⁎ .59⁎⁎⁎
RE – .63⁎⁎⁎
MH –
Mean 58.54 7.78 24.90 26.01 23.07 31.84 30.97 32.50 12.14 19.35 34.90 31.13 43.08 53.91 49.72
SD 15.05 1.68 8.94 8.01 6.68 6.11 7.22 24.05 28.41 17.56 19.66 20.72 28.56 46.43 21.36
Theoretical range N.A. 0–10 0–48 0–48 0–48 0–48 0–48 0–100 0–100 0–100 0–100 0–100 0–100 0–100 0–100
Empirical range 18–89 2–10 0–47 3–48 6–43 6–48 7–48 0–100 0–100 0–100 0–97 0–100 0–100 0–100 0–100

Note. N, Neuroticism; E, Extraversion; O, Openness; A, Agreeableness; C, Conscientiousness; PF, Physical Functioning; RP, Role Physical; BP, Bodily Pain; GH, General Health; VT, Vitality; SF,
Social Functioning; RE, Role Emotional; MH, Mental Health. High scores in health components indicate better health.
⁎ p b .05.
⁎⁎ p b .01.
⁎⁎⁎ p b .003 (after Bonferroni correction).

Only a marginally significant moderation of pain intensity emerged for In addition, we have revealed that N is negatively correlated with per-
N (β = .10, t = − 2.49, p = .013) and E (β = −.10, t = − 2.35, p = ceived health, vitality, and social functioning. Most importantly, this
.019) in the prediction of role emotional. The interaction term with existed after controlling for the effect of several covariates and the
pain was also marginally significant for O in the prediction of physical remaining personality traits. Some mechanisms underlying the relation
functioning (β = −.09, t = −2.19, p = .029). between N and health have already been described. For example, N
might influence overall health by promoting negative appraisal of ill-
4. Discussion ness (Costa & McCrae, 1987; Roberts et al., 2007). High scores for this
trait are also associated with an increased risk of engaging in unhealthy
In this investigation, we wanted to test two different hypotheses for behaviors, such as smoking, alcohol abuse, and unprotected sex (Lahey,
the inconsistencies found in the relationship between personality and 2009). Maladaptive cognitive and behavioral patterns appear to be re-
health in chronic pain. The first was that methodological shortcomings sponsible for the negative relation between N and health, with our
would explain why the personality-health associations found in the study suggesting that this relationship is crucial to several components
general population were less clear in chronic pain. A second hypothesis of well-being. Considering this, it is not surprising that N is increasingly
was that the link between personality and health was weaker in chronic a matter of public health concern (Cuijpers et al., 2010). Our results
pain due to the adaptational demands of pain. Our results provide suggest that this should be the case in chronic pain too.
support for the first hypothesis, that is, the relation between personality Different to N, E was positively associated with all components that
dimensions and health outcomes remained significant for all levels of correlated to mental health. The contribution of E, when controlling for
patient pain, replicating the findings found in the general population. several covariates and the remaining personality traits, remained signif-
In our study, N mostly contributed to psychological health, while its icant for two of these components: vitality and social functioning. Extro-
association with pain intensity was weak. This is consistent with previ- verted individuals are known to be physically active and energetic
ous research in chronic pain (Martínez et al., 2011; Schmidt et al., 2011). (Rhodes & Smith, 2006), which would explain the higher levels of

Table 2
Hierarchical multivariate regression predicting health components.

Predictor PF RP BP GH VT SF RE MH

ΔR2 β ΔR2 β ΔR2 β ΔR2 β ΔR2 β ΔR2 β ΔR2 β ΔR2 β

Step 1 .30 .06 .02 .13 .13 .12 .05 .10

Age −.30⁎⁎⁎ −.01 −.11⁎ −.10⁎ −.05 −.01 .01 −.05
Gender −.03 −.06 −.10⁎ −.01 −.12⁎⁎⁎ −.03 −.05 −.09⁎
Pain −.39⁎⁎⁎ −.21⁎⁎⁎ −.28⁎⁎⁎ −.27⁎⁎⁎ −.31⁎⁎⁎ −.13⁎⁎⁎ −.19⁎⁎⁎
Step 2 .02 .01 .01 .11 .14 .10 .19 .32
N −.03 −.07 −.17⁎⁎⁎ −.23⁎⁎⁎ −.22⁎⁎⁎ −.20⁎⁎⁎ −.43⁎⁎⁎ −.49⁎⁎⁎
E .04 .10 −.04 .08 .17⁎⁎⁎ .17⁎⁎⁎ −.04 .11⁎
O .03 −.07 .02 .05 .02 −.02 .02 .05
A −.02 −.08 −.04 −.12⁎⁎ −.04 .01 −.12⁎⁎⁎ .02
C .15⁎⁎⁎ .05 −.02 .13⁎⁎⁎ .12⁎ .04 .11⁎ .05
Total R2 .32 .07 .03 .24 .27 .22 .24 .42

Note. Pain, current pain intensity. The remaining abbreviations are identical to those reported on Table 1. Betas are standardized. R2 is adjusted.
⁎ p b .05.
⁎⁎ p b .01.
⁎⁎⁎ p b .006 (after Bonferroni correction).
10 C. Suso-Ribera, D. Gallardo-Pujol / Personality and Individual Differences 96 (2016) 7–11

vitality reported. However, of particular interest was the contribution of the negative appraisal of illness (Lahey, 2009). Even though we did
E to the prediction of social functioning. To our knowledge, no other not explicitly explore this phenomenon, we believe that our results
study has shown a relationship between personality and social perfor- are consistent with such conclusions.
mance in chronic pain settings. Individuals with high E are known to Our study certainly has some limitations. We cannot address causal-
be keen to have social interactions (Ozer & Benet-Martínez, 2006), ity because of the cross-sectional design, so longitudinal studies will be
and our results support previous findings that extroverted pain patients needed to provide further evidence on the long-term effects of person-
are more successful in preventing their health problems from interfer- ality traits on the health of patients with chronic pain. It is important to
ing with their interpersonal lives. This might have important implica- note that our results are not necessarily generalizable to all chronic pain
tions in chronic pain, especially given that research has shown social populations because of the heterogenous nature of this population
support to be associated with better health outcomes in patients with (Jensen, Turner, Romano, & Karoly, 1991). Despite this, the age and gen-
chronic pain (López-Martínez, Esteve-Zarazaga, & Ramírez-Maestre, der distribution was similar to that of previous research (Lamé, Peters,
2008). The ability of extroverts to overcome the limitations that their Vlaeyen, Kleef, & Patijn, 2005). Also, the high prevalence of back pain
health has on their social lives should not be ignored. appears congruent with other investigations of heterogeneous samples
In light of our results, there is little evidence to suggest that O and A (Asghari & Nicholas, 1999), as well as with the rate of such pain in the
are associated with health in patients with chronic pain. This seems to general population (Negrini, Fusco, Atanasio, Romano, & Zaina, 2008).
be consistent throughout the literature on chronic pain (Martínez Thus, our results should have some relevance to other Pain Clinics.
et al., 2011; Schmidt et al., 2011). In addition, the relation between While acknowledging the shortcomings of this work, we should also
these personality traits and health ceased to be significant when we observe that we have addressed some methodological issues in the
controlled for covariates and the remaining personality traits. Previous existing literature that were raised more than a decade ago (Asghari &
investigations with healthy individuals have already revealed that O Nicholas, 1999). Indeed, we gathered data for a large sample, controlled
and A do not contribute to health more than any other personality for potential confounders, and accounted for type I errors when
trait (Betz & Borgen, 2010; Magee, Heaven, & Miller, 2013). Our results conducting multiple comparisons, which should make our conclusions
support this finding in patients with chronic pain. more robust. In addition, we used the comprehensive model of health
An important finding in our investigation was that C correlated in the Short Form-36 to support new findings in the relationship be-
positively to most components of health, including physical health. tween personality and health in patients with chronic pain. We believe
Although positive relationships have been reported between C and psy- that research has failed to appreciate the significance of personality
chological health in patients with chronic pain (Newth & DeLongis, traits in chronic pain because it has focused on limited health outcomes
2004; Schmidt et al., 2011), ours seems to be the first to find an associ- such as pain intensity (Raselli & Broderick, 2007; Schmidt et al., 2011).
ation with physical health in chronic pain (specifically, physical func- The assessment of several dimensions of health in the present study
tioning in this study). Few studies have explored the relation between therefore provides a broader picture of the relationship between per-
personality and physical performance (Affleck et al., 1992; Martínez sonality and well-being in chronic pain. Specifically, we provide novel
et al., 2011). Of these, Affleck et al. only included a measure of N, which evidence for a relationship between personality and another two health
was non-significant, while Martínez et al. failed to associate any of the components in chronic pain: that is, physical functioning and interper-
Five Factor Model with physical disability. In the latter, physical disability sonal performance.
was given as a composite of several components (i.e., household, social,
and leisure activities), which might explain the discrepancy with our find- Declaration of conflicting interests
ings. Indeed, our results only provide support for the contribution of C to
the prediction of just one of these three components (i.e., physical The authors declare no potential conflicts of interest.
functioning in the daily activities, corresponding to household activities).
Despite this being a novel finding in the context of chronic pain, a positive References
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