Does Attitude Influence Outcome?
Does Attitude Influence Outcome?
Abstract & Commentary
Synopsis: In a 30-year follow-up of 839 patients in a general medical practice, those with a more pessimistic outlook on life were significantly more likely to die than those who were optimistic or whose attitudes were mixed.
Source: Maruta T, et al. Mayo Clin Proc 2000;75:140-143.
The minnesota multiphasic personality inventory (MMPI) has long been a "gold standard" instrument for assessing personality traits. Between 1962 and 1965, 1145 consecutive patients who were self-referred to the Mayo Clinic Division of Community Internal Medicine for general medical care were given the MMPI as part of a research study. Maruta and associates obtained data on the 839 patients who were residents of Olmsted County at the time of initial registration, had a complete MMPI, and for whom follow-up health status data were available. For these patients, Maruta et al used the 298-item Optimism-Pessimism (PSM) scale within the MMPI to assess personal explanatory style, or how an individual explains life events. Explanatory style has three dimensions: internality ("It’s me") vs. externality; stability ("It’s going to last forever") vs. instability; and globality ("It’s going to undermine everything") vs. specificity. Based on the results of the MMPI, Maruta et al applied a bipolar scale of optimism-pessimism to each individual in the study population based on the initial MMPI, and then correlated that with overall survival during the 30 years of follow-up.
The 839 patients, of whom 63% were women, had been 35 years old (range, 15-84 years) at the time of MMPI administration. Maruta et al managed to obtain data on 723 (86%) of them after an average of 29 years of follow-up. Application of the PSM scale showed that 124 could be classified as optimistic (PSM score, less than 40), 518 as mixed (PSM score, 41-60), and 197 as pessimistic (PSM score, 61 or higher).
Two hundred of the original 839 patients had died. As expected, older age was associated with a higher risk of dying, and men were more than twice as likely to die during the interval as were women. Individuals with a higher 15-year expected survival, based on age and sex, had a statistically greater actual survival. In addition, higher PSM scores (i.e., more pessimism) were significantly associated with a higher-than-expected mortality (P = 0.01). A 10-point increase in the T score on the PSM scale was associated with a 19% increase in the risk of death. These differences persisted after multivariate analysis adjusting for age, sex, and expected survival.
COMMENT BY DAVID J. PIERSON, MD, FACP, FCCP
This study shows that a pessimistic explanatory style, as measured by the PSM scale of the MMPI, is significantly associated with mortality—at least among residents of Olmsted County, Minnesota. The subjects in this study were from a general medical practice, not an ICU population. Do its findings have any relevance to critical care? Perhaps.
Although there are no controlled trials using optimism-pessimism or other aspects of personality as a variable, these things have long been recognized as important determinants of overall success in weaning from prolonged mechanical ventilation (Make B, et al. Chest 1984;86:358-365; Knebel AR, Am J Crit Care 1992;1:19-29; Pierson DJ, Respir Care 1995;40:289-295), as well as in technology-intensive home care (Pierson DJ, Respir Care 1994;39:294-308). It certainly seems easier to wean patients from ventilatory support who are bright-eyed and cooperative than those who are passive, detached, and resistive of our efforts.
Does an individual’s lifelong pattern of optimism or pessimism also influence his or her likelihood of surviving an episode of septic shock or acute respiratory distress syndrome (ARDS)? A skeptic would say, "Show me the data" and I would have to admit that I do not know of any. Yet we have all seen patients who seem to pull through by virtue of grit and determination rather than as a result of what we do. This study suggests that one’s degree of underlying optimism or pessimism influences survival over many years. Whether there are shorter-term effects of personality during critical illness will have to be determined by future investigators.
Patients whose personality inventory scores indicate a high degree of pessimism:
a. have a higher incidence of hypertension and stroke.
b. are more likely to develop ARDS in the presence of a given risk factor.
c. are less likely to survive an episode of septic shock.
d. have higher overall health care costs.
e. have an increased overall mortality.
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