The rheumatoid arthritic personality: A psychodiagnostic myth

PHILIP SPERGEL, ED. D. GEORGE E. EHRLICH, M.D. DOROTHEA GLASS. M.D.

The rheumatoid arthritic personality: A psychodiagnostic myth Some investigators view patients with rheumatoid arthritis as sharing a distinct personality pattern. characterized by repressed hostility and self-punishment. A preliminary comparison of psychological test scores of a group of rheumatoid arthritis patients with scores of patients with other chronic illnesses fails to support this contention, but suggests that there may be a "chronic disease personality."

ABSTRACT:

During the late 1950s and I960s. professional literature supported the theory that patients diagnosed as having rheumatoid arthritis shared a distinct personality pattern. Geist,1.2 among others. hypothesized that "rheumatoids" were individuals who repressed their hostility and enacted a rage against their body. Cobb. 3 Cormier and Wittkower,4 Ludwig.~·6 Mueller and Lefkovits,7 and Robinson 8 shared similar views. They concluded that the majority of individuals with rheumatoid arthritis had self-punitive and latently hostile tendencies, interpersonal difficulties with parents. less loving mothers, more authoritarian fathers, a greater tendency to divorce, and a lower income level than the normal population. Of course, it is FEBRUARY 1978, VOL 19· NO 2

difficult to differentiate between cause and effect in the relationship of physical and emotional factors. We question the basic design and methodology of these studies. The experiments rarely have included dependent and independent variable groups. and either have omitted comparison populations or have used suspicious comparison popu la tions. While some investigators have classified certain affective diagnostic patterns with specific disease entities, Lidz,Y Moos and Solomon,\() and others have suggested that although the chronic arthritic patient does exhibit many neurotic traits, this tendency is not necessarily specific to this population: patients with other physical conditions may manifest similar

behavior patterns. This is a crucial concept, implying the emergence of a chronic disease personality. The research conducted at the Albert Einstein Medical CenterMoss Rehabilitation Hospital Arthritis Complex has dealt with identifying a detailed profile to differentiate successful from unsuccessful rehabilitation candidates. The staff is strongly committed to a team approach. Attending physicians recognize the importance of paramedical disciplines, such as physical and occupational therapies, and also respect contributions from team members concerned with the psychosocial component. Impetus and direction for the present study came from Wolffl' and his associates at the Psychophysiological Laboratory, Department of Medicine, and the Rheumatic Disease Study Group, at the New York University Medical Center. Their work emphasized isolating factors thought to be related to outcome data and predictive indices for total rehabilitation of the chronic arthritic patient. The consensus of staff members at the Moss-Einstein 79

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Complex is that individuals with degenerative joint involvement are far from homogeneous in terms of personality. We feel that the arthritic patient has more in common with individuals in crisis situations than with others who are suffering from arthritis. Although Ehrlich l2 did not state definitely that personal adjustment disorders precede organic changes, particularly those associated with musculoskeletal disease, his writings do suggest that pervasive functional, psychogenic elements are often associated with arthritic disease. He feels that a major impediment to recovery or to the arrest of symptomatology might be the secondary psychological gains resulting from the disease process. Clardy and ClardylJ suggest that

study of self-concept is of major importance in examining characteristics of the arthritic personality. This is a frequently overlooked variable, but one that we consider quite crucial. We hypothesized that there was no such psychological entity as an arthritic personality, and used this premise as the basis for our investigation. We felt a serious methodological flaw in many of the studies reviewed was that the experimenter frequently stated his findings in comparison with a normal population. This association is immediately biased, because the rheumatoid arthritis patient is not normal in a generic or specific sense. We therefore posed the question, "What happens when the comparison group happens to be

others who have chronic illnesses?" If there was a personality classification indigenous to rheumatoid arthritis patients, group homogeneity with regard to the variables measured by the Minnesota Multiphasic Personality Inventory (MMPI) and the Tennessee SelfConcept Scale (TSCS) would be expected to be found. Method Data presented in this paper represent a pilot sample of 46 patients with rheumatoid arthritis. The 22 men and 24 women ranged in age from 19 to 71 years. with a mean age of 53. Most of them were in their first or second admission to a hospital for rheumatoid arthritis; average length of disease from date of diagnosis to time of psychologi-

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PSYCHOSOMATICS

cal assessment was three years. They were mostly in the lower middle class. Most of the men were employed, but not most women. Most patients were married. All patients in the study were given the revised edition, form R, of the Minnesota Multiphasic Personality Inventory and the Tennessee Self-Concept Scale. The MMPI has been used extensively in investigating personality and in discriminating between psychiatric diagnostic groups. Researchers such as Geist,' Rimon,14 and Bourcstom and Howard '5 have used the M M PI in studies with arthritic patients. This instrument is used primarily with individuals 16 years and older. and provides 14 personality scores. In addition, it provides numerous diagnostic scales. From the vantage point of paper and pencil tests, particularly those that measure personality, the MMPI has respectable validity and reliability. The TSCS lends itself well to investigating affective variables of disability groups. This study employed the Clinical Research Form, which consists of 100 self-descriptive statements. These can be administered either individually or in groups.

Test scales Both the M M PI and TSCS reveal certain pathological signs in the form of frequency distributions: Ushaped curves are indicative of psychosis, inverted V-shaped curves (.\) are characteristic of neurosis. and M-shaped curves reflect relatively well-adjusted individuals. The MMPI responses were scored, and individual, total group, male, and female profiles were plotted. The group profile was then compared with patterns of psychophysiological and physical disFEBRUARY 1978· VOL 19· NO 2

orders reported in A Handbook of MMPI Group Projiles. '6

Results The MMPI group profiles for the population studied were compared with patterns in other disease groups reported by Lanyon. 16 Figure I compares the distributions for patient populations with gastric ulcers, low back pain, multiple sclerosis, and rheumatoid arthritis. Figure 2 represents the distributional comparison of MMPI profiles for the male and female arthritis patients, respectively. Figure 3 compares results on the TSCS for male and female arthritis patients separately and for the total group of arthritis patients. Inspection alone, without the application of psychological statistics, shows a similarity between the slope of curves for patient popula-

tions with gastric ulcers, low back pain, multiple sclerosis, and rheumatoid arthritis. Although the MMPI profiles apparently differ from those of normal subjects, they do not differ significantly from one another. This suggests that there may be a chronic disease personality, although the data do not support the specific disease/specific personality dyad. Profiles gathered at the Complex also differ noticeably from brain lesion profiles. Graphically, the MMPI profiles are represented by T scores; a T score normalizes the values of a distribution. Data presented on the 46 patients reveal that the T scores tend to be within the nonpathological range for the MMPI. The three highest scores are typical of the neurotic triad of hypochondriasis, depression, and hysteria. Clinically, this tends to indicate that the ar-

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81

RA personality

thritic patient recelvmg treatment at the Moss-Einstein Complex is prone to somatization and is moderately depressed and mildly hysterical. However, the same might be said for other disability groups. The arthritic patients had relatively low scores on the social introversion, hypomania, and paranoia scales, suggesting that the patients examined in this study are not necessarily withdrawn or pathologically impulsive. In addition, they are not overly suspicious and they do not display markedly peculiar ideation. In reporting research performed by Sullivan and Welsh in 1952, Lanyon l6 notes that they found that 60 men suffering from gastric ulcers scored high on the MMPI hypochondriasis, depression, and hysteria scales. They scored low on the paranoia scale, with an elevation

on the psychasthenia scale, a phenomenon that also occurs with rheumatoid arthritis patients, but to a lesser degree. The ulcer group also scored low on hypomania. In addition, the neurotic trend is present in Hauvik's study of 30 males who were low back pain patients, as reported by Lanyon. 16 Similar results were found for 22 women who suffered from emphysema. 17 Sex differences We examined differences between the 24 women and 22 men arthritis patients. The MMPI revealed significant differences on K, or correction score variable (.01 level of confidence), on which a high score indicates defensiveness and a low score indicates openness; and the hypomania scale (.05 level of confidence), which measures a tendency to hyperactivity and false

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70

euphoria. Inspection of the data revealed that the men tend to be more defensive and more subject to a sense of false euphoria than the women. The women, however, are more likely to be critical of themselves than the men. One of the statistical procedures was a hierarchical cluster arrangement using the diameter method, which divided the Moss-Einstein patients into clusters according to correlations of their scores on the psychological tests. A pattern emerges most clearly with the TSCS: out of 46 subjects, 15 relatively distinct groupings of personality entities appeared. The rheumatoid arthritis patients studied at the Moss-Einstein Complex showed great individual differences on both the MMPI and the TSCS. Despite the limitations of this research, we could hypothesize the

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PSYCHOSOMATICS

same results for similar individuals admitted to a large metropolitan acute and rehabilitation hospital facility. Again, the present data tend to contradict those who believe that there is a distinct rheumatoid arthritic personality. Although the group studied at the Moss-Einstein Complex was not particularly self critical, the women appeared slightly more prone to downgrade themselves. This is consistent with the findings of other somatopsychic researchers that men seem to have a more positive response set than women. This fits the data pattern since the configuration shows that the women are less euphoric than the men. It is notable that when the 46 patients are considered as a total parameter, they do not appear to be in great or immobilizing conflict. There is, however, a moderately significant difference between the sexes; women appear to be in greater conflict than men. Women, more than men, may tend to deny their involvement and to minimize their symptoms (martyr role), but may fear eventual incapacitation (somatic preoccupation role). Thus, conflict of the approach-avoidance type appears among women.

women. Although there are definite sex differences, neither subgroup is particularly high on this index, at least not to a pathological extent. Another significant sex difference appeared on scores for the family self variable. The women seem more satisfied with the family self role than the men. Perhaps in this patient sample, the homemaker concept remains an impor-

tant organizing life principle for women. In this study, women generally display fewer personality defects than men. The group as a whole tends to have few psychopathological characteristics. Members of the group are not particularly disintegrated or poorly adjusted. The 46 subjects did score relatively high, however, in measurements indicating subtle lying.

Glossary of Abbreviations Used In Figures 1-3

I

Minnesota MUltiphasic Personality Inventory (MMPI) L: Lie scale. High scores are Pd: Psychopathic deviate scale. Tendency to act out; antiindicative of moralistic insocial behavior dividuals who attempt to present a facade of Mf: MaSCUlinity/femininity health. scale F: "Faking" scale. High scores Pa: Paranoia scale. Suspiciousare indicative of individuness; hypersensitivity. PI: Psychasthenia scale. Anxials who attempt to appear psychologically ill. ety reaction: lethargy. K: Correction scale. Those who Sc: Schizophremc scale Wlthdrawal; seclusiveness and score high tend to be defensive; those who score aloofness. Ma: Hypomania scale. Hyperaclow tend to be open and frank. tivity; false euphoria. Hs: Hysteria scale. Conversion Si: SOCial introversion. High scores suggest wlthreaction; impulsivity; narcissism. drawal; low scores sug0: Depression scale. Tendency gest sociability. towards despondency. NeurotiC triad ~ Hs, Hy, D. Hy: Hypochondriasis. Tendency Psychotic triad = Sc, Ma, towards somaticization. Pt. Tennes... SeI' Concept Scale (TSCS)

Self concepts There are also sex differences with regard to the moral-ethical self variable on the TSCS. The women are more satisfied with their moral conduct; women are apparently less guilty than men about their previous experiences. Although the relationship between perceived sin and disease has been examined, this is an important area for further research. The present data suggest that, within the study population, men tend to associate illness with misdeeds more frequently than do FEBRUARY 1978· VOL 19· NO 2

SC: Self criticism. High score indicates honesty. TF: True/false ratio. Measures general positive or negative attitude. NC: Net conflict. Reflects internal stress. TC: Total conflict. Reflects internal stress. Self-esteem measurements T: Total. 1: Identity. 2: Self satisfaction. 3: Behavior. A: Physical self.

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Moral-ethical self. Personal self. Family self. Social self. Empirical scales Total variability. Column variability. Row variability. Self image is consistent if variability scores are low. Definitive position. General maladjustment. Psychosis. Personality defects. Neuroticism. Personality integration. -

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As a group, these patients are somewhat suspicious and overly sensitive. Although their body images are quite low, the remaining characteristics constituting selfconcept do not indicate low esteem. A strong logical case could be made that the rheumatoid arthritis patient expresses feelings of downgraded body image. In view of the frequent crippling effects of the disease process, such a view would be reality-oriented. The authors feel that the TSCS is an important instrument in personality research of individuals with chronic diseases because it reveals what is healthy about the individual. This is extremely important because, in the long run, positive variables are the ones that contribute to the patient's rehabilitation. Conclusions A major purpose of this study was to investigate the existence of a rheumatoid arthritic personality. Our study did not find patients with this disease to be homogeneous. This tends to refute the long-standing inferences of Geistl.2 and others. Our data reinforce the traditional theory of individual differences frequently stressed by psychologists. However, there does appear to be a chronic disease personality. The subjects we examined were similar to other groups of disabled patients. We believe our findings suggest that medical and allied health service professionals must guard against overgeneralizations. It is dangerous to consider all patients with rheumatoid arthritis as psy-

chologically similar. Their communality may lie in the disease process, although great variance exists even there. Each patient must be viewed as an individual with personalized needs and desires. We further believe that the use of instruments other than the MMPI is imperative in disease-personality research. A measure such as the TSCS permits the identification of positive characteristics. The use of new statistical techniques and computer data analyses is also an important additional approach. As Moskowitz lS indicated in a 1969 symposium at the Moss-Einstein Complex, rheumatoid arthritis is a chronic disease that not only interferes with the physical life of the individual but its influence extends also to economic and social spheres. This study and others have

The authors wish to thank Robert Schussel for writing the computer programsfor analyzing the data, and the University Press of the University of Minnesota for permission to adapt Figures 3/, 32, 39. and 40 from Lanyon's A Handbook of MMPI Group Profiles. 0

REFERENCES 1. Geist H: The Psychological Aspects 01 Rheu· matoid Arthritis. Springfield, III. Charles C Thomas. 1966. 2. Geist H: Can RA Factor + Anger - Arthritis? Medical World News10(39):23. 1969. 3. Cobb S: Contained hostility in rheumatoid arthritis. Arthritis Rheum 2:419·425,1959. 4. Cormier BM. Wittkower ED: Psychological aspects of rheumatoid arthritis. Can Med Assoc J 77:533. 1957. 5. LUdwig AO: Psychogenic factors in rheumatoid arthritis. Bullefin on Rheumafic Diseases 2:15-16,1952. 6. Ludwig AO: Psychiatric considerations in rheumatoid arthritis. Mad Clinics N Am 39: 447-453. 1966. 7. Mueller AD, Lefkovits AM: Personality structure and dynamics of patients with rheumatoid arthritis. J Clin Psychology 12:143-147. 1956. 8. Robinson HS: The rehabilitation specialist. Pennsylvania Med 72:65-94. July 1969 9. Lidz T: General concepts of psychosomatic medicine. in Arieti S (ed): American Handbook 01 Psychiatry. New York. Basic Books, 1959. vol 1, pp 647-658. 10. Moos RH. Solomon GF: Minnesota Mulliphasic Personality Inventory response patterns in patients with rheumatoid arthritis. J Psychosam Res 1:17-28. 1964.

From the Albert Einstein Medical Center and Moss Rehabilitation Hospital. Philadelphia. Reprint requests to Dr. Spergel. Moss Rehabilitation Hospital. 12th Street and Tabor Road. Philadelphia. PA /914/.

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noted the importance of psychological factors. Polley, Swenson, and Steinhilber l9 suggest that examination of psychosocial factors ultimately leads to a better understanding of the disease process and control of the physical symptoms. A team approach is important to the overall planning and execution of a meaningful rehabilitation program for rheumatoid arthritis patients, and the same approach can be applied to treatments of other physical disorders.

11 . Wolff BB: How do rheumatic diseases relate to economic potential as influenced by personal attitudes and motivation? Rheumatic disease in industry. Pennsylvania Med72:6870. July 1969 12 Ehrlich GE: Psychosomatic aspects of musculoskeletal disorders Postgrad Med 31(6):614-619.1965 13. Clardy FA Jr. Clardy EK: Personality characteristics of arthritis: Review of the literature and suggestions for research. Rehabilitafion Research and Pracfice. Fayetteville, University of Arkansas Rehabilitation Research and Training Center. 1968. vol 1. 14. Rimon R: A psychosomatic approach to rheumatoid arthritis: A clinical sludy of 100 female patients. ACTA Rheumatologica Scandinavica (suppI13), 1969. 15. Bourcstom NC. Howard MT: MMPI characteristics of the three disability groups. Read before the American Psychological Association. Los Angeles. Sept 1964. 16. Lanyon RI: A Handbook 01 MMPI Group ProIiles. Minneapolis, University Press of the University of Minnesota. 1968. 17. Sadoughi MA. Brown MS: Comparative study of personality differences among arthritic patients. Read before the American Congress of Rehabilitation Medicine. Chicago, Aug 1969. 18. Moskowitz RW: Psychosocial aspects of rheumatoid arthritis JAlbert Einsfein Med Center. 19(1):36-39, Spring 1971. 19. POlley HF, Swenson WM. Steinhilber RM: Personality characteristics of patients with rheumatoid arthritis. Psychosomatics XI:4549.1970.

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