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ORIGINAL ARTICLES |
From the Department of Psychology (B.A.S, A.W., M.D.T, I.J.D), School of Philosophy, Psychology and Language Sciences, University of Edinburgh, Edinburgh, Scotland; and MRC Social and Public Health Sciences Unit (G.D.), University of Glasgow, Glasgow, Scotland.
Address correspondence and reprint requests to Ian J. Deary, Department of Psychology, School of Philosophy, Psychology and Language Sciences, University of Edinburgh, 7, George Square, Edinburgh EH8 9JZ, Scotland. E-mail: ian.deary{at}ed.ac.uk
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONRESULTSDISCUSSIONNOTESREFERENCES |
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Methods: Participants were members of the Health and Lifestyle Survey, a British nationwide sample survey of 9003 adults. At baseline (1984 to 1985), individuals completed a sociodemographic and health questionnaire, underwent physical health examination, and completed the Eysenck Personality Inventory. Mortality was assessed for 21 years after baseline. A total of 5424 individuals had complete data.
Results: After controlling for age and gender, 1-standard deviation (SD) increase in neuroticism was related to 9% (hazard ratio (HR) = 1.09; 95% Confidence Interval (CI) = 1.03–1.16) increased risk of mortality from all causes. The association was nonsignificant (HR = 1.05; 95% CI = 0.99–1.11) after additionally controlling for occupational social class, education, smoking, alcohol consumption, physical activity, and health. There was 12% (HR = 1.12; 95% CI = 1.03–1.21) increased risk of death from cardiovascular disease associated with 1-SD increase in neuroticism. This was still significant after adjustment. When the sample was divided into 40- to 59-year-olds and those 
60 years, neuroticism remained a significant risk for all-cause mortality and cardiovascular disease mortality; associations were nonsignificant after controlling for all covariates. Neuroticism was not associated with deaths from stroke, respiratory disease, lung cancer, or other cancers. Extraversion was protective of death from respiratory disease (HR = 0.84; 95% CI = 0.70– 1.00).
Conclusions: After controlling for several risk factors, high neuroticism was significantly related to risk of death from cardiovascular disease. The effects of neuroticism on death from cardiovascular disease may be mediated by sociodemographic, health behavior, and physiological factors.
Key Words: neuroticism • extraversion • Eysenck Personality Inventory • mortality • cardiovascular disease • social class
Abbreviations: EPI = Eysenck Personality Inventory; HR = hazard ratio; CI = Confidence Interval; HALS = Health and Lifestyle Survey; CVD = cardiovascular disease; CHD = coronary heart disease; BMI = body mass index; BP = blood pressure; FEV = forced expiratory volume.
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONRESULTSDISCUSSIONNOTESREFERENCES |
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Studies examining whether neuroticism or extraversion predict mortality in community samples have differed in many respects, including length of follow-up time, sample size, mean age of the subjects, educational achievement, and initial health. However, although the scales related to the conscientiousness personality trait are consistently shown to be protective factors (5–8), the findings for neuroticism and extraversion are mixed and require more investigation.
Of the 12 studies that included a neuroticism scale, six found neuroticism to be a risk factor (6,8–11), two studies found it was protective (5,12), and the remaining four did not find a relationship (7,13–15). The one study that used a measure of trait anxiety, which correlates highly with the neuroticism domains of personality scales (16), found it to be a risk factor for nonaccidental death but a protective factor for accidental death (17). Two studies of members of religious orders (9,11) and two recent studies of centenarians (7,8) found that extraversion was a protective factor. The remaining six mortality studies that assessed extraversion found no significant effects (5,10,12,14,15,18).
Taken together, these studies suggest that evidence for a relationship between neuroticism or extraversion and mortality is, at best, mixed. Differences in findings among studies may result from inconsistencies between the characteristics of the studies or samples. However, given the small number of studies that have investigated personality and mortality, it is as yet impossible to determine what particular characteristics may be responsible. This task is further complicated as, with the exception of three studies (6,13,18), none had follow-up periods of >7 years and only two studies (14,10) included subjects that varied widely in age.
The UK's Health and Lifestyle Survey (HALS) (19,20) has the unique advantage of being able to address some of the methodological shortcomings of prior studies as it comprises a large representative sample of healthy community-dwelling adults aged 18 to 99 years. In addition, this sample also enables us to examine whether the association between personality and mortality exists across the entire adult age range and to follow-up the sample for 21 years. Most importantly, the Health and Lifestyle Survey includes specific causes of death, which may provide some insight into the mechanisms responsible for the association between personality and mortality. Huppert and Whittington (14) also used the Health and Lifestyle Survey to examine the association between Eysenck Personality Inventory (EPI) neuroticism and extraversion and mortality. However, they had a much shorter follow-up period of 7 years and only examined all-cause mortality. The current study examines the relationships between neuroticism and extraversion and all-cause and cause-specific mortality for >21 years in a large representative sample of British community-dwelling adults aged 18 years.
METHODS
Participants and Procedure
HALS is a nationwide sample survey of all community-dwelling adults living in England, Scotland, and Wales. It was initially set up to examine physical and mental health, attitudes, and lifestyle changes (19). The survey began in 1984 when 12,254 addresses were randomly selected from UK Electoral Registers. One adult from each household was invited to participate and 9003 individuals aged between 18 and 99 years were interviewed and given physical examinations at home first by trained interviewers and by nurses during a second visit (21).
The interview questionnaire recorded information about home and family circumstances, educational achievement, income, self-reported health, health attitudes, diet, work, and health behaviors, whereas the physical examination included height, weight, girth, blood pressure (BP), pulse rate, and respiratory function measures. For the final stage, participants completed a self-report questionnaire that assessed personality and psychiatric status. This questionnaire was completed at leisure and returned by mail. Participants were continually followed up for mortality and cancer incidence. The latest available follow-up was completed in June 2005.
Measures
Personality
Personality was assessed by the EPI, a self-report personality inventory measuring neuroticism and extraversion (22). Neuroticism is the tendency to be high in "emotionality" or experience psychological distress, e.g., "Does your mood often go up and down?" Extraversion refers to the propensity to be energized by active involvement in events, e.g., "Would you be very unhappy if you could not see lots of people most of the time?" The questionnaire consists of 57 items. Participants rate each item as yes (1) or no (0) depending on whether or not the question represents the respondent's normal actions or feelings independent of their current mood state. Scores range from 0 to 24 for each personality trait with higher scores representing higher neuroticism or extraversion. Of the 57 questions, nine questions formed a lie scale, e.g., "If you say you will do something, do you always keep your promise, no matter how inconvenient it might be to do so?" This scale is used to detect responders with a tendency only to give socially desirable answers. Test-retest reliabilities of the EPI scale based on normal samples are excellent at 0.84 for neuroticism and 0.88 for extraversion with a 1-year time lapse between test and retest (22). The internal consistencies (Cronbach 
) of neuroticism and extraversion were 0.85 and 0.76, respectively.
Sociodemographic Factors (Age, Occupational Social Class, and Education)
Gender and age in years were included as covariates. Occupational social class, based on the occupation of the head of the household or the usual occupation of the retired or unemployed respondent, was also included as a predictor. Occupational social class was coded according to the Registrar General's six category classification (23): professional (I); managerial (II); skilled nonmanual (IIIN); skilled manual (IIIM); semiskilled manual (IV); and unskilled (V). Educational achievement was defined as the highest level of qualification obtained by the participant. Educational achievement was coded as: first or higher degree; semiprofessional or professional qualification, for example, nursing or teaching qualification; A-level or equivalent, including advanced City and Guilds certificates; O-level or equivalent, including ordinary City and Guilds certificates; no educational qualifications. Work-related certificates were also included in this category.
Health Behaviors (Smoking, Alcohol, and Physical Activities)
Smoking status was defined as: never smoked, former smoker, current occasional smoker, and current regular smoker. An occasional smoker was defined as smoking less than one cigarette per day, whereas a current smoker was defined as smoking one or more cigarettes per day. Alcohol consumption was calculated using weekly alcohol units consumed in the week before the interview. One alcohol unit was defined as 0.25 liter (half a pint) of beer or cider, single measure (25 ml) of spirits, 125-ml (4.5 fl. oz) glass of wine, or 55 ml (2 fl. oz) glass of fortified wine. In addition, a self-report of drinking habits was assessed on a 4-point scale: nondrinker; special occasion drinker; occasional drinker; and regular drinker. Engagement in physical activities, such as work-related activity, walking, housework, gardening, home improvement, and sports activities, was used to produce four physical activity variables: minutes spent doing vigorous activity (defined as activity that caused breathlessness); occasions spent doing vigorous activity; minutes spent doing nonvigorous activity; and occasions spent doing nonvigorous activity. Combined responses to the relevant HALS items were used to create these summary variables.
Physiological Measures (Body Mass Index, Blood Pressure, and Respiratory Function)
Body mass index (BMI) (kg/m2) was calculated from height, measured in meters, using a portable stadiometer, and weight in kilograms using electronic scales. Four measures of systolic and diastolic BP were obtained at 1-minute intervals using an automatic BP instrument (Accutor, Montvale, NJ). Mean systolic and diastolic BP were calculated from these readings. A portable electronic spirometer was used to measure forced expiratory volume (FEV). To accommodate for individual differences in body size, this value was divided by the square of height in meters.
Mental Status Measure (GHQ)
Psychological distress was measured using the 30-item General Health Questionnaire (GHQ) (24), which was designed as a screening and monitoring tool for nonpsychotic psychological distress. This version of the questionnaire covers four main elements of distress: depression, anxiety, social impairment, and insomnia. Each of the 30 questions consists of a 4-point Likert scale where respondents note the degree to which they have experienced a particular symptom. The scale ranges from "not at all," "no more than usual," "rather more than usual," to "much more than usual." The standard method of scoring, which was used here, is the 0 to 0/1 to 1 method where the first two responses are scored as 0 (symptom absent) and the second two responses are scored as 1 (symptom present). Therefore, this questionnaire produces a score ranging from 0 to 30. Endorsing at least five items is the screening threshold used to identify a probable case of psychiatric disorder. This is a frequently used measure of mental health which has good reliability and validity when used in community samples (25).
Vital Status
Deaths were ascertained by record linkage to the UK's National Health Service central registry, which provided death, certificates. In addition to date of death, death certificates noted the underlying cause of death and other secondary causes of death, all of which were coded according to the Ninth International Classification of Diseases (ICD9) (26). For the present study, the single "underlying cause" of death was used and categorized as: cardiovascular disease (CVD) (ICD9 codes 390–459), coronary heart disease (CHD) (ICD9 codes 410–414), stroke (ICD9 codes 430–438), respiratory disease (ICD9 codes 460–519), lung cancer (ICD9 code 162), and all nonlung cancers (ICD9 codes 40–161 and 163–208). We derived this "underlying cause" of mortality using the Automated Cause Coding System developed by the US National Center for Health Statistics.
Statistical Analyses
Cronbach's 
was used to estimate the internal consistency of the trait scales. For the mortality analyses, survival time was calculated from age at death or age at June 2005 for surviving participants. Cox proportional hazards regression analysis, as implemented in the SAS Version 9.1 PHREG procedure (27), was used to calculate hazards ratios, 95% Confidence Intervals, and p values for the proportionate change in mortality risk for each standard deviation (SD) change in the two personality trait scores.
The covariates used in the model were chosen on the grounds that previous studies had shown them to be independently related to mortality risk or personality (28–36). For both neuroticism and extraversion, separately, two models were fitted. The first model was a baseline model that controlled for age and gender. The second model also included occupational social class, educational attainment, smoking status, alcohol consumption, physical activity, BMI, BP, and FEV as covariates. The GHQ was added as a covariate in a third model that controlled for age, gender, and GHQ score. We included this measure of psychological distress in a separate model to test the specific hypothesis that GHQ score mediated any association between neuroticism and mortality: psychological distress is correlated with neuroticism, and can influence morbidity and mortality (14). In the current study, neuroticism and GHQ score correlate at 0.49, (p < .0001).
Preliminary analyses showed that the hazard was not proportional with age, as is assumed by the model. Therefore, analyses were carried out for all ages together and also for three broad age groups (20–39 years, 40–59 years, 60+ years). Sample sizes for the three age groups were 2316 for the 20- to 39-year age group, 1810 for the 40- to 59-year age group and 1298 for the 60+ age group. For reasons of power, analyses were carried out only on those age groups with 100 events for each cause of death. It was not possible to carry out any analyses on the 20- to 39-year age group due to small numbers of events.
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RESULTS |
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Mean age of the sample at baseline was 44.7 years (SD = 16.9) (range = 18–94 years). Of the 5424 participants, over the 21-year follow-up period, 1335 participants (614 women, 721 men) died. As shown in Table 2, the major causes of death in this cohort were CVD and all nonlung cancers.
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Neuroticism and extraversion had high internal consistencies, with Cronbach's of 0.85 and 0.76, respectively, and were not intercorrelated (r = –.02, p = .094). Mean neuroticism score was 11.4 (SD = 4.3) (range = 0–24); mean extraversion score was 9.6 (SD = 5.2), also with a similar range.
Being male is related to greater mortality and higher extraversion, whereas women usually show higher neuroticism scores. To model these facts, we included a gender*trait interaction term in the baseline model. There was no evidence that gender interacted with neuroticism (p = .94) or extraversion (p = .85), indicating that the relationship between these personality traits and mortality is the same for men and women.
All-Cause Mortality
When all ages were examined together, neuroticism was related to all-cause mortality in the baseline model (adjusted for age and gender) (Table 3); a 1-SD increase in neuroticism was associated with a 9% (hazards ratio (HR) = 1.09) increase in mortality risk (95% Confidence Interval (CI) = 1.03–1.16). However, the association was attenuated to a 5% (HR = 1.05) increase in risk and nonsignificant in the fully adjusted model (adjusted for age, gender occupational social class, education, smoking status, alcohol consumption, physical activity participation, FEV, BP, and BMI) (Table 3). A similar effect was obtained when GHQ score was added to the baseline model. Here, the association between neuroticism and all-cause mortality was attenuated by two thirds to only 3% increased risk (HR = 1.03) and nonsignificant after controlling for age, gender, and GHQ score.
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Among participants aged 40 to 59 years, neuroticism was related to all-cause mortality in the baseline model (HR = 1.12; 95% CI = 1.01–1.24) (Table 3). However, the addition of the remaining covariates in the fully adjusted model reduced this association to nonsignificance (HR = 1.05; 95% CI = 0.94–1.16). The addition of GHQ score to the baseline model also attenuated this correlation (HR = 1.02; 95% CI = 0.90–1.16). The same held true for participants who were 60 years; neuroticism was related to all-cause mortality (HR = 1.07; 95% CI = 1.00–1.15) in the baseline model, but it was not a significant risk factor in the fully adjusted model (HR = 1.04; 95% CI = 0.97–1.12) or the age, gender, and GHQ adjusted model (HR = 1.03; 95% CI = 0.94–1.12).
Extraversion in the total sample and each of the age groups was not related to all-cause mortality in the baseline or fully adjusted models.
Mortality Caused by CVD, CHD, or Stroke
For all ages, in the baseline and fully adjusted models, neuroticism was significantly related to CVD death (Table 4). Each SD increase in neuroticism was related to a 12% (HR = 1.12; 95% CI = 1.03–1.21) and 10% (HR = 1.10; 95% CI = 1.00–1.20) increase in mortality risk in the baseline and fully adjusted models, respectively. Adding GHQ score to the age and gender model attenuated the association by 25% and reduced it to nonsignificance (HR = 1.09; 95% CI = 0.98–1.21). There was no significant association between neuroticism and risk of death from CVD in either the 40- to 59-year or 60+ year age group (Table 4). The HRs were similar in magnitude to those for the total sample, but the p values were larger because of the smaller sample sizes and number of deaths.
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The only significant association between extraversion and risk of death from CVD was in the baseline model for participants aged 40 to 59 years (Table 4). After controlling for age and gender, 1-SD increase in extraversion was related to a 20% (HR = 1.20; 95% CI = 1.02–1.42) increase in the risk of death from CVD. However, when remaining covariates were added to the model, this result was no longer significant. There was no association between extraversion and CVD death in the other age groups.
For all subjects, in the baseline model, neuroticism was related to risk of death from CHD (HR = 1.14; CI = 1.02–1.28) (Table 4). This effect was attenuated by 29% and was no longer significant in the fully adjusted model, nor in the age, gender, and GHQ model where it was attenuated by 43%.
There was no significant association between neuroticism and CHD death risk in the 60+ age group, although the HR was similar to that in the full sample (Table 4). Extraversion was not related to risk of death from CHD among all ages or the 60+ age group (Table 4).
Neither neuroticism nor extraversion was related to risk of death from stroke, although it should be noted that the HRs were similar for this outcome when compared with others, and nonsignificance here reflects the small number of events (Table 4).
Mortality Caused by Respiratory Disease, Lung Cancer, or All Nonlung Cancers
Neuroticism was not related to risk of death from respiratory disease, lung cancer, or all nonlung cancers for all ages, 40- to 59-year age group, or the 60+ age group (Table 5). Extraversion was significantly associated with risk of death from respiratory disease in the all ages group in the fully adjusted model (HR = 0.84; 95% CI = 0.70–1.00). In this case, extraversion was protective of death from respiratory disease. No other significant associations were found.
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Attenuation of Personality-Health Outcome Effects by Individual Covariables
In the fully adjusted models, there is no information about which of the individual covariables caused attenuation of the personality-health outcome HRs. Such information could be useful as it might point to pathways of influence. We examined which of the individual covariates were responsible for any substantial attenuation of the significant effect sizes reported. First, we identified instances where the association between a personality trait and a health outcome had a significant (p < .05) HR in the gender- and age-adjusted model. Second, we added the covariables individually to the models and computed the degree of attenuation of the personality trait-health outcome HR. There were significant associations between neuroticism and all-cause mortality, CVD, and CHD in age- and gender-adjusted models. For each of these models, we calculated the attenuating effects of occupational social class, educational attainment, smoking status, alcohol consumption, physical exercise, BP, BMI, and respiratory function. Attenuating effects were small (data not shown, but available from the authors). The largest attenuations were as follows: 1) physical exercise reduced the neuroticism-CVD association by 16%; and 2) occupational social class, education, and physical exercise each, individually, reduced the neuroticism-CHD association by 14%. There were no significant associations between extraversion and any health outcome in the age- and gender-adjusted models. Therefore, it was not examined further.
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DISCUSSION |
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Nevertheless, the neuroticism-mortality results from the age, gender, and GHQ model must also be considered. After adding a measure of psychological distress to the basic age and gender model, all significant age- and gender-adjusted associations between neuroticism and mortality were attenuated and reduced to nonsignificance. For example, for all ages, a two-thirds attenuation of the neuroticism-mortality association was seen after entering GHQ. One possible interpretation of this is that the effect of neuroticism on mortality is mediated via low mood (depressed states) or other psychiatric illness, which is an associate of mortality (14,37–41). However, it is also important to consider the genetic correlation between EPQ neuroticism and GHQ (42,43). For example, Ivkovic et al. (42) examined personality-psychological distress genetic correlations between EPQ-R neuroticism and GHQ score in a sample of about 1000 individuals from Croatia. The genetic correlation between neuroticism and GHQ score was 0.91. Thus, to the extent that neuroticism and psychological distress were influenced by genes, they are almost entirely shared genes. Furthermore, a recent comprehensive review of twin studies has shown that genetic factors associated with neuroticism can explain the comorbidity of anxiety and depression (44). Therefore, it is impossible to rule out some other effect of neuroticism, or some other pleiotropic effect of these genes, apart from neuroticism and mood. It is possible that adjustment for GHQ results in overadjustment.
There were only two significant associations between extraversion and cause-specific mortality. In the age- and gender-adjusted association between extraversion and death from CVD in those aged between 40 and 59 years, extraversion seemed to be a risk factor. However, extraversion was protective in the fully adjusted association between extraversion and respiratory disease in the all ages group. We cannot at present explain these results and consider it likely that they were found by chance. However, others have shown a protective association between extraversion and lifestyle risk factors for respiratory disease, such as exercise. Regular exercise was associated with higher extraversion (45–47). Therefore, it is possible that factors, such as exercise and smoking, may mediate the association between extraversion and respiratory disease. However, smoking, a significant risk factor for respiratory disease, is higher in extraverts (48,49). This study did control for participation in physical exercise and smoking status.
Nevertheless, the general lack of significant results for the association between extraversion and mortality is consistent with most other studies. Of the studies on personality and mortality, only the two studies by Wilson et al. (9,11) found evidence indicating that extraversion was protective. However, the protective effect of extraversion became nonsignificant after a range of covariates were included in the model. Furthermore, the recent study by Wilson and colleagues (9) only used four of the NEO Five-Factor Inventory extraversion items. Given the diversity of age ranges among the samples of the ten studies, the relatively large sample sizes, and the fact that two studies using the same personality measures (5,10) did not find a relationship between extraversion and mortality, it is possible that these two exceptions were the result of chance or some other unique characteristic of the sample.
For neuroticism, the picture is more complicated as findings are not consistent across studies. Three studies in this area found no effects (13–15), five studies found neuroticism to be a risk factor (9–11,18,50), and two studies found that neuroticism was protective (5,12). Although we found neuroticism to be a risk factor for mortality, only the association with CVD was significant after controlling for sociodemographic and health predictors. Nevertheless, our findings may actually be a source of clarity because, in the two studies that used broad samples (9,18), both studies found neuroticism to be a risk factor, but those neuroticism effects also seemed to be mediated by other variables.
Methodological differences may also have contributed to the differences between the present study and past studies. These may include differences in the length of follow-up periods, choice of measurement instruments, participant characteristics, or general health of the study sample. However, many of these can be ruled out as other studies with similarly long follow-up periods (13,18) using varying measures of personality (5,10–12,14,50), having differing participant characteristics (5,9–15,18), or having included participants in poor or good health (5,9–15,18) have found inconsistent results for the association between neuroticism and mortality—suggesting that it is risk factor, protective factor, or no association. A further limitation of this study is the fact that the health behavior variables and the GHQ were assessed at only one time point, in 1984 and 1985. These variables, therefore, do not then capture any changes (e.g., the development of high BP, or those who stopped smoking or took up more exercise) that occurred during the 21 subsequent years.
The present study addressed these methodological issues because we had a long follow-up period of 21 years, used one of Eysenck's well-validated measures of neuroticism, examined participants across the entire adult age range, only sampled community-dwelling individuals, and controlled for a range of known risk factors. We found very little evidence to suggest an association between extraversion and either all-cause or cause-specific mortality even in the basic age- and gender-adjusted model, with some specific exceptions that were noted and can be checked against future studies' findings. A significant association between high neuroticism and increased mortality from all causes and CVD was noted. However, after controlling for age, gender, occupational social class, educational attainment, smoking status, alcohol consumption, physical activity, BMI, BP, and respiratory function, the only significant association that remained was between neuroticism and CVD mortality in the total sample. This result is supported by the extensive literature relating neuroticism and anxiety measures to CVD (51–54). Furthermore, although the sample size of the current study was large, the effect sizes for the results were relatively small. Nevertheless, the present study yielded two novel findings. First, this study presents evidence that neuroticism was a risk factor for a specific cause of death (CVD) and that this relationship was independent of a range of covariates. Second, we also found that the effects of neuroticism were attenuated, therefore being possibly mediated, by GHQ scores. Neuroticism is closely associated with anxiety and depression (55–57); the coexistence of anxiety and depression may be the result of genes linked to neuroticism (44). Thus, for example, genetically informative studies that included phenotypic measures of neuroticism, anxiety, depression, and health could inquire whether the neuroticism-mortality link was genetically mediated, and whether this was associated with depressed states. In future studies, it will be important to examine further possible mechanisms that link neuroticism and mortality, such as mediating effects of low mood/depressed states or genes.
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NOTES |
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This study was funded by a grant from the Scottish Executive Health Department Chief Scientist Office. Ian Deary is the recipient of a Royal Society-Wolfson Research Merit Award.
DOI:10.1097/PSY.0b013e31815abf83
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