What happens in a persons life can make them ill, but while some seem to get ill at the slightest provocation; others cope with the most catastrophic events without any problems at all. So why is that? Is there a biological reason – some inherited weakness in their immune system or depletion of the colonic microbiome? Do they just have more to cope with? Or might it be something about the way they were brought up that makes them less capable of regulating their physiological responses? Is there an illness personality?
Personality is the combination of ideas, attitudes and behaviours that make up a person’s temperament and character; encompassing the way they think, feel and react.
Ever since the time of Hippocrates, philosophers have attempted to explain the predisposition to certain illnesses on the basis of their personality. The humoral theory related personality and illness to the balance of four bodily fluids or humours, bile, black bile, blood and phlegm. Thus people were described as choleric, melancholic, sanguine and phlegmatic, terms that are still used to this day. Although the humoral theory held sway for over 2000 years, very few recent scientific studies have identified a credible association between personality and illness.
Franz Alexander, one of the foremost psychosomatic theorists in the 1930s and 1940s, suggested that patients with presumed ‘psychosomatic’ illness struggle with conflicts around dependency. When neglect or deprivation blocks dependency, he said, then energy is expended to the parasympathetic nervous system, but when autonomy is blocked by excessive parental control, symptoms are largely mediated by the sympathetic nervous system. This pattern is probably most clearly seen in people with eating disorders. Those who binge or comfort eat do so when they feel depressed and lonely or insecure, using food as a surrogate to balance their emotions. In contrast, anorexia nervosa is associated with the physiological signature of sympathetic overactivity and represents the sheer power of the will to keep control of the self, even if it means starvation of the body. Hunger Strike by Susie Orbach, offers a brilliant description of this situation.
Psychological researchers these days tend to identify ‘the big five’ personality dimensions: conscientiousness, extraversion, openness, agreeableness and neuroticism. Why those were chosen among many other possibilities is unclear, but they seem to have stuck. Attempts to relate specific personality to particular illnesses have not been successful, but taking a broader perspective on health and illness in general, conscientiousness, extraversion, openness and agreeableness tended to lead to better health outcomes and neuroticism to worse. More recently, researchers have suggested three dimensions: odd and eccentric (paranoid, schizoid, borderline); dramatic, emotional and erratic (antisocial, borderline, histrionic, narcissistic); anxious and fearful (obsessional, avoidant, dependant), but it seems unlikely these will elucidate specific associations with illness.
Personality is not a genetic given, although genetic predisposition may influence it; personality starts to form early in life through interaction with parents, relatives and friends and continues to develop and change throughout in response to experience. But like a tree, the basic structure personality takes is laid down in the first few years and only modified later by experience. As the Jesuits said, ‘give me the child for the first seven years and I will show you the man’.
The development of a secure, independent personality requires an age-appropriate combination of containment, guidance and freedom to explore. This is what facilitates confidence and the ability to regulate emotional and physiological responses. ‘No’, is the most important word, children ever hear. It launches them into an existence that is separate from their parents but free to form their own connections with other people. This is the project of socialisation. As children grow, they play away for longer but still need to ‘know’ their parents are there for them. This enables the self confidence not only to be by themselves but also to interact with other people. In so doing, they increasingly perceive themselves as separate people with their own ideas, attitudes and behaviour.
If, for any reason, this project of individuation and socialisation fails, then not only will it compromise the development of a stable and confident personality, it will also undermine emotional and physiological self regulation resulting in physical and emotional symptoms. Neglect and abandonment can cause tension and withdrawal, impingement or overprotection may cause frustration and inhibit the development of independent self confidence, while an unreliable and ambivalent parenting may cause a child to feel frightened and insecure. Since the emotional centres in the brain stem are closely linked to the centres that control bodily function, such emotional dysregulation is often associated with physical symptoms.
Failures of individuation and socialisation is thought to give rise to several personality subtypes, each of which can be associated with illness. A hysterical personality tends to overreact to situations with extreme anxiety, anger or distress. A borderline personality is characterised by mood swings, impulsive behaviour, unstable relationships and extreme sensitivity to criticism. Narcissistic personalities may be too preoccupied with their own feelings of vulnerability to relate confidently and instead may compensate with extravagant and grandiose behaviour. There are many other personality subtypes, but such descriptors are not always helpful and never watertight; personalities can change and show overlapping features at different times, though studies have indicated that personality usually stabilises later in life.
The implication is that disturbances in emotional development in early life and/or traumatic disruption later might create the sort of personality that is predisposed to illness does not necessarily mean that there is an illness personality, let alone personalities that characterise particular illnesses. It is more that the combination of certain personalities and life history with particularly challenging situations may lead to dysregulation and rekindling of recurrent illness.
Illness may therefore represent how people ‘feel’ about what is happening now as perceived through the meaningful filter of what has happened in the past. This explains some people are more susceptible to illness than others. On an individual level, how we feel about and react to what happens is an expression of our personality, but that does not mean there is a specific illness personality.
Personality and IBS
As far as IBS is concerned, a recent study showed that people with IBS scored highly on the neuroticism scale and low on the other dimensions. The same, however, applies to many other illnesses, raising the possibility that the experience of being ill might change the personality to become more anxious and neurotic.
IBS can show different somatic and emotional expressions. I have observed that people with constipation tend to be quiet and rather withdrawn and introspective whereas those with diarrhoea are anxious and upset and more desperate. Moreover those with an alternating bowel habit tend to show an alternating emotional expression, presumably mediated by activity in the different branches of the autonomic nervous system.
Thirty years ago, a connection between personality and bowel function was documented in a study of bowel function that was carried out in the male inmates of an American prison at the height of popular enthusiasm for dietary fibre. Volunteers were put on diets containing different amounts of fibre and underwent a series of investigations, including personality inventories. As expected the bowels were more active when people consumed more fibre, but this association was not as strong as that between personality and bowel function. People who scored highly on the extraversion scale pass large soft and frequent stores whereas those who were introverted and defended struggled to squeeze out a few small pellets. So it would seem that people suffering with diarrhoea that cannot be explained medically find it as difficult to contain their emotions as they do to contain their emotions, while those with unexplained constipation may be quite literally, uptight.