Original articles
Examination of cloninger's basic dimensions of personality in fatiguing illness: Chronic fatigue syndrome and multiple sclerosis

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Abstract

Relatively few studies have examined the personality characteristics of patients with chronic fatigue syndrome (CFS). The personality profiles of 38 CFS subjects were compared with 40 healthy controls and 40 subjects with multiple sclerosis (MS), a chronic illness that shares many symptoms with CFS (e.g., fatigue), but has a known neurological substrate. Subjects were examined within Cloninger's biosocial theory of personality, which delineates basic dimensions of temperament. Both illness groups displayed similarly elevated levels of Harm Avoidance, and lower levels of Reward Dependence as compared with healthy controls. The MS group showed a lower level of Persistence than controls and CFS subjects. Implications for the relationship between chronic illness and personality are discussed.

Introduction

Feelings of fatigue are common in modern society. Such feelings have been linked to a variety of factors, including personality characteristics, psychiatric disturbance, and medical illness. Among healthy individuals, for example, studies have found that persons high in the traits of neuroticism and perfectionism tend to report elevated levels of fatigue [1]. Likewise, fatigue (or loss of energy) is a criterion used in the diagnosis of mood disorders in the Diagnostic and Statistical Manual [2] of the American Psychiatric Association. Fatigue frequently accompanies a variety of medical disorders (e.g., flu, coronary heart disease, and multiple sclerosis [MS]) and it also forms the core symptom of chronic fatigue syndrome (CFS). According to the Centers for Disease Control (CDC), individuals with CFS suffer from debilitating fatigue lasting ⩾6 months, along with various other symptoms such as sore throat, joint pain, and difficulties with concentration and/or memory 3, 4, 5.

The cause of CFS is unknown and no consistent biological marker has yet been identified. Controversy exists as to whether the debilitating fatigue of CFS is the result of psychological factors, or is caused by infectious or toxic agents 6, 7. One hypothesis is that CFS patients possess personality characteristics that predispose them to develop and/or maintain their fatigue-related symptoms. Indeed, an increased prevalence of psychiatric disturbance, particularly affective disorders, has been reported in such patients [8].

Relatively few studies, however, have actually examined personality in chronically fatigued individuals 9, 10, 11, 12, 13. These investigations have shown a tendency toward increases in histrionic and emotional type traits in chronic fatigue subjects [14]. However, most of the studies have suffered from methodological problems, such as a lack of a control group, and/or the use of criteria other than those of the CDC to select fatigued subjects. In a study that addressed these methodological issues, Johnson and colleagues [9] found that CFS subjects displayed higher frequencies of a variety of Axis II personality disorders and elevated levels of neuroticism as compared with normal controls. However, personality pathology in the CFS group did not differ from that exhibited by subjects suffering from MS. Both groups were significantly less compromised relative to patients with major depression.

The latter finding underscores the importance of comparing CFS patients to other illness groups because a second hypothesis is that the personalities of CFS sufferers have changed as a result of living with a chronic fatiguing and functionally disabling illness. Medical illnesses are known to impact upon psychological functions, including personality, in a variety of ways [2]. As such, patients with MS are used as a comparison group in the present study. MS patients are particularly appropriate because they suffer from a chronic illness with a known neurological basis, and many of their symptoms are similar to persons with CFS, including fatigue, cognitive dysfunction, and affective disturbance 15, 16.

The present study builds upon previous research on personality in CFS by comparing CFS and MS sufferers from the perspective of Cloninger's biosocial theory of personality [17]. This relatively recent model of personality proposes that there are four basic biologically influenced dimensions that, in combination, provide an underlying framework for both normal and psychiatrically disturbed personality (e.g., neuroticism and Axis II personality disorders). Cloninger's dimensions are as follows (see Table II): (1) Harm Avoidance is defined as a tendency to respond intensely to signals of aversive stimuli, thereby inhibiting/stopping behavior, and it should be noted that one of the subscales of Harm Avoidance specifically measures fatigue; (2) Reward Dependence involves a tendency to respond intensely to signals of reward, especially social rewards (e.g., praise), thereby maintaining/continuing behavior; (3) Novelty Seeking is a tendency to respond with intense excitement to novel stimuli, or cues for potential rewards or potential relief of punishment and thereby activating/initiating behavior; (4) Persistence involves the tendency to persevere in behaviors that have been previously associated with reward or relief from punishment, despite frustration and fatigue.

According to Cloninger's model of personality, the aforementioned dimensions represent heritable temperaments based upon neurobiological substrates. A study of twins has found that genetic factors account for approximately half the variability on the dimensions [18]. Other research has identified specific genetic loci that form the neurobiological foundation of Cloninger's dimensions. For example, a gene coding for a transporter of the neurotransmitter serotonin has been linked to Harm Avoidance, including the Harm Avoidance subscale measuring fatigability [19]. Persistence, which is also relevant to fatigue as stated previously, has been linked to a gene coding for the D2 dopamine receptor [20]. It is important, however, to replicate such findings before drawing firm conclusions.

Although the dimensions are relatively stable and resistant to change [21], self-reported scores on them may be influenced by environmental factors. For example, Harm Avoidance scores tend to increase during depressive episodes 22, 23 and Novelty Seeking scores tend to decrease mildly as people grow older [21]. It is possible that medical illness may also affect scores on these dimensions, just as some patients with cancer or other serious illnesses can become more fearful or depressed [24].

The dimensions are hypothesized to influence the manner in which individuals cope with their environment. Harm Avoidance, said to be linked with passive avoidance [17], has been found to predict the ease with which individuals become classically conditioned to aversive stimuli [25]. In contrast, Reward Dependence and Persistence have been found to predict ease of classical conditioning to appetitive stimuli [25]. Cloninger [38] hypothesized that Novelty Seeking is associated with exploratory pursuit of novel stimuli, as well as to appetitive approach of potential rewards and active avoidance and escape from punishment [17].

Conventional personality variables are viewed as arising from combinations of Cloninger's four basic dimensions of temperament. For example, trait neuroticism has been found to be associated with elevations on both Harm Avoidance and Novelty Seeking [26]. In addition, the standard clusters of DSM-III-R personality disorders have been found to relate to Cloninger's dimensions in patterns predicted by the model: cluster A (aloof, eccentric) is inversely correlated with Reward Dependence; cluster B (impulsive, dramatic) covaries with Novelty Seeking; and cluster C (anxious, fearful) is positively correlated with Harm Avoidance [27]. Only Harm Avoidance and Novelty Seeking appear to be adequately represented by the Minnesota Multiphasic Personality Inventory (MMPI) [28]. Harm Avoidance and its subscales have been found to correlate strongly with MMPI scales of Depression, Social Introversion, and Hypochondriasis, whereas Novelty Seeking and its subscales displayed weaker correlations with Hypomania, Psychopathic Deviate, and Depression.

Cloninger's theory has been used successfully to distinguish specific personality profiles in a variety of psychiatric and neurological populations 29, 30, 31. For example, patients who had recovered from either unipolar or bipolar affective disorder were found to display elevated Harm Avoidance, but only bipolar patients additionally displayed heightened Novelty Seeking [31]. In addition, whereas patients with various eating disorders were all found to be high in Harm Avoidance and low in Reward Dependence as compared with healthy controls, bulimics who binge and purge were also higher in Novelty Seeking, while anorexics, who chronically restrict food intake, were additionally higher in Persistence [29]. Neurological illnesses have also been associated with specific personality profiles. For example, patients with Parkinson's disease displayed lowered Novelty Seeking in comparison with other medically ill patients, but were not atypical in other respects [30].

Only one previous published study has focused on chronically fatigued individuals from Cloninger's perspective, finding elevated levels of Harm Avoidance, although CDC diagnostic criteria were not used in the selection of the fatigued subjects [12]. In the present study, which did use CFS patients meeting CDC criteria, elevated Harm Avoidance was also expected. A second expectation was that CFS patients would also display elevated Persistence, because persistence overlaps with perfectionism, which has been linked to fatigue in healthy individuals [1]. Persons high in Persistence tend to be ambitious overachievers who display perfectionistic perseverance despite frustration and fatigue [32].

In the present study, CFS patients were compared with MS patients and healthy controls. It was reasoned that if the personality profiles of the two patient groups were similar to one another, but different from controls, this finding would be consistent with the hypothesis that different chronic fatiguing illnesses can alter personality in similar ways. However, if results showed that CFS subjects differed from both the healthy and MS groups, it would favor the hypothesis that persons with CFS have personality characteristics that have predisposed the development and/or maintenance of their symptomology.

Section snippets

Subjects

Subjects consisted of 38 CFS, 40 MS, and 40 healthy controls. CFS subjects were recruited from the CFS Cooperative Research Center and MS subjects from the MS Clinic, both at the University of Medicine and Dentistry of New Jersey (UMDNJ). Both patient groups were self- and physician-referred. Healthy control subjects consisted of individuals from surrounding local communities and colleges. Demographic information is provided in Table 1. MS subjects tended to be somewhat older than CFS subjects

Results

The overall MANOVA on the four TPQ dimensions of personality resulted in a significant group difference (Wilk's lambda 8, 224=9.31, p<0.0005). As shown in Table III, the ANOVA for Harm Avoidance was significant F2, 115=23.32, p<0.0005. Tukey tests indicated that both MS and CFS groups were significantly more Harm Avoidant than the healthy controls (p<0.0005 for both), but did not differ from each other. Individual ANOVAs for the Harm Avoidance subscales resulted in significant differences for

Discussion

The results of the present study indicate that the personality profiles of CFS and MS subjects were generally similar. Compared with the control subjects, the CFS and MS patient groups displayed similar increased sensitivity to negative stimuli as measured by Harm Avoidance. The only exception was the Fatigue and Asthenia subscale, where, as expected, the CFS subjects scored higher than the MS subjects. The two illness groups were also similar in their sensitivity to positive events (Reward

Acknowledgements

This study was supported by Grants R01-H52810A and AI-32247 from the National Institutes of Health. The authors thank David C. Glass for his helpful review of the manuscript.

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