Research report
The psychological costs and benefits of being highly persistent: Personality profiles distinguish mood disorders from anxiety disorders

https://doi.org/10.1016/j.jad.2011.09.046Get rights and content

Abstract

Background

The personality trait of Persistence is highly valued by conscientious overachievers, but it has both psychological costs and benefits. The interactions among multiple personality factors influencing the development of mood and anxiety disorders have been confounded in prior clinical samples, but can be disentangled in terms of their underlying brain circuitry and influence on perception of emotional stimuli.

Methods

285 individuals who represented the full range of personality variation in a large sample of adult volunteers from the general community of Israel were selected for follow-up by psychiatric interviews, cognitive testing, and medical examinations. The Temperament and Character Inventory (TCI) measured profiles of traits that distinguished individuals with diagnoses of mood and/or anxiety disorders using linear discriminant analysis and non-linear profile analysis.

Results

High Harm Avoidance and low Self-directedness strongly distinguished people with mood and/or anxiety disorders from those with neither. High Persistence distinguished people with only anxiety disorders from those with mood disorders. High Persistence was associated with greater health and happiness overall, but also led to more negative emotions than in people with low Persistence unless they were both unusually tolerant of frustration (i.e., low in Harm Avoidance) and self-accepting of personal limitations (i.e. high in Self-directedness).

Limitations

Subjects were volunteers over 40 years of age at assessment.

Conclusions

People who are highly persistent (i.e., persevering, ambitious, perfectionistic) are more likely to have anxiety disorders than mood disorders, even when they have other traits increasing risk for both (i.e., high Harm Avoidance and low Self-directedness). High Persistence increases both positive and negative emotions in most people. However, high Persistence reduces negative emotions and increases positive emotions if a person is easy-going (i.e., “happy-go-lucky” when low in both Harm Avoidance and Self-directedness).

Introduction

Persistence is a basic dimension of personality that is characterized by the extent to which a person will continue to expect and seek rewards even when the expected outcome is only rarely successful (Cloninger et al., 1993). Persistence is a heritable trait (Gillespie et al., 2003, Heath et al., 1994) that has been well-defined in terms of its underlying brain circuitry and its role in information processing of affective stimuli (Gusnard et al., 2003) as well as the resulting individual differences in behavioral characteristics (Svrakic et al., 1993). Nevertheless, the influence of Persistence on mood and affect has been unclear. Some work has shown that high Persistence is associated with resilience and positive emotionality (Cloninger et al., 1998, Garcia, 2011) whereas other work has associated it with compulsiveness and negative emotionality (Bulik et al., 2000, Fassino et al., 2004, Mulder et al., 1996).

People who are highly Persistent are described behaviorally as determined, conscientious, and ambitious because their enthusiasm and perseverance in hard work often leads them to becoming overachievers in academic and occupational roles. On the other hand, highly Persistent people also tend to be perfectionists who are dissatisfied with anything less than perfection, or at least feel they need to be the best at whatever they try to do (Fleet and Hewitt, 2002), as is common among physicians (Gabbard, 1985, Myers and Gabbard, 2008). Such unrelenting ambition and exaggerated positive expectations can easily lead to compulsive self-doubt and excessively harsh judgments of oneself and others. Substantial clinical work suggests perfectionism leads to a variety of personal and social problems related to anxiety, compulsivity, and depression (Beevers and Miller, 2004, Fleet and Hewitt, 2002, Hamilton and Schweitzer, 2000).

At the other extreme, individuals who are low in Persistence are described behaviorally as changeable, irresolute, and easily discouraged (Cloninger et al., 1993). As a result, they tend to be under-achievers when rewards are intermittent (that is, when efforts are not continuously reinforced). Nevertheless, people low in Persistence may be more successful than those who are highly Persistent when reward contingencies are rapidly changing over time because the highly persistent people are overly influenced by past conditioning that is no longer predictive of current outcomes (Cloninger et al., 1994). Some work has suggested that low Persistence is characteristic of people with bipolar mood disorders even when they are rated in a euthymic state (Osher et al., 1996, Osher et al., 1999). However, other studies have not observed this effect in either unipolar or bipolar patient samples (Farmer et al., 2003, Nery et al., 2008, Nery et al., 2009).

In order to understand the complex pattern of interactions by which Persistence modulates affect and related goal-directed behavior, it is crucial to understand the brain circuitry by which Persistence regulates the information processing of affective stimuli (Gusnard et al., 2003). Individual differences in TCI Persistence have been found to be strongly correlated (r = 0.79, P < 0.01) in adult human volunteers with activity in a specific brain circuit involving ventral striatum, the anterior cingulate cortex (ACC), and the orbital frontal cortex (Brodmann area 47) bilaterally (Gusnard et al., 2003). This specific brain circuit is well-known to regulate the behavioral conditioning of reward-seeking behavior in other mammals (Robbins and Everitt, 1996, Schoenbaum and Setlow, 2001, Schultz et al., 2000, Schultz et al., 2003). The regulation of this reward-seeking brain circuit was evaluated in human volunteers by having people make judgments about whether a standardized set of pictures from the International Affective Picture System were pleasant, neutral, or unpleasant (Lang et al., 1997). When making these ratings, individual's high in Persistence had increased activity throughout the circuit, whereas those low in Persistence had decreased activity. Furthermore, the differences in circuit activity between high Persistence and low Persistence subjects increased as the proportion of neutral pictures increased. In other words, as the proportion of neutral pictures increased, the activity of the circuit increased further in highly persistent people and decreased further in less persistent people, revealing a pattern characteristic of a non-linear dynamic system regulating the overall activity of this multi-nodal circuit.

However, the tendency of subjects to rate pictures as pleasant, neutral, or unpleasant was independent of the proportion of neutral pictures. Instead, the tendency of subjects to rate pictures as pleasant depended on a complex interaction of three personality variables: Persistence (r = .34, P < 0.05), Self-directedness (r = 0.50, P < 0.01), and Harm Avoidance (r =  0.44, P < 0.05) (Gusnard et al., 2003). In other words, people who were high in Persistence, high in Self-directedness, and low in Harm Avoidance made more pleasant judgments at the expense of neutral ratings. We observed no correlations between any TCI traits and the proportion of pictures rated as unpleasant, but our subjects were healthy volunteers selected by excluding anyone with a history of psychiatric or neurological disorder. These exclusion criteria restricted the range of Harm Avoidance and Self-directedness, but not Persistence (Gusnard et al., 2003). The ventral striatum is known to play a role in the guidance of behavior by regulating expectations of both pleasant and unpleasant outcomes (Schoenbaum and Setlow, 2001, Schoenbaum and Setlow, 2003, Schoenbaum and Setlow, 2005).

Other work has shown that Harm Avoidance influences the functional connectivity between the amygdala and ACC in response to anxiety-provoking stimuli (Pezawas et al., 2005), whereas Self-directedness is strongly related to the activation of the medial prefrontal cortex (Brodmann areas 8/9) when a person is consciously evaluating internal stimuli, such as whether a stimulus is felt to be pleasant, neutral, or unpleasant (Cloninger, 2004, Gusnard et al., 2001). Fear and other negative emotions reduce the ability of the prefrontal cortex to guide goal-directed behavior rationally by short-circuiting communication via the ACC (Pezawas et al., 2005). The ACC serves as a cross-road where conscious intentions interface with emotional drives to guide behavior based on expectations of unpleasant or unpleasant outcomes (Paus, 2001). In functional terms, TCI Persistence can be considered to function as a modulator of the functional connectivity of the emotional brain (i.e., limbic system regulating the emotional drives measured by a person's temperament) and the rational brain (i.e., prefrontal cortex regulating goals and values measured by a person's character) by holding incentive information in representational memory during delay periods in the guidance of goal-directed behavior.

In order to evaluate the psychological advantages and disadvantages associated with Persistence and its interactions with Harm Avoidance and Self-directedness, we need to evaluate a sample representative of both the healthy and unhealthy extremes of a general community sample. A general sample is needed to understand the complex interactions among multiple personality traits that regulate a person's well-being across its full range from resilient health to disease. Such a study was undertaken in Israel, which is particularly appropriate for the evaluation of the role of Persistence in the modulation of affect. Israel has a long cultural tradition of encouraging achievement and persistent productivity under stressful conditions (Brooks, 2010, Pease, 2009, Senor and Singer, 2009). Our study participants were highly diverse adults and included representative numbers of active workers in highly successful businesses, farms, and professions as well as individuals with clinically significant physical, emotional, and social disabilities (Cloninger and Zohar, 2011).

Section snippets

Participants

A base sample of 1102 adult volunteers in the community of the Sharon region of Israel completed a comprehensive self-report, which included extensive measures of personality, emotion, health and health behavior. The baseline sample and the measures taken at initial participation are described in detail elsewhere (Cloninger and Zohar, 2011, Zohar and Cloninger, 2011, Zohar et al., 2011). A mean 18 months later, a subset of the base sample, was invited to participate in the second study phase (N = 

Results

All axis I diagnoses were assessed for lifetime prevalence. Table 1 summarizes the results by diagnostic groups, in order of their frequency. Lifetime diagnoses of mood and anxiety disorders each occurred in about one third of subjects. Other groups of disorders (somatoform, eating, and substance disorders) occurred in fewer than 6% of subjects. There was a strong relationship between the number of lifetime psychiatric diagnoses and the level of adaptive function as rated by the SCID

Discussion

The personality trait of TCI Persistence strongly distinguishes people with anxiety disorders from those with mood disorders. This strong discriminant effect is the result of high TCI Persistence increasing both negative emotions and positive emotions in the same person. In other words, high Persistence protects against mood disorders by increasing positive emotions as measured by PANAS, such as people feeling happy, interested, strong, enthusiastic, inspired, attentive, and active. At the same

Role of the funding source

This research was supported by the United States Israel Binational Science Foundation (BSF). The BSF provided funding for the four year research described in the current paper, including paying for the laboratory personnel and procedures, the medical examinations, all the expenses of data gathering and data maintenance. The BSF did not pay the salaries of any of the authors, save Dana Dahan, who was project manager for three of the four years of the project.

Conflict of interest

No conflict of interest is present for any of the authors.

Acknowledgment

This research was supported by the United States Israel Binational Science Foundation, grant #2005-48 to AHZ and CRC.

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