Personality and Health

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• Top cited articles Howard S. Friedman1 and Margaret L. Kern2
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1
Annu. Rev. Psychol. 2014.65:719-742. Downloaded from www.annualreviews.org
• Our comprehensive search Department of Psychology, University of California, Riverside, California 92521;
email: Howard.Friedman@ucr.edu
2
Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania 19104;
email: mkern@sas.upenn.edu
Annu. Rev. Psychol. 2014. 65:719–42 Keywords

The Annual Review of Psychology is online at lifespan perspective, trajectories, conscientiousness
http://psych.annualreviews.org
This article’s doi: Abstract

10.1146/annurev-psych-010213-115123
A lifespan perspective on personality and health uncovers new causal path-
Copyright c 2014 by Annual Reviews. ways and provides a deeper, more nuanced approach to interventions. It is
All rights reserved
unproven that happiness is a direct cause of good health or that negative emo-
∗
The authors contributed equally to this article. tion, worry, and depression are significant direct causes of disease. Instead,
depression-related characteristics are likely often reflective of an already-
deteriorating trajectory. It is also unproven that challenging work in a de-
manding environment usually brings long-term health risks; on the contrary,
individual strivings for accomplishment and persistent dedication to one’s
career or community often are associated with sizeable health benefits. Over-
all, a substantial body of recent research reveals that conscientiousness plays
a very significant role in health, with implications across the lifespan. Much
more caution is warranted before policy makers offer narrow health recom-
mendations based on short-term or correlational findings. Attention should
be shifted to individual trajectories and pathways to health and well-being.
719
Contents
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 720
OUTCOMES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721
Longevity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 721
Quality of Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 722
Multiple Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 722
Limits of Biomarkers as Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 723
HAPPINESS, SUBJECTIVE WELL-BEING, AND HEALTH . . . . . . . . . . . . . . . . . . . . 723
Power of Positive Emotion? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 724
Meaning and Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726

Optimism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726
NEUROTICISM, DEPRESSION, WORRY, AND DISEASE. . . . . . . . . . . . . . . . . . . . . . 727
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
Challenge and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 729
CONSCIENTIOUSNESS, MATURITY, AND LONGEVITY . . . . . . . . . . . . . . . . . . . . 731
Early Life Influences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733
CONCLUSION: IMPLICATIONS FOR INTERVENTIONS . . . . . . . . . . . . . . . . . . . . 733
INTRODUCTION
Although the relationships among personality, well-being, and health have been studied for
millennia—since the days of the bodily humors proposed by Hippocrates and Galen—the
field remains riddled with conceptual confusion, method artifacts, and misleading conclusions.
When inferences drawn from this field are based on incomplete models, they lead to waste-
ful and even harmful interventions and treatments. Scientists and laypersons alike may over-
generalize from short-term personality correlates of health and overlook long-term causal
processes.
There is nevertheless excellent evidence that individual characteristics from earlier in life are
reliable predictors and likely causal elements of health later in life. An especially striking finding
to emerge in recent years is that a host of characteristics and behaviors associated with the broad
personality dimension of conscientiousness is predictive of health and longevity, from childhood
through old age. The reasons for these associations are complex and sometimes appear paradoxical,
as there are multiple simultaneous causal links to health. The modern study of personality, how-
ever, provides many of the concepts, tools, and models necessary for a deeper and more accurate
understanding of health, well-being, and long life.
In particular, there is considerable misapprehension concerning the pathways to good
health. In this article, we review many of the causes and consequences of the associations
among personality, behavior, well-being, and health and longevity. We do this in the context
of expanded models and perspectives. Because much of the confusion in the area of personality
and health arises from ambiguous definitions, weak measurement, and overlapping constructs
of health, we begin with health outcomes. We then review and scrutinize the connections
among happiness and health, and among depression, worry, and disease, which likely are
not what they first appear to be. Finally, we explain and evaluate the emerging consensus
on the significance of conscientiousness across the lifespan and offer suggestions for health
interventions.
720 Friedman · Kern

OUTCOMES
Study of personality—an individual’s relatively stable predispositions and patterns of thinking,
feeling, and acting—and its relationships to well-being and health continues to be plagued by an
overreliance on self-report measures. This is a special problem because many of the questions (or
items) used to assess personality are the same questions used to assess health and well-being. Much
better assessment strategies are needed.
Outcome measures of well-being may ask individuals how good they feel, how well they cope,
and how satisfied they are with life. These are very similar to personality measures of low neu-
roticism (“am relaxed most of the time”; “am calm”; “am not angry or depressed”) and high
agreeableness (“am on good terms with others”; “am warm and sympathetic”). Thus it is not sur-
prising that people who report having a joyful, cheerful, relaxed, and agreeable personality also
report life satisfaction, emotional thriving, and well-being. Such correlations have little to say
about achieving well-being. Relatedly, studies of patient populations often suffer from personality
selection artifacts (biases) because neurotic individuals are more likely to report symptoms (such as
chest pain) and to seek medical care than nonneurotics, even when there is little or no discernable
organic disease. Although such serious measurement artifacts have been recognized for decades
(Watson & Pennebaker 1989), erroneous causal deductions are still common.
Analogous issues plague self-report measures of physical health. The commonly used multi-
purpose Short-Form (36) Health Survey (SF-36), or the closely related RAND 36-Item Health
Survey (RAND-36), can be very useful for assessing overall disease burden. However, the
SF-36 contains multiple dimensions, including behavioral dysfunction, objective reports, sub-
jective rating, and distress and well-being (Ware 2004). So employing the full SF-36—without
sufficient attention to its components—as an outcome measure of health in studies of personal-
ity and health again confounds the predictor with the outcome because individuals who report
a neurotic, distressed personality also report pain, feeling sick, and a poor sense of well-being.
Sometimes this flaw is obfuscated by invoking the significant well-established finding that self-
rated health predicts mortality risk (Idler & Benyamini 1997). That is, the argument asserts that
self-reported personality predicts self-reported health, and self-reported health predicts mortal-
ity, and so therefore a study of self-reported personality and self-reported health is really a study
of personality and physical health. A valuable scientific approach, however, necessitates multi-
method assessments of personality and behavior coupled with more objective measures of health
outcomes.
Longevity
Longevity is, for most purposes, the single best measure of health. First, it is highly reliable and
valid. Although there is some unreliability of public records such as birth certificates and death
certificates, it is generally the case that if a death certificate shows that a man died on April 15,
2013 at age 80 from septicemia, then it is very likely that he lived eight decades. It is also very
likely that he is currently in terrible “health,” and so health validity is strong. Life expectancy is
thus one of the key measures of public health used worldwide.
Second, using longevity as the outcome helps avoid what we call the “all-cause dilemma”
artifact. These are cases in which a person has a disease such as cancer, and, for example, the prostate
or breast is removed, and then soon after the individual dies not of cancer but of something else.
If the focus of the study is on cancer survival (as a function of personality, coping, and treatment),
the death may not be picked up; that is, the cancer did not progress and/or the person did not die
of cancer. The patient is considered to be “cured” of cancer even if the patient dies of a different
cause. In other words, much research on personality and health is limited and even distorted by the
www.annualreviews.org • Personality, Well-Being, and Health 721

still-common focus on single-disease conditions, with insufficient attention to overall outcomes,

especially overall mortality risk.
Relatedly, it is misleading to speak of personality traits or coping styles that predict cancer risk
or heart disease risk (e.g., type A personality) if such factors equally predict (are equally relevant
to) other diseases. And, in fact, the basic five-factor personality dimensions (particularly consci-
entiousness, neuroticism, and extraversion, but also often agreeableness and openness) do predict
multiple diseases (Friedman 2007, Goodwin & Friedman 2006). This issue was noted many years
ago (Friedman & Booth-Kewley 1987), but studies of personality predictors of particular diseases,
without sufficient regard for the broader context, are still common. Rigorous research programs
on personality, well-being, and health would do better to employ multidimensional assessments
of both personality and health and, whenever possible, to include follow-ups to measure all-cause
mortality or multiple hard outcomes of disease.

Quality of Life
General health is well captured by longevity because the people who live the longest usually are
not those who have been struggling with diabetes, cancer, heart disease, and other chronic dis-
orders. But measures that also directly consider the quality of life—such as the number of years
that one lives without significant impairment—are of increasing interest. The World Health
Organization uses healthy life expectancy (HALE), defined as years lived without significant im-
pairment from disease or injury. The European Union has developed an indicator of disability-
adjusted life expectancy (“Healthy Life Years”). Health psychologists such as Robert Kaplan (2002)
have advocated for health-related quality-of-life measures that take into account years of life and
the amount of disability while minimizing the value of any “benefits” that come from curing one
disease only to have it be replaced by another. Such robust measures include rigorous definitions
of disability—such as inability to work, walk, dress, converse, and remember—rather than simply
self-report measures of how one feels.
Multiple Outcomes
Consistent with the World Health Organization’s definition of health as composed of physical,
mental, and social components, we have found (in our own research) that it is empirically and
heuristically useful to distinguish and use at least five core health outcomes in addition to longevity
(Friedman et al. 2010, Friedman & Martin 2011; see also Aldwin et al. 2006, Baltes & Baltes 1990,
Rowe & Kahn 1987). In brief, they encompass the following:
(a) Physical health (the ability and energy to complete a range of daily tasks; either diagnosed
or not diagnosed with organic disease such as heart disease or cancer). Physical health is defined
by an evaluation or evidence-based judgment by a health professional, such as an exam that might
be used to qualify for medical treatment or disability payments. (b) Subjective well-being (positive
mood; life satisfaction). Subjective well-being is often seen as having both an emotional component
(frequency of positive and negative emotions) and a cognitive component of self-perceived life
satisfaction (Diener et al. 2013). (c) Social competence (successful engagement in activities with
others). Social competence includes the ability to maintain close relationships, to have a supportive
social and/or community network, and to support others. (d ) Productivity (continued achievement;
contributing to society). Productivity involves work that has potentially monetary/economic (paid)
value or contributions of recognizable artistic, intellectual, or humanitarian value. With an aging
population in many countries, productivity is taking on new meanings and importance (Fried
2012). (e) Cognitive function (the ability to think clearly and remember) is defined in terms of

mental processes involved in symbolic operations, such as memory, perception, language, spatial
ability, decision making, and reasoning. ( f ) Longevity (see Longevity section above). As needed
and when possible, some of these outcomes can be multiplied by years to produce quality-of-life-
years measures.
These different outcomes are usually correlated (and sometimes highly correlated) with each
other. However, a key research challenge is to ascertain the causes of these outcomes and the
causal roles, if any, that are played by each of these factors in the others, and the answers will
require both independent multimethod assessment and appropriate research designs.
Limits of Biomarkers as Outcomes

A related conundrum that often bedevils research on personality, well-being, and health involves
screening, biomarkers, and overdiagnosis (Welch et al. 2011). Many examples exist of interven-
tions that affect a biomarker of disease risk (sometimes termed a surrogate endpoint) but that do
not improve quality of life or mortality risk because the causal links are not as expected. In fact,
many medical interventions decrease quality of life for many while improving it for only a few,
even though short-term biomarkers look better. The US Food and Drug Administration (FDA)
now requires that any new class of drug must have studies with hard disease or mortality outcomes,
because evaluating only the intermediate outcomes such as blood biomarkers has led to problem-
atic or dangerous treatments in the past (cf. DeMets 2013). For example, lipid levels (especially
cholesterol) are very good predictors of cardiovascular-relevant mortality risk, and niacin improves
lipid levels, but taking niacin does not decrease mortality risk. Homocysteine (an amino acid) is a
good predictor of heart disease, and B vitamins lower homocysteine levels, but B vitamins do not
in turn lower disease risk (for an Institute of Medicine report on surrogate endpoints, see Micheel
& Ball 2010). Screening for prostate cancer with the prostate-specific antigen (PSA) biomarker is
probably the most notorious case of causing significant harm to patients: Most men with elevated
PSA levels will never develop symptoms of prostate cancer, but many will face morbidity if treated;
overdiagnosis is common in other cancer screens as well (Welch & Black 2010, Welch et al. 2011).
What all this means for research on personality and health is that limited-time measurements of
outcomes such as cortisol level, vagal tone, and immune markers do not necessarily provide indi-
cators of future long-term health and longevity, especially since biomarkers naturally fluctuate as
the body maintains or reestablishes homeostasis.
Biomarkers (particularly aggregations of biomarkers as an indication of chronic physiological
dysfunction) become very important when they are studied as mediators of relations in fully
specified models, such as if the progression of cancer can be shown to have slowed as a function of
a psychosocial intervention that boosts the immune system. Biomarkers can best serve to elucidate
the mediating mechanisms of personality-to-disease processes that are discovered in longer-term
studies, but at present, such longitudinal mediation studies are quite rare.
HAPPINESS, SUBJECTIVE WELL-BEING, AND HEALTH

Some people thrive, stay generally healthy, recover quickly from illness, and live long, whereas
other individuals of the same age, gender, and social class are miserable, often ill, and at higher
risk of premature death. Personality, well-being, and physical health are intimately connected but
not necessarily simply connected. The core question is sometimes thought to be, “Why do people
become sick?” when it is really, “Who becomes sick and who stays well?”
Despite the fact that an individual’s sense of well-being is fairly stable across time, a number of
clever positive psychology interventions have been developed that increase happiness and the sense

of well-being, even in depressed populations (Lyubomirsky & Layous 2013, Sin & Lyubomirsky
2009). But will such interventions also make people healthier? This is a very important issue for
both conceptual and practical reasons. On the conceptual side, it matters how we think about the
nature of psychological and physical health and the causal models we endorse (often implicitly) or
construct. On the practical side, the true causal links between health and happiness impact what
scientists, doctors, patients, public health programs, and societies can and should do to promote
health. If happiness causes health, then positivity interventions will result in health and long life
and thus have public health importance. However, health is highly complex, and as it turns out,
multiple causal processes are simultaneously at work in preserving health or promoting disease,
although not in the ways often assumed.
Power of Positive Emotion?

A popular model is the one made famous several decades ago by Norman Cousins, commentator
and editor of the influential Saturday Review (Cousins 1979). Diagnosed with a paralyzing degen-
erative disease, Cousins checked himself out of the hospital and into a hotel room and treated
himself with laughter. Against the odds, he recovered and thereafter publicized creativity and
humor as being essential to medical treatment; this was a cultural turning point that spurred
greater attention to how the mind could heal the body. An upshot of this work was the popular
reemergence in health care of the idea that distress, grief, and psychological tension play key and
direct roles in illness and that laughter and good cheer could and should be a core part of a cure.
Watching films that you find funny, as Cousins did, will indeed make you feel happier, but should
this be a central ingredient of medical care and health promotion?
This development was followed by a number of best-selling popular books, such as Bernie
Siegel’s Love, Medicine and Miracles (1986), and Peace, Love and Healing (1990), that were advertised
as full of inspiring true stories of healing, gratitude, and love. At their best, such books provide
help in relieving the distress of coping with serious illness and can encourage some patients and
their families to follow prescribed treatment regimens and try to live healthier lives. At worst, they
provide quack treatments for wishing away one’s cancer or they blame illness upon personality
defects. Despite years of published rebuttals of feel-good “cures,” these errant beliefs still permeate
discussions of personality and health.
Richard Sloan (2011) has traced this mind-over-matter, virtue-over-disease argument
throughout twentieth-century American thought, from unconscious hostile impulses (supposedly
causing ulcers, asthma, and more) to the best-selling book, The Secret (Byrne 2006), which teaches
that you can “think” your way to health and wealth through cosmic energy. He notes, “Negative
characteristics—anger, resentment, fear—were always associated with poorer health outcomes.
One can search the literature in vain for diseases associated with positive characteristics” (Sloan
2011, p. 896). Whereas in Freud’s time and thereafter, the ill were said to be repressed, conflicted,
and hostile, today they are viewed as lacking joy, compassion, spirituality, and forgiveness.
Despite such warnings as Sloan’s, there is recurrent popular advice that a “be happy” mindset is
a key to good health.
There is no doubt that subjective well-being and related concepts such as positive emotions
are associated with better self-reported health, lower morbidity, less pain, and longevity (Chida
& Steptoe 2008, Diener & Chan 2011, Howell et al. 2007, Lyubomirsky et al. 2005, Pressman
& Cohen 2005, Veenhoven 2008). An analysis across 142 nations found that positive emotions
predict better self-rated health around the world, with positive emotion trumping hunger, shelter,
and safety in predictive value (Pressman et al. 2013). A premature conclusion is that by shifting
the population to greater levels of happiness, health will thereby improve. Diener & Chan (2011)

propose that there is good evidence “that subjective well-being causally influences health and
longevity” (p. 21), but this is an empirical question that has not yet been resolved. We believe the
truth is much more complex and that more inclusive models need to be specified. Progress in this
field will depend on the construction of a complete nomological network and the testing of more
elaborate causal pathways.
Actions or interventions that improve well-being might indirectly improve a person’s physical
function but not act directly. This is an important distinction. To take some obvious examples,
people can feel happier by watching TV comedies, eating sugary foods, riding a Ferris wheel,
taking cocaine, or partying. But they would not be healthier. On the other hand, taking long walks
through the park each day, thriving at work, and maintaining high-quality intimate relationships
with loved ones probably will have long-term impacts on both happiness and physical health. But
these are much more difficult patterns to establish and maintain. Personality often underlies such
broader lifestyle patterns in concert with genetic predispositions, environmental influences, and
social relations. Further, as noted in the “Outcomes” section above, shifting people’s perceptions
of their health from “very good” to “excellent” is an analysis of subjective well-being, not health.
We need broader causal models of the relevant relationships, such as the one shown in Figure 1.
General “life satisfaction” offers a more stable cognitive evaluation of life than does positive
emotion alone. Satisfaction items have been answered by millions of people around the world over
the past two decades. As with the simple (emotional well-being → health) model, life satisfaction
predicts health and longevity, lower suicide risk, college and job retention, and marital success
(Diener et al. 2013). But deeper analyses reveal that a simple causal model is incomplete. For
example, in an eight-year study with over 900 individuals, cross-lagged relations between health
and life satisfaction found that poor health predicted subsequent life dissatisfaction, but satisfaction
did not prospectively predict changes in health (Gana et al. 2013). Moreover, it is now well
documented that subjective well-being or happiness is adaptive in some contexts but maladaptive
in others (see Ford & Mauss 2014, Gruber et al. 2011, Hershfield et al. 2013).
Positive
intervention
Time 1 Time 2
Subjective Subjective
well-being well-being
Genetic predispositions,
environment, and
personality
Lifestyle Lifestyle
patterns patterns
Time 1 Time 2
Physical Physical
health health
Biomedical
intervention
Figure 1
Correlated outcomes model. An example of a broader, more comprehensive causal model of relationships
among personality, mediators and moderators, and correlated outcomes.

Meaning and Purpose

Beginning in the early 1960s, work by Viktor Frankl and others proposed that people function
best when they have a sense of life purpose (cf. Steger 2009; see also Antonovsky 1979). From a
eudaimonic perspective (which originated in debates about Aristotelian ethics), well-being comes
not from positive emotion or happiness but rather from fulfilling one’s potential, having a sense
of meaning or purpose in life, having mastery over one’s environment, experiencing spirituality,
engaging in life, and maintaining positive relationships with others. Many scholars have argued
persuasively that a meaningful life is not necessarily a happy one (Baumeister et al. 2013, King
2001, Ryff & Singer 2009). For example, holocaust survivor and Nobel Prize winner Elie Wiesel
has written dozens of books and won dozens of distinguished humanitarian awards, but his is not
a life of happiness, laughter, and positive emotion.
Considerable cross-sectional evidence links sense of purpose to various subjective well-being

measures, including life satisfaction, self-esteem, ego resilience, and positive perceptions of the
world (Steger 2012a). It is correlated with higher levels of agreeableness, extraversion, consci-
entiousness, and openness to experience, and with lower levels of neuroticism, depression, and
psychoticism. Having a sense of purpose facilitates active life engagement, goal setting, and goal
pursuit, so it is not surprising that some evidence suggests links between greater meaning/greater
purpose and better physical health. For example, over a five-year period, purpose in life was associ-
ated with reduced mortality risk (Boyle et al. 2009; see also Ryff et al. 2004). But here again, fuller
causal models are needed. That is, although some researchers propose that eudaimonic well-being
enables optimal physiological functioning (Ryff & Singer 1998), a limited (well-being → health)
model is typically applied, and almost all evidence is correlational or short term in nature. Further,
Steger (2012b) notes that “there have been no tests of whether the way the brain strives to restore
meaning in low-stakes lab experiments is sufficient to account for the kind of meaning and purpose
in life that Frankl argued inspired his survival of Nazi concentration camps” (p. 382).
Some theories include meaning as a critical component of well-being and flourishing (e.g.,
Ryff & Keyes 1995, Seligman 2011), whereas others see sense of meaning as a motivating factor
that leads to greater well-being. Ryan and colleagues (2006) note that rather than focusing on the
outcome of feeling good, “eudaimonic conceptions focus on the content of one’s life, and the processes
involved in living well” (p. 140). Overall, although strong empirical support is currently lacking
for sense of meaning as a vital factor in future health, it is a promising direction, especially because
there is considerable evidence that persistent, planful striving for meaningful accomplishment is
indeed a key pathway to health and longevity (see sections below titled Challenge and Health and
Conscientiousness, Maturity, and Longevity).
Optimism
Optimism—characterized by a tendency toward positive expectations for the future and confidence
in one’s ability to cope with challenges—has been consistently linked to better health (Boehm &
Kubzansky 2012, Carver & Connor-Smith 2010). Here again, caution is needed: When full models
are spelled out, there is no good evidence for the healing power of positive thought (as a causal
relationship). That is, there is little evidence that optimistic thinking will mobilize an immune
system and cause tumors to shrink and increase longevity (Coyne & Tennen 2010). However,
optimistic individuals set goals and persist longer despite challenges and setbacks (Carver et al.
2010, Lench 2011). Optimism can function as a self-regulating mechanism, with optimistic people
more likely to persevere and engage toward a goal (Carver et al. 2010). Behavioral change programs
that include goal-setting strategies can build self-efficacy and confidence for future challenges,
creating resilience through challenge. Optimism can provide the motivation to move forward, if

tempered by a realistic assessment of when to let go. And optimism can help individuals face the
challenges of recuperation from disease.
In summary, although there are many ways to increase one’s sense of well-being, only some of
them will increase health. This is a critical distinction that becomes clearer with an examination
of neuroticism, depression, and disease.
NEUROTICISM, DEPRESSION, WORRY, AND DISEASE

Are individuals who are worrying, tense, anxious, depressed, and emotionally labile more likely
to face serious illness and premature death? Overall, the mixed findings concerning neuroticism
and health are so striking and jumbled as to call into doubt the viability of further simple studies
of these relationships. Instead, more sophisticated causal models are needed that include person-
ality facets, multiple causal mechanisms, interactions with other variables, and consideration of
biopsychosocial contexts.
Assumptions that neuroticism leads to disease have existed since ancient medicine, with
excessive melancholic and phlegmatic humors believed to cause depression, cancer, rheumatism,
fevers, and other disease (Friedman 2007). In reality, the ancients were simply (but insightfully)
observing the same correlations seen today. With the discovery of hormones and the introduction
of Walter Cannon’s (1932) fight or flight model, the focus shifted toward physiological reactions
to stress (hormonal instead of humoral explanations), but the hypothesized causal model did not
change much.
According to this model, neuroticism leads to or facilitates chronic overactivation of the auto-
nomic nervous system, disturbing homeostatic balance, in turn leading to pathological breakdown,
chronic illness, and early mortality (Graham et al. 2006, McEwen 1993). The problem is that ad-
vice is then given to stop worrying, slow down, and relax. But a “healthy neuroticism” (Friedman
2000) is often a good thing, as an individual is vigilant about his or her health. For example, in the
Terman Life Cycle Study, neuroticism (measured decades earlier) was protective against mortality
risk for bereaved men (Taga et al. 2009). A study of over 11,000 Germans compared expected and
actual life satisfaction across an 11-year period (Lang et al. 2013), finding that many individuals
grew more pessimistic about their future satisfaction with increasing age, and this pessimism was
associated with lower morbidity and mortality risk. Such pessimism may reflect a flexible, realistic
adaptation to loss at older age (Baltes & Smith 2004).
Neuroticism is highly correlated with negative feelings (DeNeve & Cooper 1998) and, as noted,
with health complaints and lower perceptions of health, but its causal role in health and well-being
is complex and far from understood (Yap et al. 2012). Most importantly, neuroticism inconsistently
predicts mortality risk, with some studies finding higher risk (Abas et al. 2002, Denollet et al. 1996,
Schulz et al. 1996, Wilson et al. 2004) and many other studies finding null (Almada et al. 1991,
Huppert & Whittington 1995, Iwasa et al. 2008, Mosing et al. 2012) or protective effects (Korten
et al. 1999, Taga et al. 2009, Weiss & Costa 2005). Across four decades of adulthood in the Terman
Life Cycle Study, neuroticism was most predictive of subjective well-being but least predictive
of longevity (the most objective measure of health) (Friedman et al. 2010). The explanation for
these findings is that personality trajectories and personality interactions with life events also
matter, which strongly suggests that a simple neuroticism-to-poor-health model is incomplete
(Chapman et al. 2010, Löckenhoff et al. 2009, Mroczek & Spiro 2007).
Depression
In a meta-analysis of psychological factors in heart disease published over 25 years ago, Booth-
Kewley & Friedman (1987) uncovered the then-surprising fact that depression was an excellent

Depressive Cardiovascular
symptoms disease
Depression
treatment
Figure 2
Simple depression and disease model. An overly simple, and generally ineffective, approach to treatment
based on the stable correlation between depression and cardiovascular disease.
predictor of cardiovascular disease, although the focus at that time was on type A behavior as
a predictor. Subsequent research has confirmed this discovery (Grippo & Johnson 2002, Miller
et al. 1996, Rugulies 2002, Smith & Gallo 2001, Suls & Bunde 2005, Wulsin & Singal 2003) and
has launched a series of efforts to prevent disease by treating depression—the model represented
in Figure 2.
The American Heart Association recommends screening of patients for depression in cardio-
vascular care. Depressed patients with heart disease do indeed often have high levels of biomarkers
associated with atherosclerosis (Lichtman et al. 2008), but claims that depression causes illness
can confound predictors and outcomes if a full causal model is not specified. An important ran-
domized study found that treating depression in recent heart attack patients did not reduce the
risk of death or second heart attack (Berkman et al. 2003; see also Friedman 2011b, Thombs
et al. 2013). A Cochrane database review of randomized trials of psychological interventions in
adults with coronary heart disease found effects on depression, supporting the success of treat-
ing psychological symptoms (Whalley et al. 2011). But there was little evidence that the in-
terventions affected the disease process, with no reduction in the total occurrence of nonfatal
infarction or death. A recent meta-analysis of mental health treatments (antidepressants and psy-
chotherapies) for improving secondary event risk and depression among patients with coronary
heart disease again showed mental health treatments did not reduce total mortality (absolute risk
reduction = −0.00), although there was a minor influence on coronary heart disease events
(Rutledge et al. 2013). A French study with over 14,000 individuals found that although depres-
sion and mortality risk were strongly related (over the subsequent 15 years), this association was
confounded by hostility (hostile ways of thinking), which is known to be relevant to injury (suicide,
homicide, accidents) and to a host of unhealthy behaviors (Lemogne et al. 2010). Although there
is no doubt that many diseases are associated with higher levels of anxiety and depression, the
causal pathways have never been fully elucidated.
A lifespan perspective offers a better way of thinking about these matters by focusing attention
on processes that develop over time, with predictors, pathways, and outcomes fully specified. For
example, common symptoms in the days or weeks following a serious concussion (traumatic brain
injury) are irritability, concentration difficulties, sleep disturbances, and depression. These are
also core symptoms of posttraumatic stress disorder. It is also the case that these same symptoms
can result from infections and other sources of immune system disruptions with increases of
proinflammatory cytokines—as happens when an individual contracts the flu and suffers irritability,
disordered sleep, anhedonia, and lethargy (Kemeny 2011). After menopause, not only the odds of
heart disease but also the odds of depression for women are significantly increased (Bromberger
et al. 2011). In all of these cases, depression and/or anxiety are not only significant correlates of
illness but are also significant results of illness or of challenges to homeostasis.
The National Institute of Mental Health states that depression and anxiety are serious
illnesses—that is, they are outcomes. In the classification of major depressive disorder in the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Am. Psychiatr. Assoc. 1994),

Neuroticism
Genetic predispositions
Depressive
and socioecological
Disease symptoms
environment Loneliness Cardiovascular

disease
Unhealthy
behaviors
Figure 3
Elaborated depression and disease model. An evidence-based, more complete model that separates
personality, social environment, genetics, behaviors, and disease, allowing for more comprehensive
examination of causality. This figure is an example of promising directions, not a fully established inclusive
model.
symptoms fall into categories of unhealthy thoughts (persistent sadness or empty feelings, worth-
lessness, helplessness, difficulty concentrating, thoughts of suicide), unhealthy behaviors (overeat-
ing or undereating, insomnia or excessive sleeping), unhealthy social relations (loss of interest in
hobbies or activities including sex, withdrawal from others), and somatic symptoms (aches and
pains, digestive problems, fatigue and decreased energy). Taking into account the genetic influ-
ences on depression and the fact that many anxious or depressed individuals self-medicate with
cigarettes, mood-altering drugs, or alcohol, we have almost the full panoply of biopsychosocial
factors in health and illness. Just as the typical (well-being → health) model is incomplete, the sim-
ple (depression → disease) model likely is wrong or at least incomplete. The depression-mortality
relationship is confounded by personality, social environments, unhealthy behaviors, and genetic
predispositions. A conclusion that depression is a direct cause of disease is unjustified. A more
comprehensive model is illustrated in Figure 3.
Psychotherapy or advice to cheer up will not stop the progression of cancer or cardiovascular
disease (Coyne & Tennen 2010, Thombs et al. 2013), but if a psychosocial treatment helps the
person eat better, get out of bed, attend medical appointments, and connect with other people, it
may indeed improve health. The precise causal links are very important because if the associations
are not a function of mood induction, then interventions to improve positive mood or subjective
well-being may be useless. There are no well-controlled studies showing that interventions to
improve the chronic mood of neurotics result in direct physiological changes and consequent
improvements in progression of cancer or risk of death. To the extent that depression is a result
of the disruption of homeostasis rather than the cause of the disruption, many interventions to
treat depression in an attempt to improve later health will be futile. Such weak approaches will
also undermine the promise of positive psychology to encourage better ways of thinking about
depression, subjective well-being, and health.
Of course, if an intervention happens to affect the underlying causes of both health and depres-
sion for an individual, health will be improved. Increasing physical activity—changing someone
from an inactive to an active person—is a likely candidate in this realm (Carek et al. 2011, Pedersen
& Saltin 2006, Ströhle 2009).
Challenge and Health

Despite the common perception that very hard workers (workaholics) put their health at risk
through nervous tension, work and health are intricately related, often in a positive way. Work

can provide a sense of identity and purpose, stable social connections with others, and of course a
source of income for meeting needs for good food, safe shelter, and competent health care. Un-
employment is a well-established correlate of disability, illness, depression, health care utilization,
and mortality risk, often in vicious cycles (Roelfs et al. 2011). For example, data from the US Panel
Study of Income Dynamics showed that job loss predicted increased risk of a new health condi-
tion over the next year, with significantly higher risk if no reemployment occurred (Strully 2009).
And in England during the 2008–2010 recession, suicides and injury rates rose (Barr et al. 2012).
Not surprisingly, deteriorating health also influences work, with the US Panel study finding that
poor health predicted subsequently being fired or leaving a job voluntarily. Negative cycles often
occur, in which the sick or injured worker loses his or her job, forfeits income for self-care, and
faces further deteriorating health; absence from work is a good predictor of subsequent long-term
disability and unemployment.

Since the type A behavior pattern was proposed (during the 1950s economic boom) as a cause
of heart disease—along with warnings against trying to accomplish increasingly more in less
time (Chesney & Rosenman 1985)—there has been concern that busy workplaces are unhealthy.
Certainly, a workplace can be excessively challenging, with unreasonably heavy physical work,
chemical exposure, violence, or psychological overload (World Health Organ. 1994). But health
psychologists have long recognized that challenge is not necessarily harmful (McEwen 2000). The
term stress properly refers to a significant physiological disruption that compromises the internal
regulatory processes that maintain physiological balance within an organism. The human body
is adept at responding to internal and external change. However, when the physiological system
is chronically disturbed, resources become depleted and regulatory processes are often affected
(Cacioppo & Berntson 2011). It is usually through chronic processes, over time, that negative
psychoemotional and behavioral reaction patterns play a role in disrupting metabolism, immune
function, and physiological rhythms (including sleep), thereby increasing susceptibility to illness
and general breakdown (Kemeny 2011, McEwen 2006). Such disruption is a long-term process
that occurs through an interaction of internal and external forces as part of an individual’s long-
term trajectory, and it cannot be captured in a single measurement or experiment. Challenge and
a heavy workload can be healthy or unhealthy, depending on the person, the context, and the
person-situation interaction. In a longitudinal analysis of elderly participants in the Terman Life
Cycle Study, the continually motivated and productive men and women (who were still working
for pay, pursuing new educational opportunities, or seeking new achievements) went on to live
much longer than their more laid-back comrades, and this productive orientation mattered much
more to longevity than did their sense of happiness and well-being (Friedman et al. 2010).
It has long been recognized that challenge is a key precursor of well-being. For example,
flow—very high levels of psychological engagement—emerges when challenge and skill meet
(Csikszentmihalyi 1997). Engaged workers approach their jobs with vigor, interest, and absorp-
tion and have enthusiasm both for the task at hand and for the organization as a whole (Lepine et al.
2005, Schaufeli et al. 2006). Many studies of “hardiness” show strong beneficial effects of challenge,
especially when the individual has a sense of self-control and a commitment to something mean-
ingful (Maddi 2002). In global areas with high concentrations of centenarians (Buettner 2012),
most long-lived individuals have remained physically and socially active, embracing rather than
avoiding challenge. Much research shows an association between early retirement and increased
mortality risk, even after adjusting for various selection artifacts (Bamia et al. 2008, Carlsson et al.
2012).
Outside of the formal work environment, psychological engagement and productivity are
again important components of health and successful aging. Individuals who are involved and
maintain a sense of personal control sustain a better quality of life (Bambrick & Bonder 2005,

Brown et al. 2009, Pruchno et al. 2010, Schaie & Willis 2011). On the other hand, seeking
emotional happiness per se may impede well-being by setting oneself up for disappointment or
narcissism (Mauss et al. 2011, Twenge 2006). Modern personality theories help explain how these
enduring trajectories emerge. Personality influences the events that are experienced (i.e., situation
selection), the elicitation (or provocation) of responses by others, cognitive interpretations of chal-
lenges, emotional reactions to experiences, coping responses, and resulting actions. Personality
predicts risk exposure to key life stressors such as marriage and divorce, career success and failure,
and crime and safety (Bolger & Zuckerman 1995, Caspi et al. 2005, Magnus et al. 1993, Shanahan
et al. 2013, Vollrath 2001). About one-third of all crimes happen to the same (repeat) victims,
whereas most people face no criminal victimization at all, even after controlling for neighborhood
risks (Tseloni 2000, Tseloni & Pease 2003, Tseloni et al. 2004). Children who are both low on
conscientiousness and high on neuroticism (that is, who are impulsive and emotional) are more
likely to react with distress and anger during peer conflict, reactions which in turn are related
to higher levels of victimization (Bollmer et al. 2006; see also De Bolle & Tackett 2013). As is
discussed below, it is not the emotional lability (neuroticism) itself that is crucial, but rather the
impulsivity (unconscientiousness).
Overall, we believe that it is a misdirection of resources and attention to focus on positive
moods as direct causes of good health, or on worrying, hard work, and depression as significant
causes of poor health. Instead, a remarkable body of new research suggests that certain aspects
of personality do indeed play a significant, and likely causal, role in patterns of living that lead to
thriving, health, and longevity. The core trait is usually termed conscientiousness.
CONSCIENTIOUSNESS, MATURITY, AND LONGEVITY

Perhaps the most exciting recent discovery to emerge in the area of personality, well-being, and
health is the lifelong importance of conscientiousness. Individuals who are conscientious—that is,
prudent, dependable, well organized, and persistent—stay healthier, thrive, and live longer. The
size of this effect is equal to or greater than that of many known biomedical risk factors.
Although it has long been known in the social sciences that individuals who are impulsive and
low on self-control are prone to face troubles and failures on many fronts, such matters were mostly
overlooked in the vast research on personality and health of the past half century. Fortunately, it
has also long been known that children, teenagers, and young adults can age out of or be drawn
away from delinquent patterns (Steinberg & Morris 2001), often through the development of
increased self-monitoring, better social relationships, and more benign environments.
Extensive research following up the initial startling finding of two decades ago (Friedman
et al. 1993) that childhood conscientiousness is a strong predictor of longevity has revealed that
conscientiousness is a very strong and reliable lifelong predictor of healthy pathways and of health
and longevity (Friedman et al. 2013, Goodwin & Friedman 2006, Shanahan et al. 2013). A meta-
analysis (of 20 independent samples of approximately 9,000 participants) clearly links higher levels
of conscientiousness to the key outcome of lower mortality risk (Kern & Friedman 2008). This
finding has been repeatedly confirmed in more recent studies as well (Chapman et al. 2010,
Fry & Debats 2009, Hill et al. 2011, Iwasa et al. 2008, Taylor et al. 2009, Terracciano et al.
2008). For example, in a 17-year follow-up in the Whitehall II cohort study (N = 6,800), low
conscientiousness in midlife was an important risk factor for all-cause mortality, an association
that was partly but not fully accounted for by health behaviors and certain other disease risks
(Hagger-Johnson et al. 2012).
Conscientiousness predicts reduced disease development (Chapman et al. 2007, Goodwin &
Friedman 2006), better coping (Connor-Smith & Flachsbart 2007), fewer symptoms, and various

sorts of social competence and productivity (Bogg & Roberts 2013). Finally, low conscientiousness
also predicts Alzheimer’s disease and related cognitive problems (for a prospective study, see
Wilson et al. 2007). It is thus relevant to the full range of core health outcomes we described at
the beginning of this review.
Given the multiplicity of influences on health and well-being, how could one personality
dimension be so important across so many years? Emerging evidence suggests the relevance of
conscientiousness to a number of core biopsychosocial processes. First, conscientious individuals
engage in a variety of important healthier behaviors—for example, they smoke less, eat healthier
foods, and wear seat belts (Bogg & Roberts 2004, Lodi-Smith et al. 2010, Sutin et al. 2011). Second,
conscientiousness affects situation selection. That is, conscientious individuals choose healthier
environments, create or evoke healthier situations, and select and maintain healthier friendships
and more stable marriages (Kern & Friedman 2011, Lüdtke et al. 2011, Shiner & Masten 2012,
Taylor et al. 1997). Third and relatedly, conscientious individuals are more likely to have more
successful, meaningful careers, better educations, and higher incomes, all of which are known to
be relevant to health, well-being, and longer life (Hampson et al. 2007, Ozer & Benet-Martinez
2006, Poropat 2009, Roberts et al. 2003). For example, rank in high school class (N = 10,317 high
school graduates), which depends heavily not only on intelligence but also on conscientiousness,
was found to be a much better predictor of longevity than was IQ (Hauser & Palloni 2011).
Fourth, conscientiousness often interacts with unhealthy stressors and with other unhealthy
personality traits, moderating their detrimental effects. For example, conscientiousness can atten-
uate the health risk of career failures (Kern et al. 2009). And although being low on conscientious-
ness and high on neuroticism appears to be a particularly dangerous combination (with individuals
who are impulsive, disorganized, anxious, and emotional at very high risk), detrimental effects of
anxiety and emotionality are reduced in individuals who are also conscientious (Chapman et al.
2010, Parkes 1984, Terracciano & Costa 2004, Turiano et al. 2013, Vollrath & Torgersen 2002).
One reason for this pattern may involve better emotion regulation ability; for example, one study
of middle-aged adults found conscientiousness predicted better recovery from negative emotional
challenges ( Javaras et al. 2012).
Fifth, conscientiousness may be encouraged by certain genetic patterns—and gene-by-
environment interactions—that are also related to subsequent health. Serotonin levels in the
central nervous system are known to have a genetic basis, change with new circumstances, affect
personality (including conscientiousness), and work to regulate core bodily functions (including
sleep) necessary for good health (Carver et al. 2011, Caspi et al. 2010, Cicchetti et al. 2012; see
also Mõttus et al. 2013 regarding inflammation).
Models of conscientiousness, well-being, and health are conceptually simple at their core but
become quite complex in practice because human lives across time are quite complex. For example,
at a young age, conscientious children face fewer self-control and school problems; in adolescence,
conscientious individuals are less likely to try smoking, alcohol, and illegal drugs; and in adulthood,
conscientious people are more likely to connect with other conscientious people—personally,
socially, and at work—and to place themselves in healthier social and physical environments
(Hampson 2012). Conscientious individuals are more likely to achieve a good education (Poropat
2009), which in turn is helpful in creating more prudent, better-organized, and forward-thinking
adults (Vaillant 2012).
Conscientiousness likely also operates to promote health through reduction of very small risks.
Prudent, persistent, planful individuals make a myriad of decisions each day that minimize risk.
Whether it is carrying a raincoat, packing an extra set of medications, double locking their doors,
minimizing germ exposure (through hand-washing or other sanitary practices), or staying off
the golf course when thunderstorms are predicted, conscientious individuals slightly lower their

risks of injury and disease each day. The individual effect of each behavior is tiny (and hard to
document), but taken together and compounded over decades, a substantial effect may emerge. For
example, the odds of being struck by lightning in one’s lifetime is only one in 10,000 for Americans
(National Weather Service; http://www.lightningsafety.noaa.gov/medical.htm), but for every
10,000 highly conscientious individuals, one likely avoids this fate. Substantial effects may arise
when hundreds of such small risks are taken into account, but there is little research evaluating
the overall cumulative impact of such factors. Much more research is needed.
A number of studies suggest that high neuroticism combined with low conscientiousness is
particularly risky for poor health outcomes (Chapman et al. 2007, 2010; Terracciano & Costa 2004;
Vollrath & Torgersen 2002). On the other hand, a high degree of self-control and grit, coupled
with prudent planning and thinking ahead is especially healthy (Duckworth 2011, Moffitt et al.
2011). This pattern, together with a general cluster of conscientiousness-relevant characteristics,

is sometimes termed maturity (cf. Vaillant 1971, 2012).
Early Life Influences

When an association between conscientiousness and health is discovered, the usual tendency is to
look for the mediators. For example, to what extent is the association between conscientiousness
and longevity mediated by health behaviors such as smoking and drinking? A life course perspec-
tive, however, also encourages a look back at common predecessor influences. In particular, early
life experiences and biological predispositions (including genes, in utero hormones, nutrition, tox-
ins, and postpartum and early infant attachment and environmental challenge) can influence both
personality and later health (McEwen 1993, 2006; Puig et al. 2013; Taylor et al. 1997). That is,
personality traits, sense of well-being, and many diseases have some genetic or perinatal basis, thus
leading to later associations between personality and health that are caused in part by underlying
biosocial third variables.
Nevertheless, many of the influences of the genetic code and its expression result from alter-
ations caused by the environment, sometimes in understandable ways and sometimes randomly.
One study of large numbers of monozygotic twins found minimal predictive ability for individual
health (Roberts et al. 2012), and even these may be overestimates of direct biological effects, as
genetic predispositions play a role in situation selection and evocation. For example, Swedish twin
studies suggest that core health-relevant social relations such as stable, happy marriages can be
partly predicted by genetic variation (Walum et al. 2008; see also Mosing et al. 2012). When the
genetic code and early-life stress are viewed as an initial step in a long-term trajectory—in other
words, in terms of personality and development—then the model becomes much more powerful
as health risks cumulate. It would be a mistake to think of research on personality, well-being,
and health as a holding pattern that awaits definitive biological stress research. It may be better
to conceive of genetic and perinatal research as one of the developing pieces necessary for a more
complete understanding of personality and health.
CONCLUSION: IMPLICATIONS FOR INTERVENTIONS

One of the primary reasons for studying personality and health is to understand ways to improve
health and reduce mortality risk. We have argued that a more complete lifespan perspective (with
expanded causal models) reveals that certain common assumptions about health and well-being
are untenable and some common interventions are unjustified. Nonetheless, hints of effective
interventions are emerging. Fuller models of personality and health help clarify causality and offer
likely points for successful intervention.

Some elements of the pursuit of happiness may very well result in increased health, but over-
simplification of the strong correlations between subjective well-being and physical health can
lead to the “no worries” approach to life, with goals of seeking positive emotions and laughter,
avoiding “stress,” taking it easy, retiring from work, and avoiding commitment. And it also leads
to the unconscionable blaming of disease victims. Analogously, a misinterpretation of the corre-
lations of depression with disease can result in the targeting of the wrong behavioral patterns for
intervention. For example, there may be advice involving ways to cheer up or overprescription of
medication for mild anxiety or depression. Further, the misunderstanding of the role of worrying
may lead to minimization of sober, thoughtful, conscientious life patterns now known to be health
protective.
Personality is also highly relevant to who completes the research study. Individuals higher on
positive emotions, agreeableness, and conscientiousness are much more likely to stay in ongoing
studies, thus creating differential attrition and distorting findings (Czajkowski et al. 2009, Friedman
2011b). For example, in a study of medication after a myocardial infarction, being conscientious
enough to fully cooperate with treatment (even if with a placebo) emerged as a more important
predictor of mortality risk than the medication (Horwitz et al. 1990). A fuller understanding and
more comprehensive causal models of personality, health, and well-being would make these sorts
of artifacts less likely.
Some of the solutions to these research challenges are well established in the fields of epidemi-
ology and randomized clinical trials but too often are overlooked, or are avoided because they are
viewed as too complicated, in the study of personality, health, and well-being. The first solution is
to sample randomly from the full relevant population, preferably an initially healthy population.
(Sometimes, use of a healthy control group is a reasonable and the only feasible alternative in a
study of patients.) Second, employ independent, valid, multidimensional measures of personality
and personality change. Third, use the best possible experimental or quasi-experimental design
with the proper control groups, including placebo control groups. Fourth, employ intent-to-treat
analyses in which everyone is included in the data analyses (including those who did not com-
plete or were not fully exposed to the treatment). And fifth, use multiple outcome measures, both
subjective and objective, including all-cause mortality.
These recommendations are difficult to put into practice. Often, longitudinal observational
studies and quasi-experimental research designs are necessary and informative, coupled with
shorter-term experiments. Fortunately, with the increasing number of long-term data sets, more
rigorous information is now emerging (Friedman et al. 2013). Further, new analytic techniques
allow integration of extant studies to test lifespan models (Kern et al. 2013, Picinnin & Hofer
2008). Multiple causal links to health exist, and models of the hypothesized full long-term path-
ways should be spelled out in all research in this field, even when the full model is not being
investigated in a particular study (for a discussion of causal inference in personality psychology,
see Lee 2012).
In summary, a key contribution of modern personality research to understanding health and
well-being is the focus on healthy patterns, clusters of predictors, and what we like to call pathways
to health and longevity. One of the most striking and important surprise conclusions of the eight-
decade “Longevity Project” studies of the Terman Life Cycle Study (Friedman & Martin 2011)
is the extent to which health risk factors and protective factors do not occur in isolation but rather
bunch together. For example, the unconscientious boys in the Terman sample—even though very
bright—were more likely to grow up to achieve less education, have unstable marriages, drink and
smoke more, and be unsuccessful at work, all of which were relevant to dying at younger ages. Such
health risks and relationship challenges (e.g., divorce or job loss, loneliness and social isolation)
are usually studied as independent health threats. But attention to personality can broaden and

sharpen research approaches because it is stable and slow changing, and it is tied to a full range
of biopsychosocial influences. Fundamental attention to the individual person across time draws
consideration to the deeper causal processes.
Although the evidence for widely effective interventions is not yet available, more comprehen-
sive models point toward core patterns that may indeed emerge as efficacious policies in promot-
ing a well-organized, healthy, productive, long life. For example, the three elements of healthy
lifestyles described in the following paragraph all involve long-term patterns, are potentially mod-
ifiable, and are known to be highly relevant to good health and well-being and to reestablishing
homeostasis in the face of environmental challenges. They are deserving of increased research
attention.
First, individuals with good ties to social networks and who are well integrated into their com-
munities tend to be happier and healthier (Hawkley & Cacioppo 2010, Taylor 2011). And, the
degree and quality of such relations can be changed. Second, people who are physically active—
doing things—tend to have better mental and physical health. Although physical activity levels (not
formal exercise per se) are somewhat stable over time, they too can be modified, and increased ac-
tivity usually produces beneficial effects (Bouchard et al. 2012, Mutrie & Faulkner 2004, Pedersen
& Saltin 2006). Third, self-controlled, conscientious individuals who live and work with purpose
and are involved with helping others appear to thrive across the long term (Friedman & Martin
2011). This third factor may be the most important because it plays a role in the first two as well.
One of the biggest but most promising challenges of health psychology, of positive psychology,
and indeed of public health is to understand and develop interventions at the individual level, the
social (interpersonal) level, the community level, and the societal level to help launch individuals
on these healthy pathways, to help them maintain and deepen adherence to these pathways, and
to help them recover when they stumble or are forced off these roads to health and well-being.
Isn’t this the same as promoting happiness, reducing work challenge, and treating depression?
Not at all. One could argue that increasing physical activity, strengthening social ties, and de-
veloping a meaningful sense of purpose are all established elements of treating depression. The
problem is that many other approaches to treating depression and subjective well-being likely are
not very relevant to health. Further, such approaches often do not consider long-term lifespan
trajectories and the understanding of context.
There is no longer a need for studies that simply correlate personality with health and subjective
well-being, or that correlate happiness and health, or even that involve simple predictive studies
of personality and later health outcomes. Instead, the field is ready for longitudinal studies of me-
diators and moderators, and for intervention studies of how, when, and why changes in individual
character affect health and well-being. Individual differences earlier in life are reliable predictors
and likely causes of well-being and health status later in life, and a fuller understanding of the
causal pathways and how they can be altered holds the promise of significant value to individuals
and to society.
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.
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PS65-FrontMatter ARI 13 November 2013 20:27
Annual Review of
Contents
Psychology
Volume 65, 2014

Prefatory
I Study What I Stink At: Lessons Learned from a Career in Psychology
Robert J. Sternberg p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Stress and Neuroendocrinology

Oxytocin Pathways and the Evolution of Human Behavior

C. Sue Carter p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p17
Genetics of Behavior
Gene-Environment Interaction
Stephen B. Manuck and Jeanne M. McCaffery p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p41
Cognitive Neuroscience
The Cognitive Neuroscience of Insight
John Kounios and Mark Beeman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p71
Color Perception
Color Psychology: Effects of Perceiving Color on Psychological
Functioning in Humans
Andrew J. Elliot and Markus A. Maier p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p95
Infancy
Human Infancy. . . and the Rest of the Lifespan
Marc H. Bornstein p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 121
Adolescence and Emerging Adulthood

Bullying in Schools: The Power of Bullies and the Plight of Victims
Jaana Juvonen and Sandra Graham p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 159
Is Adolescence a Sensitive Period for Sociocultural Processing?
Sarah-Jayne Blakemore and Kathryn L. Mills p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 187
Adulthood and Aging

Psychological Research on Retirement
Mo Wang and Junqi Shi p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 209
Development in the Family

Adoption: Biological and Social Processes Linked to Adaptation
Harold D. Grotevant and Jennifer M. McDermott p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 235
vi
Individual Treatment
Combination Psychotherapy and Antidepressant Medication Treatment
for Depression: For Whom, When, and How
W. Edward Craighead and Boadie W. Dunlop p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 267
Adult Clinical Neuropsychology

Sport and Nonsport Etiologies of Mild Traumatic Brain Injury:
Similarities and Differences
Amanda R. Rabinowitz, Xiaoqi Li, and Harvey S. Levin p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 301
Self and Identity

The Psychology of Change: Self-Affirmation and Social
Psychological Intervention
Geoffrey L. Cohen and David K. Sherman p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 333
Gender
Gender Similarities and Differences
Janet Shibley Hyde p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 373
Altruism and Aggression

Dehumanization and Infrahumanization
Nick Haslam and Steve Loughnan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 399
The Sociocultural Appraisals, Values, and Emotions (SAVE) Framework
of Prosociality: Core Processes from Gene to Meme
Dacher Keltner, Aleksandr Kogan, Paul K. Piff, and Sarina R. Saturn p p p p p p p p p p p p p p p p 425
Small Groups
Deviance and Dissent in Groups
Jolanda Jetten and Matthew J. Hornsey p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 461
Social Neuroscience
Cultural Neuroscience: Biology of the Mind in Cultural Contexts
Heejung S. Kim and Joni Y. Sasaki p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 487
Genes and Personality

A Phenotypic Null Hypothesis for the Genetics of Personality
Eric Turkheimer, Erik Pettersson, and Erin E. Horn p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 515
Environmental Psychology
Environmental Psychology Matters
Robert Gifford p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 541
Contents vii
Community Psychology
Socioecological Psychology
Shigehiro Oishi p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 581
Subcultures Within Countries

Social Class Culture Cycles: How Three Gateway Contexts Shape Selves
and Fuel Inequality
Nicole M. Stephens Hazel Rose Markus, and L. Taylor Phillips p p p p p p p p p p p p p p p p p p p p p p p p p 611
Organizational Climate/Culture
(Un)Ethical Behavior in Organizations

Linda Klebe Treviño, Niki A. den Nieuwenboer, and Jennifer J. Kish-Gephart p p p p p p p 635
Job/Work Design
Beyond Motivation: Job and Work Design for Development, Health,
Ambidexterity, and More
Sharon K. Parker p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 661
Selection and Placement

A Century of Selection
Ann Marie Ryan and Robert E. Ployhart p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 693
Personality and Coping Styles

Personality, Well-Being, and Health
Howard S. Friedman and Margaret L. Kern p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 719
Timely Topics
Properties of the Internal Clock: First- and Second-Order Principles of
Subjective Time
Melissa J. Allman, Sundeep Teki, Timothy D. Griffiths, and Warren H. Meck p p p p p p p p 743
Indexes
Cumulative Index of Contributing Authors, Volumes 55–65 p p p p p p p p p p p p p p p p p p p p p p p p p p p 773

Cumulative Index of Article Titles, Volumes 55–65 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 778
Errata
An online log of corrections to Annual Review of Psychology articles may be found at
http://psych.AnnualReviews.org/errata.shtml
viii Contents
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Jacque L. Duncan • Retinal Ganglion Cell and Subcortical Contributions to Visual
• Angiogenesis in Eye Disease, Yoshihiko Usui, Feature-Selectivity, Onkar S. Dhande, Benjamin K. Stafford,
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Leah Scheppke, Felicitas Bucher, Susumu Sakimoto, • Ribbon Synapses and Visual Processing in the Retina,
Liliana P Paris, Edith Aguilar, Martin Friedlander Leon Lagnado, Frank Schmitz
• Color Vision and the Cone Mosaic, David H. Brainard • The Determination of Rod and Cone Photoreceptor Fate,
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• Image Formation in the Living Human Eye, Pablo Artal • Visual Memory, George A. Alvarez
• Imaging Glaucoma, Donald C. Hood • Visuomotor Functions in the Frontal Lobe, Jeffrey D. Schall
• Mitochondria and Optic Neuropathy, Janey L. Wiggs • What Does Genetics Tell Us About AMD? Felix Grassmann,
• Neuronal Mechanisms of Visual Attention, John Maunsell Thomas Ach, Caroline Brandl, Iris Heid, Bernhard H.F. Weber
• Optogenetic Approaches to Restoring Vision, Zhuo-Hua Pan, • Zebrafish Models of Retinal Disease, Brian A. Link,
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PS65CH26-Friedman ARI 31 October 2013 17:18

• Other articles in this volume

Annu. Rev. Psychol. 2014. 65:719–42 Keywords

This article’s doi: Abstract

Meaning and Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 726

720 Friedman · Kern

www.annualreviews.org • Personality, Well-Being, and Health 721

still-common focus on single-disease conditions, with insufﬁcient attention to overall outcomes,

mortality or multiple hard outcomes of disease.

722 Friedman · Kern

Limits of Biomarkers as Outcomes

HAPPINESS, SUBJECTIVE WELL-BEING, AND HEALTH

www.annualreviews.org • Personality, Well-Being, and Health 723

Power of Positive Emotion?

724 Friedman · Kern

www.annualreviews.org • Personality, Well-Being, and Health 725

Meaning and Purpose

Considerable cross-sectional evidence links sense of purpose to various subjective well-being

726 Friedman · Kern

NEUROTICISM, DEPRESSION, WORRY, AND DISEASE

www.annualreviews.org • Personality, Well-Being, and Health 727

728 Friedman · Kern

environment Loneliness Cardiovascular

Challenge and Health

www.annualreviews.org • Personality, Well-Being, and Health 729

disability and unemployment.

730 Friedman · Kern

CONSCIENTIOUSNESS, MATURITY, AND LONGEVITY

www.annualreviews.org • Personality, Well-Being, and Health 731

732 Friedman · Kern

2011). This pattern, together with a general cluster of conscientiousness-relevant characteristics,

Early Life Influences

CONCLUSION: IMPLICATIONS FOR INTERVENTIONS

www.annualreviews.org • Personality, Well-Being, and Health 733

734 Friedman · Kern

www.annualreviews.org • Personality, Well-Being, and Health 735

Bambrick P, Bonder B. 2005. Older adults’ perceptions of work. Work 24:77–84

736 Friedman · Kern

mortality in the United States. Am. J. Epidemiol. 171:83–92

www.annualreviews.org • Personality, Well-Being, and Health 737

older adults. J. Health Psychol. 14:513–24

738 Friedman · Kern

seeing a dark future? Psychol. Aging 28:249–61

www.annualreviews.org • Personality, Well-Being, and Health 739

ed. PA Linley, S Joseph, pp. 146–64. Hoboken, NJ: Wiley

740 Friedman · Kern

psychology interventions: a practice friendly meta-analysis. J. Clin. Psychol. 65:467–87

www.annualreviews.org • Personality, Well-Being, and Health 741

Acad. Sci. USA 105:14153–56

742 Friedman · Kern

Volume 65, 2014

Stress and Neuroendocrinology

Oxytocin Pathways and the Evolution of Human Behavior

Adolescence and Emerging Adulthood

Adulthood and Aging

Development in the Family

Adult Clinical Neuropsychology

Self and Identity

Altruism and Aggression

Genes and Personality