Psychosomatics 2012:53:303–318
© 2012 The Academy of Psychosomatic Medicine. Published by Elsevier Inc. All rights reserved.
Review Articles
Positive Psychological Attributes and Cardiac Outcomes:
Associations, Mechanisms, and Interventions
Christina M. DuBois, B.A., Scott R. Beach, M.D., Todd B. Kashdan, Ph.D., Maren B. Nyer, Ph.D.,
Elyse R. Park, Ph.D., M.P.H., Christopher M. Celano, M.D., Jeff C. Huffman, M.D.
Background: Intervention research at the intersection
of psychiatry and cardiology has primarily focused on
the relationship between negative psychological syndromes (e.g., depression) and cardiac outcomes, with
less emphasis on positive psychological attributes, such
as optimism, gratitude, and well-being, as they relate to
cardiac disease. Methods: Literature is reviewed in
three specific areas regarding positive attributes and
cardiac disease: (1) associations between positive attributes and cardiac outcomes, (2) potential mechanisms—
both behavioral and physiologic— by which positive psychological states may impact cardiovascular health, and
(3) interventions aimed at cultivating positive psychological attributes in healthy and medically ill persons.
Results: There is significant evidence that positive psychological attributes— especially optimism—may be independently associated with superior cardiac outcomes.
Positive attributes appear to be associated with in-
creased participation in cardiac health behaviors (e.g.,
healthy eating, physical activity) linked to beneficial
outcomes; data linking positive psychological states and
biomarkers of cardiac health (e.g., inflammatory markers) is mixed but suggests a potential association. Positive psychological interventions have consistently been
associated with improved well-being and reduced depressive symptoms, though there have been few such
studies in the medically ill. Conclusions: These findings
regarding the relationship between positive psychological attributes and cardiac health are promising and suggest that positive psychology interventions may be worth
study in this population. However, questions remain
about the strength and specificity of these relationships,
the most salient positive psychological attributes, and
the impact of positive psychological interventions on
health outcomes in cardiac patients.
(Psychosomatics 2012; 53:303–318)
P
Given the link between psychological factors and cardiac health, multiple studies have targeted psychological
symptoms in cardiac patients in an attempt to improve
medical outcomes. However, such studies have typically
sychological factors play an important role in the
development and progression of cardiac disease.
For example, patients who suffer from depression early
in life are more likely to develop and die from cardiac
disease than those without depression, independent of
traditional cardiac risk factors.1– 4 Among patients with
established cardiac disease, depression is independently
associated with recurrent cardiac events and mortality
over the next year.5,6 Similarly, anxiety (including anxiety disorders such as generalized anxiety disorder) is
associated with adverse cardiac outcomes in initially
healthy persons and in patients with acute cardiac illness.7,8
Psychosomatics 53:4, July-August 2012
Received February 2, 2012; revised March 30, 2012; accepted April 2, 2012.
From Dept. of Psychiatry, Massachusetts General Hospital, Boston, MA
(CMD, SRB, MBN, ERP, CMC, JCH); Harvard Medical School, Boston,
MA (SRB, MBN, ERP, CMC, JCH); Dept. of Psychology, George Mason University, VA (TBK); Benson Henry Institute for Mind Body
Medicine, Boston, MA (ERP). Send correspondence and reprint requests
to Jeff C. Huffman, M.D., Massachusetts General Hospital 55 Fruit
Street/Blake 11, Boston, MA; e-mail: [email protected]
© 2012 The Academy of Psychosomatic Medicine. Published by
Elsevier Inc. All rights reserved.
www.psychosomaticsjournal.org
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Positive Attributes and Cardiac Outcomes
focused on the minority of cardiac patients who have a
diagnosable psychiatric disorder such as major depression.
Furthermore, interventions focusing on these disorders
have failed to improve medical outcomes in cardiac patients in the vast majority of cases.9 –13
Positive psychological states, such as mindfulness and
gratitude, and enduring strengths of character, such as
curiosity and self-discipline, have been less well-studied in
cardiac patients, and there has been limited research on
interventions to cultivate such positive attributes in this
cohort.14 However, there is increasing data that positive
psychological attributes may play a critical role in cardiac
health and recovery from illness. Even after adjusting for
demographic factors, cardiac risk factors, and health behaviors, optimism and other positive cognitions/emotions
have been associated with superior cardiovascular outcomes in persons with and without known heart disease.15–20 Furthermore, the association between positive
attributes and cardiac outcomes has been independent of
negative psychological states in many cases, suggesting
that cardiovascular benefits associated with positive attributes may be more than the absence of distress and disorder.18,19,21–25
The field of positive psychology has focused on the
cultivation of positive cognitive and emotional states,
largely through specific exercises that promote systematic and deliberate activities.26 –28 Trials of positive psychology interventions have shown promising results in
a variety of populations totaling more than 4000 persons, with improvements in mood, vitality, and wellbeing.29,30 However, despite their potential impact,
there has been limited study of such interventions in
patients with medical illness; this is especially true for
heart disease.
In this article, we aim to provide a broad overview of
the literature studying links between positive psychological attributes and cardiac disease (for the purposes of this
review, ‘positive psychological attributes’ will refer both
to positive emotions [e.g., happiness] and cognitions [e.g.,
optimism, gratitude]). First, we will review established
relationships between positive psychological attributes
and cardiovascular outcomes. We will next describe potential behavioral and biological mechanisms that may
underlie these relationships. Finally, we will outline current data regarding positive psychology and related interventions that could promote psychological health in individuals with—and at risk for— cardiac illness. Where
appropriate, we have inserted major issues sections that
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discuss the limitations and questions regarding existing
empirical research.
To generate this review, we performed a search of
major psychology and medical databases (e.g., Medline,
PsycInfo) using relevant search terms (e.g., optimism, cardiovascular disease), and reviewed cited literature from
identified articles to discover additional relevant literature.
However, this is not a comprehensive, systematic overview of the literature on these topics; for such reviews, see
Boehm and Kubzansky (positive psychological well-being
and cardiac health)31 and Sin and Lyubomirsky (positive
psychology interventions).30
Links Between Positive Psychological Attributes and
Cardiovascular Outcomes
Optimism is the positive attribute most consistently
linked to cardiovascular health.15–17,32–34 Most studies of
optimism in this context have focused on dispositional
optimism, a trait construct that quantifies the extent to
which a person consistently has positive, confident expectations about his or her own future outcomes; this construct is typically measured using the Life Orientation
Test-Revised (LOT-R),35 a six-item scale that contains
optimism and pessimism subscales. For example, Scheier
and colleagues34 found that dispositional optimism was
independently associated with reduced readmissions following coronary artery bypass graft (CABG) surgery, after
controlling for age, education level, and serum cholesterol
level. Data from the longitudinal Zutphen Elderly Study
found that dispositional optimism was associated with reduced all-cause and cardiovascular mortality in 773 elderly men, independent of cardiovascular risk factors and
sociodemographic factors.33
Among women, Tindle and colleagues’16 analysis of
97,253 participants from the Women’s Health Initiative
study36 found that dispositional optimism was associated
with reduced cardiac and all-cause mortality, independent
of other covariates such as age, hypertension, hyperlipidemia, smoking, and diabetes mellitus.16 Overall, a comprehensive meta-analysis of 83 studies found optimism to
be positively and independently related to physical health,
including healthy cardiovascular outcomes, less pain,
fewer cancer symptoms, greater immunological functioning, and reduced mortality.17
Other positive attributes have also been linked to a
reduced risk of developing cardiac illness. Vitality, in
addition to optimism, was independently associated with
reduced risk of incident heart disease in a cohort of 7942
Psychosomatics 53:4, July-August 2012
DuBois et al.
healthy adults, taken from a larger study.32,37 In another
study of a large subsample (over 6000 patients) from the
National Health and Nutrition Examination Surveys I
study, there was a significant association between greater
positive affect (feelings of enthusiasm, vitality, and interest) and reduced risk of heart disease, even after controlling for health behaviors and depressive symptoms.22
In addition to reduced risks of cardiac illness, positive
psychological attributes might reduce rates of mortality in
this cohort. In a sample of more than 800 patients undergoing cardiac catheterization, Brummett and colleagues38
found that greater positive affect was associated with survival over the course of an average prospective time frame
of 11 years; however, this association failed to remain
after adjusting for negative affect. Finally, a recent, comprehensive meta-analysis of 26 studies (involving more
than 50,000 participants) found that subjective well-being
was associated with lower rates of mortality in both initially healthy and medically ill populations, independent of
medical disease state and treatment.39
Possible Mechanisms Connecting Positive Psychological
Attributes and Cardiac Outcomes
Published models linking positive emotions with cardiac outcomes include both behavioral and physiologic
components.15 Individuals with greater optimism and
other positive psychological states may have superior cardiac outcomes because they are more likely to engage in
healthy behaviors, such as healthy eating, physical activity, smoking cessation, and medication adherence, each of
which is associated with superior cardiac outcomes.22,40
Positive attributes have also been associated with lesser
abnormalities of physiologic biomarkers that are linked
to cardiac outcomes, such as measures of inflammation
and autonomic nervous system activity. We will first
review the impact of positive attributes on cardiac
health behaviors.
Health Behaviors
Diet
Optimism has been linked to healthier baseline diet
and superior dietary adherence. Kelloniemi and colleagues41 found that young Finnish adults with greater
optimism consumed a greater quantity of fruits, vegetables, and high-fiber foods, and a smaller quantity of alcohol, coffee, and candy. Optimism may also facilitate
Psychosomatics 53:4, July-August 2012
healthy dietary change, as suggested by a large study of
postmenopausal women enrolled in the large Women’s
Health Initiative Dietary Modification Trial. Women with
greater optimism at baseline who were randomized to the
low-fat intervention arm of the trial were more likely to
have beneficial dietary changes change in all three studied
domains (fat, fruit/vegetable, grain) at the one-year follow-up.42 Similarly, the Zutphen Elderly Study that followed elderly men for as many as 15 years found that
dispositional optimism was linked to a greater likelihood
of healthy dietary changes, defined as greater consumption
of fruit, vegetables, and whole grain bread.33
Physical Activity
Several studies suggest that older adults with greater
optimism have higher rates of physical activity, another
factor essential to cardiac health.33,40,43 The Zutphen Elderly Study found that dispositional optimism was significantly associated with increased physical activity, independent of age, education, living arrangement, self-rated
health, cardiovascular disease, diabetes mellitus, cancer,
and body mass index.33 Steptoe and colleagues40 found
that dispositional optimism in older adults was associated
with brisk walking (in both sexes) and vigorous physical
activity (in women), independent of multiple relevant covariates, such as age, chronic illnesses, medication count,
socioeconomic status, and BMI. In addition, Browning
and colleagues43 found that optimism may influence adherence to a recommended exercise routine. Older adults
who held healthy attitudes about exercise, including optimism and the concept that health behavior is under one’s
own control (e.g., “there is a lot that older adults can do to
stay healthy,”) were more likely to engage in exercise.
Smoking
At least four studies have suggested that optimistic
individuals are less likely to smoke. The previously noted
studies of older adults led by Giltay and Steptoe that found
dispositional optimism to be independently linked with
physical activity also found optimism to be independently
associated with lower rates of smoking.33,40 In a study
performed in Finland, the proportion of current smokers
was lower among optimistic men and women, and individuals with greater optimism were likely to be categorized as having no lifetime smoking history.41 A final
study found that middle school students with greater optimism reported less frequent use of cigarettes.44 Though
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Positive Attributes and Cardiac Outcomes
optimism is associated with decreased smoking, unrealistic optimism (also referred to as optimistic bias, discussed
further below) may impede attempts to quit smoking because patients may underestimate the difficulties inherent
in smoking cessation.45
Adherence to Medical Treatment
There is extensive work in patients with human immunodeficiency virus (HIV) linking positive psychological attributes and medication adherence,46 – 48 but more
limited evidence in cardiac patients. A study of patients
undergoing heart transplant for end-stage cardiac disease
found that optimism about the upcoming transplant operation was associated with greater adherence to the complex post-transplant medication regimen in the 6 months
following the procedure.49 A larger study of over 1000
patients with hypertension found that a ‘sense of coherence’ (a sense of having a meaningful life and a sense that
life challenges can be understood and controlled), but not
optimism, was associated with adherence to antihypertensive medications.50
In sum, positive psychological attributes have been
linked with improved adherence to a number of behaviors
that are important to cardiovascular health. Such behaviors
have included healthy eating, exercise/activity, smoking
cessation, and medication adherence. Additional studies
have also found links between positive attributes and other
health-related behaviors, such as alcohol use and sleep
quality.31
Positive Psychological Attributes and Physiologic
Changes
Positive attributes have also been linked to biological
indicators of superior cardiac outcomes, though the results
of studies of this association have been somewhat mixed.
Autonomic Function
Autonomic dysfunction is associated with adverse
cardiac outcomes, including mortality.51,52 Optimism and
other positive attributes have been associated with reduced
autonomic dysfunction. Positive affect has been linked to
individual differences in resting respiratory sinus arrhythmia (an index of autonomic nervous system function),53
and optimism has been linked to lower systolic and diastolic ambulatory blood pressure.54 In addition, positive
affect has shown associations with less reactivity of blood
pressure and heart rate to stress,55 and faster cardiovascu306
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lar recovery from the induction of negative emotional
states including fear and sadness.55,56 Among patients
with coronary artery disease, higher levels of positive
affect were associated with increased vagal control, demonstrated by increases in the low-frequency power component of heart rate variability; this relationship held after
controlling for covariates that included age, medications,
and posture of participant.57 Positive affect was also associated with more rapid recovery of heart rate variability
following exposure to mental stress in a cohort of college
students.58 In contrast, Ryff and Singer59 did not find
positive psychological well-being to be associated with
resting systolic blood pressure in a study of older women.
Inflammation
Elevated inflammatory markers are predictors of adverse cardiac events.60 – 62 Studies of the association between positive attributes and inflammation have been
mixed. Three carefully controlled studies in large prospective cohorts, and two smaller epidemiologic studies, have
found some association between positive affect/optimism
and inflammatory markers. In the prospective Multi-Ethnic Study of Atherosclerosis (MESA) study63 of over 6000
men and women, dispositional optimism was measured via
LOT-R. Dispositional optimism in this cohort was associated with lower levels of interleukin-6 (IL-6), C-reactive
protein (CRP), and fibrinogen. After correcting for sociodemographic factors, negative psychosocial factors,
health behaviors, body mass index, hypertension, and diabetes mellitus, only an association between the LOT-R
pessimism subscale (not the optimism subscale) and fibrinogen remained. Steptoe and colleagues64 assessed participants’ responses to stress in a laboratory setting and
found that persons reporting higher levels of happiness
had smaller plasma fibrinogen responses to stress, independent of psychological distress, gender, age, body mass
index, smoking status, and socioeconomic status.
A study of 2873 healthy adults taken from a larger
prospective study37 found positive affect and life satisfaction to be associated with lower IL-6 and CRP in women
but not men.65 Similarly, Prather and colleagues66 found
that positive affect was associated with lower IL-6, specifically in older women, after controlling for relevant risk
factors and depression. A recent analysis of data from 340
older men without existing heart disease (taken from the
VA Normative Aging Study) found optimism to be associated with lower IL-6, a result that remained significant
after adjusting for multiple covariates including depressive
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DuBois et al.
symptoms.67 In contrast, Friedman and colleagues68 did
not find an association between IL-6 and older women,
even after controlling for depression and cardiac risk factors.
Additional Physiologic Effects
Endothelial dysfunction is independently associated
with adverse cardiac outcomes,69 and negative psychological syndromes (e.g., depression) have been linked to endothelial dysfunction.70 The previously noted analysis
from the Normative Aging Study found optimism to be
positively associated with one marker of endothelial function (soluble intracellular adhesion molecule [sICAM] receptor) in multivariate models, though not with a second,
related marker (soluble vascular cell adhesion molecule
[sVCAM]).67 Activation of the hypothalamic-pituitary-adrenal axis/hypercortisolemia has also been linked to cardiac health, and positive affect and optimism have both
shown inverse relationships with cortisol levels.71
Much of the work on the physiological benefits of
positive attributes has focused on optimism or momentary
positive emotions. However, a systematic study in women
age 65 years and older assessed the association between
multiple biological indicators of physical health and eudaimonic well-being (eudaimonic well-being is an aggregate of positive constructs that includes purpose, selfactualization, autonomy, and positive relations with
others; this is in contrast to hedonic well-being, a construct
associated with happiness, pleasure attainment, and pain
avoidance68,72–74). In a preliminary exploration of eudiamonic- and hedonic well-being and medical health, a sense
of personal growth and life purpose were linked to higher
high-density lipoprotein (HDL) cholesterol and lower salivary cortisol. Higher life purpose scores were also associated with lower levels of IL-6 receptors.72 Furthermore,
multiple eudaimonic constructs/factors were also associated with lower glycosylated hemoglobin. Indicators of
hedonic well-being were not associated with most biological factors.
In other studies examining associations between positive attributes and cardiovascular risk factors, Richman
and colleagues75 found that in graduate students and general medicine patients, vitality was associated with lower
cholesterol during a 1-year period, taking into account age,
gender, smoking, anger, anxiety, exercise, alcohol intake,
and marital status. However, a study by Shepperd and
colleagues76 found no association of dispositional optimism with HDL, low-density lipoprotein (LDL), or total
Psychosomatics 53:4, July-August 2012
cholesterol, after controlling for age, depression, and relevant risk factors.76
Overall, there have been some links between positive
attributes and physiologic markers of cardiovascular
health. However, these links appear to be less consistent
and less powerful than the links between these positive
constructs and health behaviors. Additional research, using large cohorts, controlling for multiple relevant covariates, and simultaneously including measures of health
behavior and biomarkers, is needed to further clarify these
connections.
Major Issues
Are the Number and Quality of Existing Studies Sufficient
to Support a Claim that Positive Attributes Cause Better
Cardiac Outcomes?
At this stage, it would be premature to claim that
positive psychological attributes cause superior cardiac
outcomes. The medical literature is filled with examples
of initially promising results and associations later contradicted by additional, larger, and better-controlled
studies,77 and given the limitations of the extant literature on positive attributes, caution is warranted. There
is substantial variability in the positive psychological
constructs being studied, and some studies suffer from
limitations related to sample size and use of crosssectional (rather than prospective) data. At the same
time, there are now a substantial number of prospective
studies in this field, and the vast majority of such studies have found a significant association between positive states and medical outcomes.
Regarding the heterogeneity of psychological attributes and measures, it is certainly true that multiple positive psychological constructs have been examined using a
variety of measures. However, as noted, there is mounting
evidence for dispositional optimism as an attribute that is
consistently linked to superior outcomes, and this construct has been measured using the LOT-R in nearly all
recent studies.15–17,32–34
Although the use of relatively small samples and
cross-sectional trials dot this literature, there are several
large, prospective studies examining the links between
positive attributes and cardiac health. A number of the
above studies have been prospective epidemiologic
studies that included over 1000 subjects,16,18,23,63,65
though several studies have been cross-sectional and are
therefore less informative regarding causality or directionalwww.psychosomaticsjournal.org
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Positive Attributes and Cardiac Outcomes
ity, given that following a healthy diet, exercising, and/or
having lower levels of inflammation may well lead to subsequent optimism, vitality, and overall well-being. Another
alternative is the possibility of bidirectionality, with positive
states leading to better behavior/physiology, and such improvements in behaviors and physiology facilitating the further development of positive psychological attributes. More
large, prospective studies in a variety of populations will
further strengthen the literature. Additional work on the independence of positive psychological constructs from one
another is needed.
Do the Studies Linking Positive Attributes and Cardiac
Health Account Properly for Relevant Sociodemographic
and Medical Variables? Do They Control
for Depression?
The issue of covariate control is a vital one in establishing an independent relationship between positive attributes and medical outcomes. In the meta-analysis examining positive states and mortality by Chida and
colleagues,39 the majority of studies that demonstrated a
protective relationship between positive states and mortality controlled for sociodemographic factors such as age,
sex, race, and socioeconomic status, and those in medically ill populations generally controlled for basal disease
state. Furthermore, the majority of studies on positive
psychological states and cardiac outcomes consider key
cardiac risk factors (i.e., physical activity, hypertension,
diabetes mellitus, smoking, and hyperlipidemia). Some
studies control for all of these factors,16,22,24,32 and some
control for the majority of these factors.18 –20,25,34,78 Of
note, however, one study controlled for all five risk factors
but did not find a significant result after adding negative
affect into the analysis.79
Regarding depression, at least eight studies have
additionally controlled for depressive symptoms using
validated scales that included the Center for Epidemiologic Studies-Depression scale (CES-D),80 Hospital
Anxiety and Depression Scale (HADS),81 Hamilton
Rating Scale-Depression (HRS-D),82 and Beck Depression Inventory (BDI).83 Even after controlling for depression, six studies still found relationships between
positive states/attributes—in the forms of life orientation, satisfaction with aging, and optimism—with allcause mortality.84 – 89 The remaining two studies, mentioned earlier, found relationships between positive
states and lower IL-667 and reduced risk of heart disease22 after controlling for depression. However, some
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studies noted above found that links between positive
states and medical outcomes did not remain after controlling for ‘negative affect’.38,68,79
What About Controlling for Negative Psychological States
Other than Depression?
This is an important issue, given that anxiety and
anger have been associated with adverse cardiac outcomes, and that anger/hostility in particular has been
linked with cardiac outcomes in randomized controlled
trials. For example, Friedman and colleagues90 found
that in patients with a prior myocardial infarction and
Type A personalities (a group of personality traits characterized by hostility, ease of arousal, and time-urgency), a 4.5-year behavioral counseling program to
target their personalities led to reductions in cardiac
morbidity and mortality, compared with a control group
who received only cardiac counseling. During a 1-year
follow-up, the counseling group continued to have significantly lower rates of mortality compared with the
control condition.91 An ongoing limitation of positive
psychology literature is the lack of control in some
studies for negative psychological states other than depression. However, in addition to the previously noted
studies that controlled for depression, there are a substantial number of studies that controlled for negative
states (such as anxiety, anger, hostility, or aggression).
With respect to anxiety, a pair of studies examining
the links between vitality and outcomes did control for
both depression and anxiety, and these studies found
independent associations between all-cause mortality21
and non-cardiac mortality,22 respectively. Overall, at
least six studies in this field have controlled for anxiety,
with all demonstrating an association between positive
emotional states and improved outcomes, independent
of anxiety.18 –20,23,75,78
At least five studies in this field have controlled for
hostility, and all such studies found an independent
association between positive emotional states and improved outcomes.18,19,23–25 A study by Richman and
colleagues75 controlled for both anger and anxiety, and
found that mental vitality was associated with reduced
prevalence of heart disease, independent of traditional
risk factors that included age, gender, smoking, marital
status, exercise, and alcohol intake. For additional information regarding these important issues, see Boehm
and Kubzansky.31
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DuBois et al.
When Measuring Positive Attributes, Aren’t We Simply
Measuring an Absence of Depression and Other Negative
Constructs?
attributes and depression, and with other negative states
such as anxiety and anger, though these relationships are
less well-studied (Table 1).
First, as noted, many of the studies cited have found
that positive attributes (e.g., optimism) are linked with
superior outcomes even after controlling for depression,
suggesting that these attributes have independent effects
on outcome. Furthermore, though there is clear overlap
between positive attributes and negative states such as
depression, these constructs only have some association
with one another in clinical samples. For example, optimism and depression appear to demonstrate a moderate
correlation with one another (r ⫽ ⫺0.28 to 0.60 [median
r ⫽ ⫺0.43]) in ten identified studies examining such correlations (see Table 1).35,92–100 Even in cardiac patients
with known depression, a recent analysis of a large trial of
cardiac surgery patients found that optimism was not
strongly correlated with depressive symptoms (r ⫽
⫺0.27), and optimism was associated with decreased risk
of rehospitalization independent of depressive symptoms.100 Similar correlations are seen with other positive
Positive Psychology Interventions
TABLE 1.
Positive psychological attributes appear to be important to health, but can they be cultivated or taught?
Careful study of the factors contributing to positive
psychological well-being have estimated that after accounting for other factors (genetic, demographic, and
cultural factors, and external life events), intentional
choices and behaviors account for approximately 40%
of the variance in well-being.101,102 Positive psychology
interventions—which promote intentional behaviors to
improve well-being— have targeted activities in several
domains, including altruism, optimism, gratitude, and
using one’s strengths of character (Table 2). Such exercises are typically brief, easy to administer, and have
low provider and participant burden.103 Most of these
exercises involve brief instruction about the details and
rationale for the task, followed by independent comple-
Correlations between Positive Attributes and Negative Psychological Constructs
Study
Achat et al. (2000)93
Bandiera et al. (2002)100
de Moor et al. (2006)92
Herzberg et al. (2006)35
Population
Positive Attribute
(LOT)131
(LOT-R)35
(LOT-R)35
(LOT-R)35
Optimism
Optimism
Optimism
Optimism
Hirsch and Britton (2010)99
Morgenstern et al. (2011)94
Rajandram et al. (2011)97
Scheier et al. (1994)95
Scioli et al. (1997)96
Tindle et al. (2012)98
Chipperfield et al. (2000)134
Healthy middle- to older-aged men
Healthy college students
Ovarian cancer
Healthy and medically ill
(diabetes, CHD, hypertension,
hyperlipidemia)
Opiate dependence
Stroke
Cancer survivors
Healthy college students
Healthy college students
Coronary artery bypass graft
Elderly community-dwelling adults
McCullough et al. (2002)136
McCullough et al. (2002)136
Healthy college students
Healthy college students
Gratitude (GQ-6)137
Gratitude (GQ-6)137
Puskar et al. (2008)140
Healthy rural adolescents
Optimism (LOT-R)35
Optimism (LOT-R)35
Optimism (LOT-R)35
Optimism (LOT-R)35
Optimism (LOT)131
Optimism (LOT)131
Optimism (LOT-R)35
Life satisfaction (LSIA)135
Negative Construct
Depression
Depression
Depression
Depression
(CES-D)80
(BDI)83
(CES-D)80
(DSQ)132
Depression (CES-D)80
Depression (PHQ-9)133
Depression (HADS)81
Depression (BDI)83
Depression (CES-D)80
Depression (HRS-D)82
Sadness
Anger (Self-reported
frequency in prior 2
days)
Anxiety (BSI)138
Envy (before
controlling
covariates) (DES)139
Anger (state)
Anger (trait)
(STAXI)141
Correlation
Coefficient (r)
⫺0.44
⫺0.42
⫺0.39
⫺0.47
⫺0.60
⫺0.31
⫺0.55
⫺0.42
⫺0.28
⫺0.34
⫺0.29
⫺0.21
⫺0.20
⫺0.39
⫺0.29
– 0.21
BDI ⫽ Beck Depression Inventory; BSI ⫽ Brief Symptom Inventory; CES-D ⫽ Center for Epidemiologic Studies-Depression scale; DES ⫽
Dispositional Envy Scale; GQ-6 ⫽ Gratitude Questionnaire-6; HAD ⫽ Hospital Anxiety and Depression Scale; HRS-D ⫽ Hamilton Rating
Scale-Depression; LOT ⫽ Life Orientation Test; LOT-R ⫽ Life Orientation Test-Revised; LSIA ⫽ Life Satisfaction Index A; DSQ ⫽ Depression
Screening Questionnaire; PHQ-9 ⫽ Patient Health Questionnaire-9; STAXI ⫽ State-Trait Anger Expression Inventory.
Psychosomatics 53:4, July-August 2012
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Positive Attributes and Cardiac Outcomes
TABLE 2.
Sample Positive Psychology Exercises
Exercise (Domain)
Best possible self (Optimism)
Best future social relationships
(Optimism)
Counting blessings (Gratitude)
Gratitude letter (Gratitude)
Benefit finding (Gratitude)
Three acts of kindness
(Altruism)
Pleasurable and meaningful
acts (Purpose, Happiness)
Using strengths (Strengths)
Forgiveness letter
(Forgiveness)
Forgiveness exercises
(Forgiveness)
Loving-kindness meditation
(Life satisfaction)
Cultivating sacred moments
(Spirituality)
Positive writing (Happiness/
joy)
310
Summary/Instructions to Participants Selected Impact
Imagine your best overall possible future (over the next 5 years) and consider how to actualize this future.
This exercise has been associated with feeling happier, experiencing less emotional distress, and being sick
less often, compared with a control condition.142,143 Furthermore, this exercise has been linked to
persistent improvements in well-being long after the intervention.143
Imagine your best possible interpersonal relationships (with family, friends, and colleagues) over the next
several years and consider how to take steps toward these optimal relationships.
Given the importance of perceived social support in heart disease outcomes, this exercise was tested in a
pilot study of cardiac patients, with good effect.104
Recall and record in detail three events in the past week for which you are grateful.
This exercise has been linked to beneficial effects on mental health (i.e., depression, optimism, well-being,
and social engagement) and physical health/health behaviors (physical complaints, frequency of exercise,
amount and quality of sleep).144
Recall another person’s kindness and write a letter that describes the feelings of gratitude associated with
this event.
Completing a gratitude letter led to sustained improvement of well-being for up to 6 months in one
study.143
Write about your genuine feelings toward medical illness and any benefits that may have resulted from this
situation.
Women with breast cancer who completed this exercise had reduced physical symptoms, fewer medical
appointments, and better heart rate habituation to stress than control subjects.145
Perform three kind acts for others within a single day.
Prior work has found that performing and recording acts of kindness is associated with improved mood and
that such an intervention may provide sustained mood benefit.101,146 Participants are typically asked to
perform all of their kind acts on the same day given evidence that such clustering may be most
effective.101
Complete three acts in a single day: a pleasurable act done alone (e.g., gardening), a pleasurable act done
with others (e.g., walking with friends), and a meaningful or important act (e.g., creating a blood sugar
log).
This exercise aims to help participants foster engagement, pleasure, and meaning in their lives, as all three
domains have been linked to life satisfaction.147
Complete a brief survey of personal strengths, and then select a strength (e.g., perseverance, self-control)
to be used deliberately in the next week. Write about how you used the strength and the outcome.
A prior controlled trial found that this activity decreased depression and increased happiness at 1- and 6months post-treatment.29
Write a letter of forgiveness to a person who did or said something that made you upset. If you cannot
forgive the person for everything they did or said, try to forgive them for one part of their actions.
This intervention has been used clinically, and sending the letter is not required and is only encouraged if
the participant experiences the forgiveness as genuine.148
At least two years after a hurtful event, engage in exercises related to defining forgiveness, examining
emotions, committing to forgiveness, grieving your pain, reframing the situation, exploring empathy,
practicing goodwill, and finding meaning and purpose in the situation.
Emotionally abused women who completed forgiveness exercises had reduced anxiety, greater self-esteem,
were better able to find meaning in suffering, and showed increased environmental mastery and
identification with “survivor status,” compared with attentional controls.149
Utilize a focused form of meditation aimed at cultivating mindfulness and loving feelings toward self and
others.
This intervention has been linked to reduced depressive symptoms and increased life satisfaction, primarily
through increases in positive emotions.150
Create a ‘sacred moment in time’ with the use of mindfulness. Focus on an object (jewelry, mantra,
nature) that you have deemed sacred, and develop a spiritual connection with qualities of preciousness,
blessedness, or holiness.
This exercise has been liked to increased positive affect, lesser negative affect, and greater feelings of
meaning and purpose in life.151
Write about the most positive, happy, ecstatic moments of your life. Include all of the emotions you
experienced. Think also about how you can use this experience now to tap into inspiring, positive
feelings.
Subjects who completed this exercise reported higher levels of life satisfaction compared with controls.152
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DuBois et al.
tion of the exercise by the participant. In some cases,
the ‘instructor’ and participant reconvene to discuss the
process and outcome of the exercise.
Positive psychology interventions have consistently
been linked to increased positive emotions and cognitions,30 especially if the exercises are systematically performed, episodic, varied, and meaningful to the participant. Completing activities in an intensive but intermittent
manner appears to be important. For example, participants
in one study asked to perform one act of kindness on five
separate days each week experienced no gains in wellbeing, but experienced significant gains when asked to
perform the five separate acts of kindness in a single
day.101
Below, we review the literature on positive psychology interventions. To date, most of these exercises have
been studied in healthy research subjects or depressed
individuals. There has been substantially less study of
these exercises in medically ill populations.
Positive Psychology Interventions in Healthy Individuals
Over 20 different positive psychology exercises
have been used in intervention studies in healthy subjects (see Table 2 for sample exercises). These exercises
have been administered in person or remotely over the
internet, have been performed in a variety of cohorts
(e.g., college students, elderly persons), and have consistently led to short-term gains. A meta-analysis by Sin
and Lyubomirsky30 of more than 50 trials involving
more than 4000 participants found that positive psychology interventions have consistently led to increases
in self-reported life satisfaction, other well-being indicators (e.g., positive affect, optimism), and reductions
in depressive symptoms; this includes positive changes
in ‘trait-like’ dispositions such as dispositional optimism.104,105 The authors found that the overall effect
size of positive psychology interventions on depressive
symptoms (r ⫽ 0.31; medium effect size) was essentially identical to that seen in reviews of standard (and
typically much more intensive and costly) psychotherapies (r ⫽ 0.32).106 These effects were also greater than
the calculated effect size for antidepressants on mood
symptoms in depressed patients (d ⫽ 0.32; small effect
size) in recent reviews.36,107
There has been much less study of the sustainability
of gains in positive attributes in this population. However,
Cohn and Fredrickson108 conducted a follow-up of a loving-kindness meditation intervention for healthy particiPsychosomatics 53:4, July-August 2012
pants. They found that participants who were randomized
to the intervention maintained the gains they made during
the initial intervention, including greater mindfulness, increased social support, reduced illness, and greater life
satisfaction over a 15-month follow-up.
Positive Psychology Interventions in Depressed
Individuals
Positive psychology interventions have also been
studied in patients with depression. Using a randomized, placebo-controlled design in patients with mild to
moderate depression, Seligman and co-workers29 found
that a subset of positive psychology exercises led to
immediate reductions in depressive symptoms. Participants were randomized to completion of one of six
positive psychology exercises or to a control condition,
and three of the six exercises (documenting daily three
reasons to feel grateful, completing a gratitude visit,
and using strengths in new ways) were associated with
significantly greater ratings of happiness compared with
the control group. Though patients in the experimental
condition only completed these exercises for 1 week,
two of the exercises (three reasons to feel grateful and
use of strengths) were associated with persistent and
significant reductions in depressive symptoms at the
6-month follow-up, compared with patients in the control condition.
In another pair of studies, this same research group
first evaluated a six-exercise group positive psychotherapy intervention over 1 year in young adults with mild
to moderate depression. Compared with individuals in
the no-treatment group, participants receiving the intervention had a significant decrease in depressive symptoms. Next, the authors found that individual positive
psychotherapy delivered to outpatients with major depression over the course of 1 year led to greater remission rates than did treatment as usual and treatment as
usual plus medication.103
Additionally, Freedman and co-workers109 examined
the effect of a forgiveness intervention on female survivors of incest who also suffered from depression. The
12-week once-weekly intervention focused on confronting
negative emotions, reframing the situation, using empathy
and compassion, and recognizing negative feelings associated with the situation. After the intervention, the experimental group experienced significantly reduced rates of
anxiety and depression and increased hope and enthusiasm, relative to the control group.
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311
Positive Attributes and Cardiac Outcomes
Positive Psychology Interventions in Those with Noncardiac Medical Illness
Although some ‘resiliency programs’ in medical patients have included small components of positive psychology interventions,110,111 specific trials of positive psychology interventions in the medically ill have been
rare.112 Regarding noncardiac populations, there have
been several small studies of positive psychology interventions in cancer patients, and there is some suggestion
that these interventions improve social support and quality
of life, reduce pain and anxiety, and promote adherence.113–115 However, such interventions have not been
linked to substantial improvements in ‘harder’ outcomes,
such as survival times or biomarkers. We are not aware of
positive psychological interventions in patients with other
chronic non-cardiac diseases, such as renal disease, diabetes, or HIV.
(persons with hypertension, asthma, and coronary artery
disease) increase positive affect and feelings of selfaffirmation over the course of 12 months. Huffman and
colleagues104 completed a three-arm, randomized feasibility study among patients recently hospitalized for an
acute coronary syndrome or heart failure. This trial
compared positive psychology exercises related to optimism, altruism, and gratitude to two control conditions (RR and an attentional control). The authors found
the positive psychology intervention to be feasible and
to have greater effects than the two control conditions
on mood, anxiety, happiness, and mental health-related
quality of life. However, this small exploratory trial
(n ⫽ 26 completers) had insufficient power to detect
significant between-group differences and these findings must be replicated.
Major Issues
Positive Psychology Interventions in Cardiac Populations
While there has been minimal study of positive
psychology interventions in patients with cardiac disease, related interventions have been used in this population. Mindfulness-based stress reduction (MBSR)
provides systematic training in mindfulness meditation
as a self-regulation approach to stress reduction and
emotion management.116,117 At least three small studies
of cardiac patients found MBSR to be associated with
reduced psychological symptoms and distress, and in
some studies, improved quality of life and decreased
physical symptoms.118 –120
Similarly, the relaxation response (RR) uses meditation in the form of guided relaxation,121 and has been
found to lower blood pressure in healthy adults122 and
to reduce tension, anger, and rates of supraventricular
tachycardia in cardiac surgery patients (without effects
on other physiologic variables/outcomes).123 In a randomized trial, RR decreased systolic blood pressure
(approximately 9 mmHg) in elderly patients with stage
I systolic hypertension, allowing significantly more participants in the RR group to eliminate an antihypertensive medication, compared with a lifestyle modification
group.124
However, it appears that there have been only two
systematic positive psychological intervention trials for
cardiac patients. Charlson and colleagues112 have reported methods, but not results, from a randomized
controlled trial that aimed to help three populations
312
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Why Not Focus on the Effects of Antidepressant Treatment
on Cardiac Outcomes?
Depression in cardiac patients is an important public health problem and must be addressed. However,
only a minority of cardiac patients have clinical depression that requires treatment, and there is no evidence
that antidepressant treatment has utility in patients with
subsyndromal depressive symptoms.125 Furthermore,
the impact of antidepressants alone on depressive symptoms has been relatively modest (and in some cases not
better than placebo)107 and prospective studies have not
yet found that antidepressants are linked to reduced
cardiac events or mortality,10,12,126 though there is some
suggestive data from epidemiologic studies.127,128 In
contrast, many patients may benefit from a boost in
optimism or other positive states in the context of medical illness, and such an intervention might impact
health behaviors or physiology. Whether positive psychological interventions are effective in this population
is, as yet, entirely unclear.
Might an Intervention that Cultivates Positive States
Cause “Optimistic Bias”?
Optimistic bias is an inaccurate, unrealistic belief
that positive outcomes will be easily accomplished
(such as attaining remission from cancer or terminating
smoking). Such bias may be associated with less consistent or planful efforts in these conditions, lowering
Psychosomatics 53:4, July-August 2012
DuBois et al.
rates of success,45,129 for example, in smoking cessation
when patients overestimate the ease with which they
can quit.119,120 However, positive psychological interventions generated for medically ill cohorts should address (and could actually decrease) the risk of optimistic
bias. A well-designed positive psychology intervention
should not ignore the obstacles to wellness or the endorsement of unrealistic thinking, but instead would
focus on cultivating and maintaining positive attributes
and using these attributes to reasonably navigate challenging life circumstances.
Why Are There so Few Intervention Studies
in This Area?
Though there is a growing literature on the connections between positive attributes (especially optimism)
and cardiovascular outcomes, there is still much to be
learned regarding the design and delivery of interventions targeting these attributes. The field needs clarification on the attributes and strengths of character (e.g.,
positive affect, optimism, mindfulness, meaning and
purpose in life, gratitude) with the strongest, most consistent associations with cardiac health so these may be
specifically targeted. In particular, eudaimonic wellbeing indices (e.g., meaning and purpose in life) might
represent deeper, more valuable targets than indices of
hedonic well-being (e.g., life satisfaction, positive emotions, optimism).
Furthermore, though positive psychology interventions exist, the majority has been in nonclinical cohorts,
and much work will need to be done to adapt interventions to be acceptable, relevant, and effective in patients
with significant medical illness. There are additional
considerations worthy of contemplation in the refinement of positive psychology interventions. For example, should the interventions in this cohort be combined
with other established interventions (e.g., behavioral
activation or motivational interviewing) for maximum
effect? Are there situations in which optimism or other
states should not be cultivated, such as situations when
unrealistic optimism impedes adherence or provides
false hope? Given that this field is in its relative infancy
and that both the intervention target and the methodology of interventions need further refinement, it is not
surprising that intervention studies have yet to be prevalent, and certainly there is insufficient evidence for
routine use in clinical practice.
Psychosomatics 53:4, July-August 2012
Future Directions
In summary, positive attributes are associated with
improved cardiac outcomes, and this connection is likely
mediated by both behavioral and physiologic factors. Positive psychology and related interventions may represent a
means by which positive states and strengths of character
can be cultivated in patients with— or at risk for— cardiac
disease, though these interventions have not been wellstudied in cardiac patients in clinical care settings. Though
this line of work has great potential, the field must be cautious
about these interventions and their effects. Some studies linking positive attributes to medical or behavioral outcomes
have been cross-sectional, preventing assessment of causality. Associations between positive attributes and health outcomes may be explained by variables or factors that were not
accounted for in statistical analyses. For example, given the
clear links between anxiety and depressive disorders with
poor outcomes, it is important to conduct tests of construct
specificity to ensure that links between positive attributes and
superior outcomes exist independently of negative psychological syndromes. Even if positive attributes are prospectively linked to major cardiac outcomes, there remains a
paucity of data regarding whether psychological interventions that target these states actually impact objective medical
outcomes; indeed, this is a lesson hard-learned from the depression treatment literature.10 –12,130 Furthermore, there is
much still to be learned regarding the best psychological
target for these interventions and the methods (e.g., content,
frequency, duration, mode of delivery) of potential positive
psychology interventions in this population.
Future studies that address these issues have the potential to open up a new line of clinically-relevant work in
psychosomatic medicine that could lead to improved wellbeing and health for the large number of patients who have
cardiovascular illness.
This work was supported in part by grant R01DP00336 from the United States Disease Control and
Prevention (CDC) to Herbert Benson. Todd Kashdan was
funded by the Center for Consciousness and Transformation at George Mason University.
The authors thank Dr. Julia Boehm for providing
links to published literature and additional information
on positive psychological well-being and cardiac
health.
Disclosure: The authors disclosed no proprietary or
commercial interest in any product mentioned or concept
discussed in this article.
www.psychosomaticsjournal.org
313
Positive Attributes and Cardiac Outcomes
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