Trait Negative Affect Relates to Prior-Week Symptoms, But Not to Reports of Illness Episodes, Illness Symptoms, and Care Seeking Among Older Persons

Trait Negative Affect Relates to Prior-Week Symptoms, But Not to Reports of Illness Episodes, Illness Symptoms, and Care Seeking Among Older Persons PABLO A. MORA, MS, CHANTAL ROBITAILLE, PHD, HOWARD LEVENTHAL, PHD, MARY SWIGAR, MD, AND ELAINE A. LEVENTHAL, PHD, MD Objective: Use the commonsense model of self-regulation to generate and test hypotheses about the relationships of trait negative affect (NA) and self-assessed health (SAH) to reports of current symptoms (acute and chronic), episodes of illness, and use of health care during illness in a sample of elderly, community-dwelling respondents. Trait NA and SAH were compared with the properties of the illness episodes in models predicting the use of medical care. Methods: Data were obtained from two successive annual interviews (N 790 and 719, respectively) conducted with elderly respondents (mean age 73 years). Results: Both NA and SAH correlated (positively and negatively, respectively) with reports of prior-week acute and chronic symptoms at each of the two interviews. Trait NA and SAH also predicted changes in prior-week symptoms 1 year later. Neither trait NA nor SAH was related to reports of acute illness episodes, but each showed a very small relationship to reports of chronic illness episodes. Neither trait NA nor SAH predicted the average number of symptoms reported during acute or chronic episodes. The use of medical care during acute and chronic illness episodes was related to the properties of the episode: reported duration, novelty, and severity. Neither NA nor SAH predicted use of care for acute episodes; SAH was related to use of care for chronic episodes. Worry about the illness episode, but not trait NA, was related to care seeking for participants interviewed during a chronic episode. Conclusions: Trait NA does not bias elderly adults reports of symptoms, illness episodes, symptom reports for episodes, or the use of health care. Both NA and SAH reflect independent sources of common sense and self-knowledge, and each contributes valid information about the elderly individuals perceptions of their somatic states. Key words: trait negative affect, self-assessed health, symptoms, care seeking, self-reports. CI confidence interval; NA negative affect; OR odds ratio; SAH self-assessed health. INTRODUCTION Two types of variables were related to the reporting of symptoms and to the use of medical care in this study of over 700 community-dwelling, well-educated, mostly retired, white elderly subjects (mean age 73): 1) stable characteristics of the participants (trait NA, that is, reports that one is usually tense, anxious, sad, and/or blue (1), and SAH (2, 3)) and 2) the perceived properties of specific illness episodes. Our data allowed us to make two types of comparisons. One type of comparison explored the relationship of trait NA with the reporting of symptoms, illness episodes, and use of medical care to the relationship of SAH From the Institute for Health and Department of Psychology (P.M., C.R., H.L.), Rutgers University, New Brunswick, NJ; and Department of Psychiatry (M.S.) and Department of Medicine (E.A.L.), Robert Wood Johnson School of Medicine, University of Medicine and Dentistry of New Jersey, New Brunswick, NJ. Address reprint requests to: Howard Leventhal, Institute for Health, Rutgers University, 30 College Avenue, New Brunswick, NJ 08901-1293. Email: howardl@rci.rutgers.edu Received for publication July 19, 2000; revision received September 17, 2001. Current address for Chantal Robitaille, PhD: Emergency Department, Research Division, Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec, Canada. with the same health variables. These comparisons are of interest because trait NA is assumed to be related to biased, over-reporting of symptoms, whereas SAH is a powerful predictor of critical health outcomes such as mortality. The second type of comparison explored the relationship of stable, person characteristics (trait NA and SAH) with the use of medical care during illness episodes to the relationship of the features of the episode (eg, its duration, novelty or unexpectedness of its symptoms, and episode-specific worry) with this outcome. Expectations regarding the relationship between these predictors and outcomes were generated from the commonsense model of illness cognition. This framework proposes that people are active problem solvers who assess the meaning of somatic sensations by forming hypotheses about their identity (ie, label), cause (ie, stress or virus), timeline, controllability, and consequences (4). These hypotheses guide the selection, performance, and evaluation of coping procedures for the management of illness episodes. Feedback from these procedures can reshape the hypotheses and alter subsequent coping actions (5, 6). The constructionist or problem solving emphasis of this framework suggests that the perceived features of illness episodes (ie, whether the symptoms exceed their expected duration, are novel or unexpected, and pose images and thoughts of severe consequences) will be more important as predictors of the use of medical care than will personality characteristics such as trait NA or SAH (7, 8). Thus, our overall expectation was that the use of medical care would be predicted mainly by properties of the episode. 436 Psychosomatic Medicine 64:436 449 (2002) 0033-3174/02/6403-0436 Copyright 2002 by the American Psychosomatic Society

NEGATIVE AFFECT AND ILLNESS BEHAVIOR We also expected that the relationships of trait NA and SAH to care seeking would differ for acute and chronic episodes. Episode properties should dominate care seeking for common, acute conditions because they have no special meaning for the self system. Thus, NA and SAH are of less consequence for care seeking for such conditions in comparison to the features of the specific episode, that is, whether it proves overly long and severe or has novel and unexpected features. Person characteristics, particularly SAH, should contribute to decisions to seek care for episodes of chronic conditions because these long-lasting conditions have implications for the overall health status of the self (9). A second set of expectations was designed to clarify the processes underlying the relationship of trait NA to reports of everyday symptoms, illness episodes, episode-specific symptoms, and the use of health care. Multiple studies have shown that trait NA has a positive relationship to current symptom reports but has no significant relationship to objective measures of health (eg, 10, 11), indicating that correlations of trait NA and symptom reports cannot be used as evidence that trait NA is a cause of illness (10, 12). These relationships led to the formulation of the symptom perception hypothesis (10), which states that high levels of vigilance and awareness of internal stimuli and signs of threat (13) underlie the association of trait NA to the reporting of current symptoms in the absence of disease. Because similar hypotheses have been advanced to account for the relationship of hypochondriasis and somatization to current symptom reports (14, 15), it might be expected that individuals who are high on trait NA would also be more likely to report being sick and more likely to use medical care during illness episodes. The commonsense framework suggests a different perspective on the relationship of NA to symptom reporting by elderly individuals. Because the elderly have a substantial history of interpreting symptoms associated with acute and chronic conditions, both minor and possibly serious, it is reasonable to assume that they will develop a degree of expertise in identifying when they are sick vs. when they are well. When sick, they should be able to determine whether their condition is acute or chronic, novel or expected, highly symptomatic or relatively mild, and conforming to an expected time course and trajectory. From the commonsense framework, the vigilance associated with trait NA is an additional source of motivation for the acquisition of this type of self-knowledge. Decades of vigilance can be expected, therefore, to create a form of commonsense, although anxious, expertise. Thus, the elderly high trait NA respondent will have a detailed perspective of his or her usual, somatic background, that is, ongoing chronic symptoms, and the ability to identify departures from this background and develop appropriate strategies such as seeking health care to deal with illness-related departures and their associated emotional upset (4, 6, 16). If high NA is associated with such commonsense expertise but is unrelated to vulnerability to illness, we can expect NA to be positively associated with current (ie, the everyday background) symptoms, particularly symptoms of a chronic nature, and to be unrelated to reporting of illness episodes, particularly those of acute, expected, common conditions (eg, colds). We would also expect trait NA to be unrelated to seeking medical care for acute episodes, although it might encourage care seeking for chronic episodes, particularly for difficult-to-control conditions. Although this expertise will seem psychologically rational, it may depart from rationality when the elderly, trait-anxious person believes the threat to be serious, that is, when control efforts fail, hence our inclination to label this expertise as anxious. SAH was included in our analyses because we expected that comparing its relationship with symptom reporting and care seeking to the similar relationships of trait NA would further support our interpretation of trait NA as a form of commonsense expertise when assessed in elderly respondents. Although SAH and trait NA are related to one another, with high levels of trait NA associated with low levels of SAH (r values ranging from 0.30 to 0.45), SAH has a strong relationship to health outcomes (17). Unlike many other psychological factors, which have a small or no relationship with health outcomes for people over 65 years of age (18), low self-ratings of health (poor and fair SAH) are related to both self-reported symptoms and mortality (eg, 19); both relationships replicate with regularity, and both are substantial in magnitude. Indeed, individuals reporting poor to fair SAH are two or more times as likely to be deceased 2 to 20 years after their selfassessments. These effects appear in analyses that control for multiple factors including age and objective measures of physical health (2, 3). The data for SAH suggest that some subjective reports can exceed objective indicators in predicting objective health outcomes. Cross-sectional and longitudinal data were analyzed to assess the relationship of trait NA and of SAH with prior-week current (ie, background) symptoms (those judged to be acute and those judged to be chronic), illness episodes, and symptoms reported for these episodes. The use of medical care during episodes of acute and chronic illness was predicted using both stable self-appraisals (eg, trait NA and SAH) and episode-specific measures, such as number of symptoms, severity and duration of the episode, and the novelty Psychosomatic Medicine 64:436 449 (2002) 437

P. MORA et al. of the episode. Additionally, we examined the relationship of these stable characteristics and episodespecific variables to care seeking in a subset of participants who reported ongoing illness episodes at the time of the interview. Our expectations were as follows: 1. Compared with their low trait NA peers, elderly individuals who reported high levels of trait NA were expected to be more aware of and report a greater number of background symptoms during the prior week, particularly of symptoms they self-identified as chronic. Because high and low trait NA elderly are believed to be equally susceptible to physical illness, we expected them to report similar frequencies of illness episodes during the prior 3 months. 2. If we assume that high trait NA elderly are more attentive to their bodies and less likely to ignore somatic changes, especially when those changes signal potential threat, we could expect that they would detect and report more symptoms during chronic episodes (ie, conditions that are cyclical and impinge on individual functioning) but would not do so for typical, acute illness episodes. These assumptions led to two hypotheses: 1) compared with low trait NA individuals, high trait NA individuals would report more symptoms during episodes or flares of chronic conditions in the prior 3 months and 2) both high and low trait NA individuals would report similar numbers of symptoms for episodes of acute illness in this same prior 3-month period. 3. We expected that the properties of the illness episode would affect care seeking and would do so in similar degrees for high and low trait NA individuals. Thus, we hypothesized that 1) properties of the episode, particularly its duration and its novelty or unexpectedness, would have a greater impact on care seeking than would trait NA or SAH and 2) SAH but not trait NA would relate to care seeking for chronic conditions because poor SAH implies vulnerability to decline in function from chronic conditions. 4. We also examined the relationship of emotional reactions during ongoing illness episodes (ie, episode-based worry) to care seeking in a subset of our respondents, allowing us to assess and contrast the relationship of trait NA and emotional states to care seeking. We expected that episodespecific worry would lead to care seeking and trait NA would not. METHODS Participants Data for these analyses were obtained during the second (1992) and third annual interviews (1993) of a 9-year longitudinal survey of community-dwelling older adults in central New Jersey (1992: N 790; 1993: N 719). The 1992 interview served as the baseline (wave 1), and the 1993 interview served as the 12-month follow-up (wave 2). 1 Subject loss averaged 9.75% per year due, in approximately equal parts, to death, moving away from the community, and withdrawal from the study. The mean age at baseline was 72.8 years (range, 49 93), and 83.6% of the participants were 65 years of age. The division by sex at baseline was 479 (56%) female and 311 male (44%), and 72% of the female subjects and 80% of the male subjects had 12 years of education. Design and Procedure The two waves of data allowed for the examination of crosssectional and longitudinal relationships of NA and SAH to reports of acute and chronic symptoms in the prior week (current background symptoms), acute and chronic illness episodes experienced during the prior 3 months, the symptoms associated with each of these episodes, and the use of medical care for each episode. All participants answered questions about current acute and chronic symptoms during the prior week, and all subjects reported on the presence of acute and chronic illness episodes during the past 3 months. Approximately one-third of the respondents reported having had at least one illness episode in the past 3 months at each wave (1992: acute 190, chronic 264; 1993: acute 197, chronic 234). Care seeking was predicted cross-sectionally at both waves (1992 and 1993) using both trait and episode-specific factors. 2 Longitudinal analyses assessing the effects of trait variables on change in both current acute and current chronic symptoms entered current 1992 acute or current 1992 chronic symptoms (ie, baseline symptom measure) as the first factor in their respective analyses. Longitudinal analyses for acute and chronic episodes (1993 outcome) used 1992 episode reports as the first control variable. Because different individuals reported illness episodes at each of the two annual waves, longitudinal analyses for episode-linked symptoms reported during 1993 episodes used current (prior week) 1992 symptoms as a control because all participants had values for this control variable. In all of these analyses, age, illness burden, and sex were entered as controls after the baseline values for dependent measure and then were followed by trait NA and SAH from the 1992 interview. A more detailed report of factors affecting care seeking was obtained from a subset of respondents who reported an acute and/or chronic illness episode that was ongoing at the time of the interview: 43 subjects reported an ongoing acute condition, and 121 subjects reported an ongoing chronic condition. These respondents provided 1 The 1992 interview was selected as the baseline for two reasons: 1) prior-week symptoms were obtained from only half of the respondents in 1991 and 2) 1991 measures of trait NA and SAH were used for prospective analyses of care seeking in 1992. 2 For the analyses predicting medical care seeking we used only one illness episode per individual in each category (ie, acute or chronic). For participants who reported more than one illness episode, we decided to randomly select one illness condition for analytic purposes. The numbers of people who reported more than one illness episode in each wave were as follows: wave 1, acute 31 and chronic 63; wave 2, acute 30 and chronic 59. 438 Psychosomatic Medicine 64:436 449 (2002)

NEGATIVE AFFECT AND ILLNESS BEHAVIOR information about the course of their episode and a measure of episode-linked emotional state, that is, how much they worried about the illness. Because these respondents are included in the overall analyses of responses during acute or chronic illnesses during the prior 3 months, we conducted a separate set of analyses from which this subset was excluded. Because these latter findings replicated findings using all participants, we report the data both for the subset and for the complete set, which includes these 164 participants. Measures Assessed for all Participants: Trait NA and SAH Trait NA. Trait NA was assessed with two, five-item adjective lists, one for depressed (eg, blue; sad) and one for anxious (eg, tense; worried) mood. Each question asked, How are you usually? ; responses were recorded on five-point Likert scales (range, 1 not at all to 5 very much). Cronbach s alphas were very high for the five-item scales assessing depressed ( 0.91 and 0.90, for 1992 and 1993, respectively) and anxious mood ( 0.88 for both years) and higher yet for the combined scale of trait NA (1992: 0.93; 1993: 0.92). Analyses examining the stability of NA over time revealed test-retest figures of r tt.74 over 1 year and r tt.71 over 2 years. These figures match those for other widely used trait inventories such as the Neuroticism, Extraversion, Openness Personality Inventory (NEO PI) (20, 21) and the Positive Affect-Negative Affect Scale (PANAS) (22). Preliminary results from Latent Growth Curve analyses (23, 24) examining the intra-individual stability of NA indicated that the NA measure was very stable, showing that the average elderly participant realized an approximately 2% change in NA scores over a 1-year period and an approximately 7% change over a 2-year period. SAH. Self-assessments of health were reported in response to a single item: In general, how would you rate your health...excellent, very good, good, fair, or poor. Responses to this item have proven to be a powerful and consistent predictor of health outcomes such as mortality (2, 3). The test-retest reliability for this single item was 0.66 over 1 year and 0.61 over 2 years. Latent Growth Curve analyses showed that an average individual realized a 3% change in SAH scores over 1 year and a 6% change over 2 years. Health Status Measures Current Symptom Check List. Current symptoms were assessed by 45 questions that asked about problems experienced in specific parts of the body during the prior week. The stem for each question asked: Have you had any problems or trouble with in the past week? ; the blank was filled with specific areas of the body (eg, lung, arm, hand, or shoulder). Questions about specific symptoms (eg, chest discomfort or pain, stomachaches, or diarrhea) substituted, symptoms for problems or trouble. For each problem, respondents indicated whether it was acute or chronic. The seven response categories were not at all, yes acute (mild, moderate, or severe), or yes chronic (mild, moderate, or severe). Separate scores for acute and chronic symptoms were obtained by summing the number of yes responses in each category (actual range: acute, 0 12, chronic, 0 19). The questions and format were based on the standard review of systems used in internal medical practice (25). Illness Episodes. Acute and chronic illness episodes experienced during the 3 months before the interview were assessed by asking In the past 3 months, did you have any episodes of illness, such as a cold, pneumonia, or upset stomach? and In the past 3 months, did you have the onset of a new chronic condition or the recurrence, worsening or flare-up of an existing chronic condition or health problem? The computer interview allowed for recording of up to four different episodes in each category. Separate scores were generated for acute and chronic episodes. Measures of Illness Episodes: Prior and Ongoing Prior Episodes. Subjects who reported having had an acute or chronic episode in the prior 3 months answered a series of questions covering the properties of those episodes. The questions asked about the duration of the episode: About how long did it last (or has it lasted)? (responses transposed to hours); its symptoms: What symptoms went along with it? (scored in number of symptoms); and severity: How severe was it? (five-point scale from not at all to very). Current (Ongoing) Episodes. An additional series of questions was posed to the subset of individuals who reported an episode that was ongoing at the time of interview. Questions were asked about the speed of onset, severity (separately at onset and at worst point), responses to control the episode and their effectiveness (eg, use of over-the-counter medications), and perceived causes of the episode (eg, illness, age, and stress); however, we examined only the data from the four questions asking about emotional reactions. Worry at episode onset was assessed by two questions, When you first noticed any symptoms, how nervous were you about it and its consequences? and...how anxious were you about it and its consequences? Worry when the episode was at its worst was assessed by two additional items, When it was at its worst, how nervous were you about it and its consequences? and...how anxious were you about it and its consequences? Five-point scales (not at all, a little bit, moderately, quite a bit, and very) were used to assess worry, severity, and cause. Alpha for the four-item worry scale was high (0.88). Novelty or Unexpectedness of the Illness Episode. Each person s self-defined illness episode was reviewed by a board-certified geriatric physician and classified for its likely perceived novelty or unexpectedness. Two factors were involved in the decision: 1) the ambiguity vs. the distinctiveness of the symptoms as signs of a specific illness and 2) how likely it would be for an elderly person to decide that she or he was ill and needed medical care given the label and symptoms reported. An illness episode was classified as not novel (coded as 0) if the symptoms were not distinctive indicators of serious disease and/or people would be likely to discount the symptoms as indicating a benign condition (eg, cold or aging). All other illness episodes were categorized as novel (coded as 1). Control Measures Illness Burden. A measure of lifetime illness burden was created from a detailed review of each individual s illness history. Each reported condition was rated for 1) level of functional impairment (scale of 1 100) and 2) threat to life (scale of 1 100). The ratings by six internists were averaged to form a severity index that served as the estimate of the burden imposed by that illness. Cronbach s for the six ratings across all diseases was 0.97. Although the alpha coefficient was high, the decision was made to drop the highest and lowest ratings, the average of the remaining four serving as the final severity score. The individual s illness burden was the sum of these scores. At baseline, participants reported an average of 6.60 (range, 0 20) illness conditions for their lifetime, and their average illness burden score at baseline was 170.21 (range, 0 692). Functional Limitations. Five items assessed limitations in daily function ( 0.85): 1) Does your health limit the kinds or amounts of vigorous activities you can do such as running, lifting heavy objects, or participating in strenuous sports or activities? ; 2) Does Psychosomatic Medicine 64:436 449 (2002) 439

P. MORA et al. your health limit the kinds or amounts of moderate activities you can do such as moving a table, carrying groceries, bending, or lifting? ; 3) Do you have any trouble walking one block, uphill, or a few flights of stairs? ; 4) How much do problems with your health stand in the way of doing the things you would like to do? ; and 5) How much do problems with your health stand in the way of doing the things you need to do? The response scale ranged from 1 not at all to 5 very much. The total score for each subject was computed by averaging responses to the five items. RESULTS Self-Appraisals (NA and SAH) and Prior-Week Symptoms Cross-sectional Results. The zero-order correlations between trait NA and reports of current (prior week) acute and chronic symptoms are shown in Table 1 for both waves of data (1992 and 1993: all p values.01). The magnitude of the associations replicated prior research (10) by showing that higher levels of trait NA were related to increased symptom reporting. These correlations were essentially the same for both women and men and changed no more than 0.05 units when age and illness burden were entered as controls. The results were very much the same for the correlations of SAH to current acute and chronic symptom reports (Table 1). Additionally, we examined the relationships of NA and SAH to the perceived severity of current symptoms. These results showed that NA was related to the perceived severity of prior-week chronic symptoms (r values.14, p.01 for both waves) but was unrelated to the perceived severity of acute symptoms in both waves (r values.08, NS). SAH, on the other hand, was related to the perceived severity of both acute and chronic symptoms (1992: acute r.15, chronic r.25; 1993: acute r.19, chronic r.28; all p values.01). Regression models assessed the joint relationship of trait NA, the factor imputed to be a source of reporting error, and SAH, the factor known to be a powerful predictor of health outcomes, to the number of both current acute and current chronic symptoms in both waves. The models accounted for significant variance at both waves for both current acute and current chronic symptoms (acute: 1992 R 2 0.09, F(5,783) 15.06, p.01; 1993 R 2 0.10, F(5,713) 16.37, p.01; chronic: 1992 R 2 0.28, F(5,783) 59.56, p.01; 1993 R 2 0.28, F(5,713) 56.27, p.01). The analyses showed that trait NA and SAH accounted for more variance in chronic symptoms than for variance in acute symptoms at both waves (Table 2). Although trait NA and SAH were moderately correlated (1992: r.34; 1993: r.37), there was little overlap in the variance they accounted for in symptom reporting; each accounted for a similar amount of variance whether entered before or after the other in the hierarchical models. Longitudinal Results. Both trait NA and SAH reported in wave 1 significantly predicted reports of current (prior week) symptoms 1 year later (Table 2, prospective analyses). The amount of variance accounted for by trait NA and SAH was statistically significant but small, less than 2% for each of the two factors after controlling for reports of symptoms at wave 1 (1992), age, sex, and illness burden. The total models were significant both for acute (R 2 0.08, F(6,712) 9.61, p.01) and chronic symptoms (R 2 0.35, F(6,712) 63.98, p.01). In addition to the significant increases in current acute and chronic symptoms predicted by both trait NA and SAH over a 1-year interval, sex predicted increases in acute symptoms (women reporting more changes in symptoms) 1 year later, and older age predicted an increase in the number of current chronic symptoms reported 1 year later. Because studies have shown that older women report more symptoms and have higher frequencies of arthritic conditions than older men (26), separate analyses were conducted for men and women, respectively. These analyses showed that both trait NA and SAH predicted small yet significant increases in TABLE 1. Zero-Order Correlations of Current (Prior Week) Acute and Chronic Symptoms With Trait Negative Affect and Self-Assessed Health Health Variable Wave 1 (N 790) All Participants Women Men Wave 2 (N 719) Wave 1 (N 479) Wave 2 (N 442) Wave 1 (N 311) Wave 2 (N 277) Current symptoms, correlation with NA Acute.22.22.22.17.22.28 Chronic.36.42.33.42.39.42 Current symptoms, correlation with SAH Acute.21.27.24.24.16.30 Chronic.44.42.44.45.44.37 All P values.01 (two-tailed). 440 Psychosomatic Medicine 64:436 449 (2002)

NEGATIVE AFFECT AND ILLNESS BEHAVIOR TABLE 2. Cross-Sectional and Prospective Relationships of Trait NA and SAH to Current (Prior Week) Acute and Chronic Symptoms Controlling for Age, Illness Burden, and Sex Step Predictors Concurrent Wave 1 (N 790) Concurrent Wave 2 (N 719) Prospective (N 719) R 2 R 2 R 2 Acute symptoms Step 1 0.025** 0.027** 0.053** Baseline 0.128** Age 0.070 0.023 0.008 Illness burden 0.041* 0.005 0.019 Sex 0.106** 0.120** 0.118** Step 2 0.041** 0.039** 0.014** Trait NA 0.156** 0.131** 0.095* Step 3 0.022** 0.036** 0.008* SAH 0.168** 0.217** 0.100* Chronic symptoms Step 1 0.114** 0.101** 0.320** Baseline 0.412** Age 0.088** 0.145** 0.108** Illness burden 0.145** 0.099** 0.045 Sex 0.101 0.054 0.017 Step 2 0.095** 0.135** 0.018** Trait NA 0.227** 0.294** 0.116** Step 3 0.067** 0.047** 0.012** SAH 0.296** 0.245** 0.131** * p 0.05 (two-tailed); **p 0.01 (two-tailed). chronic symptoms for women (NA: R 2 0.03, F(1,437) 19.20, p.01; SAH: R 2 0.03, F(1,436) 17.45, p.01), but not for men (R 2 values 0.00, F values 2.64, NS). The pattern was different for acute symptoms. Trait NA was not a significant predictor of acute symptoms one year later for women (R 2 0.00, F 1.00, NS) but was for men (R 2 0.07, F(1,272) 20.57, p.01). SAH showed the opposite pattern; it was a significant predictor of subsequent changes in acute symptoms for women (R 2 0.02, F(1,436) 6.55, p.05) but was not for men (R 2 0.00, F 1.00, NS). Once again, it is important to note that the effect sizes were very small over a 1-year time frame. In summary, three of the four prospective relationships were significant for women, and those for changes in chronic symptoms were stronger than those for changes in acute symptoms, whereas for men, only one of the four possible relationships was significant. Self-Appraisals (NA and SAH) and Illness Episodes If trait NA does nothing more than bias self reports, it should have the same relationship to reports of illness episodes as reports of current symptoms. The cross-sectional results did not confirm the hypothesis that trait NA is a general, biasing factor because it was unrelated to reports of acute illness episodes in both waves of data (Table 3): trait NA was not associated with an over-reporting of acute illness episodes. Because SAH is a judgment of an attribute of the self system and a valid predictor of major health outcomes, we expected it to predict chronic episodes but not acute episodes. The relationship of SAH to acute illness episodes was similar to that of NA: it failed to predict acute episodes in wave 1, but it had a very small, although statistically significant relationship, to acute episodes at wave 2 (1993: R 2 0.01, F(1,713) 7.32, p.01). The cross-sectional analyses showed that both trait NA and SAH were significantly associated with reports of chronic illness episodes at each wave, although they accounted for modest amounts of variance (Table 3, bottom half). Separate analyses by sex showed that trait NA was related to reports of chronic illness episodes for women at both waves (1992: R 2 0.04, F(1,474) 16.99; 1993: R 2 0.02, F(1,438) 9.74; both p values.01), but not for men (R 2 values 0.00, F values 1.46, NS). SAH, on the other hand, was related to reports of chronic illness episodes for both women and men at both waves: for women in 1992, R 2 0.03, F(1,473) 17.10; for women in 1993, R 2 0.02, F(1,438) 7.22 (both p values for women.01); for men in 1992, R 2 0.04, F(1,306) 12.09; for men in 1993, R 2 0.03, Psychosomatic Medicine 64:436 449 (2002) 441

P. MORA et al. F(1,272) 8.84 (both p values for men.01). In summary, for reports of acute illness episodes, only one of eight possible associations with trait NA and SAH was statistically significant: SAH to acute episodes for men. By contrast, for chronic episodes, 6 of the 8 possible associations with trait NA and/or SAH were significant: all four were significant for women (NA and SAH to chronic episodes in 1992 and 1993), and two were significant for men (SAH to chronic episodes in 1992 and 1993). Longitudinal analyses were conducted to provide partial insight into the possible directionality of the relationships of trait NA and SAH to illness episodes. The control variables in these analyses (ie, baseline episodes, age, sex, and illness burden) accounted for small amounts of variance in the subsequent number of acute and chronic illness episodes (Table 3). Trait NA (1992), however, failed to predict changes in the number of either acute or chronic illness episodes reported 1 year later (1993, wave 2). The picture was identical for men and women. SAH also failed to predict onset of acute illnesses 1 year later, but it did predict onset and/or flares of chronic illness episodes 1 year later. Separate analyses by sex showed similar effects for men and women, although neither was statistically significant due to smaller sample size. There was no evidence, therefore, of a bias in reporting of illness episodes for trait NA or for SAH. Individuals reported acute illness episodes with equal frequency regardless of their level of trait NA or SAH, and this held in both cross-sectional and longitudinal analyses. Both trait NA and SAH were associated with reports of chronic illness episodes in cross-sectional data, but only SAH predicted chronic illness episodes prospectively when the regression equation controlled for baseline episodes, age, sex, and illness burden. It is important to note that the variance accounted for was small. Use of Health Care Acute Episodes. Wave 1 (1992) and wave 2 (1993) measures of trait NA and SAH were used to predict care seeking for those respondents reporting acute illness episodes at each respective wave (1992 or 1993). As hypothesized, neither trait NA nor SAH predicted use of health care, but the attributes of the episodes did (Table 4). The odds ratios were very large for novelty or unexpectedness (1992: OR, 16.10; 1993: OR, 13.46) and duration (1992: OR, 1.07 for each of the 29 steps in duration; 1993: OR, 1.08 for each step), and the odds ratios for severity were substantial (1992: OR, 1.47 for each of the five steps in severity; 1993: OR, 2.15 for each of the five steps in severity). TABLE 3. Cross Sectional and Prospective Relationships of Trait NA and SAH to Reports of Acute and Chronic Illness Episodes Controlling for Age, Illness Burden, and Sex Step Predictors Concurrent Wave 2 (N 790) Concurrent Wave 2 (N 719) Prospective (N 719) R 2 R 2 R 2 Acute Illness Episodes Step 1 0.007 0.007 0.021** Baseline 0.117** Age 0.013 0.040 0.019 Illness burden 0.015 0.027 0.041 Sex 0.076* 0.062 0.062 Step 2 0.003 0.000 0.001 Trait NA 0.045 0.021 0.037 Step 3 0.002 0.010** 0.000 SAH 0.050 0.114** 0.001 Chronic Illness Episodes Step 1 0.029** 0.012* 0.034** Baseline 0.127** Age 0.082* 0.060 0.040 Illness burden 0.013 0.025 0.031 Sex 0.136** 0.068 0.056 Step 2 0.019** 0.014** 0.003 Trait NA 0.076* 0.068 0.029 Step 3 0.034** 0.020** 0.007* SAH 0.211** 0.159** 0.099* * p 0.05 (two-tailed); ** p 0.01 (two-tailed). 442 Psychosomatic Medicine 64:436 449 (2002)

NEGATIVE AFFECT AND ILLNESS BEHAVIOR TABLE 4. Relationship of Trait NA, SAH, and Attributes of Illness Episodes to Care Seeking for Acute and Chronic Illness Episodes Predictors Wave 1 (N 190) OR (96% CI) Acute Episodes Wave 2 (N 197) OR (95% CI) Wave 1 (N 264) OR (95% CI) Chronic Episodes Wave 2 (N 234) OR (95% CI) Control variables Age 1.05 (0.99, 1.11) 1.05 (0.99, 1.11) 0.97 (0.92, 1.01) 1.02 (0.97, 1.07) Illness burden 1.00 (0.99, 1.00) 1.00 (0.99, 1.00) 0.99 (0.99, 1.00) 1.00 (0.99, 1.00) Sex 1.25 (0.57, 2.76) 1.11 (0.50, 2.44) 0.72 (0.35, 1.46) 1.28 (0.62, 2.63) Traits NA 0.79 (0.25, 2.51) 0.76 (0.22, 2.62) 0.64 (0.22, 1.84) 0.56 (0.17, 1.78) SAH 0.78 (0.50, 1.24) 0.95 (0.60, 1.50) 0.51 (0.34, 0.77) 0.89 (0.58, 1.36) Episode attributes Severity 1.47 (0.97, 2.23) 2.15 (1.46, 3.15) 1.66 (1.18, 2.35) 2.33 (1.54, 3.54) Number of symptoms 0.97 (0.69, 1.37) 0.82 (0.56, 1.19) 0.82 (0.56, 1.18) 0.72 (0.49, 1.07) Duration 1.07 (1.03, 1.12) 1.08 (1.04, 1.12) 1.06 (1.03, 1.09) 1.06 (1.03, 1.09) Novelty 16.10 (5.22,49.69) 23.46 (6.03,91.36) 13.47 (6.01,30.19) 6.99 (2.89,16.89) A possible corollary of the symptom perception hypothesis is that high levels of trait NA would increase care seeking for individuals with poor self-perceptions of health. Thus, the combination of poor SAH and high trait NA would lead to increased attention to the body, worry about symptoms, and increased seeking of medical care. We explored this idea by examining the relationship of the interaction of trait NA with SAH to care seeking. This interaction did not predict use of medical care in either wave of data in our sample of elderly participants (1992: OR, 0.85, CI, 0.24 3.04; 1993: OR, 0.61, CI, 0.19 1.89). Chronic Episodes. Two sets of models were tested for care seeking during chronic illness episodes. In one set, trait NA and SAH were measured the same year the episodes were reported (1992 or 1993, respectively), and in the other set, they were measured the previous year (ie, prospective models using 1991 trait NA and SAH to predict care seeking for episodes in 1992 and 1992 trait NA and SAH to predict care seeking for episodes in 1993). It was important to compare these models because trait NA and SAH could be affected by the illness episodes when measured at the same interview (1992 or 1993), that is, the presence of a chronic condition may lead to higher levels of NA and a decrease in SAH when these variables are measured concurrently. The results of the cross-sectional analyses (trait NA and SAH at the same year as the episode) essentially repeated the effects for acute episodes because the attributes of the episodes showed strong relationships to the use of medical care. Novelty was a strong predictor at both waves (1992: OR, 13.47; 1993: OR, 6.99) as was duration (1992 and 1993: OR, 1.06 for each of 28 steps of duration). Severity was also a substantial predictor (1992: OR, 1.66; 1993: OR, 2.33). Trait NA was not related to the use of medical care at either wave, although poor SAH was related at wave 1 (1992) but not at wave 2 (1993). Models using trait NA assessed a year before these chronic episodes showed that NA was unrelated to care seeking in 1992 (OR, 0.40, CI, 0.14 1.15) but was significantly related in 1993 (OR, 0.26, CI, 0.09 0.79). It is important to note, however, that the relationships were opposite to those predicted by the symptom perception hypothesis, that is, each unit increase in trait NA was related to a decrease in the odds of using medical care. Crosssectional analyses showed the expected negative relationship of SAH to the use of medical care, which was significant only in wave 1 (1992: OR, 0.51, CI, 0.34 0.77; 1993: OR, 0.89, CI, 0.58 1.36): an increase in SAH was associated with a decrease in the use of medical care. The same pattern appeared using the prior-year ratings of SAH (SAH in 1991 and use of care in 1992: OR, 0.68, CI, 0.47 0.98; SAH in 1992 and use of care in 1993: OR, 0.84, CI, 0.54 1.30). We also examined whether the trait NA by SAH interaction predicted care seeking for chronic episodes. The interaction term was not significant for either wave of data whether the variables were measured at the same or the prior year (1992: OR, 2.22, CI, 0.86 5.69; 1993: OR, 0.54, CI, 0.17 1.71). Symptom Amplification and Episode-Based Anxiety Although trait NA was unrelated to the reporting of acute illness episodes and to the use of medical care for these illness episodes and was only marginally related (negatively) to the use of medical care for chronic illness, it is still possible that trait NA is related to the attributes of the episodes, including those that were strong predictors of the use of care. The Psychosomatic Medicine 64:436 449 (2002) 443

P. MORA et al. symptom perception hypothesis would predict that trait NA would be positively associated with the number of symptoms reported during acute and chronic episodes. The data provided little support for this hypothesis because trait NA had no relationship to the average number of symptoms reported during episodes of acute or chronic illness at either wave of data (Table 5). Thus, there was no indication that trait NA results in increased amplification during episodes of acute or chronic illness when the average number of symptoms reported for illness episodes is used as the outcome measure. The result was the same for SAH. In addition, NA was unrelated to reported duration or to reported severity for acute conditions at both waves (r values ranged between.00 and.10, all p values.22). Results for chronic conditions showed that NA was unrelated to duration but was modestly related to reported severity (r.13 for both waves, p.05). A more elaborate version of the symptom perception hypothesis would predict that increases in emotional distress by high trait NA during illness episodes would lead to increased use of medical care. A more detailed assessment of episode-related variables, including a report of episode-specific worry (ie, anxiety) conducted for the subset of participants who reported an ongoing chronic illness at the time of the 1992 (wave 1) interviews allowed us to partially test this hypothesis. The number of participants reporting an ongoing chronic condition (N 121) was sufficient to test a seven-variable model predicting the use of medical care. All episode attributes in the model were statistically significant or nearly significant: duration (OR, 11.22, CI, 3.69 34.15), novelty (OR, 2.64, CI, 0.85 8.24, p.09), and episode-specific anxiety (OR, 27.68, CI, 1.49 511.75). In addition, each of the individual difference factors was significant: an increase in age was associated with a decrease in the odds for the use of health care (OR, 0.92, CI, 0.86 0.99), the odds in favor of using care were larger for men than for women, (OR, 0.31, CI, 0.11 0.91), increases in NA were associated with a decrease in the use of medical care (OR, 0.16, CI, 0.03 1.08, p.06), and increases in SAH were related to a decrease in the odds for the use of health care (OR, 0.46, CI, 0.24 0.91). Thus, whereas episode-specific worry was positively related to care seeking, generic measures of trait NA were related negatively such that high trait NA was associated with less care seeking. The surprising and opposite relationship of trait NA and episode-specific worry to care seeking is not inconsistent with the data because trait NA and episode-specific worry were only moderately correlated (r.34, p.01). Finally, we tested whether the interaction of NA with episode-specific worry was predictive of care seeking for ongoing episodes. These TABLE 5. Cross-Sectional and Prospective Relationships of Trait NA and SAH to Number of Symptoms Reported During Acute and Chronic Episodes Controlling for Age, Illness Burden, and Sex Step Predictors Concurrent Wave 1 (N 212) Concurrent Wave 2 (N 225) Prospective (N 225) R 2 R 2 R 2 Average No. of Symptoms During Acute Episodes Step 1 0.033 0.043* 0.045* Past week 92 0.034 Age 0.152* 0.074 0.063 Illness burden 0.098 0.074 0.084 Sex 0.081 0.182** 0.189** Step 2 0.000 0.000 0.000 NA 0.032 0.011 0.029 Step 3 0.000 0.000 0.002 SAH 0.026 0.003 0.051 Average No. of Symptoms During Chronic Episodes No. 276 257 257 Step 1 0.042** 0.013 0.016 Past week 92 0.048 Age 0.003 0.103 0.133 Illness burden 0.088 0.051 0.030 Sex 0.162 0.037 0.051 Step 2 0.009 0.001 0.000 NA 0.090 0.034 0.019 Step 3 0.001 0.000 0.000 SAH 0.033 0.017 0.032 * p 0.05 (two-tailed); ** p 0.01 (two-tailed). 444 Psychosomatic Medicine 64:436 449 (2002)

NEGATIVE AFFECT AND ILLNESS BEHAVIOR results did not support the more elaborate version of the symptom perception hypothesis as this interaction term was unrelated to the use of medical care for ongoing chronic conditions (OR, 0.07, CI, 0.00 35.19). Because participants with an ongoing, chronic condition were included in the previously reported analyses of the wave 1 care seeking data, the earlier wave 1 analyses were repeated excluding these respondents. The new analyses were nearly identical to the earlier ones, although the significance levels declined somewhat due to reductions in sample size. DISCUSSION The positive, cross-sectional associations of trait NA with prior-week symptoms reported by our elderly participants replicated prior findings for middle-aged and younger persons (eg, Ref. 10), as did the negative association of SAH with these same symptom reports (19). By allowing our respondents to classify their symptoms as acute or chronic, we also determined that the relationships of both trait NA and SAH are more robust to symptoms regarded as chronic than to those regarded as acute. In addition, the small, but significant, prospective associations to increases in chronic symptoms 1 year later were due primarily to increases in chronic symptoms for our elderly, female participants, an effect that is likely to reflect a bidirectional influence of chronic somatic distress from arthritic conditions. A 1-year time frame was sufficient for a small number of the 700 elderly individuals sampled (mean age of 72.8 years with an average of slightly more than 10 lifetime illnesses) to experience changes in somatic sensations. We have no explanation for the unexpected, positive relationship of trait NA to acute symptoms in the prospective data for male respondents. Given the absence of cross-sectional associations for these variables, the prospective association may well be a random effect. Although the data replicate the often-reported positive relationship of trait NA and symptoms, they provide little support for expectations derived from the symptom perception hypothesis (ie, that trait NA biases all health reports). Neither trait NA nor SAH was related to reports of acute illness either cross-sectionally or longitudinally. Colds, stomachaches, and other such minutiae are acute, self-limited events that may have little or no implication with respect to one s overall emotional or health status (19). The absence of significant relationships of trait NA and SAH to reports of episodes of acute illnesses further suggests that the occasional unanticipated prospective relationships of trait NA and SAH to symptoms during acute episodes may reflect chance relationships. By contrast, self-appraisals of emotionality (trait NA) and health (SAH) were correlated with stable chronic conditions that have implications for the elderly person s self system (9): higher levels of trait NA were associated with reports of more chronic episodes, and excellent SAH ratings were associated with reports of fewer chronic episodes. The relationship of chronic episodes to SAH was somewhat stronger than the relationship to trait NA because trait NA was not related to chronic episodes for men. The prospective analysis yielded a small but significant relationship of SAH to chronic episodes 1 year later. Neither measure, however, was related to the number of symptoms reported during these episodes. The similar pattern of relationships between these two self-ratings and reports of symptoms and illness episodes suggests that both factors are correlated with reports of somatic status, SAH more so than trait NA. That SAH is the more robust predictor is not surprising because it is a global appraisal of health status (17, 19). By contrast, when participants report the extent to which their usual mood is anxious and/or depressed, they are not directly assessing their health status. As Smith et al. (27) noted in their study of disease impact and function in patients with rheumatoid arthritis,...[r]esearchers who rely on self-reports to study stress, coping, and health ought to be concerned with NA...NA was neither the dominant factor in our respondents reports, nor was it able to account for the majority of relations that were observed among the self-report variables we examined. It is worth reviewing the ways in which trait NA can be related to elderly participants reports of symptoms and illness episodes. First, the physiological processes underlying mood experiences could involve immune suppression and the occurrence of illness; Watson and Pennebaker (10) labeled this the psychosomatic hypothesis. Data support this hypothesis for the common cold (28) and chronic conditions such as coronary events (29). The current analyses did not yield similar relationships because trait NA was not related to acute conditions cross-sectionally nor longitudinally and showed unimpressive relationships to chronic conditions longitudinally, although the sample size and limited time frame are less than optimal for the occurrence of a substantial number of new, major stressrelated chronic events in an elderly sample. We conclude, therefore, that trait NA fails to assess the affective processes underlying the stress effects for acute and chronic illness reported, respectively, by Cohen et al. (28) and Kamarck and Jennings (29), rather than suggest that these data provide negative evidence with respect to the psychosomatic hypothesis. Second, the similarity of the positive association of Psychosomatic Medicine 64:436 449 (2002) 445