Optimism is associated with a reduced incidence of CHD and total mortality. Mortality reduction appears to be driven by reduced CHD-related death in blacks and whites and additionally by reduced cancer-related mortality in blacks. Conversely, cynical hostility was associated with an increased risk of total mortality and cancer-related mortality. To the best of our knowledge, this is the largest study to report the association of optimism and reduced mortality (which persisted after adjustment for a number of important cofactors) in white and black women. The present findings confirm and extend prior research on optimism and reduced CHD-related and total mortality.8
Optimism was associated with a favorable profile and cynical hostility with an unfavorable profile of baseline risk factors for CHD and mortality, including measures of socioeconomic status, health conditions, personal habits, and physical and laboratory measurements. Nevertheless, the relationship between optimism and cynical hostility and important health outcomes persisted after adjustment for baseline risk factors. Optimism and hostility may influence physiology directly,22, 23
perhaps by altering the time course of disease processes such as atherosclerosis,24,25
or indirectly, by influencing health behaviors such as smoking or adherence to treatment regimens26
or by modifying the risk of incident depression (previously shown to be reduced among optimists).27
However, the present findings persisted even after adjustment for important health behaviors and depressive symptoms. Furthermore, the results likely represent a conservative estimate of the overall effects of optimism and cynical hostility, given the adjustment for proposed mediators including health behaviors and depressive symptoms.
Optimism and cynical hostility are known to be associated with perceived stress, coping ability, and social support. Optimists (compared with pessimists) tend to cope with adversity in healthier ways28
and to build stronger social relationships.29
In contrast, hostility may impair the stress-buffering effects of social support.30
These processes may contribute to more frequent or more severe experiences of negativity in pessimistic23
individuals, which may in turn unfavorably alter cardiovascular physiology, such as blood pressure. Neural imaging studies suggest differential neural responses in optimists versus pessimists32
and in hostile and nonhostile individuals.33
Optimism and cynical hostility were associated with somewhat larger total and cancer-related mortality effects in black women than in white women, and reasons for this are unclear. The study sample was limited by a relatively low prevalence of highly cynical, hostile white women and a relatively high prevalence of black women with high cynical hostility. Cynical attitudes toward others may be both realistic and adaptive in minority groups with a long history of exposure to discrimination, representing an appropriate coping response. Nonetheless, there may be a physiological cost of such an adaptation. It is theoretically possible that physiological reactions to mental phenomena (such as hostile cognitions) were more pronounced in black women, thus leading to greater amplitude or longer time course of emotional responding, in turn producing greater neural, endocrine, or inflammatory physiological responses that facilitated greater disease burden. However, real-time physiological data are beyond the scope of the original Women’s Health Initiative design.
The present study had several important strengths, including an all-female sample large enough to examine whites and blacks, adjudicated health outcomes, and inclusion of relevant cofactors. We used well-studied and validated measures of optimism and cynical hostility. The sample size allowed for simultaneous assessment of optimism and cynical hostility, and the prospective study design allowed for a reasonable follow-up time to assess important cardiovascular and other health outcomes.
If psychological attitudes such as optimism and cynical hostility matter for health, the extent to which they can be modified remains unclear. Prior behavioral trials have targeted type A behaviors,34
and depression and social support37,38
with mixed results. None targeted hostile or optimistic attitudes; although perhaps indirectly, these studies did modify psychological attitudes. Further research is needed to understand how and why optimism and cynical hostility affect health outcomes in women and how they develop in earlier stages of life, as well as to identify therapies to alter these attitudes in healthy ways.
Over time, practicing clinicians often become intimately familiar with aspects of their patients’ personalities, including optimistic or cynical, hostile psychological attitudes. Optimism and cynical hostility also appear to be independent risk factors for important health outcomes, including mortality. Optimism and cynical hostility may affect the risks of physical disease via 2 main pathways: (1) Directly, by altering activation of the autonomic nervous system, hypothalamic-pituitary axis, or other stress-response systems, which may in turn speed up the process of diseases such as atherosclerosis; and (2) indirectly, by influencing health behaviors such as smoking, eating patterns/obesity, and adherence to treatment regimens. In this sample, the magnitude of the effects of optimism and cynical hostility was less than but similar to the effect of hypertension for total mortality. The fact that these psychological factors are potentially modifiable increases their clinical relevance, especially when clinicians consider populations at higher risk, such as blacks.