Psychologic Functioning and Physical Health: A Paradigm of Flexibility

ALAN ROZANSKI, MD, AND LAURA D. KUBZANSKY, PHD

Recent evidence suggests that positive psychologic factors may be protective against coronary artery disease (CAD). We consider
this possibility through a paradigm that explores three interrelated factors that may promote healthy psychologic functioning:
vitality, emotional flexibility, and coping flexibility. Vitality is a positive and restorative emotional state that is associated with a
sense of enthusiasm and energy. Flexibility is related both to the ability to regulate emotions effectively and cope effectively with
challenging daily experiences. A variety of factors may diminish vitality, including chronic stress and negative emotions.
Pathophysiologically, chronic stress and negative emotional states can both invoke a “chronic stress response” characterized by
increased stimulation of the sympathetic nervous system and hypothalamic–pituitary–adrenal axis, with resultant peripheral effects,
including augmented heart rate and blood pressure responsiveness and delayed recovery to stressful stimuli. Research indicates a
wide array of stressful conditions—associated with either elements of relative inflexibility in psychologic functioning and/or
relatively unabated stressful stimulation—that are associated with this type of exhausting hyperarousal. Conversely, new data
suggest that positive psychologic factors, including positive emotions, optimism, and social support, may diminish physiological
hyperresponsiveness and/or reduce adverse clinical event rates. Still other positive factors such as gratitude and altruistic behavior
have been linked to a heightened sense of well-being but have not yet been tested for beneficial physiological effects. Pending
further study, these observations could serve as the basis for expanding the potential behavioral interventions that may be used to
assist patients with psychosocial risk factors for CAD. Key words: positive psychology, stress, psychologic, emotions, cardio-
vascular diseases.

CAD ⫽ coronary artery disease; SNS ⫽ sympathetic nervous sys- We address these questions by first examining paradigms
tem; HPA ⫽ hypothalamic–pituitary–adrenal. for healthy physical and psychologic functioning, and then
assess how both negative and positive psychosocial factors
INTRODUCTION might induce their effects in the context of this framework.

B oth depression and chronic stress accelerate atherosclero-

sis and promote the development of adverse cardiac events
(1). These conditions share overlapping characteristics. For
example, depressive symptoms are a common consequence of
chronic stress, such as that seen among those experiencing job
strain (2,3). In addition, depression shares features of a
chronic stress response whereby physiologically arousing
emotions such as fear and anxiety commonly co-occur, as do
symptoms of physiological hyperarousal such as increase in
resting heart rate and high circulating norepinephrine levels
(4), and also somatic hyperarousals such as insomnia and
early-morning awakening (5). Recently, adverse clinical
events have been linked to a variety of other conditions
associated with hyperarousal, including pessimism (6,7),
worry (8), sleeplessness (9), and lack of vacation time (10,11).
Together, these observations raise a series of broad questions:
Is the presence of continual hyperarousal one common factor
explaining the link between adverse life conditions such as
stressful job overload and caregiver strain, and the develop-
ment and acceleration of coronary artery disease (CAD)? If so,
what is the pathophysiological basis for this association?
Moreover, can positive psychosocial conditions buffer the
relationship between psychosocial factors known to promote
CAD through hyperarousal, and if so, by what mechanism(s)?
From the Division of Cardiology, St. Luke’s–Roosevelt Hospital Center,
and the Department of Medicine, Columbia University College of Physicians
and Surgeons, New York, NY (A.R.); and the Department of Society, Human
Development and Health, Harvard School of Public Health, Boston, Massa-
chusetts (L.K.).
Address correspondence and reprint requests to Alan Rozanski, MD, Di-
vision of Cardiology, St. Luke’s–Roosevelt Hospital Center, 1111 Amsterdam
Ave, New York, NY 10025. E-mail: AR77@columbia.edu
Received for publication December 14, 2004; accepted February 22, 2004.
In accordance with CME accreditation guidelines, the authors of this article
disclosed no real or potential conflicts of interest.
DOI: 10.1097/01.psy.0000164253.69550.49
CHARACTERISTICS OF PHYSICAL WELL-BEING
Healthy physiological systems are characterized by a great
degree of complexity (12), which translates into highly vari-
able values for physiological parameters. Because competing
autoregulatory influences are generally present, these systems
function under conditions of nonlinear dynamics (e.g., non-
proportional dose–response relationships) rather than linear
dynamics (e.g., proportional dose–response relationships).
This nonlinearity may result in healthy variability in measure-
ments of “response”— but not tightly “controlled”—physio-
logical parameters. For example, narrow variation through
tight feedback control is desirable for controlled parameters
such as blood pressure and arterial blood gas as well as
hormone levels. Other parameters, however, tend to change in
response to alterations in the controlled parameters (e.g., heart
rate changes reflexively with blood pressure and respiration
changes with alterations in blood gas). Thus, high heart rate
variability is a sign of physiological health, but high blood
pressure variability is not. Along these lines, a reduction in
homeostatic efficacy of the baroreceptor reflex results in
greater variability in blood pressure (the controlled parameter)
and reduced variability in heart rate (the response parameter).
Overall, variability of measurements such as heart rate inter-
vals is reflective of a large capacity in physiological respon-
siveness and the ability to quickly return physiological activity
to a “relative” baseline after stress. For example, healthy
cardiovascular conditioning is associated with a relatively
rapid decline postexercise. Anatomic systems are also char-
acterized by complexity that manifests itself as fractal (i.e.,
self-similar or branching “treelike”) patterns such as the
branching nature of the nervous, pulmonary, circulatory and
His-Purkinje systems. Such anatomic design promotes the
rapid transfer of information or nutrients and provides excess

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 A. ROZANSKI AND L. D. KUBZANSKY

capacity and nonlinear capability for dealing with unexpected
stress.
Advancing age is associated with progressive loss of com-
plexity in physiological and anatomic systems that produce
adverse changes such as diminution in heart rate variability,
reduced muscle and joint mechanics, and increased vascular
wall stiffness. Similarly, medical illness can produce loss of
complexity and resultant regularization among specific target
systems such as the regularization in function that is observed
for respiration in heart failure, for gait in Parkinson’s disease,
for white blood cell counts in leukemia, or for diminution of
heart rate variability (reflecting autonomic nervous system
dysfunction) across many disease states.
Thus, healthy physiological functioning is characterized by
inherent flexibility and resiliency, and both age and disease
are characterized by loss of flexibility, resulting in a decreased
ability to compensate for changes in the internal or external
environment. Accordingly, it would be reasonable to postulate
that conditions of chronic psychosocial stress may also dimin-
ish this inherent physiological flexibility. We might also ask
whether flexibility—in the psychologic domain— character-
izes healthy functioning and/or influences pathophysiology
and subsequent physical health outcomes.
FLEXIBILITY AND HEALTHY PSYCHOLOGIC
FUNCTIONING
As suggested by healthy anatomic and physiological sys-
tems, there are numerous interrelated components likely to
contribute to healthy psychologic functioning in a nonlinear
fashion. This complexity allows for rapid response to envi-
ronmental challenges (through the emotions) and provides
reserve capacity for coping with the myriad of different ex-
periences and situations with which individuals are daily con-
fronted. To understand how a paradigm of flexibility applies
to these response mechanisms, we identify and consider three
potentially relevant components of healthy psychological
functioning, as discussed subsequently (see Fig. 1).
Recent work has suggested that a sense of vitality is a
particularly relevant barometer of both physical and emotional
health (13,14). The definition of “vitality” varies somewhat
according to theorists, but most agree that it is a positive state
that is associated with a sense of enthusiasm and energy (6).
Vitality is a composite of positive emotions, including a sense
of joy and a sense of interest (15,16), and may be considered
both restorative and regenerative. When these emotions are
blended, a sense of positive energy and well-being is gener-
ated, which in turn, appears to enhance a variety of resources,
including the ability to concentrate, problem-solving and in-
tellectual performance, the ability to mobilize social re-
sources, and the willingness to take on new challenges, as
outlined by Fredrickson (17). Vitality, then, connotes a sense
of “freshness”—a certain excitement and energy for living.
Both physical factors such as fatigue and medical illness,
and psychologic factors may diminish vitality. Two broad
psychologic categories are prominent in this regard. The first
is states of chronic stress, particularly if accompanied by

Figure 1. A paradigm of psychologic well-being based on 3 interrelated components. Central to this paradigm is “vitality,” a positive energetic state that is
characterized by enthusiasm and a sense of aliveness. The energy associated with vitality helps to foster the work needed to regulate positive and negative
emotions and to cope with life problems. This relationship is bidirectional because effective emotional competence and coping skills, in turn, help to preserve
vitality by diminishing the frequency of energy-depleting negative emotions and/or taxing life problems. Emotional and coping flexibility are seen as key
indicators of one’s ability to successfully manage negative emotions and solve problems effectively.

S48 Psychosomatic Medicine 67, Supplement 1:S47–S53 (2005)

CHRONIC STRESS AND POSITIVE PSYCHOLOGIC FACTORS
conflicts and/or demands that negatively affect one’s sense of
autonomy, being able to cope, or interpersonal relationships.
The second is states of chronic negative emotion. Whereas
positive emotions are transiently energizing, negative emo-
tions have the opposite effect (when they are acute, some
negative emotions such as anger or anxiety may also provide
a sense of energy or arousal, but they do not contribute to a
sense of vitality (13)). Chronic negative emotions can be
self-sustaining and may also be viewed as inflexible states that
deplete energy and impair coping. Thus, either chronic stress
or negative emotions may initiate a vicious cycle, which
reduce one’s ability to respond adaptively to life’s inherent
challenges.
A consideration of the factors that diminish vitality may
suggest the importance of flexibility for healthy psychologic
functioning. Specifically, flexibility may broadly characterize
two key aspects of psychologic functioning that contribute to
maintaining vitality: the ability to regulate negative emotions
effectively and the ability to cope effectively with chronic
stress.
The regulation of negative emotions can involve a variety
of skills such as the ability to control impulses, the ability to
positively reappraise stimuli that might initiate a negative
emotional experience, the ability to inhibit various evoked
emotional responses according to situational demands (e.g.,
such as induced anxiety or fear during public interactions),
and the ability to process one’s emotional experiences effec-
tively. People who are skilled in such abilities are more likely
to manifest “emotional flexibility,” which can be defined op-
erationally as the ability to flexibly regulate emotions across a
wide range of situations (18,19). Although the concept of
emotional flexibility has hardly been assessed relative to med-
ical outcomes, Bonanno et al. recently demonstrated that the
ability to flexibly enhance and suppress emotions under ex-
perimental laboratory conditions among entering college
freshman was associated with reduced levels of subjective
psychologic distress over 1.5 years of follow up (20). Simi-
larly, other data indicate that failure to express emotions is
associated with the buildup of negative thoughts and a ten-
dency to ruminate, a decreased ability to achieve emotional
closure, and negative physiological consequences (21,22). By
contrast, experimental research has indicated the health ben-
efit associated with the expression of upsetting or traumatic
experiences through expressive writing assignments (23).
Coping flexibility has also been proposed as a hallmark of
the ability to respond effectively to chronic stress (24,25).
Like with the regulation of negative emotions, there are a
variety of coping responses that may be used to deal with life
problems such as adjusting goals or priorities to cope with
changing circumstances, setting limits, invoking social sup-
port, or seeking advice or counseling. Although these are all
useful responses to stress, Cheng has recently postulated that
it is coping flexibility, per se, rather than the use of specific
coping responses that best predicts successful adaptation to
stressful circumstances (25). Coping flexibility may have a
number of relevant dimensions. For example, one aspect of
Psychosomatic Medicine 67, Supplement 1:S47–S53 (2005)
coping flexibility may be the ability to flexibly switch be-
tween coping strategies that are oriented toward problem
management versus those oriented toward emotional regula-
tion. Problem-oriented coping strategies have been deemed
more appropriate for situations involving controllable stress,
whereas emotional regulation may be more appropriate for
uncontrollable stress (26,27). A second aspect of coping flex-
ibility may be “appraisal flexibility.” For example, flexible
appraisers are those who can flexibly appraise some stressors
as controllable and others as not. By contrast, depressed
individuals are prone to appraising any stressor as uncontrol-
lable, whereas individuals who strongly desire control are
often more likely to appraise stressors as controllable even
when they are not (28). A third aspect of coping flexibility
revolves around individuals’ abilities to flexibly adjust goals
to changing life circumstances. This ability may be of partic-
ular importance to medical patients, because changes in health
status can often have profound effects on one’s ability to
pursue cherished life goals.
Vitality, emotional flexibility, and coping flexibility form a
dynamic and complex system of psychologic functioning. The
excitement and energy that accompanies a sense of vitality
may serve to enhance the flexibility and creativity with which
individuals respond to the environment in terms of their ability
both to regulate emotions and to use effective coping strate-
gies. Such effects, however, are likely bidirectional. When
emotion regulatory processes and effective coping mecha-
nisms are in place, they also serve to conserve energy and help
augment one’s sense of vitality.
SOURCES OF CHRONIC STRESS THAT MAY LEAD
TO INFLEXIBILITY
Chronic stress adversely affects both sides of the bidirec-
tional relationship associated with vitality and flexibility by
both promoting emotional inflexibility and by draining vital-
ity. For example, job strain promotes depression (2,3) and, as
demonstrated in the recent Maastricht Cohort Study on Fa-
tigue at Work (29), it also promotes fatigue, failure to unwind,
and even frank burnout. Under such circumstances, it becomes
increasingly difficult to regulate emotions or use effective
coping strategies. This type of exhausting hyperarousal has
now been linked to a variety of conditions associated with the
development of CAD and/or adverse clinical outcomes, in-
cluding negative cognitive states (e.g., pessimism) (6,7), de-
pression (1), work stress (30 –32), marital stress (33–36),
caregiver strain (37–38), lack of vacations (10,11), inadequate
sleep (independent of depression) (9), and low socioeconomic
status (39,40) (see Fig. 2).
THE PHYSIOLOGICAL BASIS OF A CHRONIC
STRESS RESPONSE
Troubling life problems and the failure to resolve negative
emotional states such as depression may generate continual
physiological stimulation, frequently invoking a chronic phys-
iological stress response. The continual stimulation of the
sympathetic nervous system (SNS) and the hypothalamic–
S49

Figure 2. Patterns of inflexibility that have been shown to be associated with the development of abnormal cardiovascular pathophysiology and/or adverse
clinical outcomes ranging from negative cognitive states (such as rumination, pessimism, and worry) to lifestyles that are likely to be associated with chronic
physiological overload such as chronic job stress or caregiver strain.
pituitary–adrenal (HPA) axis that results from such chronic
stress can produce a cascade of negative pathophysiological
consequences, as illustrated in Figure 3. Normally, elevations
of cortisol that are associated with acute stress serve to down-
regulate HPA function through a negative feedback mecha-
nism. However, under chronic stress, cortisol binds to central
nervous system receptors, resulting, paradoxically, in a con-
tinued secretion of cortisol (41). This hypercortisolemia is
associated with a loss in the normal physiological plasticity of
the HPA, as manifested by reduced variability in cortisol
secretion measurements and diminution in the normal sensi-
tivity of the HPA axis to exogenous suppression using dexa-
methasone. The enhanced SNS activation that is evoked under
conditions of chronic stress may also lead to elevated resting
heart rates and autonomic nervous system imbalance, as char-
acterized, for example, by reduced resting heart rate variabil-
ity (4). In addition, impaired function of the parasympathetic
nervous system is known to cause reduced recovery in rest
heart rates after exercise, and although the pathophysiological
mechanisms remain to be clarified, slow recovery of resting
heart rate and blood pressure has been noted in the presence of
both acute and chronic forms of psychologic stress as well.
Chronic stress also appears to produce an intrinsic increase
in “cardiovascular reactivity” (i.e., heightened heart rate and
blood pressure responsivity to acute physiological stimuli)
that, in recent animal studies, has been linked to the activation
of an anatomic chronic stress network, involving several spe-
cific brain centers (42). This pathophysiological change may
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A. ROZANSKI AND L. D. KUBZANSKY
be particularly important in light of recent studies that link
heightened cardiovascular reactivity to a greater presence
and/or progression of subclinical atherosclerosis (43– 46). Of
note, physiological hyperreactivity to acute stressors appears
to be characteristic among various states indicated in Figure 2.
For example, among cognitive states, job-related worry has
recently been linked to higher cortisol levels on work days
(47), and preliminary studies suggest that laboratory-induced
state rumination may prolong recovery of heart rate and blood
pressure after acute physiological stimulation (48). Similarly,
among emotional disorders, both depressed subjects (4) and
those with hostility (49) show heightened neuroendocrine
responses in the laboratory compared with normal subjects.
Among life situations, chronic job strain as characterized by
high job demand but low job latitude (30) has also been linked
to prolonged heart rate and blood pressure elevations after
work, which, in the case of blood pressure, may last for days
at a time (50), to higher cortisol levels while at work (47), and
to both enhanced blood pressure responsivity to pharmaco-
logic challenge (phenylephrine) and decreased baroreflex sen-
sitivity (51). The accompanying feeling of being unable to
relax after work (32) may represent a clinical mirror of re-
duced physiological plasticity. Lack of adequate sleep may
also result in neuroendocrine activation (52), and low SES has
been similarly linked to physiological hyperreactivity (53).
The heightened output from the HPA and SNS associated
with chronic stress serves to produce a variety of other
changes that have been strongly linked to CAD, including
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CHRONIC STRESS AND POSITIVE PSYCHOLOGIC FACTORS

Figure 3. Individuals with chronic emotional disorders such as depression or who experience chronic stress may be subject to chronic physiological stress
responses characterized by chronic overstimulation of the hypothalamic–pituitary–adrenal (HPA) axis and sympathetic nervous system (SNS). The resultant
dysregulation of these systems may lead to decreased cortisol variability, hypercortisolemia, high norepinephrine levels, autonomic dysfunction, elevated resting
heart rates, and other peripheral affects that are not shown. The chronic stress response is also characterized by a prolonged recovery to physiological stimulation
and to enhanced cardiovascular reactivity to novel stressors.

signs of increased inflammation, central obesity, hyperinsu-
linemia, diabetes, hypertension, and endothelial dysfunction,
as reviewed elsewhere (1).
POSITIVE PSYCHOLOGIC FACTORS AS A
POTENTIAL BUFFER
Whether the model of psychologic functioning we have
proposed actually protects cardiac health remains to be tested
empirically. Until recently, little was known concerning the
ability of positive psychologic factors to promote health and
longevity and to act as a potential buffer against the adverse
effects associated with chronic psychologic stress. However,
recent studies have linked various positive factors to benefi-
cial outcomes. For example, both optimistic explanatory style
(6) and dispositional optimism (7) have been linked to lower
overall mortality rates and dispositional optimism to reduced
progression of atherosclerosis as demonstrated by carotid ul-
trasound (54) and enhanced recovery after myocardial infarc-
tion (55), heart transplantation (56), and coronary bypass
surgery (57,58). Other data have linked greater social connect-
edness or emotional social support to lower adverse clinical
event rates (1). Several studies have also linked positive
emotions to a number of health outcomes, including longer
longevity among nuns (59), reduced susceptibility to the com-
mon cold (60), and reduced likelihood of having diabetes or
developing hypertension over 2 years of follow up in adults
aged 55 and over (61).
In addition, investigators have increasingly focused on the
potential impact of positive psychologic factors on cardiovas-
cular pathophysiology. For instance, Fredrickson et al. used an
experimental design to demonstrate that positive emotions
could shorten the recovery of physiological indices after ex-
posing experimental subjects to a stimulus designed to induce
negative emotions (62). Positive social support (a coping
resource) also has been shown to reduce physiological reac-
tivity to acute laboratory stressors (63). Moreover, those scor-
ing highly on trait measures of forgiveness have been shown
to exhibit less cardiovascular reactivity to acute stressors (64),
suggesting that this and other positive traits may merit more
study relative to their beneficial physiological effects. Similar
results have been noted preliminarily among those demon-
strating trait optimism (Willem J. Kop, personal communica-
tion). Together, these studies suggest positive psychologic
factors can reduce cardiovascular reactivity to stress in direct
opposition to the heightened reactivity that may be induced by
chronic stress and depression.
FUTURE DIRECTIONS
These observations suggest areas of needed investigation.
First, the potential clinical and pathophysiological benefits
associated with positive emotions are based on sparse data that
needs to be confirmed by further clinical studies and extended
to assess a wider variety of positive traits and emotions. For
example, although traits such as altruistic behavior (65) and

Psychosomatic Medicine 67, Supplement 1:S47–S53 (2005) S51


gratitude (66) have been linked to higher levels of psychologic
well-being, their ability to influence the clinical course of
CAD remains to be determined.
The finding of a persistent association between CAD and
even mild negative emotions (67) may also provide insight
into aspects of healthy psychologic functioning that may be
important, particularly in relation to chronic hyperarousal. For
example, Steptoe et al. have recently demonstrated that the
physiological effects of an acute stressor can vary among
those experiencing job strain, depending on whether that stres-
sor is experienced as a controllable or uncontrollable stress
(68). In other recent work, caregiving stress was only associ-
ated with excess cardiovascular events if a sense of emotional
strain was also felt (38). These observations suggest that
healthy psychologic functioning, including emotional and
coping flexibility and the presence of factors that promote
vitality (e.g., work that is perceived as meaningful), may
mitigate against the atherogenic effects of conditions associ-
ated with chronic hyperarousal such as job or caregiver strain.
Such possibility could be addressed by considering the rela-
tionship of both positive and negative psychosocial factors
and their interrelationships with chronic stress in future epi-
demiologic investigations.
CLINICAL RELEVANCE
A variety of life situations have been linked with poor
cardiac outcomes and may be linked with depleted psycho-
logic health as outlined earlier in Figure 2. If healthy psycho-
logic functioning and flexibility indeed mitigate effects of
chronic stress, this suggests that clinical attention to patients’
emotional states and life circumstances may yield important
information about both risk for future events and also potential
targets for intervention. Viewed through this lens, the partic-
ular characteristics of a given situation or exposure may be
optimally assessed by also considering its related drain on
emotional health. Shifting focus to an individual’s capacity for
renewal and regeneration may help clinicians to provide con-
crete help to their patients. Such interventions may be targeted
at reducing negative cognitive patterns such as rumination or
pessimism, at promoting more rest and relaxation through
better sleeping habits and/or more vacations, at helping pa-
tients prone to overwork change their work habits, at building
a greater range of positive emotions and experiences, or at
building greater emotional and coping flexibility. A number of
specific strategies that may be helpful have been outlined in a
recent paper (1).
Taken together, the available evidence suggests there may
be a clinical rationale both for increasing our understanding of
the links between psychologic functioning and cardiac health,
and for assessing the cardiovascular effects of behavioral
interventions designed to reduce chronic physiological stim-
ulation and enhance healthy psychologic functioning.
The authors thank Dr. Patrice Saab, Dr. Elliot Brown, and Dr.
Deborah A. Scheuer for comments on an earlier version of the
manuscript.
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A. ROZANSKI AND L. D. KUBZANSKY
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