FOR BITTER OR WORSE EMBITTERMENT IN RHEUMATIC DISEASES. David Blom

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1 FOR BITTER OR WORSE EMBITTERMENT IN RHEUMATIC DISEASES David Blom

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3 FOR BITTER OR WORSE EMBITTERMENT IN RHEUMATIC DISEASES In bittere tegenspoed verbittering bij reumatische aandoeningen (met een samenvatting in het Nederlands) Proefschrift ter verkrijging van de graad van doctor aan de Universiteit Utrecht op gezag van de rector magnificus, prof.dr. G.J. van der Zwaan, ingevolge het besluit van het college voor promoties in het openbaar te verdedigen op donderdag 22 mei 2014 des ochtends te uur door David Blom geboren op 9 september 1983 te Utrecht

4 Promotoren Prof.dr. R. Geenen Prof.dr. J.W.J. Bijlsma The research described in this thesis was financially supported by a full grant of the Dutch Arthritis Foundation (Reumafonds). Printing of this thesis was financially supported by the Dutch Arthritis Foundation (Reumafonds).

5 TABLE OF CONTENTS Chapter 1 General introduction 7 Chapter 2 Chapter 3 For bitter or worse: personality and affect correlates of embitterment Anxious attachment may be a vulnerability factor for developing embitterment Chapter 4 A combination of illness invalidation from the work environment and helplessness is associated with embitterment in patients with fibromyalgia 35 Chapter 5 Embitterment in patients with a rheumatic disease after a disability pension examination: occurrence and potential determinants 49 Chapter 6 The prospective association between embitterment and the level and course of mental well-being and physical functioning in patients with a rheumatic disease following a disability pension examination: a 15-month longitudinal study 65 Chapter 7 Summary and general discussion 81 Samenvatting (Dutch summary) 93 Dankwoord 101 About the author 107

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7 Chapter 1 GENERAL INTRODUCTION 7

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9 Pain, fatigue and musculoskeletal problems are prevalent in rheumatic diseases and may be accompanied by helplessness and social invalidation. There is a long tradition of research on helplessness as a learned consequence of uncontrollable experiences in rheumatic diseases [1]. Recently, attention has been given to the negative effects of social invalidation [2]. This thesis examines the hypothesis that the combination of these two influences is particularly detrimental, leading to embitterment (disappointment and resentment), which challenges the mental well-being and physical functioning in patients with rheumatic diseases. Before introducing the specific topics of this thesis, a broad introduction of the psychopathological construct embitterment will be given. EMBITTERMENT Embitterment is a common reaction to negative life events. It is constituted by a blend of cognitions, emotions and behaviors with a core relational theme: being treated unjustly by others [3]. Typical of embitterment are emotional disturbance, anger and resentment, negative mood, rumination on past injustices, effort to gain acknowledgement for one s victimization, and a pessimistic and misanthropic stance. Although these features can be constituents of phenomena such as depression and aggression, it is their combination that constitutes embitterment. It varies dimensionally with the propensity to gain high and clinically relevant levels [4]. Embitterment is observed in other cultures than the Western culture also. For example, among West-Papuan refugees who have been exposed to prosecution, the chronic state of mental distress related to anger and resentment is termed Sakit Hati [5]. In Korean culture, individuals who feel victimized yet restrained in releasing or ventilating their anger may be diagnosed with Hwa-byung (literally meaning firedisease ), which encompasses emotional distress, including sadness, a general feeling of malaise and pessimism, nervousness, and feelings of rage, hate, resentment, frustration, mortification, regret, and shame [6]. In Western nosological systems such as Diagnostic and Statistical Manual of Mental Disorders (DSM), the nexus between perceived injustice and affective disturbance in the form of embitterment and resentment is unacknowledged. For example as outlined by Linden et al. [7] in the DSM-IV there is the class of adjustment disorders with the possibility to differentiate between predominantly depressed mood (309.0), anxiety (309.24), mixed depression and anxiety (309.28), disturbance of conduct (309.3), and disturbance of conduct and emotion (309.9); further categories are Posttraumatic Stress Disorder (PTSD) (309.81) and acute stress disorders (308.3) which are listed under anxiety disorders. Embitterment is a far more impressive and destructive phenomenon than anxiety or depression [7]. The psychological process behind embitterment goes with impressive affective, behavioral and cognitive manifestations. Clinical experts posit that the sting of embitterment is in the violation of an individual s psychological integrity: personal value systems that encompass religious or political beliefs and values as well as basic definitions of oneself and one s personal goals in life [4]. These values are conceptions of the desirable that guide the ways people select action and evaluate events [8]. When an 9

10 event violates an important value, i.e., when being fired violates the value of being a deserving member of society, and when cognitive and behavioral coping sources do not diminish this threat, embitterment may be a final resort to secure one s integrity. Embittered individuals ruminate in an effort not to forget (and accept) what happened, they go at great length to convince others of the injustice of what happened, they tend to devaluate perceived wrongdoer(s), and manifest avoidance of potential subsequent threats. AFFECT CORRELATES OF EMBITTERMENT In cognitive theories of emotion, negative emotions arise from stress and inconsistency between our motivational goals and the perceived reality [9]. The subsequent appraisals that one makes color the emotional experience. In accordance with clinical observations [4, 3], three appraisals are assumed to constitute embitterment. First, the individual appraises undermining of one s values (e.g., I am a deserving member of the community), giving rise to the feeling of shame [10], whereas the social undesirable manifestations of embitterment (e.g., misanthropy) may go with appraised flouting of one s norms (e.g., I should behave like a deserving member of the community), giving rise to both guilt and shame [10]. Second, others are perceived to be responsible for one s situation, either by doing wrong or by doing nothing [3], which gives rise to feelings of anger and hostility [11]. Third, the situation is perceived as uncontrollable and thus as infinite [3], giving rise to feelings of sadness [11]. Notably, the focus in embitterment is on the past rather than the future, and the fear appraisal that one is at risk of an unfavorable outcome is likely less relevant. Based on these notions, the hypothesis is that embitterment particularly goes with shame and guilt, hostility, and sadness, and not with fear. PERSONALITY VULNERABILITY FACTORS Every individual experiences negative situations and injustices during the course of life. It is yet unclear why some persons tend to react with embitterment to such experiences [4]. In terms of the Big Five personality traits, high neuroticism and low agreeableness may underlie this reaction. Individuals with high neuroticism are emotionally reactive to negative events and individuals with high agreeableness value harmonious ties with others [12, 13]. Previous research has shown that both high neuroticism and low agreeableness are correlated with embitterment [14] and with its common aspects perceived organizational injustice [15, 16] and low forgiveness [17]. We hypothesize that this pattern of correlations reflects a combinative effect [18], i.e., that particularly those individuals with high neuroticism who lack agreeableness will experience higher embitterment. As a negative attachment history predisposes to the use of defensive strategies [19], it may be a vulnerability factor for developing embitterment. Four attachment styles have been defined by their position on the dimensions anxiousness and avoidance [20]: secure (low anxious-low avoidant), preoccupied (high anxious-low 10

11 avoidant), dismissive (low anxious-high avoidant), and fearful (high anxious-high avoidant). The anxious (hyperactivating) strategies aim to avoid a lack of support from others through amplifying distress and devaluating the self as a needy individual. The avoidant (deactivating) strategies aim to avoid dependency on others through dismissing distress, aggrandizing the self, and devaluating others [19]. In agreement with the anxious (hyperactivating) attachment strategy, embittered people typically try to persuade oneself and others of how badly they have been treated through displaying high distress, ruminating on past interpersonal injuries, and displaying oneself as a helpless victim [4, 15]. In accordance with the avoidant (deactivating) strategy, embittered people tend to devaluate others [21, 22], but dismissing distress is atypical for embitterment. We hypothesize that especially the anxious attachment styles fearful and preoccupied are associated with embitterment. COMBINED ILLNESS INVALIDATION AND HELPLESSNESS AS DETERMINANTS IN PATIENTS WITH A RHEUMATIC DISEASE Two immediate psychological constituents for embitterment are proposed: invalidation and helplessness. Invalidation refers to the appraised undermining of one s psychological integrity. Helplessness refers to the belief that one s coping efforts to master an unpleasant situation are futile. We propose that the coexistence of invalidation and helplessness comes with embitterment. Clinical and vocational professionals regularly encounter patients in the context of work or disability pension examinations with high embitterment. Both invalidation and helplessness are prompted by the nature of rheumatic diseases. Invalidation is provoked by the relative invisibility of symptoms such as pain, stiffness and fatigue. Colleagues and employers may, for example, deny the seriousness of the disease, fail to understand symptom fluctuations or think that the patient should have a tougher attitude [23, 24]. Helplessness is typically provoked by the uncontrollable and unpredictable nature of symptoms as detailed in learned helplessness theory [25, 26]. As invalidation and helplessness are common in employed patients with a rheumatic disease, this is an appropriate population to test the hypothesis that the joint experience of invalidation and helplessness is associated with high embitterment. AIMS AND OUTLINE OF THE THESIS The aim of this thesis was to improve insight into the phenomenon of embitterment in patients with a rheumatic disease by examining its occurrence, correlates, potential determinants and consequences. First, with regard to the affective constituents of embitterment, its associations with the affects guilt, anger, sadness and fear were examined. Second, pertaining to trait vulnerability factors, it was examined whether the anxious attachment orientation and the combination of high neuroticism and low agreeableness were associated with embitterment. Third, with reference to determinants of embitterment in patients with a rheumatic disease, it was examined whether the joint experience of illness invalidation from the work environment and helplessness regarding one s illness were associated with embitterment. Fourth, 11

12 pertaining to the significance of embitterment for patients health status, its prospective association with physical functioning and mental well-being was examined. The aim of chapter 2 was to improve our understanding of the embitterment construct by examining its personality and affect correlates. We hypothesized that embitterment is associated with the combination of the personality variables high neuroticism and low agreeableness and with the affects guilt, sadness, and hostility. In order to clarify whether attachment styles are a potential vulnerability factor for embitterment, the aim of chapter 3 was to examine the association between attachment styles and embitterment. We hypothesized that especially the anxious attachment styles fearful and preoccupied would be associated with embitterment. The aim of chapter 4 and chapter 5 was to test in employed patients with fibromyalgia (chapter 4) and patients with rheumatic disease after a disability pension examination (chapter 5) the hypothesis that embitterment is associated with the joint experience of invalidation from the work environment and helplessness regarding one s illness. Another aim of chapter 5 was to examine the occurrence of high embitterment in patients with rheumatic disease after a disability pension examination. The aim of chapter 6 was to examine whether embitterment disadvantages patients functioning and well-being over a period of 15 months after the disability pension examination. REFERENCES 1. Nicassio PM, Wallston KA, Callahan LF, Herbert M, Pincus T. The measurement of helplessness in rheumatoid arthritis: The development of the arthritis helplessness index. Rheumatol. 1985; 12: Kool MB, Van Middendorp H, Lumley MA, Schenk Y, Jacobs JWG, Bijlsma JWJ, Geenen R. Lack of understanding in fibromyalgia and rheumatoid arthritis: the Illness Invalidation Inventory (3* I). Ann Rheum Dis. 2010; 69: Znoj H. Embitterment a larger perspective on a forgotten emotion. In: Linden M, Maercker A, editors. Embitterment: societal, psychological, and clinical perspectives. Vienna: Springer; p Linden M. Posttraumatic embitterment disorder. Psychother Psychosom. 2003; 72: Rees S, Silove D. Sakit Hati: A state of chronic mental distress related to resentment and anger amongst West Papuan refugees exposed to persecution. Soc Sci Med. 2011; 73: Somers SL. Examining anger in culture-bound syndromes [internet] [cited 2014 Jan 2]. Available from: 7. Linden M, Baumann K, Rotter M, Schippan B. The psychopathology of posttraumatic embitterment disorders. Psychopathology. 2007; 40:

13 8. Kluckhohn FR. Values and value orientations in the theory of action: An exploration in definition and classification. In: Parsons T, Shils EA, editors. Toward a general theory of action. Cambridge. Harvard University Press; p Lazarus RS. Emotion and adaptation. New York: Oxford University Press; Teroni F, Deonna JA. Differentiating shame from guilt. Conscious Cogn. 2008; 17: Ellsworth PC, Scherer KR. Appraisal processes in emotion. In: Davidson RJ, Scherer KR, Goldsmith HH, editors. Handbook of affective sciences. New York: Oxford University Press; Costa PT, McCrae RR. The NEO personality inventory manual. Odessa: Psychological Assessment Resources; Costa PT, McCrae RR. Revised NEO personality inventory (NEO-PIR) and NEO five-factor inventory (NEO-FFI) professional manual. Odessa: Psychological Assessment Resources; Dodek A, Barnow S. Personality as risk and resilience in embitterment reactions. In: Linden M, Maercker A, editors. Embitterment. Vienna: Springer; p Sensky T. Chronic embitterment and organisational justice. Psychother Psychosom. 2010; 79: Shi J, Lin H, Wang L. Linking the Big Five personality constructs to organizational justice. Soc Behav Pers. 2009; 37: Wang TW. Forgiveness and Big Five personality traits among Taiwenese undergraduates. Soc Behav Pers. 2008; 36: Ode S, Robinson M, Wilkowski B. Can one's temper be cooled?: A role for agreeableness in moderating neuroticism's influence on anger and aggression. J Res Pers. 2008; 42: Mikulincer M, Shaver PR, Cassidy J, Berant E. Attachment-related defensive processes. In: Obegi JH, Berant E, editors. Attachment theory and research in clinical work with adults. New York: Guilford Press; p Bartholomew K, Horowitz LM. Attachment styles among young adults: A test of a fourcategory model. J Pers Soc Psychol. 1991; 61: Wurmser L. The superego as herald of resentment. Psychoanal Inq. 2009; 29: Znoj H. BVI. Berner Verbitterungs Inventar. Manual. Göttingen: Verlag Hans Huber Hogrefe AG; Kool MB, Van Middendorp H, Boeije HR. Understanding the lack of understanding: Invalidation from the perspective of the patient with fibromyalgia. Arthritis Rheumatol. 2009; 61: Lacaille D, White MA, Backman CL, Gignac MA. Problems faced at work due to inflammatory arthritis: New insights gained from understanding patients perspective. Arthritis Rheumatol. 2007; 57: Abramson LY, Seligman MEP, Teasdale JD. Learned helplessness in humans: Critique and reformulation. J Abnorm Psychol. 1978; 87: Samwel HJ, Kraaimaat FW, Crul BJ, Evers AW. The role of fear-avoidance and helplessness in explaining functional disability in chronic pain: A prospective study. Int J Behav Med. 2007; 15:

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15 Chapter 2 FOR BITTER OR WORSE: PERSONALITY AND AFFECT CORRELATES OF EMBITTERMENT David Blom Submitted 15

16 ABSTRACT Embitterment is a common reaction to negative life events such as divorce, unemployment and chronic illness. It involves a blend of emotions and cognitions including injustice and resentment towards perceived wrongdoers, intrusive memories, hopelessness and hostility. We aimed to further the understanding of embitterment by examining its personality and affect correlates. We hypothesized that embitterment is associated with the combination of high neuroticism and low agreeableness and with the negative affects shame and guilt, hostility, and sadness. Multiple regression analyses in a general population sample supported our hypotheses. Our findings suggest that combined vulnerability for negative internalizing affect (i.e., high neuroticism, sadness, shame, and guilt) and externalizing affect (i.e., low agreeableness and high hostility) are key to embitterment. 16

17 INTRODUCTION Embitterment is a common reaction to negative life events such as divorce, unemployment and chronic illness. It involves a blend of emotions and cognitions including injustice and resentment towards perceived wrongdoers, intrusive memories, hopelessness and hostility [1, 2]. Despite the high face validity and clinical relevance of embitterment, empirical research of the construct is still in its infancy. One step in improving our understanding of embitterment is to examine its personality and affect correlates. Such insight may help to develop interventions to prevent or treat this detrimental condition. Regarding personality correlates, it may be particularly relevant to conceptualize embitterment in terms of combined rather than single dimension of personality [3]. In terms of the Big Five personality traits, high neuroticism and low agreeableness may underlie the hopelessness and resentment components of embitterment. Individuals with high neuroticism are emotionally reactive to negative events. Individuals with high agreeableness value harmonious ties with others [4, 5]. Previous research has shown that both high neuroticism and low agreeableness are correlated with embitterment [6] and with its common aspects perceived organizational injustice [7, 8] and low forgiveness [9]. We hypothesize that the pattern of correlations reflects a combinative effect [10], i.e., that particularly those individuals with high neuroticism who lack agreeableness will experience higher embitterment. Negative emotions depend on the joint influence of circumstances such as stress or inconsistency between motivational goals versus the perceived reality and on the subsequent appraisals that one makes [11]. In accordance with clinical observations [1, 2], we hypothesize that three appraisals constitute embitterment. First, the individual appraises undermining of one s value(s) (e.g., I am a deserving member of community) [1, 2], giving rise to the feeling of shame [12], whereas the social undesirable manifestations of embitterment (e.g., misanthropy) may go with appraised flouting of one s norms (e.g., I should behave like a deserving member of community), giving rise to both shame and guilt [12]. Second, one perceives others to be responsible for one s situation, either by doing wrong or by doing nothing [2], which gives rise to feelings of anger and hostility [13]. Third, the situation is perceived as uncontrollable and thus as infinite [2], giving rise to feelings of sadness [13]. Notably, the focus in embitterment is on the past rather than the future, and the fear appraisal that one is at risk of an unfavourable outcome is likely less relevant. Based on these notions, we expect that embitterment particularly goes with shame and guilt, hostility, and sadness, and not with fear. The aim of the present study was to improve our understanding of the embitterment construct by examining its personality and affect correlates. We hypothesized that embitterment is associated with the combination of the personality variables high neuroticism and low agreeableness and with the negative affects shame and guilt, anger, and sadness. 17

18 METHODS Participants People from the general population completed an online questionnaire. Participants were recruited through websites, s, and flyers. The only inclusion criterion was an age above 18 years. Two-hundred-and-seventy Dutch-speaking respondents completed the online questionnaire. The sample consisted of 184 (68%) women and the mean age was 34.9 years (SD= 14.7). Hundred-and-sixty-four participants (61%) were married or partnered, 98 participants (36%) were single, and 8 participants (3%) were divorced. Regarding educational level, 135 participants (50%) completed tertiary education, 128 participants (47%) completed secondary education, and 7 participants (3%) completed primary education. With respect to employment status, 112 participants (41%) were employed, 93 participants (34%) were college student, 42 participants (16%) main daily task was housekeeping, 10 participants (4%) received Workmen s Compensation Act/benefit, and 8 participants (3%) were retired. Materials Embitterment. Embitterment was measured with the Bern Embitterment Inventory (BEI- NL) [2, 14]. Participants rated their agreement with 18 statements on a 5-point Likert scale (0=does not apply, 4=fully applies). The items referred to four components of embitterment: emotional embitterment (the tendency to feel bitterness), misanthropy/ aggression (holding low expectations and respect towards others), pessimism/ hopelessness (holding low expectations of one s future), and performance-related embitterment (perceiving lack of acknowledgement for achievements). The internal consistency of the embitterment scale was good, Cronbach s α =.89. Personality. The Big Five Inventory (BFI-NL) assesses the Big Five factors of personality [15]: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Cronbach s α s ranged from.70 (conscientiousness) to.84 (extraversion and neuroticism). Negative affect. To assess negative affect, two markers of each of the basic negative affect scales of the Positive and Negative Affect Schedule (PANAS) were used: the affects sadness (i.e., sad and upset ; Cronbach s α =.78), fear ( afraid and scared ; Cronbach s α =.74), guilt ( guilty and ashamed ; Cronbach s α =.64), and hostility ( hostile and irritable ; Cronbach s α =.59) [16]. Participants indicated how often they experienced these affects during the past 4 weeks on a 5-point Likert scale (0 = hardly or not at all, 4 = completely). Data analysis Multiple regression analyses were performed with SPSS for Windows 16.0; p-values <.05 were considered significant. The score distribution of the personality variables was 18

19 normal (skewness and kurtosis < 1). The embitterment and affect variables were somewhat positively skewed (skewness ranged from 1.02 for hostility to 1.74 for guilt) and kurtosed (kurtosis ranged from 1.01 for embitterment to 3.88 for guilt). However, the residual plots showed that the assumptions of linearity (residuals versus predicted values) and normality (normal probability plot of the residuals) were sufficiently met to apply multiple regression analysis. The potential interactive effects of neuroticism and agreeableness on embitterment were tested with multiple regression analyses according to the Aiken and West procedure [17]. Because education level was related to embitterment, it was included in the first block. In the second block, neuroticism and agreeableness were entered as centred variables. In the third block, the 2-way interaction term of neuroticism with agreeableness was entered [18]. To probe a significant interaction effect, a graph was drawn and simple slope analysis was conducted. Following Cohen s conventional values for effect sizes, effects of 0.20, 0.50, and 0.80 were taken to indicate small, medium, and large effects, respectively [19]. When significant, the same procedures were repeated for the four components of embitterment. To test whether embitterment is associated with the negative affects shame and guilt, hostility, sadness, and fear, we computed rank correlations and conducted multiple regression analyses to examine which negative affects predicted the embitterment components while adjusting for the other affects. RESULTS Descriptives The mean embitterment score was 0.92 (SD=0.60). Based on the cut-off value of 2.2 that was proposed by the authors of the Bern Embitterment Inventory [20], 3% of our sample experienced high levels of embitterment. Neuroticism and agreeableness Table 1 shows the results of regression analysis predicting embitterment from neuroticism and agreeableness. In Block 2, both high neuroticism and low agreeableness were additively associated with more embitterment. In Block 3, over and above these effects, the interaction between neuroticism and agreeableness was significantly associated with embitterment (t = -2.56, p =.01). As shown in Figure 1A, particularly people both high on neuroticism and low on agreeableness showed high embitterment scores, while the other three groups estimated on basis of the regression equations were closer together. The link between neuroticism and embitterment was of moderate strength at high levels of agreeableness (d =.47, simple slope β =.19, p =.01) while it was strong at low levels of agreeableness (d =.89, simple slope β =.45, p <.001). The four components of embitterment were examined separately. This showed that the interaction component of neuroticism and agreeableness was significant for emotional embitterment (t = -2.26, p =.03) and misanthropy/aggression (t = -2.96, p =.003), but not for the other two components. Figure 1B and 1C show these 19

20 interactions. Simple slope analyses for these components confirmed that especially the combination of high neuroticism and low agreeableness was associated with high embitterment. For emotional embitterment the slope statistics were d =.35 (simple slope β =.17, p =.02) for high agreeableness and d =.83 (simple slope β =.41, p <.001) for low agreeableness. For misanthropy/aggression the slope statistics were d =.12 (simple slope β =.06, p =.41) for high levels of agreeableness and d =.72 (simple slope β =.36, p <.001) for low levels of agreeableness. Table 1. Hierarchical regression analyses with neuroticism and agreeableness predicting embitterment Block Predictor variable Block 1 Secondary education Tertiary education Block 2 adjδr² (adjusted R²) with significance levels (p) of F-change *p<.05, ** p<.01, *** p<.001 b SE b β p adjδr² p Neuroticism *** Agreeableness *** Block 3 Neuroticism Agreeableness **.02 **.19 ***.02 * Figure 1. Standardized embitterment scores in individuals low (-1 SD) and high (+1 SD) on neuroticism separately for low (-1 SD) and high (+1 SD) levels of agreeableness 20

21 Negative affect Table 2 shows the association of negative affect with embitterment. The correlations between the four affects and embitterment were largely similar and of moderate magnitude. Multiple regression analyses showed that guilt, sadness and hostility, but not fear, had unique contributions to the prediction of embitterment (right column of table 2). For these affects, we analysed the association with the components of embitterment. We present these findings in in order of strength of association (the data are not shown in tables). Guilt was associated with all four components of embitterment ranging from t = 3.42, p =.001 for pessimism/hopelessness to t = 4.36, p <.001 for emotional embitterment. Hostility was associated with emotional embitterment (t = 2.78, p =.01), performance-related embitterment (t = 2.45, p =.01), and misanthropy/ aggression (t = 3.52, p =.001). Sadness was associated with emotional embitterment (t = 3.59, p <.001) and pessimism/hopelessness (t = 2.48, p =.01). Table 2. Association of negative affect with embitterment: Spearman correlations (ρ) and regression coefficients of linear regression analyses (b and β) while adjusting for education level Embitterment variable Correlation Regression Affect variable ρ p b SE b β p Total embitterment Guilt.39 *** *** Hostility.42 *** ** Sadness.36 *** * Fear.37 *** *p<.05, ** p<.01, *** p<.001 DISCUSSION The present study shows that the combination of high neuroticism and low agreeableness was associated with embitterment. In terms of affects, the internalizing affects sadness, fear and guilt as well as the externalizing affect hostility were associated with embitterment. The observation that both neuroticism and low agreeableness are associated with embitterment has been supported by a previous observation [6]. New to our study is that particularly the combination of high neuroticism and low agreeableness was observed to be associated with embitterment. Agreeableness can be conceptualized as a constellation of emotional competencies including perception and acceptance of emotions, empathy, serenity, and long-term perspective [21]. These competencies may work to cool down the hot reactive emotionality of neuroticism; especially insofar these emotions threaten one s interpersonal ties [10]. They can successfully be learned in therapy and empower individuals with high neuroticism to refrain or detach from embitterment [22]. 21

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