1. Personality and Prevention in Public Health Ben Chapman, PhD MPH Person Centered Health Decisions Network University of Rochester Medical Center

2. Preventive Medicine Prevention preferable to treatment –Pre-empt or reduce suffering, mortality, individual and systemic costs Targeted: Aimed at a certain group of individuals at risk for an undesirable outcome –More cost effective, conditional on correct identification of at-risk population segment Increasing emphasis on prevention to reduce individual and societal burden

3. Prevention and Public Health Inception Patho- genesis Signs and Symptoms Diagnosis Control  Remission Progression  Death Primary and Secondary Prevention Treatment and Tertiary Prevention Palliative Care Public Health Objective Disease Course Low High Quality of Life Cost Upper Bound of Public Health Criteria to be Optimized

4. Personalized Medicine Hinges on individual risk assessment –Accomplished through screening/testing Need an accurate picture of potential outcomes for a particular patient Enables closer surveillance, pre-emptive action, earlier detection, treatment tailoring Risk profiling depends on available information, capacity to predict outcomes from that information, and costs of getting the information

5. Personalized Medicine Tools Genetic testing (costly) –BRCA gene for breast cancer Health behavior (cheap) –Smoking for lung cancer / cardiovascular disease (CVD) Basic clinical biomarkers (cheap) –Systolic blood pressure, lipids for CVD Doctrine of Specific Etiology Personality? –Broadband information, maximal predictive power for many different heatlh conditions at minimal cost

6. Health Information Indexed by Personality Broad DimensionsBroad Dimensions Daily Health Behavior -Activity -Diet -Tobacco -Alcohol -Risk-taking Health Service Use -Preventive Care -Timely treatment -Adherence Decision Making -Risk preferences -Delay - Discounting Overweight / Obesity Endocrine / Immune Dysregulation Illness Burden Accumulation -Hypertension -Diabetes -CVD -Dementia - Cancer -Arthritis -COPD -Others C1 C2 C3 C4 C5 Chronic Stress Response -HPA Axis Overactivity -SNS Overactivity Neural Substrates of Effortful Control -Prefrontal Activity -Serotonergic systems P re m at u re D e at h Social Cognition Self-monitoring Self-efficacy Self-regulation Goal Setting Social / Emotional Process -Affect regulation -Social motivation -Role engagement -Social reliability Hierarchically Organized Traits Social Activity -Loneliness -Conflict -Role Under/ Overextension Intermediate Biological Processes Cognitive / Affective ProcessesIntermediate Social / Behavioral OutcomesBiological Outcomes Genetics & Environment

7. The Person in Personalized Medicine Personality tendencies are usually distal in etiologic chain leading to outcome –Convey information on the probability of intermediate and more proximal risks before they develop –Ideal for screening and prevention Personality phenotype captures broad bandwidth of health relevant information –Underlying behavioral processes (self-regulation) –Social cognitive processes relevant to health (risk evaluation, emotion regulation) –Genetic endowment in conjunction with environmental history (product of gene*environment interaction)

8. Conventional vs. Personalized Medicine: Target of Assessment Proximal: Negative Outcome Imminent Risk Information Bandwidth Location in Etiologic Chain Distal: Negative Outcome Imminent High: Multiple Levels and Biopsycho- social Domains Low: Single Domain Personality Personalized Medicine: Early Risk Profiling for Prevention Conven- tional Medicine: Diagnosis for Treatment of Specific Outcome

9. Incorporating Personality Information into Risk Profiling Factorial / structural approach—intact unifactorial scales: Factorial validity –Internally consistent, limited number of well- understood constructs, not optimized for particular predictive power (but de-facto general predictive power) Criterion-keying approach: Predictive Validity –Infinite number of scales each optimized to predict a particular outcome, each hybrids of multiple traits Get both with general item set –Maximize description and prediction

10. EPI Items Associated With All Cause Mortality

11. Independent Test Sample Prognostic Accuracies, 25 Year All-Cause Mortality Risk ScoreAUC95% CI EPI Mortality Risk Scale.76.74-.78 EPI N, E, Lie Scales.69.66-.72 Chronic Disease Score.64.61-.66 Charlson Co- Morbidity Score.61.59-.63

12. Translational Science Challenges Time vs. information trade-off: feasible in real- world public health and medicine –Serial testing (general brief, followed by selective in- depth assessment) Comparative effectiveness in vs. conventional and genetic risk scores in predictive trials –Specific outcomes –Versatility / breadth of predictable outcomes Incremental effectiveness over conventional scores –Cost effectiveness Translation of scores into meaningful information for practitioners